Artigo 2 When the Shoe is on the Other Foot

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WHEN THE SHOE IS ON THE OTHER FOOT:

A QUALITATIVE STUDY OF INTERN-LEVEL TRAINEES

PERCEIVED LEARNING FROM CLIENTS

JESSICA V. STAHL, CLARA E. HILL, TOVA JACOBS, STACEY KLEINMAN,DANIEL ISENBERG, AND ALEXA STERN

University of Maryland, College Park

Twelve trainees (3 men and 9 women)who had recently completed predoc-toral internships at a university coun-seling center were interviewed aboutwhat they had learned from clients.

Data were analyzed using a consen-sual qualitative research method.Participants reported learning thingsabout doing therapy, themselves, cli-ent dynamics, human nature, the ther-apy relationship, and the usefulnessof supervision. In addition, partici-pants highlighted the importance ofconsultation and self-reflection tohelp them recognize what they

learned. Implications for practice andresearch are discussed.

Keywords: learning from clients, train-ing, supervision, internship

As trainers of psychotherapists, it is incumbenton us to investigate how our students learn aboutpsychotherapy so that we can modify our trainingprograms to make them more effective. Most of

the literature has focused on helping skills train-ing (see Hill & Lent, 2006) and supervision (seeBernard & Goodyear, 2004) as the key factors intraining psychotherapists. It is interesting thatless attention has been paid to learning fromclients, although there is some evidence that ther-

apists attribute the majority of their learningabout therapy to their clients. For example, Rn-nestad and Skovholt (2003), in their qualitativestudy of therapist development, stated that:

Counselors/therapists at all levels of education and experienceexpressed in unison a voice that interacting with clients is apowerful source of learning and development. By disclosingtheir distress, their developmental histories, and ways of man-aging and coping with their problems of living, clients informcounselors/therapists of causes and solutions to human dis-tress. The knowledge thus attained not only supplements andexpands, but also brings depth and intensity to the theoretical

knowledge obtained in formal schooling. (p. 33)

Likewise, Orlinsky, Botermans, and Rnnestad(2001) found that more than 4,000 therapists from avariety of specialties, nationalities, and theoreticalorientations identified experience in therapy withclients as the most important influence on theiroverall professional development. Other qualitativeaccounts of therapist development have also high-lighted the importance of clients as primary teachersof therapists (e.g., Farber, 1983; Freeman & Hayes,2002; Goldfried, 2001; Skovholt & McCarthy,

1988; Skovholt & Rnnestad, 1992). These studiesare important because they confirm that therapistsdo learn from clients, but they provide no evidenceabout what therapists learn from clients.

Most of the literature about what therapistslearn involves personal accounts of learning fromclients. For example, Crawford (1987) delineatedlessons he learned from a beginning practicum.Bugental (1991), Strupp (1996), Mahrer (1996),Lazarus (1996), Kaslow (1996), and Ellis (1996)each described what they learned from a lifetime

of conducting or researching psychotherapy. Inaddition, Freeman and Hayes (2002) describedtheir changes on personal, professional, and spir-

Jessica V. Stahl, Clara E. Hill, Tova Jacobs, Stacey Klein-

man, Daniel Isenberg, and Alexa Stern, Department of Psy-

chology, University of Maryland, College Park.

Jessica V. Stahl is now at The Massachusetts School of

Professional Psychology in Boston, MA.

This article is based, in part, on the dissertation of Jessica

V. Stahl under the direction of Clara E. Hill. A version of

these results was presented at the 2007 annual meeting of the

Society for Psychotherapy Research in Madison, WI.

Correspondence concerning this article should be ad-

dressed to Jessica Stahl, The Massachusetts School of Pro-fessional Psychology, 221 Rivermoor St., Boston, MA 02132.

E-mail: [email protected]

Psychotherapy Theory, Research, Practice, Training 2009 American Psychological Association2009, Vol. 46, No. 3, 376 389 0033-3204/09/$12.00 DOI: 10.1037/a0017000

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itual levels as a result of experiences with oneclient; Kahn and Fromm (2001) synthesized 16hypnotherapists accounts of how each waschanged by a particular client. Although theseaccounts provide foundational information aboutwhat therapists learn from clients, their anecdotalnature makes it difficult to obtain a systematicperspective of what therapists learn from clientsand what they do with what they learn.

In the two published empirical studies on theimpact of clients on their therapists, therapistsreported that they were affected by their clients inseveral ways. For example, they describedchanges in personality and sense of self, such asbecoming more psychologically minded and in-trospective (Farber, 1983) or experiencing more

self-esteem and self-confidence (Farber, 1983;Myers, 2002). In addition, therapists indicatedthat they gained a greater appreciation for therapyas a partnership between client and therapist anda greater understanding of the process of therapy(Myers, 2002). Farber (1983) also found somenegative impacts, such as acting therapeuticallytoward others outside the office and experiencingless emotionality at home. Unfortunately, Farber(1983) and Myers (2002) did not provide muchdetail about measures used and coding methods,making it difficult to judge the validity of thefindings. Hence, the purpose of this study was toinvestigate what therapists learn from clients.

Given the paucity of research on this topic, aqualitative approach was used to allow us tocollect in-depth data about the experiences oftherapists-in-training. More specifically, wechose to use consensual qualitative research(CQR; Hill, Thompson, & Williams, 1997; Hill etal., 2005) because it has been used widely forpsychotherapy research and because it allowed usto collect consistent data across participants as

well as to pursue in-depth unique informationfrom individual participants.

Furthermore, given that what therapists learnfrom clients probably differs on the basis of theirlevel of training, it seemed important to restrictthe level of training in this study. Hence, wedecided to focus this investigation on predoctoralinterns. At this level, students are immersed intraining full time for a year and so are deeply intothe experience and thus likely to be good observ-ers about what they have learned. In addition,

students at this level have been involved for sev-eral years in supervision, and thus are likely tohave paid attention to their experiences and to be

good reporters of those experiences. Because amajor principle in qualitative research is tochoose participants who are experts and capableof reporting on their experiences (see Hill et al.,1997), predoctoral interns seemed like an idealpopulation.

As is typical in qualitative research, we did nottest a theoretical framework in this study becausewe wanted to allow the theory to emerge from thedata. Relatedly, because there was little founda-tion from the literature to guide the developmentof hypotheses and because qualitative researcherseschew hypotheses as potentially biasing the in-vestigators, we instead formulated research ques-tions to guide our study. Our research questionswere the following: What do interns perceive that

they learn from their clients? How do internscome to realize what they learn? How do internsreport applying what they learn from clients?

