Abstract
For more than 30 years counselling and psychotherapy services in China have progressed rapidly. Currently, various Chinese universities, hospitals, official mental health centres, and private mental health service organizations provide psychotherapy training programs. However, little is known about Chinese psychotherapy trainees and their development. This pilot study investigated the characteristics and perceived professional development of 20 Chinese trainees during and after an advanced training program for psychosomatic medicine and psychotherapy, which is a collaboration project between Peking Union Medical College Hospital and the Department of Psychosomatic Medicine and Psychotherapy from the University Medical Center Freiburg in Germany. Trainees completed questionnaires from the SPRISTAD (Society for Psychotherapy Research Interest Section on Therapist Training and Development) study at the beginning (T1), at the end (T2), and one year after finishing the program (T3). Seventeen of the twenty participants were clinicians. Trainees reported a prominent rise of Currently Experienced Growth throughout the training period, which nearly dropped to the baseline level after the training, although Retrospective Career Development showed a trend of an overall increase. Both ‘experience in therapy with patients’ and ‘participation in courses or seminars’ were the most important positively perceived sources of influence on trainees’ development. This implies the importance of continuous psychotherapy training for the development of therapists during their career. Future research with a larger sample size should also assess trainees’ development from the viewpoint of trainers, supervisors, and patients.
Key words: Psychotherapy training, psychotherapy trainees’, perceived development, China, SPRISTAD project
Introduction
Psychotherapy and psychotherapy training in China
Theories and techniques of western psychotherapy were introduced to China in the early years of the 20th century. However, it was not until after the Cultural Revolution in the 1980s that clinical practice, education and research in the field of counselling and psychotherapy services only began to develop rapidly (Li, Duan, Ding, Yue, & Beitman, 1994; Qian et al., 2012). The number of professionals who were providing psychotherapeutic service (counselling and psychotherapy) in general and psychiatric hospitals was ~12,000 in 2007 (Chen, Qian, Zhang, & Zhang, 2010), reflecting an increase of 12% from 2001 (Qian, Chen, Zhang, & Zhang, 2010).
In 2002, the Chinese Ministry of Labour Forces certified that psychological counsellors, after a few months of theoretical training from various psychiatric clinics or private training institutions and after passing a written exam, were allowed to provide psychotherapeutic services. In 2013, the first Mental Health Law in China went into effect (Shao, Wang, & Xie, 2015). To protect the public from unqualified practitioners, the diagnosis and treatment of mental disorders, including psychotherapy, were restricted to psychiatrists or clinical psychologists working in medical facilities. However, what types of services were to be considered as psychotherapy or what training for qualification of psychotherapy needed to be provided, remained ill-defined (Clay, 2019).
Currently, various Chinese universities, hospitals, official mental health centres, and private mental health service organizations provide psychotherapy training programs. No specific regulatory body has been set up to monitor the qualification of training institutions and the competency of practitioners. Both the performance and quality of the trainings differ substantially (Lin, Jiang, & Duan, 2016; Qian et al., 2012).
Advanced training for psychosomatic medicine and psychotherapy in China
Since 2002, the Department of Psychosomatic Medicine and Psychotherapy from the University Medical Center Freiburg in Germany provides professional training to support Chinese postgraduate medical doctors and other medical and mental health professionals to improve their psychosomatic competence and to develop psychosomatic medicine in China. With 15 years of teaching-experience in different places in China (e.g., Beijing, Shanghai, Chengdu, Guangzhou) the programs have been developed and largely adapted to Chinese culture (Fritzsche et al., 2012).
In 2016, with the funding from the Deutscher Akademischer Austauschdienst (DAAD), the program ‘Advance Training for Psychosomatic Medicine and Psychotherapy’ was launched in cooperation with the department of psychological medicine from Union Medical College Hospital in Beijing (PUMCH). The content and methods of this training program are based on the curricula of continuing education for psychosomatic medicine and psychotherapy in Germany encompassing lectures, live patient interviews, role playing and fostering of selfawareness. The self-awareness training is not well-known in China and the methods (e.g., self-experience, personal therapy) are not clearly differentiated from each other. Therefore, we considered the self-awareness training during the curriculum as ‘self-experience’, whereas we considered other respective activities outside of the curriculum as ‘personal therapy’ in this research.
