Exploring the Impact of Genuineness in Psychotherapy: A Self-Practice/Self-Reflection (SP/SR) Report

Candice Fischer ^1,*, Carolina Eugenia Cáceres Videla ²

1. Pontificia Universidad Católica de Chile, Santiago, Chile

2. Coventry University, Coventry, UK

* Correspondence: Candice Fischer 

Academic Editor: Robert Marx

Special Issue: The Personal and the Professional: Mindfulness, Spiritual Life and Health Care

Received: March 21, 2024 | Accepted: August 01, 2024 | Published: August 12, 2024

OBM Integrative and Complementary Medicine 2024, Volume 9, Issue 3, doi:10.21926/obm.icm.2403046

Recommended citation: Fischer C, Cáceres Videla CE. Exploring the Impact of Genuineness in Psychotherapy: A Self-Practice/Self-Reflection (SP/SR) Report. OBM Integrative and Complementary Medicine 2024; 9(3): 046; doi:10.21926/obm.icm.2403046.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Background

Personal practice (PP) of therapeutic techniques for personal and professional growth during psychotherapy training has been a standard expectation of counseling training [1,2]. However, cognitive behavioral therapies’ (CBT) training focuses on theoretical conceptualizations, the implementation of outcome measurements, and evidence-based interventions without a mandatory requirement of PP [3]. Notwithstanding, in the last two decades, research has highlighted the value of PP in the form of self-practice/self-reflection (SP/SR) [4]. The main content and sub-content of “Experiencing CBT form the Inside Out: A SP/SR Workbook for Therapists” is summarized in Table 1 [5]. SP/SR in one-year CBT training requires an introductory session led by qualified therapists to answer questions, instruct trainees to create a safety plan, and set group rules for 12 facilitated small group sessions spread across the year [5]. By the end of the training, submitting a reflective report is a qualification requisite.

Table 1 Main content and sub-content of “Experiencing CBT from the Inside Out: A SP/SR Workbook for Therapists” [5].

A growing body of evidence has highlighted the limitations of relying solely on positivist research when summarizing SP/SR results since it might hinder pluralistic perspectives arising from unique backgrounds and life experiences [6]. Autoethnography, an approach to qualitative research aiming to systematically review personal experiences in the context of cultural identity in retrospect, has been proposed as a solution [7,8]. Critical features to understanding autoethnography are: The researcher also takes part in the process as a participant, and there is narrative visibility of the researcher’s self. Therefore, the present personal case study of SP/SR draws upon autoethnography to explore my experience while completing the one-year training.

To acknowledge feedback from previous supervisors, I decided to concentrate on the impact of genuineness when delivering psychotherapy. Beyond my motives, therapists’ authenticity has been historically put forward in CBT due to its advantages on building a solid therapeutic alliance (TA) [9]. Its relevance has been addressed in the Cognitive Therapy Scale (CTS-R) and The Mindfulness-Based Interventions-Teaching Assessment Criteria MBI: TAC [10,11]. The CTS-R and the MBI: TAC consider authenticity an integral relational skill to be developed and maintained by psychotherapists at all stages of their training.

1.1 Rationale

As previously stated, acknowledging the role of genuineness in the person of the psychotherapist can expand on previous studies and inform clinicians’ practice by protecting the TA [9,10,11]. Secondly, SP/SR can be applied remotely, an expanding modality since the COVID-19 pandemic, which requires isolation as a public health measure [12]. Since one psychotherapist can conduct SP/SR remotely with fellow practitioners, its implementation might positively influence the provision of affordable interventions to prevent burnout by supporting well-being and resilience [13].

1.2 Objectives

In the present reflective report, I aim to conduct quantitative and qualitative research on myself to explore the impact of concentrating on genuineness when delivering psychotherapy as a trainee. This article provides concrete examples of how therapists’ authenticity could benefit the TA.

2. Methods

2.1 Participants

The case study focuses on my experience, which emerged from conducting SP/SR while completing a Postgraduate Diploma in CBT. At that time, I met the British Association for Behavioural and Cognitive Psychotherapies (BABCP) “Knowledge, Skills and Attitudes” (KSA) criteria via other relevant vocational and training experiences. The clients consented to anonymizing their data for research and publication while completing an initial therapy contract.

2.2 Measures

Outcome measurements were implemented twice, at the beginning and end of SP/SR, to set clearer goals and monitor and inform the discussion. The process did not involve statistical analysis. The therapist completed the following questionnaires: 15-item five-facet mindfulness questionnaire (FFMQ-15), the Center for Clinical Interventions’ assertiveness questionnaire, the authenticity scale, and the values in action (VIA) inventory [14,15,16,17]. Conversely, the working alliance inventory-short, revised version (WAI-SR-C) [18] was filled out by clients during mid-treatment reviews.