Method

Participants

Interviewees. Participants were 12 (3 men, 9women; 7 White, 1 biracial, 2 African American,1 Asian American, 1 Middle Eastern, meanage 34.00 years, SD 7.11; 11 counseling, 1clinical; 10 PhD, 2 PsyD) doctoral students whohad recently completed APA-accredited predoc-toral internships at university counseling centers.To provide contextual information about the sam-ple, we asked participants to rate the degree towhich they believed in and adhered to the tech-niques of four major theoretical orientations on5-point scales (1 not at all, 5 completely).Using these rating scales, participants rated hu-manistic approaches an average of 3.75 (SD 0.87), psychodynamic approaches an average of

3.71 (SD 0.92), feminist/multicultural ap-proaches an average of 3.58 (SD 0.90), andbehavioral cognitive approaches an average of2.75 (SD 0.97). Thus, this sample was primar-ily composed of White, female, in their 30s,predoctoral psychology interns who were rela-tively eclectic in theoretical orientation butleaned toward humanistic, psychodynamic, fem-inist approaches.

Research team. The primary research teamincluded five White Jewish members (a 27-year-

old female advanced doctoral student in counsel-ing psychology, two female and one male post-baccalaureate individuals ages 23 or 24, and one

Interns Perceived Learning From Clients

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22-year-old upper level female psychology majorstudent) who had all completed counseling-related courses. The auditor was a 58-year-oldWhite female PhD counseling psychologist whohad extensive experience in psychotherapy re-search and developed CQR.

Measures

Demographics questionnaire. Participantswere asked for age, sex, and doctoral program(clinical vs. counseling; PsyD vs. PhD), and en-dorsement (1 not at all, 5 completely) ofhumanistic, psychodynamic, behavioralcognitive, and feminist/multicultural theoreticalorientations.

Semistructured interview. The interview pro-tocols were developed by the first author on thebasis of the existing literature on learning fromclients, her clinical experience, two focus groupsof graduate students and faculty members, andtwo practice interviews. Through these practiceinterviews, we discovered that participants gavemore concrete information about lessons if theyfirst described lessons from one selected clientand then talked about other lessons they hadlearned. Hence, the final protocol was structuredaround asking first about lessons from one par-ticular client and then asking more generallyabout other lessons that had been learned fromclients.

The first interview began by asking therapists toprovide background information about the selectedclient (e.g., demographics, number of sessions, howlong ago they saw the selected client, personal re-actions). Participants were then asked an open-ended question about what they learned from theselected client. When participants could not thinkof anything more that they had learned from the

selected client, they were asked about learningfrom the client about themselves, therapy, clients,and human nature. Participants were next askedto discuss how they came to realize what theylearned, and how they had applied or anticipatedthat they would apply the lessons learned fromthis client. Participants were then asked aboutwhat they had learned from other clients, usingthe questions described above.

A follow-up interview was included, as sug-gested in CQR (see Hill et al., 1997, 2005) to

encourage in-depth data and allow participants tothink more about the topic between interviews.The follow-up interview began with questions

left over from the first interview (where appro-priate) and any clarification questions that cameup for the interviewer on the basis of reviewingthe tape of first interview. Participants were thenasked about their reactions to the first interview,further thoughts about learning from clients, andwhat they had learned from participating in theinterviews.

Procedure

Participant recruitment. Five doctoral in-terns in the first authors counseling psychologyprogram were sent an e-mail asking them to par-ticipate and to recommend fellow interns whomight be willing to participate. Those individu-

als, in turn, were asked to recommend other in-terns they knew who might be willing to partic-ipate. All potential participants were sent ane-mail that briefly described the purpose of thestudy, listed the risks and benefits of participat-ing, and included a copy of the interview proto-col. Once a potential person agreed to participate,the interview was scheduled at a mutually con-venient time, and participants were asked to readthe protocol and think about their answers priorto the interview.

Interviews were audiotaped and conducted byphone by the first author. The first interviewlasted 1 to 1.5 hr, after which the interviewerlistened to the tape to determine whether therewere issues that needed clarification in the secondinterview. The follow-up interview was held inthe next 1 to 7 days and lasted 15 to 30 min. Afterboth interviews, the interviewer recorded her im-pressions of the interview and the interviewee. Intotal, 31 interns were invited to participate; 12agreed to participate and completed both inter-views (39% completion rate).

CQR process. Interviews were transcribedand checked for accuracy. All identifying infor-mation was removed from transcripts, and caseswere assigned code numbers.

Before coding began, team members read thetwo CQR articles (Hill et al., 1997, 2005). Earlymeetings focused on creating an atmosphere inwhich all judges felt comfortable contributing tothe consensus process. The first task involvedrecording and discussing biases (i.e., personalissues that make it difficult to respond objectively

to the data) and expectations (i.e., beliefs aboutwhat the data will look like). We report these heregiven that it is standard practice in qualitative

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articles to describe the expectations and biases ofjudges so that readers have a context withinwhich to judge the results. The judges expectedthat therapists would have learned about (a) thediversity of lifes problems and methods individ-uals employ to conquer adversity; (b) their ownissues through working with a client with similarissues; (c) themselves as therapists most whenthey had trouble connecting with clients, whentheir approach to therapy was challenged, or as aresult of exposure to different presenting prob-lems, diagnoses, and symptoms; (d) technical is-sues (e.g., self-disclosure, countertransference is-sues) and separating their own issues from thoseof their clients; and (e) existential issues. Oncethey expressed their expectations, judges were

asked to set these expectations aside (bracketthem) and focus on the data during data codingand analysis. Judges were encouraged to discusstheir expectations and biases as they arose and tochallenge each other during the process of thestudy about these so that they could try to keep asobjective a perspective as possible.

In the first step of analyzing the data, domains(i.e., topic areas) were derived from reading andcoding the first few interviews. These domainswere modified considerably while going throughthe remaining transcripts. Once the list was sta-ble, team members independently read each tran-script and identified domains for each completethought. The team then met to discuss and agreeon the domain codings.

After identifying the domains for each thoughtunit in a case, the team collaborated to constructcore ideas (i.e., a concise yet comprehensivesummary that stays as close to the participantswords as possible) for each thought unit of rawdata. In the meeting, a team member read athought unit out loud (to understand the context

of the case) and shared her or his version of thecore ideas for that thought unit. The team thendiscussed and coconstructed the final core ideas.

The auditor read through the consensus version(which included domain titles, core ideas, and allthe raw data for each domain) to determinewhether the raw material was in the correct do-main, that all the important material in eachthought unit was included in the core ideas, andthat the wording of the core ideas accuratelycharacterized the data. The team then met to

consider (accept or reject) all suggestions madeby the auditor. Once discussion about the audi-tors comments was complete and the accepted

changes were incorporated, the transcript wasreturned to the auditor so that she could see howthe team responded to her comments and suggestfurther changes if appropriate. Because this was adissertation and the auditor (the second author)was helping the first author learn CQR, great carewas taken to ensure that the team clearly under-stood the CQR process; hence, the auditing pro-cess continued for each case until the auditor wassatisfied that the team captured the essence of thedata.