The aims are to qualify doctors, nurses, and psychologists in terms of: i) recognition and differential diagnosis of mental and psychosomatic problems and disorders; ii) application of basic psychotherapeutic skills derived from psychodynamic, cognitive-behavioral and systemic approaches in an integrative way; iii) cooperation with higher level mental health specialists in patient care and quality management.
Trainees were chosen by the Chinese cooperation partner (PUMCH). The implementation of the curriculum was guided by trainers from Germany. All instructional materials were translated into Chinese and compiled in both digital and hard-copy tool books.
The training lasts 20 months and includes 80 hours of theory lecture, 30 hours of case seminars, and 50 hours of self-experience in the group, amounting to a total of 160 hours. The 160 hours are divided into four blocks with one block every six months, which lasts five days. In between, the trainees are required to finish 40 hours of theory learning, 15 double hours of Balint groups, 25 hours of individual personal therapy or 50 hours of group therapy, and 120 treatment hours under supervision.
Psychotherapy training research
Researchers have begun to pay attention to psychotherapy trainees and psychotherapy training only recently. Studies focused on the process of professional development of psychotherapy trainees, the interrelatedness of professional development and psychotherapeutic work as well as factors of psychotherapy training that facilitate or impede trainees’ development and their clinical practice (Carlsson, 2012; De Bei, Rocco, & Salcuni, 2019; Rønnestad & Skovholt, 2003; Rønnestad & Ladany, 2006; Rønnestad, Orlinsky, Schröder, Skovholt, & Willutzki, 2019).
A cross-sectional and longitudinal qualitative study of the development of 100 counsellors and therapists (Rønnestad & Skovholt, 2003) indicated that professional development is a lifelong process that sometimes can be intensive, sometimes slow, and interpersonal experiences in the private and professional life are more significant influences of professional development than ‘impersonal’ experience. Messina et al. (2018a) found that psychotherapists with more years of training reported significantly higher levels of perceived development and experienced their therapeutic work more as a Healing Involvement and less stressful.
In a survey of more than 2500 Norwegian and German psychiatrists and psychologists, Lorentzen, Rønnestad, and Orlinsky (2011) emphasized the importance of direct patient contact, supervision, and personal therapy for the training of therapists, regardless of therapists’ professional background. In a more recent study trainers’ relational competencies was detected as the main important factor, among the obtained factors, in training activities, which suggested the quality of the trainer-trainee relationship as a relevant mediator in the development of clinical competence of trainees (Rocco, Gennaro, Filugelli, Squarcina, & Antonelli, 2019).
However, most studies are primarily cross-sectional and more longitudinal studies are needed to evaluate how trainees experience their professional development during and after the training. On the other hand, the bulk of researches on psychotherapy training was implemented in western societies, where standardized psychotherapy training is already well-established (Evers, Schröder-Pfeifer, Möller, & Taubner, 2019; Rønnestad et al., 2019). In light of the above-mentioned special circumstances regarding psychotherapy and psychotherapy training in China, it would be valuable to get an impression of the characteristics of Chinese psychotherapy trainees and their development during and after a psychotherapy training.
Research questions and hypotheses
Based on the above considerations, as part of the SPRISTAD (Society for Psychotherapy Research Interest Section on Therapist Training and Development) international collaborative study of psychotherapy training (Orlinsky et al., 2015), we conducted a longitudinal pilot study on the development of Chinese psychotherapy trainees in the framework of an advanced training for psychosomatic medicine and psychotherapy with the following research questions: i) What are the sociodemographic and professional characteristics of Chinese trainees enrolled in this training program? ii) How did trainees experience their own development during the training and one year after the training? iii) Which potential factors may have influenced trainees’ development as a therapist?
On the basis of the findings from previous studies, we tested the following hypotheses: i) Chinese trainees experience an increase in Healing Involvement (HI), Currently Experienced Growth as well as Retrospective Career Development and a decrease of Stressful Involvement (SI) as well as Currently Experienced Depletion throughout the training period. Changes in these variables (HI, SI, Currently Experienced Growth, Currently Experienced Depletion and Retrospective Career Development) are expected to last after the training; ii) Interpersonal experiences such as supervision, the therapist’s own personal therapy, and working with patients are the most important influences on trainees’ professional development.
