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Research in Psychotherapy : Psychopathology, Process, and Outcome logoLink to Research in Psychotherapy : Psychopathology, Process, and Outcome
. 2024 Feb 15;27(1):722. doi: 10.4081/ripppo.2024.722

Therapist self-awareness and perception of actual performance: the effects of listening to one recorded session

Raquel Pereira 1,✉, António Pazo Pires 1,2, David Dias Neto 1,2
PMCID: PMC11064770  PMID: 38357990

Abstract

Research in psychotherapy has emphasized the relevance of the therapist’s role, particularly the impact of deliberate practice and self-awareness (SA). This study aims to explore how SA is presented in the accounts of psychotherapists and assess the impact of attending to actual performance. Twenty cognitive behavioral therapy psychotherapists in training were interviewed before and after listening to their session recordings. The interview was based on five domains of self-awareness: recognition of emotional experience, assessment of personal skills, recognition of prejudices and implicit biases, and awareness of personal values. Results show that SA is frequently attained in skills identification and emotional experience. Recognizing the influence of personal values and bias, and emotional regulation was less frequently identified. There were minor differences before and after listening to the recording. There is an increase of SA in identifying the therapist’s personal skills, and aspects such as our prejudices and biases are more internalized and difficult to change. This article suggests the importance of deliberate practice strategies to promote SA and increase the effectiveness of psychotherapy.

Key words: psychotherapists’s competence, self-awareness, self-reflectivity, self-monitoring

Introduction

Psychotherapy research has consistently shown that specific characteristics of psychotherapists are not significantly correlated with their effectiveness. For example, the theoretical orientation (Anderson et al., 2009; Brown et al., 2005; Wampold & Brown, 2005), being in training or supervision (Budge et al., 2013; Nyman et al., 2010), or the number of years of experience (Goldberg et al., 2016), are not significant predictors for the increase of the effectiveness of clinical practice. Therapeutic outcomes are explained mainly by the difficulties therapists experience in their clinical practice and how they deal with them (Nissen-Lie et al., 2015).

Psychotherapists’ awareness of the difficulties in their work and the ability to question themselves can be beneficial. Nissen- Lie et al. (2010) studied professional self-doubt. They showed that it is related to the concern with their current skills and, more specifically, to healthy self-criticism, openness, sensitivity, reflexivity, and taking responsibility for the relationship struggles in therapy.

Awareness of the complexity of psychotherapeutic work promotes professional development. Furthermore, the ability to question self-capacities is constructive and significantly impacts psychotherapy’s clinical effectiveness. In the study by Macdonald and Mellor-Clark (2014), therapists work more effectively when they are more aware of the challenges and uncertainties of their work and less “blind” regarding their needs. A healthy critical attitude about the therapists’ performance is important for successful professional development.

Self-awareness

Since therapists are themselves essential tools in effective psychotherapy, self-awareness (SA) becomes a critical focus (Pieterse et al., 2013). SA is commonly considered a synonym for self-knowledge, but it must be more specifically described as a transition of states of consciousness. Williams (2008) proposes the following definition of SA: “The ‘therapists’ momentary recognition of and attention to their immediate thoughts, emotions, physiological responses, and behaviors during the therapy session” (p. 141). Furthermore, the same author argues that, depending on different moments, therapists can be more or less in tune with their internal states. SA comprises aspects of consciousness about thoughts, feelings, beliefs, behaviors, and attitudes. It is shaped by the experiences and life history of the therapist (Pieterse et al., 2013).

The promotion of the development of SA enables psychotherapists to be more effective. Williams (2003), in the results of his investigation, finds an inverse relationship between the momentary absorption of the therapist and the perception of its usefulness for clients. This shows that the concern with aspects of consciousness may not be beneficial because psychotherapists considered themselves more anxious before the session, and clients classified them as less helpful. Fauth and Williams (2005) show that SA is generally useful and does not negatively influence the therapeutic process, except when awareness distracts the therapist. Furthermore, the study shows that self-awareness variables during the session predicted more than 50% of the variation in their interpersonal involvement. Currently, SA is described as self-insight, related to personal processes, conflicts, family dynamics and prejudices. SA is beneficial for effective psychotherapy, unlike self-focus, which can interfere with concentration during the session (Pieterse et al., 2013).