For the cross-analysis, the judges indepen-dently examined the data in each domain acrosscases to think about the underlying themes.Judges then brainstormed possible categories andarrived at consensus about the final list. Once

they had a final list, they discussed the placementof core ideas into categories until consensus wasachieved. When questions arose, they returned tothe raw data to make sure that they were repre-senting the data fairly. The auditor reviewed thecross-analysis to consider wording and represen-tativeness of the categories and whether catego-ries should be collapsed or further subdivided.The research team then considered the auditorscomments as described above.

For the lessons domains, we compared findingsfor the selected client versus additional clients.No differences were found in categories of les-sons discussed, indicating that these groups werenot distinct (i.e., interns learned the same types oflessons from both groups). Hence, the data werecombined across all clients.

Once the cross-analysis was complete, catego-ries were labeled to indicate the degree to whichthey represented the sample. Following Hill et al.(2005), the term general was used for categoriesthat included 11 or 12 cases, typical 7 to 10 cases,variant for 3 to 6 cases. Categories emerging

from one or two cases were placed into a miscel-laneous category.

Results

We begin the results by comparing the demo-graphics of our sample with interns in general tohelp readers place our sample in context. In termsof degree type, our sample differed from thelarger intern cohort, as 92% of our sample wereearning degrees in counseling psychology (vs.

16% nationally), and 83% of our sample werepursuing PhDs (vs. 64% nationally; Associationof Psychology and Postdoctoral Internship Cen-


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ters, 2004). For age, gender, and race, we com-pared our sample with the 20052006 cohort(Association of Psychology and Postdoctoral In-ternship Centers, 2005) because this informationwas not collected on the 20042005 cohort. Interms of gender, our sample was fairly similar tothe national sample (75% of our group werefemale vs. 78% female nationally). Otherwise,our participants were a bit older (M 34.00years, SD 7.11 vs. M 30.83 years, SD 6.56), and more diverse (58% of our sample wasWhite vs. 78% nationally) than the national sam-ple. Thus, our sample was ethnically diverse, andcomposed primarily of women in their mid-30swho were seeking counseling psychology PhDdegrees.

Three domains emerged from the data: lessonslearned from clients, how intern realized lessonsfrom selected client, and how intern applied les-sons from selected client. The categories, subcat-egories, and frequencies of the each of thesedomains can be found in Tables 1 and 2. In thetables, we list all the findings to provide the rangeof topics that participants talked about, but inthe text we present only the findings that were atleast typical. In addition, a prototypical case ispresented to illustrate the findings.

Lessons Learned From Clients

There were five types of typical lessonslearned from clients: doing therapy, self, clients,human nature, and therapy relationship (see alsoTable 1).

Lessons about doing therapy. Participantsmostly discussed learning about how to do ther-apy. First, they described learning about therapyskills plus, which refers to learning the nuts andbolts of how to conduct therapy. Under this ru-

bric, they discussed learning about the need touse and be aware of oneself in sessions (e.g., topay attention to your feelings and reactions to aclient and kind of basic countertransferencestuff, that they should use their own feelings andreactions to the client as information about theclient, and that it was important to communicatetheir own reactions or feelings to client appropri-ately). Second, they described issues related totheoretical orientation, such as the helpfulness ofsupplementing their theoretical approach with

specific techniques (e.g., [This client] reaffirmedmy trust in paradoxical work. The I know youreprobably not going to come back next week be-

cause of what happened today, so . . . . But shewould come back just to show me, which is agood thing.). Third, they talked about session orcase management. They talked here about suchthings as learning how to work with specificdiagnoses as well as the limits and benefits ofdiagnosis; setting and maintaining boundaries(e.g., how to do it, that they struggle with it); theprocess of making referrals, dealing with outsidetherapists and agencies, and hospitalizing clients;and the need to make, keep track of, and check ontherapy goals.

Participants also talked about the challengesand limitations of therapy. For example, one par-ticipant said,

I learned maybe that change is slow and gradual and thats

okay. I think she did a lot of work in that 6- or 8-month periodeven though to her or even to people outside of her they mightnot have noticed a change at all . . . it reminds me that peopledont change that quickly and therapy is such a long processof difficult work.

Participants also typically mentioned havinglearned about the complexity and challenge ofdoing therapy. For example, one participantnoted,

I knew this before . . . theres no recipe for [therapy]. I thinkthis is where the art of therapy comes in. Its really a creativeprocess for the therapist and for the client, but its not creativein the ways we think it is . . . its emotionally creative . . . thatmakes it both scary but exciting and fun at the same time.

Similarly, another said, Im just always struckby how complex [therapy] is . . . its always anegotiation, so were trained to kind of be withthe client where they are and at the same time Ihad my own notions of what would be helpful.

Lessons about self. All participants discussedlessons that they had learned about themselves.These lessons typically involved personal limita-tions (e.g., I learned about my own comfort and

discomfort with boundary setting and really chal-lenged my, sort of need to be liked by a client;[Ive learned that] the idea that as a therapist Imdifferent than my clients is just not true. I thinkwere all people and we all have our problem-s . . . and we all deal with them in our ownways). On the flip side, participants also typi-cally reported having learned that they weregood enough therapists or discussed having feltan increased sense of competence as a therapist(e.g., I learned I could do good enough work

with my clients. It doesnt have to be outstandingwork or brilliant work, it just has to be goodenough work).

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TABLE 1. Categories, Subcategories, and Frequencies for Lessons Learned From Clients

Domain, category, and subcategory Frequency

1. Lessons about doing therapy GA. Therapy skills plus G

1) Process skills Ga. Need to use and be aware of self in sessions T

1. Need to be self-monitoring and self-aware when working with clients V2. Need to use own feelings and reactions to client as information about client V3. Need to communicate genuine or vulnerable attitude to clients V

b. Importance of being responsive to clients Vc. Need to give clients responsibility for change Vd. Importance of trusting the process Ve. Need to communicate feelings to clients Vf. Need to sit with own and clients feelings in a session V

2) Issues related to theoretical orientation Ga. Usefulness of [technique] in lieu of (or in addition to) theoretical orientation Tb. Need to be flexible with theoretical orientation, approach, or conceptualization Vc. Preference for theoretical orientation V

3) Session and case management Ta. Working with and impact of diagnoses Vb. Skill and strategies for setting and maintaining boundaries Vc. There is a specific process to make a referral and deal with outside therapists and agencies;

hospitalizing clients; learned about system Vd. Need to keep track of, make therapy goals, and check in with clients on how things are going V

4) Specific skills and interventions (e.g., silence, self-disclosure, challenge) VB. Challenges and limitations of doing therapy T

1) There are limits to what therapy can accomplish; what are realistic expectations and goals for clientchange (e.g., change is slow) T

2) Therapy is hard, unpredictable, complex, and challenging T3) It is hard to tell who (therapist or client) is responsible for therapy outcome V