Materials and methods
Study design
This is a longitudinal evaluation study of a 20-month long training program with one year follow-up. The above-mentioned training was conducted from Oct. 2016 to May 2018. Questionnaires were distributed to all the trainees at the beginning of the training (Oct. 2016, T1), at the end of the training (May 2018, T2), and one year after the training (May 2019, T3).
Participants
At the beginning of the training, there were 42 participants in total, nine of which took part in only the first course, whereas six finished two courses in the first year. Of the 27 participants who finished all the courses within two years, seven participants were excluded, as they exhibited more than 50% missing data. Missing data of the remaining 20 participants amounted to less than 5% (see Figure 1).
Ethical approval
This study was approved by the institutional review board of Peking Union Medical College Hospital, registered under the number ZS-1645 and the institutional review board of the University of Freiburg, registered under the number 155/18. All trainees were informed about the study in detail and written informed consent was signed by all participants.
Figure 1.
Flowchart for enrollment in the study.
Measures
SPRISTAD has developed a multisite longitudinal study including multiple instruments assessing progressive changes over time in trainees as therapists, with the goal of identifying factors that may facilitate or impede trainee development (Orlinsky et al., 2015). These instruments are based on the ‘Development of Psychotherapists Common Core Questionnaire’ (DPCCQ) previously used in cross-sectional surveys of psychotherapists in different countries (Orlinsky et al., 1999; Orlinsky & Rønnestad, 2005). In the present study, as a part of the SPRISTAD study, the core instruments from the SPRISTAD study were independently translated and back-translated from English into Mandarin Chinese, according to a state-ofthe- art translation procedure in accordance with the ‘ITCTest Adaptation Guidelines’ of the International Test Commission (Hambleton, Merenda, & Spielberger, 2005). Independent translations were first completed by three Chinese native speakers (psychiatrists) who are fluent in written and spoken English. Translations were discussed during project meetings to develop a preliminary version of the back translation. The back-translated version was compared with the original one by a German psychologist fluent in English. After correction of discrepancies, the final Chinese version was formed. In our study, the paperpencil version of the instruments used for data collection.
SPRISTAD has developed a multisite longitudinal study including multiple instruments assessing progressive changes over time in trainees as therapists, with the goal of identifying factors that may facilitate or impede trainee development (Orlinsky et al., 2015). These instruments are based on the ‘Development of Psychotherapists Common Core Questionnaire’ (DPCCQ) previously used in cross-sectional surveys of psychotherapists in different countries (Orlinsky et al., 1999; Orlinsky & Rønnestad, 2005). In the present study, as a part of the SPRISTAD study, the core instruments from the SPRISTAD study were independently translated and back-translated from English into Mandarin Chinese, according to a state-ofthe- art translation procedure in accordance with the ‘ITCTest Adaptation Guidelines’ of the International Test Commission (Hambleton, Merenda, & Spielberger, 2005). Independent translations were first completed by three Chinese native speakers (psychiatrists) who are fluent in written and spoken English. Translations were discussed during project meetings to develop a preliminary version of the back translation. The back-translated version was compared with the original one by a German psychologist fluent in English. After correction of discrepancies, the final Chinese version was formed. In our study, the paperpencil version of the instruments used for data collection.
Each core instrument is comprehensive and consists of several scales. To investigate the specific research questions of the present study, only the relevant parts of scales from the TBIF and the TCPR were used:
Trainee background information form (TBIF). The TBIF was applied to collect the following information: i) sociodemographic characteristics of participants (e.g., age, education, present family status); ii) professional background of trainees (e.g., work experience, experience in psychotherapy prior to the training); iii) the motivation to become a psychotherapist. In the context of the longitudinal study, the TBIF was fulfilled only at the beginning (T1), since it can be assumed that these characteristics remain relatively stable over the time of the study (Messina, Gullo, Gelo, Giordano, & Salcuni, 2019; Orlinsky et al., 2015). Data from TBIF was used to evaluate research Question i).