2.3 Data Analysis

Thematic content analysis (TCA) was applied to the 3000-word written reflective report submitted for assessment during the training [19]. This written report conveyed (1) what I had learned about myself and (2) how I related this personal learning to my clinical practice. Its findings were derived from SP/SR, an emotional avoidance formulation diagram, assertiveness training modules, attending personal psychoanalysis once per week, and mindfulness [5,15,20].

Once completed, the report was extensively reviewed and inputted by one personality and mindfulness expert to ensure the supporting theories' fidelity. I invited this expert to collaborate as a second author of the paper in line with Bennett-Levy et al. [5]’s suggestion of incorporating cultural role models that strengthen new ways of being through embodiment. Autoethnographically, this Associate Professor played a crucial role in my career development by providing feedback, extending opportunities to collaborate with her in research, supporting my application to postgraduate studies, and introducing me to mindfulness.

3. Results

3.1 Emotional Awareness, Acceptance, and Expression

For specific monitoring, I completed the FFMQ-15 (2006), where items that required improvement were: “I think some of my emotions are bad or inappropriate, and I should not feel them” and, “I tell myself I should not be feeling the way I am” [14]. Accordingly, it led me to set goals related to emotional acceptance, which was a pivotal step in the process. Emotional acceptance collaborated with a contemplative approach to the feelings remaining after each client’s interaction, leaving enough time after each session for record keeping and reflection. Gibbs's [21] model of reflection facilitated the assimilation of unpleasant emotions to attend supervision before the client’s next session. Unpleasant emotions often lead to points for professional development. For instance, the points for improvement stated by the clients were demonstrating more appreciation for their homework completion and setting more explicit session goals [18]. On the other hand, I felt more at ease when I kept diagnostic levels at the assessment stage to be a horizontal facilitator in the sessions. Additionally, from abstract conceptualization, it became clear that I needed to integrate other theoretical approaches to make sense of therapeutic experiences [21].

As an illustration, I present a vignette from a personal reflection produced during the assertiveness training. In this excerpt, I elicit frustration in the interaction with one of my clients, who I will call SP, and analyze the experience in the light of psychodynamic concepts. At the time of the assessment, SP was a 27-year-old female, single without offspring, employed full-time. Her symptoms were indicative of a recurrent depressive disorder, and her goals pointed toward improving her self-esteem and interpersonal relationships.

“At that moment in time, I did not know what I found exactly triggering about my sessions with her. SP was not diagnosed with a personality disorder. Still, other factors which have been related to perceiving a patient as difficult were present, such as a past challenging life context, interpersonal difficulties, self-destructive behaviour, and emotional dysregulation [22]. Contrarily, SP presented the following protective factors in our therapeutic alliance: Ability to form close relationships and her attitude towards the treatment, the NHS in England, and myself [22]. Supervision of our session’s recordings did not help me to engage her with the structure required for CBT. Although SP did attend promptly and prepared, our sessions hardly went as planned, and I was left with an unsteady sensation after speaking with her. The process report touched on several areas that had not been explored by me until that point. Among them, I could mention issues with eliciting emotions, where SP would prefer narrating her dreams, which occurred often during the treatment. From a personal perspective, I also experienced parapraxis or behavioral slips whilst writing her process report, where I unconsciously wrote the assignment in the third person [23]. Thus, I realized that our interaction needed further growth on my part to be able to fulfill her needs. Despite these obstacles, she acknowledged my feedback when I expressed my feelings towards our progress”.

In view of the learning points, I paid particular attention to my emotions in the sessions when the clients reported symptoms of depression and interpersonal difficulties. As the experiences presented could be indicative of emotional avoidance in both the client and the therapist, I enhanced my emotional awareness, acceptance, and expression.

3.2 Approaching Psychotherapy as a Process of Compassionate Research

Experiencing questionnaires, formulations, goal monitoring, and interventions from the inside out gave me added empathy toward service users [13]. Due to the challenges of SP/SR, I was keener on approaching therapy as a recursive process of qualitative research that was specified by quantitative measurements [24]. From a personal viewpoint, reading and answering the questionnaires to gain awareness initially came as a negative experience of boredom and frustration. Hence, I became compassionate towards clients’ avoidance and gently prompted them to complete them when needed. In addition, I discussed with them the benefits of keeping a record to remember their baseline and overcome selective attention to the negative by the end of the treatment. For example, some clients experiencing symptoms related to perfectionism or low self-esteem usually did not feel entitled to reward themselves for their progress and tended to perceive it as “not enough”.

3.3 Cultural Awareness as the First Step in Equality, Diversity, and Inclusion (EDI)

Coming from Chile, in Latin America, and having recently moved to the United Kingdom (UK), I consequently went into studying my own five-part CBT formulation informed by cultural factors [25]. Therefore, I used culturally informed formulations when clients were going through acculturation to aid their adjustment. Moreover, I delved into relational reflexivity to visualize how our similarities and differences played out in the sessions [26]. In addition, I borrowed the following questions from our lecturer on EDI: “What do you think is characteristic of your culture? Do you identify yourself with those characteristics? If yes, what aspects are helpful or unhelpful?” And finally, “What is the relationship to help in your culture?” [27].