2. Lessons about self GA. Participant has personal limitations (idiosyncratic to participant) T

B. Participant is good enough therapist; felt increased sense of own competence as therapist TC. Participant learned that s/he has biases (what they are) and how they affect the work TD. Participant has high expectations for self (wants to be perfect), but realized it is okay to not be perfect VE. Participant learned something about own personal characteristics, issues, or countertransference triggers

(idiosyncratic to participant); gained self-awareness VF. Participant prefers to work with certain types of clients (actual preference is idiosyncratic to participant) VG. Participant learned about own personal rewards for therapy work V

3. Lessons about clients GA. Change is hard for client and is very individual to client (e.g., clients motivation to change plays a big

role) TB. Our knowledge and understanding of clients are limited VC. Clients interpersonal style in therapy is a replication of their outside relationships; there are parallels

between therapy relationship and clients outside relationships VD. Conceptualization of client evolves over time and should be flexible V

E. Clients have reasons for behaving the way they do V4. Human nature G

A. Our environment, family, culture, and early experiences shape our lives and problems TB. Life is unfair and can change in an instant VC. People have negative qualities (e.g., selfish, evil, critical, complex, rigid) VD. People are resilient and can change when they want to VE. People are ambivalent about change, want a quick fix, and do not want to take responsibility for their lives VF. Therapy plays an important role in peoples lives and society V

5. Lessons about therapy relationship TA. The therapy relationship is important and curative VB. The therapy relationship is complex V

6. Supervision, consultation, collaboration, and training are important and useful V

Note. N 12. G general (this category occurred for 11 or 12 participants); T typical (this category occurred for

7 to 10 participants); V

variant (this category occurred for 3 to 6 participants).


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Participants also typically indicated that theylearned about their own biases (i.e., what theyare) and how these biases affect their work astherapists. For example, an African Americanparticipant noted,

I learned a lot about . . . introducing race and culture into mywork . . . . She was White and I didnt do a great job of that,and since then it caused me to think more about how I thinkabout White people and their cultural development . . . . Ireally tend to focus on culture with people of color and notWhite people.

Lessons about clients. Participants generallydiscussed lessons about clients. The only typicalsubcategory here was learning about clients mo-tivation to change (i.e., participants said theylearned that change is hard for some clients, and

that change is very individual to clients level ofmotivation, readiness to change, or specific areasof resistance). According to one participant, Cli-ents have taught me [that] we are all ambivalentabout change. And every client is going to man-ifest that differently . . . [there is a] variety ofways that I get the hand.

Lessons about human nature. All partici-pants discussed lessons about human nature. Typ-ically, they reported having learned that back-ground shapes ones life and problems. Forexample, one participant said,

Her childhood was fairly chaotic and dysfunctional . . . yetshe was still incredibly protective and loving toward both

mom and dad, just very difficult for her to say anythingnegative about them . . . . It just really showed me how strongthat bond is and how children do that because they have tosurvive and how deeply positive that can be but also howdamaging that can be.

Lessons about the therapy relationship. Par-ticipants typically reported having learned aboutthe therapy relationship. They discussed havinglearned that the therapy relationship is importantor curative (e.g., One thing that I got from her[was] . . . the importance really of having a con-fidential place to get support . . . but then alsohaving somebody to whom one holds oneselfaccountable), and that the therapy relationship iscomplex (e.g., I had to learn that would notmake me an effective therapist if I just worked atkeeping them liking me . . . you can be challeng-ing and confronting . . . but it doesnt take awayany sense of attachment or any sense of connec-tion that we have).

How Intern Realized Lessons FromSelected Client

Table 2 lists the ways in which interns realizedwhat they learned from clients. First, all partici-pants described learning from direct discussionswith others, such as supervisors (e.g., I felt very

comfortable talking with [my supervisor] aboutmy reactions to clients and things like that . . . itwas very helpful to be able to talk to him justabout my surprise of her willingness to work withme . . . . I think supervision was probably the mainthing) or peers (e.g., [My conversations about]my general experiences and who I am as a therapistand how I may have changed and how my perspec-tives have changed and what I learned . . . I feel likeI had those with my peers, my cohort of interns).Self-reflection was also typically discussed by in-

terns as a source of learning. For example, oneintern noted, I think some of it I learned, prob-ably most of it, just from the amount of time Iinvested in thinking about this client outside ourtherapy . . . so I think a lot of self-questioning, alot of self-reflection during the process of meet-ing with her.

Application of Learning

Participants described two primary ways in

which they had or would in the future apply whatthey learned from their clients (see Table 2).First, participants generally indicated that they

TABLE 2. Categories, Subcategories, and Frequencies forHow Lessons Were Realized and Applied

Category and subcategory Frequency

1. How realized lessons

A. Talking to others G1) Supervision G2) Consulting with others T

B. Self-reflection TC. Readings or class VD. Directly from the client him-/herself; from

observing the client; from doing therapywith subsequent clients V

E. From the interview V2. How applied lessons

A. Applied to clinical work G1) Used in subsequent work with clients G2) Shared with others (colleagues,

supervisees) V

B. Applied to self V

Note. N 12. G general (this category occurred for11 or 12 participants); T typical (this category occurredfor 7 to 10 participants); V variant (this categoryoccurred for 3 to 6 participants).

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had used or will use what they learned from theirclient in subsequent work with clients. For exam-ple, one intern (whose client had a very signifi-cant history of trauma) said that since seeing thisclient, she has done a better job getting historiesfrom clients; another (whose client elicited strongfeelings of anger in her) discussed being able tosupervise herself more effectively regardingstrong reactions to clients. Second, participantsdiscussed how they apply what they learned fromtheir client to themselves. They described havinggained an appreciation for their own lives or usedthe lessons to foster personal growth.

Prototypical Case: I Wanted to KILL Him!

To bring the findings to life, we present onecase to illustrate how one intern discussed thelessons she learned from the client she selected,how she realized the lessons from that client, andhow she has or would in the future apply thelessons. This particular case was chosen becausethe research team agreed that it was a particularlygood example of the range of lessons participantsdiscussed. To protect confidentiality, the identi-ties of the therapist and client have been dis-guised. The therapist has read and approved thiswrite-up of her case.

W was a 34-year-old White female therapistwho discussed a 25-year-old African Americanmale law student client who presented with de-pression and procrastination problems. Theyworked together for 24 sessions on getting theclient to take responsibility for his work and lifegiven that the client was a chronic underachiever.W remarked that this client was brilliant but thathis emotional wounds were great (he had grownup in a military family and his father was de-scribed as a rage-aholic) and that his emotional

resources did not match his intellectual capacity.When asked about her reactions to the client, Wsaid, I wanted to kill him. She described theprocess of their therapy as very difficult, as theclient could not own his anger, and would dis-tance himself from W by flirting or trying toengage her in intellectual conversations abouttherapy (e.g., Do all people struggle like this?Why havent I made any progress yet? Whydo we need to talk about feelings?). Thingsshifted after Session 15 when W asked the client

what it was like to not make progress; subse-quently, he was able to access some of his angerand be more vulnerable in sessions.