Trainee current practice report (TCPR). The TCPR measures the following aspects: therapists’ current therapeutic activity, supervision and personal therapy, as well as the experience of therapeutic work, which was assessed with scales of therapeutic skills, relational agency, relational manner, feelings in therapeutic sessions difficulties in practice, and coping strategies. Apart from the scale measuring trainees’ relational manner, which is a 7-point scale (ranging from 0=not at all to 6=very much), all scales are rated on 11-point scales (ranging from 0=not at all to 10=very much). These five scales form two superordinate constructs of Working Involvement, termed Healing Involvement (HI) and Stressful Involvement (SI)(Orlinsky & Rønnestad, 2005). The HI construct is defined with the factors of: i) Basic Relational Skills; ii) Technical Expertise; iii) Constructive Coping; iv) In-session Feelings of Flow; v) Relational Agency: Invested and Efficacious; and vi) Relational Manner: Affirming. The SI construct encompasses the factors of: i) Difficulties in Practice; ii) Avoidant Coping; and iii) In-Session Feelings: Anxious and Bored.
Moreover, therapists’ perspectives on their development are measured on two 11-point scales (0=not at all; 10=very much): i) Currently experienced change (growth or decline) in competence and skilfulness, termed Currently Experienced Growth and Currently Experienced Depletion; and ii) an aggregated experience of positive change over time named Retrospective Career Development. The scale of currently experienced change contains 10 items (e.g. ‘in your current work as a therapist/counselor, do you feel you are changing as a therapist?’) whereas the scale of Retrospective Career Development contains 6 items (e.g. ‘Since starting this training, how much have you changed overall as a therapist?’).
Additionally, with the leading question ‘How much (positive and/or negative) influence do you feel each of the following aspects is having on your current development as a therapist?’ the (positive and/or negative) impact of nine different potential factors on trainees’ overall development as a therapist were investigated. Each of these items was presented twice (once for positive influence and once for negative influence) and rated on a seven-point scale ranging from 0 (none) to 6 (very positive/very negative).
Participants were asked to complete the TCPR repeatedly across the above mentioned three different time points (T1-T3). TCPR data was used to investigate research questions 2 and 3.
Statistical analysis
Analyses were processed via SPSS 27.0. Means and standard deviations were used to describe the distributions of the continuous variables. Frequencies and percentages were used for nominal variables. Repeated measures ANOVA was used to compare mean differences in trainees’ professional characteristics across different time points. Cochran’s Q Test was used to compare differences in the rate of therapeutic practice, the amount of personal therapy, and supervision across different time points. The significance level for this study was set at P<0.05. With a sample size of 20 the present study is exploratory and the weak statistical power will be discussed.
Results
Sociodemographic and professional characteristics
Participants were on average 37.35 years old (SD=7.14). Most participants were women, and the majority were medical doctors (psychiatrists and physicians). Differences in sociodemographic characteristics between participants who completely finished the questionnaires and those who did not were statistically significant. Trainees’ motivation for becoming psychotherapists was evaluated with the question ‘How much do you think your decision to become a therapist was influenced by motivation to explore and resolve your personal issues or problems?’. It is notable that nearly half of the trainees indicated that personal issues played an important role in their decision to become a therapist. Detailed information regarding sociodemographic characteristics of the sample (N=20) are shown in Table 1.
There were 17 (85%) participants who had completed some form of psychotherapy training before the current training and had practiced psychotherapy beforehand, with an average clinical experience of 7.52 years (SD=4.53). 15 participants (75%) reported having prior supervision experience, while only four trainees (20%) indicated currently having regular supervision hours at the beginning of the training (T1).
At the beginning of the training, seven participants (35%) possessed experience in personal therapy apart from the current training program. One participant (5%) offered personal therapy for training and self-growth, whereas another participant took part in personal therapy for training, self-growth and solving problems. Two participants (10%) sought out personal therapy not for training, but for selfgrowth and solving problems. One participant (5%) took part in personal therapy for solving problems, and another one (5%) did it only for another training.
Frequencies of therapeutic practice, personal therapy, and supervision reported by participants at different measure points are presented and compared in Table 2. Only the percentage of trainees who were in supervision increased significantly at the end of the training (P<0.001). However, it decreased one year after the training (P<0.05).