Considering the numerous definitions for the concept, this study will look at the domains of SA according to a model proposed by Knapp et al. (2017). Some models of SA have extensive definitions or relate SA to the personality characteristics of the psychotherapists or their life history. In this model, the authors define SA as a set of concrete domains that can be developed and refer to the practice and context of psychotherapy. The model (Knapp et al., 2017) considers five domains of SA that can contribute to increasing the effectiveness of psychotherapists (Table 1).

Several empirical studies support particular dimensions of the model. Concerning the first domain, psychotherapists who are more aware of their thoughts and emotions are considered more effective in session (Wolf et al., 2017). The observation supports the second domain that the most effective psychotherapists have quite varied domains in which they are good and recognize their strengths and weaknesses (Krauns et al., 2011). In a study by Storey (2016), none of the psychotherapists considered themselves below average in their abilities, and 30% still thought themselves far above average. Walfish et al. (2012) studied 129 mental health professionals and found that 25% considered being in the 90th percentile regarding their skills. Psychotherapists seem to overestimate their abilities, which influences how predictions about clients are made and even interferes with assessing their own ethical, personal and professional issues (Knapp et al., 2017).

Concerning the third domain, Banajj and Greenwald (2013) showed that even psychotherapists who consider themselves more open and committed to egalitarian values have implicit biases influencing their behavior. This bias occurs even without immediate awareness. The study of LaChapelle et al. (2014) shows the importance of considering the positive prejudices of therapists as well, showing that they can be influenced by inadequate assessments of the therapeutic processes with their clients, for example, when they see them as healthier or more attractive.

Table 1.

Definition of each dimension of the self-awareness model (Knapp et al., 2017).

Domain Definition
Recognition of emotional reactions to events and patients This refers to the process of paying attention to the emotions and internal signals of the body. This recognition allows discerning how this can influence them before any response or judgment.
Appropriate judgment of capabilities This domain relates to assessing psychotherapists’ skills and adequate recognition of their strengths and weaknesses. Psychotherapists vary in their effectiveness in different domains and tend to overestimate bias, influencing their perception and decision-making.
Recognition of the existence of implicit prejudices This refers not only to the negative but also to positive prejudices. The most conscientious psychotherapists recognize that they may have implicit prejudices and must identify and monitor them, knowing their influence on their work and seek to compensate or replace them.
Awareness that you may succumb to useless cognitive and heuristic biases This domain involves awareness of inevitable cognitive and heuristic shortcuts. An example is confirmation bias, which leads to the interpretation of information according to pre-existing beliefs or hypotheses. Although this type of heuristic is difficult to access, more conscious psychotherapists actively oppose this bias.
Full awareness of personal values Although it is impossible to avoid the influence of personal values, it is crucial to be aware of their influence. More conscious psychotherapists look for strategies that remind them of their values to recognize better when they influence their professional practice.
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The fourth domain is supported by the notion that psychotherapists can sometimes reduce their effectiveness even more if they are unaware of them (Knapp et al., 2017). The cognitive biases most commonly found in psychotherapists’ work are confirmation bias (i.e., interpretation of information according to pre-existing beliefs) and the fundamental attribution error (which includes overestimating the characteristics of therapists) (Rogerson et al., 2011). In addition to being influenced by these biases, psychotherapists are increasingly able to see their presence in others than in themselves and believe that they are less biased than others. This bias can influence judgments, behaviors, and decision-making, making individuals less receptive. Introspection alone may not be sufficient to recognize these biases because they operate implicitly.