W discussed three lessons about doing therapy.First, she learned that she needed to have appro-priate expectations for the therapy process andoutcome related to how wounded a client is;clients who are more wounded may not be able togo as far as less wounded clients. In addition, shelearned about the importance of getting clients totake responsibility for their feelings. The shifthappened when she simply asked the client whatit was like to not be making progress (vs. tryingto reassure the client or explain why things hadnot changed); this taught her that it is not her jobto heal her clients, but to help them heal them-selves. Third, she learned how to use her ownreactions to conceptualize what is going on for aclient and how to direct the work. She conceptu-

alized the anger she felt during sessions as stim-ulated by the client as his way of connecting toher, such that she was experiencing the anger thathe could not own or experience. She needed toexperience those feelings to help him connect,have compassion for those feelings, and use thefeelings in sessions.

From this client, W learned some lessons aboutherself, primarily that she is not incompetent.After discussing this client in supervision, Wrecognized that her feelings of incompetencecame only after sessions with this particular cli-ent. From recognizing this, she was able to feelgood about herself and recognize that her evalu-ation of her competence as a therapist was sepa-rate from what the client did. In addition, becausethis client really wanted her to be directive andgive him homework, W also learned that she isnot very good at being directive. Although shemet him there as best she could in ways that wereconsistent with who she was as a therapist, theirwork highlighted for her that she does not like todo directive therapy.

Regarding client dynamics, W learned how toconceptualize flirting as a defensea way ofavoiding connecting with her emotionally ratherthan as a sign of sexual attraction. By conceptu-alizing it in this way, she was able to discuss theflirting with the client in an ethical manner. Shealso learned that not all clients of color want totalk about race; even though the clients racialidentity was part of her conceptualization (e.g.,he was African American but identified as White,which she saw as a way of not accepting himself),

he was not ready to talk about it. A third majorlesson for W about client dynamics was that herclients angry presentation and the feelings of


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anger and incompetence that he elicited in herwere a manifestation of his narcissistic wounds.Fourth, this client highlighted for W how limitingit is when clients cut you off from pieces ofthemselves; this client would not talk about howhis family dynamics contributed to what wasgoing on with him. However, W felt that if theydid not address his family dynamics, she couldnot help him the way she wanted to. So, she hadto learn to be okay with what she could do withthe things he would discuss.

Finally, in terms of human nature, W learnedthat an important part of being human is takingresponsibility for oneself, and that doing so isdifficult. Although this is something she wasaware of before, this client challenged her on that

more than had any previous client.W noted that much of what she learned about

this client came through self-reflection. She fur-ther explained that she learned what to do with it(e.g., that it was not her job to take on the fullresponsibility for the sessions) from supervision.W indicated that her supervisor was pivotal inhelping her gain understanding about her strongreactions to the client because she could only getso far when reflecting on them by herself.

Having gone through the experience with thisclient, W felt more able to supervise herself whenshe had strong reactions to clients. Furthermore,she was able to help a fellow intern deal with asimilar reaction. W also noted that since workingwith this client, she found it easier to use heremotional reactions to conceptualize and focusthe work. Working with this client also made iteasier for her to have more realistic expectationsfor clients, the kind of work they can do, andwhat it feels like to put responsibility back on theclient. Finally, W learned to accept that althoughall clients are wounded, their presenting issues

and the amount of progress they can make willdiffer.

Discussion

These 12 predoctoral psychology interns fromuniversity counseling centers reported that theyhad learned a lot of profound lessons from theirexperiences with clients, and these lessons helpedthem become better therapists. Interns reportedlearning about doing therapy, themselves, clients,

human nature, the therapy relationship, and su-pervision, all of which have been reported at leastbriefly in previous anecdotal literature. Freeman

and Hayes (2002) reported that they personallyhad changed on personal, professional, and spir-itual levels as a result of their experiences withspecific clients. Similarly, Kahn and Fromm(2001) stated that therapists can be changed byclients in terms of learning new approaches (spe-cific changes on the therapists practice), individ-uation (intellectual or emotional change in thetherapist, such as a perspective shift), and trans-formation (therapists understanding and world-view are shifted). In this section, we first discussthe lessons learned and then put the findings intoa developmental framework.

Lessons

Lessons about doing therapy. As one wouldexpect of individuals who had just completed anintensive therapy training experience such as in-ternship, all participants discussed many lessonsthey had learned about doing therapy. The rangeof lessons that participants discussed across thiscategory demonstrates the wide variety of thingsthat interns learn about doing therapy. In additionto learning about therapy at both the micro level(i.e., specific interventions like silence and self-disclosures) and the big picture level (e.g., learn-ing to trust in the process, the limits of whattherapy can accomplish), interns learned aboutvarious components of doing therapy (e.g., pro-cess skills, session and case management, havingand using a theoretical orientation, the challengesand limitations of doing therapy).

Many of the lessons about doing therapy dis-cussed by participants are consistent with anec-dotal accounts of learning from clients as well asempirical studies on the impact of clients on theirtherapists. For example, several more experi-enced authors have discussed learning the impor-

tance of using a variety of therapeutic techniques(Kahn & Fromm, 2001) and being flexible withones theoretical approach when working withspecific clients (Lazarus, 1996; Norcross, 1996).Lessons discussed by participants have also beenreported by similarly experienced or less experi-enced therapists (e.g., Crawford, 1987, who waswriting about what he had learned on completinghis first practicum; Myers, 2002, whose partici-pants experience ranged from 5 to 30 years),such as learning to use ones own feelings or

reactions as information about the client (Craw-ford, 1987) and about the need to give clientsresponsibility for change (Crawford, 1987;

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Myers, 2002). Perhaps as a result of the sheernumber of lessons participants discussed in thiscategory, many of the specific lessons in thiscategory had not previously been reported. Les-sons that at least three participants reported thathad not been not discussed in the previous liter-ature included: need to communicate genuine orvulnerable attitude to clients, importance of trust-ing in the process, working with and impact ofdiagnoses, the process of making referrals anddealing with outside agencies, using silence andchallenges, the limits of what therapy can accom-plish, the difficulty and complexity of doing ther-apy, and the difficulty of knowing who is respon-sible for therapeutic change.