Trainees’ working involvement and their experienced development
Table 3 shows a comparison of therapists’ Working Involvement (HI & SI) and experienced development at the different measure points. Results revealed that SI decreased significantly one year after the training (P<0.05). The score of Currently Experienced Growth, which increased by the end of the training (P<0.05), returned nearly to the baseline one year after training.
Table 1.
Sociodemographic characteristics (N=20).
| Variables | N | % |
|---|---|---|
| Gender | ||
| Female | 16 | 80 |
| Male | 4 | 20 |
| Marital status | ||
| Single, unattached | 3 | 15 |
| Single, in a relationship | 1 | 5 |
| Living with a partner | 2 | 10 |
| Married | 11 | 55 |
| Separated or divorced | 3 | 15 |
| Profession | ||
| Psychologist and psychotherapist | 2 | 10 |
| Marital therapist/Counselor | 1 | 5 |
| Psychiatrist | 8 | 40 |
| Psychiatrist and psychotherapist | 5 | 25 |
| Physician | 4 | 20 |
| First academic degree | ||
| Bachelor | 6 | 30 |
| Master | 4 | 20 |
| Doctor of Philosophy or Doctor of Medicine | 10 | 50 |
| Previous different profession | ||
| Yes | 10 | 50 |
| No | 10 | 50 |
| Motivation to become a therapist* | ||
| Not at all | 3 | 15 |
| Slightly | 5 | 25 |
| Somewhat | 3 | 15 |
| Moderately | 5 | 25 |
| Very | 4 | 20 |
*The question is ‘how much do you think your decision to become a therapist was influenced by motivation to explore and resolve your personal issues or problems?’
Table 2.
Prevalence of therapeutic practice, supervision and personal therapy (N=20).
| Variables | T1 | T2 | T3 | Overall* | T1-T2° | T1-T3° | T2-T3° | |||
|---|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | P | P | P | P | |
| Current therapeutic practice | 15 | 75 | 19 | 95 | 16 | 80 | 0.236 | 0.219 | n.s. | 0.375 |
| Current supervision | 4 | 15 | 16 | 80 | 9 | 45 | 0.000 | <0.001 | 0.125 | 0.017 |
| Current personal therapy | 6 | 30 | 9 | 45 | 4 | 20 | 0.178 | 0.451 | 0.727 | 0.125 |
*Cochran’s Q Test was used to compare the differences of rate of therapeutic practice, personal therapy and supervision over all 3 measurement points; °McNemar test was used to pairwise comparisons for the variables between two time points. n.s., not significant; P<0.05; P<0.001.
Perceived sources of influence on experienced development
The mean value of influences at each measure point is presented and ranked in Tables 4 and 5. It is striking that therapists cited considerably more positive (max M=4.85, SD=1.00) than negative influences (max M=1.65, SD=1.46) on their development. The two most strongly endorsed positive influences were ‘experiences in therapy with patients’ and ‘taking course and seminar’ at all measurement points.
Despite of the generally lower score of negative influences on current development in all sources, ‘the institutional conditions in which the participants work’ emerged as the most important negative influence reported by participants. Close behind as negative influences on current development at T1 was ‘experience in therapy with patients’ and at T2 and T3 was ‘experiences in personal life.’ The other sources were viewed as having little negative effect (M<1.00).
Table 3.
Working involvement and experienced development.
| Variables | T1 | T2 | T3 | Overall* | T1-T2° | T1-T3° | T2-T3° | |||
|---|---|---|---|---|---|---|---|---|---|---|
| M | SD | M | SD | M | SD | P | P | P | P | |
| Healing involvement | 7.05 | 1.03 | 7.23 | 0.93 | 7.21 | 1.16 | 0.512 | n.s. | n.s. | n.s. |
| Stressful involvement | 2.95 | 1.00 | 2.86 | 0.93 | 2.49 | 0.84 | 0.028 | n.s. | 0.067 | 0.018 |
| Currently experienced growth | 7.04 | 1.19 | 7.78 | 1.22 | 7.21 | 1.44 | 0.032 | 0.024 | n.s. | 0.009 |
| Currently experienced depletion | 1.83 | 1.43 | 2.00 | 2.25 | 1.04 | 1.68 | 0.108 | n.s. | 0.173 | 0.229 |
| Retrospective career development | 5.74 | 2.57 | 6.84 | 1.51 | 6.78 | 1.42 | 0.071 | 0.250 | 0.152 | n.s. |
For the Healing Involvement and Stressful Involvement, final valid sample N=20. HI and SI consist of different subscales. The higher the score, the stronger the (healing/stressful) involvement. For the Currently Experienced Growth, Currently Experienced Depletion, and Retrospective Career Development final valid sample N=19, rated 0=not at all to 10=very much. *Repeated measures ANOVA was used to compare each variable among three different time points; °Bonferroni post hoc test was used to pairwise comparisons for variables between two time points. M, mean; SD, standard deviation; n.s., not significant; P<0.05.