The final and fifth domain refers to psychotherapists considering their professional code of conduct when dealing with an ethical conflict. However, in response to what they would do in practice, they tend to be guided by personal values (Smith et al., 1991). It is also relevant to consider situations with conflicting values (Crowley & Gottlieb, 2012).

There is still a considerable lack of studies on SA, namely in its development and specifically its role in psychotherapy training. This may be due to the tendency for SA to be seen as a result of experience (Pieterse et al., 2013). Literature indicates that psychotherapists’ professional growth in training is strongly associated with developing awareness of their reactions to clients (Hill et al., 2007), specifically for therapists in training.

Regarding the most beneficial aspects of SA training, the literature indicates individual therapy, personal development groups (Pieterse et al., 2013), and insight (Howard et al., 2006). The initial phase of psychotherapy training is considered especially relevant in terms of the experience of emotional reactions to different clients and therapeutic processes (Collins & Pieterse, 2007; Hill et al., 2007). The initial training phase imposes challenges on the trainee’s values and worldviews. At this time, psychotherapists in training should seek to be more flexible and understand how their different personal and identity aspects professionally influence the therapeutic process with their clients. These are relevant factors because they influence the therapist’s own reactions, the client’s global perception, and even conceptualizing the case (Aponte & Winter, 2000; McGoldrick, 1998; Williams, 2008).

Despite the positive recognition of self-reflection and SA in psychotherapists, there still seems to be a significant resistance to adhering to strategies that promote their development. As an explanation, Pieterse et al. (2013) highlight the possible fine line in the perception between individual therapy and the use of these techniques to deepen SA. Also, in supervisory groups, this exposure may be associated with anxiety and discomfort by exploring challenging personal aspects that may arise as a reflection.

Confronting actual performance

In a study by McMahon and Ledden (2019), with 120 Irish psychotherapists, about half stated that they never recorded a therapy session during their training period. The participants considered this practice as both positive in terms of learning and negative for its character, possibly inhibiting or capable of distorting reality.

Since the 1960s, session recordings have been a practice with increasing use, yet it does not have a central role in the clinic (Abbass, 2004). There are several advantages of this practice in training or supervisory contexts, namely: the possibility of change in the psychotherapists’ self-perception, the promotion of self-analysis, the re-experience of the session, and a more accurate appreciation of the performance by the supervisor (e.g., Huhra et al., 2008).

Session recording is used scarcely due to the therapists’ belief about resistance to client consent and the therapist’s anxiety (Shepherd, 2009). The recording also changes the session environment, making the therapists aware that their behavior will be observed and possibly evaluated. According to Haggerty and Hilsenroth (2011), this may lead psychotherapists to change their behavior.

The present study aims to understand the process of SA after attending the actual performance. This is achieved by inviting psychotherapists in training to listen to a psychotherapy session. The goals of the present study are to: i) understand in what way SA is reflected in the accounts of the psychotherapists in the five dimensions of the model (Knapp et al., 2017); ii) understand how the domains of SA are related to the way psychotherapists express their SA; iii) compare the SA before and after listening to a recorded session; iv) study the association of SA with professional variables (e.g., years of experience, training).

Based on the literature review, it would be expected that, after listening to the recorded session, psychotherapists in training would demonstrate higher levels of SA in domains such as emotional experience (EE), for example, as it can be considered more noticeable when listening to a recorded session. Domains such as identification of values (IV) would be more difficult to recognize a gain in consciousness, since these are more deeprooted aspects. We could also expect more years of experience to reveal greater SA, for example. However, several studies mentioned in the literature review point to the fact that this variable is not a predictor of therapeutic efficacy, which leads us to think that it may also not be correlated with SA.

Methods

Participants

Forty-five psychotherapists in training at the Portuguese Association of Behavioral Cognitive Therapies (APTCCI) were invited to participate, of whom 20 agreed. Psychotherapy training in Portugal involves having a Bachelor's and Master's (MA) degree in a health profession and five years of specialized training in a psychotherapy association. The training includes a theory and practical course on psychotherapy, personal development or psychotherapy, and supervision. Before specific training in psychotherapy, many professionals have previous clinical experience as psychologists after their initial academic training. The study of this stage of professional development – psychotherapy training – was due to an expected greater impact of listening to a recording since psychotherapists are explicitly developing their competencies.