Delving into EDI, I began to consider client’s religion in their formulations and as a coping mechanism by being part of a community, among other resources derived from their spirituality [28,29]. For instance, in the case of obsessive-compulsive disorder (OCD), the Qur’an, as a spiritual text, acted as a source of positive statements to encourage treatment engagement [30]. In addition, awareness of the dates of cultural events was crucial so that behavioral experiments were not placed during periods of celebration or abstinence, such as Ramadan. From the therapist’s perspective, I used my Latino cultural characteristics to enhance emotional expression through non-verbal communication and elicit emotions [31].

3.4 A Cohesive Self Across Personal and Professional Domains

By increasing my awareness of who I am, I could appreciate that my personal self and therapist self were intertwined, although I had tried to separate them. I used to believe this would help me to set healthy boundaries and prevent burnout, but it ultimately led me to an unpleasant feeling tone in the sessions. As a result of the insight, I opted to wear different hats without aiming to divide myself. This integration ultimately helped me to reduce uncomfortable bodily sensations and led me to a more Socratic approach in my overall interactions. On the other hand, I experienced the satisfaction of combining my passion for mental health, activities I share with significant others, and hobbies.

4. Discussion

4.1 Implications for Practice

The management of difficult emotions coupled with the development of compassion, a practice that promotes EDI, and a cohesive sense of self were some of the benefits I experienced from concentrating on genuineness when delivering psychotherapy. Thus, similarities can be found with benefits recently proposed by Presley & Jones [32], who emphasize professional development through enhanced TA skills and attending to emotional experiences. Differences might be related to the specific SP/SR topic, additional steps added to Bennett-Levy’s [5] methodology, personal values, and being a dual citizen.

This study emphasizes emotional awareness as the first step towards authenticity, which regular mindfulness sessions can facilitate. As proposed by other supporters of the use of mindfulness, its practice promoted my abstract thinking [33]. The previous might be particularly relevant when feedback from the client and psychotherapist appeared contradictory. Thus, integration is required before responding [21]. For instance, clients might ask the facilitator to lead in setting the agenda for each session while the practitioner is attempting to collaborate. Here, meta-competence development might require the therapist to adapt their style in response to the patient while maintaining guided discovery [34].

With regard to compassion and a paced approach, issues might arise in services requiring outcome measurements to be reduced to the point of recovery by the end of the treatment. Because qualitative information provided by clients can be time-consuming for service managers to monitor progress, changes in work and social adjustment may be considered in addition to general and specific outcome measurements [35].

4.2 Recommendations for Future Research

Methodologically, future studies on the role of genuineness might be enhanced by conducting a systematic literature review and applying a standardized protocol based on the methods gathered. Although I followed Bennett-Levy et al. [5] steps, it seemed that the topic of genuineness required additional input. It would be beneficial to explore whether this methodology could be applied to a representative sample of trainees or qualified psychotherapists in which research could be conducted. Nonetheless, it is worth mentioning that since TCA focuses on looking for patterns across written accounts, phenomena that occur in only one individual can be overlooked, thus the richness of the present study. Another significant limitation is the challenge that an author analyzing its work represents in terms of objectivity, which was minimized by including a mentor reviewer, who acted as an external observer. Finally, it is worth mentioning that the report did not cover setbacks encountered nor detrimental effects that might appear in the therapeutic alliance, thus being a point for further research.

The research paper's uniqueness is one of its strengths since it appears to be the first published attempt to investigate the effects of genuineness through SP/SR. It demonstrates how therapists can enhance their CBT personal and professional practice using autoethnographic principles. Additionally, it considers the model's limitations, where an event has been theorized following psychodynamic principles.

5. Conclusion

The study approaches authenticity as a value constantly pursued in a continuously evolving ideal self [36]. Due to the dynamic nature of psychotherapy, there is a need for continuous learning and growth to adapt to the changing needs of clients and the advances in the field. To summarize, although an introduction to CBT competencies can be grasped during a one-year training, a life of committed professional improvement and practice is warranted, where maintaining authenticity requires ongoing reflection from therapists.

Acknowledgments

We extend our appreciation to Coventry University for including self-practice in cognitive behavioral therapists’ training. Particularly, we thank Gwion Jones from the Center of Freudian Analysis and Research (CFAR). This article might not have been possible without the inspiration brought by him to Friday morning lectures on EDI and reflective practice.

Author Contributions

Carolina Eugenia Cáceres Videla: Conceptualization, methodology, analysis, and writing - Original draft. Candice Fischer: Writing – Review & editing. Both authors have read and approved the published version of the manuscript.

Competing Interests

The authors have declared that no competing interests exist.