Table 4.
Perceived sources of positive influence (N=20).
| Source of influence | T1 | T2 | T3 | |||
|---|---|---|---|---|---|---|
| M | Rank | M | Rank | M | Rank | |
| Experience in therapy with patients | 4.85 | 1 | 4.85 | 1 | 4.65 | 1 |
| Taking courses or seminars | 4.65 | 2 | 4.85 | 2 | 4.50 | 2 |
| Getting supervision or consultation | 4.50 | 3 | 4.55 | 4 | 4.25 | 3 |
| Personal therapy, analysis | 4.35 | 4 | 4.60 | 3 | 3.92 | 5 |
| Institutional conditions of one’s practice | 4.20 | 5 | 3.65 | 9 | 3.25 | 8 |
| Experiences in personal life | 4.00 | 6 | 4.10 | 7 | 4.20 | 4 |
| Informal case discussion with colleagues | 3.95 | 7 | 4.15 | 6 | 3.75 | 7 |
| Reading relevant books | 3.90 | 8 | 4.30 | 5 | 3.85 | 6 |
| Observing other therapists | 3.85 | 9 | 3.95 | 8 | 3.15 | 9 |
Ranging from 0=none to 6=very positive.
Table 5.
Perceived sources of negative influence.
| Source of influence | T1* | T2° | T3* | |||
|---|---|---|---|---|---|---|
| M | Rank | M | Rank | M | Rank | |
| Institutional conditions of one’s practice | 1.16 | 1 | 1.65 | 1 | 1.37 | 1 |
| Experience in therapy with patients | 1.00 | 2 | 0.85 | 4 | 0.89 | 3 |
| Observing other therapists | 0.95 | 3 | 0.84 | 6 | 0.74 | 4 |
| Personal therapy, analysis | 0.95 | 4 | 0.75 | 7 | 0.37 | 9 |
| Taking courses or seminars | 0.89 | 5 | 0.70 | 8 | 0.74 | 5 |
| Getting supervision or consultation | 0.84 | 6 | 0.70 | 9 | 0.68 | 7 |
| Experiences in personal life | 0.79 | 7 | 1.25 | 2 | 1.05 | 2 |
| Informal case discussion with colleagues | 0.79 | 8 | 1.00 | 3 | 0.68 | 6 |
| Reading relevant books | 0.74 | 9 | 0.85 | 5 | 0.58 | 8 |
*N=19
°N=20. Ranging from 0=none to 6=very negative.
Discussion
So far no longitudinal study has focused on Chinese psychotherapy trainees’ development. We collected data from 20 Chinese psychotherapy trainees via well-established questionnaires in the context of the international SPRISTAD study to represent the first glimpse into the sociodemographic characteristic and perceived professional development of therapists in China.
Sociodemographic characteristics
In contrast to previous studies in western countries (Lorentzen et al., 2011; Messina et al., 2018b; Taubner, Kächele, Visbeck, Rapp, & Sandell, 2010), the majority of Chinese trainees in our studies were medical doctors instead of psychologists. This could be related to our training setting, which focused on medical doctors working in the hospital to qualify them in the recognition and treatment of mental disorders.
Motivation to become a therapist and persona therapy
In the study of Hill et al. (2013), all of the ten psychology students expressed both other-oriented (e.g. helping others who had similar painful experiences) and self-oriented motivations (e.g. helping one’s self) for wanting to become therapists, whereas Messina et al. (2018b) found that negative personal experiences were the most frequently reported motivations by trainees. Congruent with the latter finding, nearly half of the trainees in our study reported personal issues as an important driver behind the goal of becoming therapists. Previous studies reference the concept of the ‘wounded healer’ to explain this phenomenon and emphasize the importance and the desirability of personal therapy of trainees for safe and effective practice (Barnett, 2007; Messina et al., 2018b).