Seventeen (85%) psychotherapists in training were females between 28 and 59 years old. 80% of the participants completed the theoretical course in psychotherapy, and all had over two years of completed training. 75% of the participants completed their personal development module and had an average of 118 hours of supervision. All the participants had an MA and between 1 and 20 years of clinical experience (mean=9 years; standard deviation=5.1).

Interview

The interview developed for the present study used the model of Knapp et al. (2017). It included questions regarding each of the dimensions of self-awareness in the model. The interview was adapted to the two moments of study: before and after listening to a recorded session (Supplementary Material). The first interview contains questions such as: “What skills do you, as a psychotherapist, consider most relevant to the therapeutic process with this particular client?”. The second interview questioned the psychotherapists in training about the same domains. It included questions such as: “What are your skills as a psychotherapist that have been most relevant in this particular session?”. Open-ended follow-up questions (e.g., can you tell me more about…) were included when participants did not understand the question or provided a minimal answer.

The interviews before and after the recording had a similar script so that the differences in the narratives of the psychotherapists in training reflected SA and not the interview process. We conducted one interview to pilot the interview. This interview was conducted with a therapist who was not included in the study and referred to moment one. From the pilot, we reformulated the questions that were deemed less clear. In the final interview construction after the pilot study, we removed the question related to the fourth domain (recognition of cognitive and heuristic biases) because it is not easy to understand in terms of self-reflection.

Procedure

The scientific board of ISPA – Instituto Universitário ethically approved the study (process number 23219). The psychotherapists in training at APTCCI were contacted in their adult supervision groups. All participants gave their informed consent to participate in the study. Special ethical considerations were adopted and shared with the therapists. Confidentiality and anonymity of the data were assured. Researchers had no access to the recording or any data of the client. Informed consent helped the clients understand the terms and conditions of their therapist’s participation, the use given to the recordings and its eventual elimination at the end of the study.

Afterwards, an interview was conducted with the therapist via Skype or in person. At the start of the first interview, the psychotherapists in training filled out a form with some information related to professional variables (age, semesters of training, hours of supervision and years of experience).

Each psychotherapist in training was asked to audio record the next psychotherapy session with the same client discussed in the first interview. After the psychotherapist in training listened to the recorded session, the last phase consisted of conducting a second interview. Depending on the frequency of the client’s sessions, one to three weeks elapsed between the first and the second interview. Before the first interview, the therapist already knew that both interviews would have similar questions, but the second one related to the session recorded.

Analysis

Each of the 40 interviews was transcribed. The data analysis resulting from the interviews was done in two phases. The first phase involved a qualitative analysis to identify themes that emerged in the psychotherapists’ interviews. The first author, who has specific training in thematic analysis, conducted the analysis. The second author served as an auditor for the analysis, critically questioning the procedures. Considering the study’s aims, despite the emergent character of the analysis, themes to describe the SA model were explicitly sought. The second phase consisted of a quantitative content analysis of the full interviews. This analysis included all the categories identified from the first phase. The quantitative score reflects the frequency of each category in each interview. This second analysis allows to study each domain's frequency and compare the first and second interviews.

First phase: qualitative analysis

The interview data were analyzed using the Thematic Analysis (Braun & Clark, 2006). Thematic analysis is a method of analyzing textual data using predominantly inductive procedures. Following the suggested steps, broader themes were found that reflect meaning patterns in the psychotherapist’s interview.

Second phase: quantitative analysis

The coding scheme (Supplementary Material) was created to transform the themes found in the first phase into a coding system for quantitative data analysis. Each utterance of each interview was coded using a coding system. All statistical analyses used SPSS 1.0.0.1406.