In addition, the lessons participants discussed

in the therapy skills plus category mirror adistinction made by Hill and Lent (2006) that inaddition to learning specific helping skills (e.g.,reflections of feeling, restatements, interpreta-tions), therapists-in-training learn additionalskills that facilitate their therapeutic endeavors(e.g., theoretical framework, self-awareness, fa-cilitative attitude, responsiveness to clients, caseconceptualization skills, case management skills,professionalism, and ethics). The findings in thepresent study confirm that Hill and Lents dis-tinction is a useful one for conceptualizing train-ees lessons about doing therapy, as interns dis-cussed learning about both helping skills and theplus additional skills. Furthermore, the findingthat interns spoke relatively little about learninghow to do therapy at the micro level (i.e., learninghelping skills, although a few of them did discussthe use of silence, self-disclosures, and chal-lenges) but reported learning a whole lot at higherlevels (i.e., everything else in the therapy skillsplus lessons subcategory) is consistent withHill and Lents conclusion that a focus on the

additional skills continues throughout training.The present findings contrast nicely with Hill,Sullivan, Knox, and Schlosser (2007), who foundthat novice therapists asked to keep a journal oftheir experiences in a prepracticum course re-ported a lot of learning about helping skills.These interns were clearly at a more expert statusthan were the novice therapists.

These findings are consistent with research onthe development of therapy expertise. Specifi-cally, the therapy expertise literature suggests

that as one gains experience with conductingtherapy, basic therapy skills become automatizedsuch that they fade into the background and be-

come second nature, allowing the therapist toattend to more complex cognitive tasks such asclient conceptualization (e.g., Cummings,Slemon, & Hallberg, 1993; Sakai & Nasserbakht,1997). Furthermore, it is notable that when par-ticipants discussed learning about specific inter-ventions, these lessons concerned using suchskills at a complex level (e.g., sitting in silencefor 6 or 7 min, disclosing ones sexual orientationto a client in a clinically appropriate time andmanner, challenging a client about his marijuanause). Together, these findings suggest that internshad automatized basic therapy skills (e.g., reflec-tions of feeling, restatements, interpretations),opening up space in their working memory toattend to and learn more cognitively complex

skills and tasks such as trusting in the process,becoming flexible with ones theoretical orienta-tion, and session and case management. Thissupports the idea that therapists reach some de-gree of expertise on completion of their training,although research on expertise in the cognitivescience field posits that approximately 10 yearsof experience are required to be considered anexpert (Sakai & Nasserbakht, 1997).

Lessons about self. The finding that partici-pants learned about themselves from clients con-firms previous literature. In a study of more than4,000 therapists of diverse backgrounds, Orlin-sky, Rnnestad, and Willutzki (2004) found thattherapy interactions influenced therapists livesand personalities. In addition, Freeman andHayes (2002) and Kahn and Fromm (2001) indi-cated that therapists changed personally as a re-sult of their work with specific clients; Farber(1983), Myers (2002), and Kaslow (1996) re-ported that therapists became more psychologi-cally minded, self-aware, and self-assured.

Two of the specific lessons about themselves

described by at least three participants in thisstudy have not previously been reported. The firstwas that the participants had high expectationsfor themselves as therapists (i.e., wanted to beperfect) but that it was okay to not be perfect.This finding is consistent with the perfectionismassociated with participants advanced studentstatus (see Rnnestad & Skovholt, 2003). Thesecond unique lessonabout the types of clientsthe participants each liked to work withmakessense given that these participants had just com-

pleted internship, where they worked with manydifferent clients, perhaps gaining exposure a widerange of types of clients for the first time.


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Lessons about clients. Trainees learned aboutclients and client dynamics, which is necessaryfor therapists to be responsive to clients individ-ual needs (Hill & Lent, 2006). The lesson thatchange is hard for clients and is very individual toclients (the only lesson in this category discussedby more than half the participants) is similar tofindings reported by Myers (2002) that therapistsno longer gave up on clients after their experi-ences with influential clients. Similarly, Freemanand Hayes (2002) indicated that therapistslearned about the change process from coura-geous clients. This lesson is also reflective ofparticipants transition into the novice profes-sional phase of therapist development, in whichthey gain an appreciation for both the complexity

of therapy and the importance of client feedbackin assessing how the work is going (see Rnnes-tad & Skovholt, 2003).

Several lessons about clients and client dynam-ics have not previously been reported in the lit-erature. These include that our knowledge andunderstanding of clients is limited, clients inter-personal style is a replication of their outsiderelationships, conceptualization of clients evolvesover time and should be flexible, and clients havereasons for behaving the way they do.

Lessons about human nature. Participantslessons reflected both positive aspects of humannature (e.g., resilience) and about human weak-nesses and flaws (e.g., people can be selfish orcritical; people are ambivalent about change).These findings are consistent with Yaloms(2002) description of clients and therapists asfellow travelers who learn about the human ex-istence from each other. Similarly, Bugental(1991), Kahn and Fromm (2001), and Freemanand Hayes (2002) have written about the ways inwhich therapists gained an understanding of the

role of therapy in peoples lives and society as aresult of their work with clients.

Lessons about the therapy relationship. Thelesson that the therapy relationship is importantand curative is consistent with previous literatureon client impact and learning from clients (e.g.,Crawford, 1987). The lesson that the therapyrelationship is complex, however, has not explic-itly been found in previous literature, but thislesson is not surprising given that one mightargue that all relationships are complex (particu-

larly when one is trained to examine them at thelevel to which one does as a therapist). Further-more, research on the various components (e.g.,

transference/countertransference configuration,working alliance, real relationship) of the therapyrelationship and the many factors that go intoeach one (e.g., tasks, bond, and goals of theworking alliance) certainly reflect the complexityof the therapy relationship (e.g., Gelso & Hayes,1998).

Putting the Lessons in a DevelopmentalFramework

Our intent with this study was not to test aparticular theoretical framework, but to allowtheory to emerge from the data. Yet, lessonslearned are consistent with what one would ex-pect based on Rnnestad and Skovholts (2003)

model of therapist development. Specifically, in-terns are transitioning from the advanced studentphase (students beyond the beginning year whoare working as counselors and therapists-in-training and receiving regular and formalized su-pervision) to the novice professional phase (indi-viduals in their first few years after graduation).According to the model, advanced students oftenfeel pressure to do things perfectly, appreciate theimpact of their professional training, seek confir-mation and feedback from seniors and peers, andcritically evaluate and assess models in an effortto differentiate, accept, and reject model compo-nents. Participants lesson about their theoreticalorientation (e.g., the importance of incorporatingvarious techniques into their approach) and theirrealization that they have high expectations forthemselves suggests that interns still exhibit fea-tures of this stage.

In addition, some of the interns lessons (e.g.,need to use and be aware of self in sessions,learning that they are a good enough therapist,learning about their own biases and how they

affect the work) are consistent with the externalto internal shift that Rnnestad and Skovholt(2003) posited. They suggested that as studentsprogress through the advanced student phase,they move from an external focus (e.g., looking atsupervisors for how to be a professional) to aninternal focus (e.g., looking at more complexissues of personal development, parallel process,transference/countertransference, etc.).

Interns discussed several lessons that reflecttheir transition into the novice professional phase.