However, our study shows that personal therapy was not widely pursued among Chinese therapists. About half of the participants who had or have pursued personal therapy reported that they did so only for the sake of completing the training. This finding could explain why the frequency of personal therapy decreased from 45% during the training to 20% one year after the training. In western countries, this rate varies from 66% to 96% (M=83%), and personal therapy is considered desirable by many psychotherapists (Orlinsky, Norcross, Rønnestad, & Wiseman, 2005). Despite of the unclear effect of personal therapy on psychotherapy outcome, studies have supported the positive association between personal therapy and professional functioning (Orlinsky & Rønnestad, 2005; Orlinsky et al., 2005; Orlinsky, Schofield, Schroder, & Kazantzis, 2011).
These findings imply that self-awareness training is an indispensable component which should be implemented more rigorously in Chinese training programs. Only through the improvement of self-awareness and understanding of personal suffering as well as internal conflict themes, the psychotherapist could better understand and help others.
Perceived development of professional characteristics
Over the past 20 years, most of conducted systematic empirical studies on the professional development of counsellors and psychotherapists are primarily cross-section studies in western countries. Therapists’ developmental patterns were mostly inferred by comparing cohorts of therapists at different career levels (Orlinsky & Rønnestad, 2005; Rønnestad et al., 2019). In our study the therapeutic Working Involvement (HI & SI) and self-experienced development were compared across the training and one year after the training. These comparisons partially confirmed our first hypothesis.
Overall, we found high levels of HI (MT1=7.05, MT3=7.23) and low levels of SI (MT1=2.95, MT3=2.49) of the Chinese trainees, as did in other international studies (Nissen- Lie, Monsen, & Rønnestad, 2010; Orlinsky & Rønnestad, 2005). This pattern of results suggests that the Chinese trainees across the three years generally experienced themselves as invested, receptive, affirming, skillful and able to cope constructively with difficult situations in practice. Trainees also experienced a considerable amount of SI in the form of frequent difficulties, feelings of boredom or anxiety, and use of avoidant strategies in coping with difficulties.
It is worth noting that there was a trend of observable increases in HI across the training. However, this change was not statistically significant with the small sample size in the present study and could become significant after ensuring sufficient statistical power. The stagnation of SI during the training in our findings seem to be consistent with previous studies (Evers et al., 2019; Orlinsky & Rønnestad, 2005; Zeeck et al., 2012), demonstrating that the therapists’ SI is strongly associated with their private life, personality and negative inter-session feelings, and less related to the training status (Zeeck et al., 2012).
In addition, it is noteworthy that Currently Experienced Growth during the study was scored higher, when compared with Currently Experienced Depletion. The observed significant increase of Currently Experienced Growth during the training and the relative decrease one year after training seems to reflect that the process of training provided the trainees a feeling of becoming more skillful, a deepening understanding of therapy, experiencing positive change and an increasing enthusiasm in therapeutic work. We found evidence of this trend also from therapists consistently rating ‘taking courses and seminars’ as a positive influence on their development. Another explanation for this finding could be the increased rate of participation in supervision during the training. Supervision is strongly recommended as an important developmental learning arena and was rated as a very important influence on the development from the perspective of therapists from varied professional backgrounds, in different countries, and at all career levels (Rønnestad & Ladany, 2006).
Although Currently Experienced Growth rose and then tended to decline after the completion of training, Retrospective Career Development showed a trend to increase that remained stable at follow-up. This finding likely reflects trainees’ overall perceived positive experience, which is supported by the significant lessening in their experience of therapeutic work as a SI. At the same time Currently Experienced Depletion - which represents a sense of change as decline or impairment, loss in capacity to be empathic, and a feeling that therapeutic work was becoming just routine - was stable during the training but declined one year after the training. The difference was statistically not significant in current study; however it could become significant after expansion of sample size.