Results

Analyzing self-awareness: themes and domains

The study’s first goal was to understand how the SA is reflected in the psychotherapists’ according to the model’s five dimensions. To this end, a thematic analysis was made. The themes investigated in the qualitative analysis can be divided into three groups (Table 2).

The first includes codes for each SA domain (i.e., recognition of EE, emotional regulation (ER), skills identification (SI), recognition of prejudice and bias (PB), influence of personal values). The second refers to how the SA domains are expressed. We designated this group of codes as processes. They refer to: i) valence (i.e., if SA is expressed positively or negatively); ii) abstraction (i.e., if SA is expressed in a concrete or abstract way); iii) focus (i.e., if SA is done focused on the client, therapist or relationship). This allows to compare, for example, if the identification of skills is positive vs. negative or general vs. specific.

The third includes the categories referring to the subjective indicator of SA themes that were translated into the codes SAI (self-awareness indicator) and IASA (indicator of an absence of self-awareness), which, although general, do not belong to the presented coding system model. All three groups are considered to be independent of each other. This means that the same excerpt could be coded with the categories of each of the three groups.

The self-awareness present in the therapist’s accounts

The second goal was to understand how, in the psychotherapists’ accounts, the SA domains of the model are related to the processes of SA. This analysis was based only on the first interview to understand how the psychotherapists expressed themselves regarding their SA.

Concerning valence (i.e., positive vs. negative), it is possible to highlight the significant differences found for EE, SI, and PB. The psychotherapists recognized significantly more positive aspects of their EE, considered their RE significantly more times as positive, and recognized more positive skills in themselves. On the other hand, psychotherapists recognized more negative biases than positive ones.

Concerning abstraction, the analysis suggests that psychotherapists refer mainly to specific skills more than general skills. Regarding focus, psychotherapists’ descriptions are mainly related to the impacts that each of the domains of SA may have on themselves more than the impacts on the client or relationship.

The total values suggest that psychotherapists’ descriptions of SA domains are mostly based on positive aspects of their practice, with a significantly major recognition of specific aspects than general and more focused on the therapist rather than the client or the relationship (Table 3).

Before and after the recorded session

The third goal was to compare the therapists’ accounts before and after listening to the recorded session. The results showed no significant differences in the domains’ expression and SA processes before and after the psychotherapists listened to the recorded session. The results show a difference in the indicator of the absence of self-awareness value between the first and second interview, i.e., the subjective expression of the absence of SA significantly decreased in the second interview.

The results also express that the recognition of negative skills about their practice increased in the second interview. Although in general the difference in SI is not significant, the specific results of the identification of negative valence skills are close to statistical significance. A Wilcoxon test shows this improvement, Z=-1,901, P=.057. This suggests that with the increase in the number of the sample, this difference could have greater expression in this particular aspect (Table 4).

Self-awareness and professional variables

An additional analysis was made to relate SA to professional variables. SA dimensions showed no correlation with age and years of experience. ER showed a negative correlation with training and hours of supervision. This suggests an effect not of experience but of training in that dimension of SA. Awareness of ER becomes less relevant throughout training (Table 5).

Table 2.

Themes and sub-themes of thematic analysis.

Broad themes Categories Sub-categories
Domains of SA Emotional experience
Emotional regulation
Skills identification
Prejudice and bias
Influence of personal values
Discrimination of values
Processes of SA Valence Positive Negative
Abstraction General Specific
Focus Focused on the therapist Focused on the client Focused on the relationship
Subjective indicators of SA Self-awareness indicator
Indicator of the absence of self-awareness
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SA, self-awareness.

Table 3.

Descriptive statistics for each process of self-awareness in each domain of self-awareness referring to the first interview.