According to Rnnestad and Skovholt (2003),novice professionals experience a sense of beingon their own, and they often test the validity of

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what was learned in school only to discover thegaps in their training, leading to a sense of disil-lusionment. At times, they feel lost without thesupport of graduate school and supervision, andlook to mentors for guidance and support. At thisstage, client feedback becomes an increasinglypowerful means of assessing what works, and thetherapist becomes increasingly aware of the waysin which his or her own personality is present inthe work. Several of the participants lessons(e.g., the need to use their own feelings andreactions to the client as information about theclient, learning about their own personal limita-tions as a therapist, and learning about their owncharacteristics) reflected an increased reliance onclient feedback and awareness of ones own role

in the therapy work.Finally, Rnnestad and Skovholt (2003) noted

that the novice professional often experiences anincreasing sense of the complexity of therapywork and recognizes the importance of the ther-apy relationship for client progress, while simul-taneously expressing a renewed interest in learn-ing techniques specific to the work being done.These changes were reflected in the present studyin that participants discussed learning about thechallenges and limitations of doing therapy (e.g.,there are limits to what therapy can accomplish,that therapy is complex and challenging), learn-ing to trust in the process of therapy, learning thatthe therapy relationship is important and curative,and learning that specific techniques are useful inaddition to (or in lieu of) ones theoretical ap-proach. Thus, these findings provide some con-firmation for Rnnestad and Skovholts model.

How Interns Realized Lessons

Participants realized that they learned what

they did from their clients through a variety ofsources (e.g., supervision, consultation with oth-ers, readings and class, self-reflection, directlyfrom the client, from the interview). Of thesesources of realization, supervision and consultingwith others were most commonly endorsed byparticipants, highlighting the importance of dis-cussing with and getting feedback from others tosolidify things learned from clients. Similarly,Bernard and Goodyear (2004) highlighted theimportance and value of supervision.

Self-reflection was also endorsed by most par-ticipants as responsible for their realization of thethings they learned from clients. Given that much

of therapy training requires that one engage inself-reflection (especially in regards to oneswork; Hayes, 2002), this finding is not surprising.The primary importance placed by participantson both supervision or consultation and self-reflection is also consistent with experientiallearning theory, which posits that immediate orconcrete experiences must be followed by ob-servations and reflections to be assimilated intolong-term memory and subsequently used(Abbey, Hunt & Weiser, 1985; Kolb, Boyatzis,& Mainemelis, 2001).

Application of Learning

The finding that participants generally indi-cated that they have already applied or will applywhat they learned to their current or subsequentclinical work is consistent with the literatureabout changes clients engender in their thera-pists practice of psychotherapy (Kahn & Fromm,2001; Myers, 2002). Participants also occasion-ally shared what they learned from specific cli-ents with colleagues or supervisees, suggestingthat interns gain clinical knowledge not onlyfrom their own clinical experiences, but fromeach others. A few participants also indicated

that they applied what they learned from theirclient to themselves, which is consistent with theliterature (Farber, 1983; Kahn & Fromm, 2001).For example, a few participants indicated that asa result of working with clients, they appreciatedtheir own life or fortune more or that they usedwhat they learned from their client to foster per-sonal growth.

Limitations

As is common to all qualitative research (Polk-inghorne, 2005), the self-report, retrospective na-ture of the data may have affected the findings.Participants may have been motivated to respondto questions in a socially desirable manner.

In addition, interviews took place 2 to 3months after the completion of a very intenseyear of internship. Thus, participants were report-ing what they perceived that they learned fromtheir clients. Without having assessed partici-pants knowledge before and after seeing the

selected client or gaining corroboration fromtheir supervisors, we cannot know how accu-rately participants reported their lessons.


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Furthermore, although providing participantswith a copy of the research protocol ahead oftime gave them the opportunity to reflect on thetopic and potentially provide richer data, thequestions and prompts listed in the protocol mayhave biased participants thinking about learningfrom clients. Similarly, although steps were takento minimize raters bias (e.g., writing about anddiscussing expectations and biases at the begin-ning of the coding process and checking inthroughout), judges expectations and biases mayhave influenced findings (e.g., led us to find whatwe expected to find).

Finally, the small sample size limits the gen-eralizability of the findings. The results of thisstudy may apply only to recent interns at univer-

sity counseling centers who are willing to talkabout their experiences. Interns who completedinternships in different settings may have learneddifferent things or may have learned more incertain categories (e.g., someone who interned ata psychiatric hospital may have discussed learn-ing more about psychopathology). Similarly, theresults may not be generalizable to therapists atother levels of development (e.g., beginning ther-apists or expert therapists).

Implications for Practice and Training

Despite the fact that therapists often say thatexperience with clients is the most importantinfluence on their professional development (e.g.,Orlinsky et al., 2001), learning from clients hasrarely been discussed in therapy training or re-search. This lack was reflected in the surprise thatsome participants expressed at never having be-fore been asked about what they learn from cli-ents (e.g., I feel like this shouldnt be the firsttime Im being asked what Ive learned from my

clients). The results of this study thus suggestthat supervisors should explicitly ask their super-visees what they learn from clients.

The potential utility of incorporating this ques-tion into supervision is supported by research onthe role of intention to learn on memory acquisi-tion. Although intention does not directly influ-ence memory acquisition, it influences the strat-egy individuals choose to use when encodingnew information, which in turn influences thequality of memory acquisition. Specifically,

when one is told that one should be learningsomething specific from a given stimulus, infor-mation is processed at a more elaborative level,

thus facilitating the quality of memory acquisi-tion (Reisberg, 1997).

Furthermore, because reflection on learningfrom clients helps therapists explicitly considerwhat they have gained personally and profession-ally from their therapeutic work, such reflectionmay prevent burnout. One might hypothesize thatreflection on learning from clients could prevent(or ameliorate) the emotional exhaustion compo-nent of burnout, which involves feeling drainedand emotionally overextended by ones contactswith other people (Maslach & Jackson, 1984).

Finally, practitioners might consider telling cli-ents for whom it would be clinically appropriatewhat they learned from them. This implicationstems directly from a comment made by one

participant: I think its sad that clients dontknow how much we learn from them . . . . I thinksome clients need to think that we know every-thing. But to the clients who dont have that need,I think it would mean a lot to them . . . . I wonderif theres some way to talk about it that is help-ful . . . . I think a lot of clients would like to knowthey had an impact on us.

Implications for Research

Future researchers might investigate what ther-apists of different experience levels (novices vs.those with more than 10 years of experience),from different settings (hospitals vs. schools),with different client populations (severe psycho-pathology, trauma, disabilities, etc.) or theoreticalorientations learn from clients. Are there somethings that therapists within a particular experi-ence level learn regardless of setting (e.g., allinterns learn about trusting in the process)? Sucha study could validate Rnnestad and Skovholts(2003) phase model of therapist development and

the hypothesis posed by expertise theory thatnovices would focus on individual helping skills,whereas experts focus more on higher order con-structs such as case conceptualization (e.g., Cum-mings, Slemon, & Hallberg, 1993; Sakai & Nass-erbakht, 1997).