The study of Orlinsky and Rønnestad (2005) highlighted the cyclical and reciprocal relationship between therapeutic practice and development. The Currently Experienced Growth has been shown to be the strongest predictor of Healing Involvement (and vice versa), while Currently Experienced Depletion and Stressful Involvement are each other’s strongest predictor.
Perceived influences on professional development
As expected, ‘experiences in therapy with patients’ emerged as the strongest perceived positive influence on professional development in our study. Unexpectedly, the second strongest perceived positive influence, ‘taking courses and seminars’, ranked more highly than other interpersonal experiences such as ‘getting supervision or consultation’ or ‘personal therapy’. In international studies (Orlinsky, et al., 2001; Orlinsky & Rønnestad, 2005), the most important positive influences were practice-related interpersonal situations, chiefly the experience of working with patients, as well as supervision and the therapist’s own personal therapy. Academic learning was accorded a significant, but distinctly secondary role. Psychiatrists and psychologists in Germany und Norway (Lorentzen et al., 2011) also rated practice-related interpersonal experience as the most important positive influences. ‘Taking courses or seminars’ was not rated as highly as these interpersonal experiences. This could reflect the obvious different learning models of psychotherapy trainees in China and in western countries with regards to the question: how the training program could be culturally adapted and conducted in China.
What stands out is that ‘institutional conditions’ took the first place among the perceived negative influences on the professional development, as was found in previous studies (Lorentzen et al., 2011; Orlinsky, Botermans, & Rønnestad, 2001; Orlinsky & Rønnestad, 2005). 85% of trainees in this study were doctors working in hospitals. In China, practicing psychotherapy in hospitals is paid poorly or not paid at all by health insurances. Additionally, a therapy session is in most cases limited to a maximum of 30 minutes. Such limiting working circumstances could possibly exert an adverse impact on the development of Chinese psychotherapists, similar to what has been found elsewhere.
Taken together, the findings from this pilot study demonstrate the sensitivity of the TBIF in detecting trainees’ characteristics and the sensitivity of the TCPR in measuring longitudinal changes among Chinese psychotherapy trainees over the time. In the multinational SPRISTAD study of trainee development, the present study provides data from countries others than Europe or the USA.
Limitations
Even though most of the results point to a positive and intended development of the trainees during the training, the small sample size limits the statistical power and representativeness of our study. Further, development was evaluated from the subjective perception of the trainees, which likely is influenced by many factors, such as trainees’ own expectation, personality or social desirability. In addition, the scales assessing Chinese trainees’ personal self in close relationships, attachment style, and interpersonal manner as a therapist were not evaluated in present study. This will be discussed in the next paper.
Conclusions
Overall, the main findings of our study can be summarized as following: Throughout the training, Chinese trainees reported a substantial increase in Currently Experienced Growth over the 20-month-long training period, which dropped to the baseline after the training, although Retrospective Career Development showed a trend of an overall increase. SI stayed stable during the training and showed a significant decrease one year after completion of the training. This pattern hints at the importance of continuous psychotherapy training for the development of therapists during their career. A tailored and adaptive training, as well as a stronger connection between didactic and practical elements of training, could help trainees to overcome problems and challenges in the therapeutic process.
The two most positively perceived influences on the professional development of Chinese therapists were ‘experiences in therapy with patients’ and ‘taking course and seminar’. From the standpoint of trainees, this indicates the importance of the combination of practice-oriented as well as theory-oriented learning in the training program. The most critical, negative influence - ‘the institutional conditions’ - leads us to consider that the context of practice is also an important factor in therapist development.
To gain a more complete picture, a future study with a larger sample size of trainees in different training programs should be conducted. It should also assess trainees’ development from the viewpoint of trainers, supervisors and patients. In combination with self-perception and perception of others, a comprehensive understanding of the development of the trainees could be achieved.
Acknowledgements
We would like to thank the SPRISTAD group, in particular Professor David E. Orlinsky of the University of Chicago for his theoretical contribution and help with text editing. We are also most grateful to all the trainees who made the study possible by completing the questionnaire.
Funding Statement
Funding: this study was funded by grants from the program ‘Advance Training for Psychosomatic Medicine and Psychotherapy’ (Projects Nr.: 57218137), supported by Deutscher Akademischer Austauschdienst (DAAD).
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