Valence Abstraction Focus
Positive Negative General Specific Therapist Client Relationship
M SD M SD M SD M SD M SD M SD M SD
EE 1.2a 1.09 .6a .95 .7 .80 1.3 .87 1.8h 1.54 1.0h 1.32 .6h .76
RE .7b 1.30 .1b .22 .1 .22 .1 .22 .2 .72 .1 .31 - -
SI 3.8c 1.96 .7c 1.03 .6f 1.27 1.8f 1.63 1.6i 1.73 1.2i 1.11 .3i .47
PB .1d .31 .5d .69 .3 .73 .6 .99 .7j .98 .1j .31 .2j .37
IV .8 .91 .4 .81 .6 .76 .8 .83 1.1k 1.25 .4k .49 .4k .59
Total 5.8e 2.82 2.1e 1.97 2.2g 2.08 4.6g 2.48 5.4l 3.73 2.7l 2.39 1.4l 1.31
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M, mean; SD, standard deviation; EE, emotional experience; ER, emotional regulation; SI, skills identification; PB, prejudices and biases; IV, identification of values. aZ=-1.897, p=.058; bZ=-2.214, p=.027; cZ=-3.740, p<.001; dZ=-2.309, p=.021; eZ=-3.165, p=.002; fZ=-2.190, p=.029; gZ=-2.465, p=.014; hχ2(2)=15.207, p<.001; iχ2(2)=6.226, p=.044; jχ2(2)=6.226, p=.044; kχ2(2)=9.686, p=.008; lχ2(2)=18.600, p<.001.

Table 4.

Comparison of means for each of the domains of self-awareness between the first and second interviews.

Domains of SA First interview Second interview Z* Sig.
M SD M SD
EE 7.15 4.13 6.70 4.401 -1.07° 0.284
ER 1.20 2.31 .60 1.50 -.93° 0.351
SI 10.05 5.09 10.65 6.64 -.428# 0.669
PB 3.80 2.38 3.40 3.72 -1.244° .214
IV 5.25 2.31 5.25 2.22 -.066° .948
SAI 2.95 2.69 3.85 3.897 -1.490# .136
IASA 2.35 2.39 .95 1.099 -2.582° .010
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SA, self-awareness; M, mean; SD, standard deviation; EE, emotional experience; ER, emotional regulation; SI, skills identification; PB, prejudices and biases; IV, identification of values; SAI, self-awareness indicator; IASA, indicator of the absence of self-awareness. *Wilcoxon Signed Ranks Test; °Based on positive ranks; #Based on negative ranks.

Table 5.

Correlations between continuous professional variables and domains of self-awareness for the first interview.

Domains of SA N. Age Semesters of training Hours of supervision Years of experience
r p r p r p r p
EE 20 .023 .923 -.207 .381 .125 .600 .076 .750
ER 20 -.218 .355 -.477 .034* -.525 .018* -.101 .672
SI 20 .179 .450 -.185 .436 .296 .205 -.178 .452
PB 20 .203 .392 -.308 .186 -.133 .575 .081 .734
IV 20 -.106 .656 -.246 .295 .232 .325 .306 .189
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EE, emotional experience; ER, emotional regulation; SI, skills identification; PB, prejudices and biases; IV, identification of values. *p<.05.

Discussion

Reflexivity and increased SA are particularly important dimensions of the psychotherapist practice (e.g., Knapp et al., 2017; Pieterse et al., 2013). This research sought to study how therapists structure their self-awareness and assess a concrete strategy to increase SA. This study analyzed the effect of listening to a recording of a psychotherapy session. This was considered as an opportunity for therapists to confront with their actual performance and increase SA (Haggerty & Hilsenroth, 2011).

Regarding the study’s goals, results show that the domains of SA vary according to the valence (positive or negative), abstraction (general or specific) and focus (self, client or relationship) of the therapist accounts. SA is more frequently achieved for SI and EE. Otherwise, recognizing the influence of personal values and bias, and emotional regulation occurs less frequently. Certain domains, such as identifying one's own EE, are often looked at by therapists and linked to effectiveness (Wolf et al., 2017), and other domains related to bias and prejudice operate more implicitly without immediate awareness (Banajj & Greenwald, 2013), are operated implicitly. Therapists are better able to identify them in others than in themselves. These differences suggest there are SA domains that are easier to develop.