Finally, it could be helpful to develop a mea-sure of learning from clients. The measure couldbe a paper-and-pencil means of identifying themost important lessons therapists take away fromtherapy sessions or relationships. Furthermore,

assessing other dimensions of the lesson (e.g.,newness, likelihood of applying the lesson toother clients, relationship of the lesson to various

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categories of learning, impact of lessons on self)would allow researchers to investigate both qual-itative and quantitative dimensions of learningfrom clients.

References

ABBEY, D. S., HUNT, D. E., & WEISER, J. C. (1985).Variations on a theme by Kolb: A new perspective forunderstanding counseling and supervision. The Coun-

seling Psychologist, 13, 477501.Association of Psychology and Postdoctoral Internship

Centers. (2004, March 15). 2004 APPIC match: Surveyof internship applicants. Retrieved December 18, 2008,from http://appic.org/match/5_2_2_4_6_match_about_statistics_surveys_2004.html

Association of Psychology and Postdoctoral InternshipCenters. (2005, May 8). 2005 APPIC match: Survey of

internship applicants. Retrieved December 18, 2008,from http://appic.org/match/5_2_2_4_7_match_about_statistics_surveys_2005.htm

BERNARD, J. M., & GOODYEAR, R. K. (2004). Fundamen-tals of clinical supervision (3rd ed.). Needham Heights,MA: Allyn & Bacon.

BUGENTAL, J. F. T. (1991). Lessons clients teach thera-pists. Journal of Humanistic Psychology, 31(3), 2832.

CRAWFORD, R. (1987). A students experience of practi-cum: Learning from clients. Texas Association forCounseling and Development Journal, 15(1), 7176.

CUMMINGS, A. L., SLEMON, A. G., & HALLBERG, E. T.(1993). Session evaluation and recall of importantevents as a function of counselor experience. Journal of

Counseling Psychology, 42, 156165.ELLIS, A. (1996). How I learned to help clients feel betterand get better. Psychotherapy, 33, 149151.

FARBER, B. A. (1983). The effects of psychotherapeuticpractice upon psychotherapists. Psychotherapy: Theory,Research and Practice, 20, 174182.

FREEMAN, M. S., & HAYES, G. (2002). Clients changingcounselors: An inspirational journey. Counseling andValues, 47, 1321.

GELSO, C. G., & HAYES, J. A. (1998). The psychotherapyrelationship: Theory, research, and practice. New York:Wiley.

GOLDFRIED, M. R. (2001). Conclusion: A perspective onhow therapists change. In M. R. Goldfried (Ed.), How

therapists change: Personal and professional reflections(pp. 315330). Washington, DC: American Psycholog-ical Association.

HAYES, J. A. (2002). Playing with fire: Countertransfer-ence and clinical epistemology. Journal of Contempo-rary Psychology, 32, 9399.

HILL, C. E., KNOX, S., THOMPSON, B. J., WILLIAMS, E. N.,HESS, S. A., & LADAny, N. (2005). Consensual qualita-tive research: An update. Journal of Counseling Psy-chology, 52, 196205.

HILL, C. E., & LENT, R. W. (2006). Training for novicetherapists: Helping skills plus. Psychotherapy, 41, 1116.

HILL, C. , SULLIVAN, C. , KNOX, S . , & SCHLOSSER, L.(2007). Becoming a psychotherapist: The experiences

of novice trainees in pre-practicum training. Psycho-therapy: Theory, Research, Practice, Training, 44, 434439.

HILL, C. E., THOMPSON, B. J., & WILLIAMS, E. N. (1997).A guide to conducting consensual qualitative research.The Counseling Psychologist, 25, 517572.

KAHN, S., & FROMM, E. (2001). Introduction. In S. Kahn& E. Fromm (Eds.), Changes in the therapist (pp. xiiixxvi), Mahwah, NJ: Erlbaum.

KASLOW, F. W. (1996). Memorable lessons from a mul-tifaceted career. Psychotherapy, 33, 153170.

KOLB, D. A., BOYATZIS, R. E., & MAINEMELIS, C. (2001).Experiential learning theory: Previous research andnew directions. In R. J. Sternberg & L. Zhang (Eds.),Perspectives on thinking, learning, and cognitive styles(pp. 227247). Mahwah, NJ: Erlbaum.

LAZARUS, A. A. (1996). Some reflections after 40 years oftrying to be an effective psychotherapist. Psychother-apy, 33, 142145.

MAHRER, A. R. (1996). Lessons from 40 years of learninghow to do psychotherapy. Psychotherapy, 33, 139141.

MASLACH, C., & JACKSON, S. E. (1984). Burnout in orga-

nizational settings. Applied Social Psychology Annual,5, 133153.MYERS, S. (2002). The other outcome: How therapists

integrate their experiences with clients. In P. Shohov(Ed.), Advances in psychology research (Vol. 17, pp.113130). Hauppauge, NY: NOVA Science Publishers.

NORCROSS, J. C. (1996). The lifetime lessons of six psy-chologists: An introduction. Psychotherapy, 33, 129130.

ORLINSKY, D. E. , BOTERMANS, J.-F., & RNNESTAD,M. H. (2001). Towards an empirically grounded modelof psychotherapy training: Five thousand therapistsrate influences on their development. Australian Psy-chologist, 36, 139148.

ORLINSKY, D. E., RNNESTAD, M. H., & WILLUTZKI, U.(2004). Fifty years of psychotherapy process-outcomeresearch: Continuity and change. In M. J. Lambert(Ed.), Bergin and Garfields handbook of psychother-apy and behavior change (pp. 307390). New York:Wiley.

POLKINGHORNE, D. E. (2005). Language and meaning:Data collection in qualitative research. Journal ofCounseling Psychology, 52, 137145.

REISBERG, D. (1997). Cognition: Exploring the science ofthe mind. New York: Norton.

RNNESTAD, M. H., & SKOVHOLT, T. M. (2003). Thejourney of the counselor and therapist: Research find-ings and perspectives on professional development.

Journal of Career Development, 30, 544.SAKAI, P. S. , & NASSERBAKHT, A. (1997). Counselor

development and cognitive science models of expertise:Possible convergences and divergences. EducationalPsychology Review, 9, 353359.

SKOVHOLT, T. M., & MCCARTHY, P. M. (1988). Criticalincidents in counselor development. Journal of Coun-

seling and Career Development, 67, 6972.SKOVHOLT, T. M., & RNNESTAD, M. H. (1992). Themes

in therapist and counselor development. Journal ofCounseling and Development, 70, 505515.

STRUPP, H. H. (1996). Some salient lessons from researchand practice. Psychotherapy, 33, 135138.

YALOM, I. D. (2002). The gift of therapy: An open letter toa new generation of therapists and their patients. NewYork: HarperCollins.


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