Furthermore, SA tends to be significantly done in positive terms (except for PB), in specific (rather than general) terms and focusing on the therapist (followed by the focus on the client and relationship). If, on one hand, specific and focus on the therapists are good indicators of SA. On the other hand, in this sample, SA is structured around more positive aspects of the therapists’ practice. The literature indicates that therapists overestimate their abilities (Storey, 2016; Walfish et al., 2012). This leads us to question psychotherapists’ level of awareness regarding their practice’s negative aspects.

Concerning the difference between the two interviews, there was only one significant change after listening to a session recording: The expression of lack of awareness was lower in the second interview. There was also an increased recognition of the negative skills in their practice that almost reached statistical significance. The analysis of the difference between the two interviews allowed us to understand that this type of deliberate practice strategies can contribute, for example, to reducing the therapists’ lack of knowledge about certain aspects of their SA. However, therapists show resistance and levels of anxiety related to recording sessions (Shepherd, 2009). In addition, other strategies are mentioned for developing SA, such as personal therapy, personal development groups, or supervision (Pieterse et al., 2013).

On the other hand, the domains of SA seem to be expressed by therapists consistently in both interviews. No significant relationship was found between SA and years of experience or hours of supervision, in line with the literature, which states that effectiveness in psychotherapy is not related to this type of variable (Budge et al., 2013; Goldberg et al., 2016; Nyman et al., 2010).

Despite the exploratory nature of this study, it provides an overview of how psychotherapists structure their self-awareness. Considering that only one session was recorded and listened to, there was still a change between the two interviews. This difference hints at the possibility that SA can change with deliberate practices such as listening to recordings. Future research could analyze the effect of repeating this practice. Furthermore, the sample for this study was collected from psychotherapists training in the cognitive behavior therapy model, and it would be interesting to study the impact of this deliberate practice strategy on psychotherapists from other theoretical models. It would be interesting to evaluate other theoretical models that are more oriented towards insight, or towards the therapeutic relationship, for example, whether differences could manifest themselves in other domains of SA. Cultural impacts on the way SA is de-scribed and potentially transformed could also be studied.

As found in other studies, recruitment was affected by resistance by some therapists to confront actual performance (e.g., McMahon & Ledden, 2019). The absence of significant differences between the therapists’ first and second narratives may, in the first place, be due to the number of participants. Alternatively, since the second interview refers only to the recorded psychotherapy session, the psychotherapist may have been asked about SA domains that did not appear or were not evident in that session. Even so, when this happened, the participants spontaneously shared it and reflected on their SA increase in the second interview about a certain domain. Still, regarding the limitations that may arise from the interview questions, it is important to note that these were thought to be sufficiently comprehensive to avoid bias in the response. Simultaneously, due to the scope and lack of direction of the questions in the interview, the participants answered in a contradictory way about some SA domains (for example, stating in the same answer that they do not recognize any prejudice towards the client but end up recognizing it and mentioning it). This fact can be relevant, particularly regarding quantity and expression in the interview rates. However, it is simultaneously an indicator that suggests a lack of self-reflection by the therapists.

The absence of significant differences before and after listening to the recorded session may be related to the characteristics of the therapist or the patient chosen as a reference for this study. Given that self-awareness is related to the therapist's personal dimensions (e.g., Pieterse et al., 2013), it would be relevant to investigate how the characteristics of the patients and the quality of the therapeutic relationship influence the therapists' ability to recognize these dimensions of SA.

Conclusions

The results highlight the importance of the therapists questioning themselves, reflecting on their performance, and encouraging concrete strategies for the continuum of professional development. Deliberate practice can increase SA in psychotherapists. Future studies could reflect on other strategies that can influence the SA in the practice of psychotherapists, in general, and in the particularity of each SA domain. The sample was collected in a specific context and theoretical orientation. It is unclear if older therapists or theoretical models and different structures SA in the same way.

Funding Statement

Funding: none.

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