On reflection: part 5 – reflective self-awareness

The role of self-reflective awareness in professional development and clinical practice

Summarising the literature on therapist competence and client outcomes, Bennett-Levy, McManus et al. (2009) state that while there is increasing evidence linking competence to client outcomes, the evidence that training contributes to competence is mixed, with some studies reporting positive associations where others find little or no enduring effects. They also point out that it is still unclear how specific pedagogical techniques map on to domains of competence. For example, what sorts of teaching help develop declarative knowledge, as opposed to those that help develop procedural expertise or reflective capacity both in therapy sessions and when reflecting on events after they have occurred (for example, in supervision). Additionally, the authors state that breaking down competence into the domains of conceptual, technical and interpersonal skills means that they map across declarative and procedural domains.

For example, developing and sharing a collaborative longitudinal conceptualisation requires a high degree of conceptual knowledge about the aetiology and phenomenology of psychological disorders (declarative domain), the technical interviewing skills to elicit from the client information about their symptoms and personal history that can confirm or disconfirm a specific diagnosis e.g. using the Structured Clinical Interview for DSM-5 (procedural skills), and the interpersonal skills to share a provisional hypothesis or formulation, which may be a matter of great sensitivity to the client. Overseeing this process is the reflective capacity to monitor the process in real time for potential therapeutic ruptures or adverse reactions from the client to the information being shared. The technical, interpersonal and interpersonal complexity of CBT means that a wide range of teaching inputs may be required to develop each facet of practitioner competence. A list of potentially helpful learning strategies that are appropriate to each of the memory systems was presented by Bennett-Levy (2006) that is reproduced here as Table 5.

Table 5: helpful learning strategies for the three systems (Bennett-Levy 2006)

In a subsequent survey of experienced CBT therapists, Bennett-Levy, McManus et al. (2009) reported that modelling, reading and lectures were perceived as most effective in enhancing declarative knowledge but that reflective practice, self-experiential work, modelling and role play were most effective for procedural skills. Reflective practice and self-experiential work were most effective in enhancing reflective capacity, which increases when it is practised in a facilitative context (Bennett-Levy, 2006). A somewhat different pattern emerged when viewing skill development in terms of conceptual, technical and interpersonal components. Modelling and demonstration, lectures and reading were seen as most useful for enhancing conceptual knowledge and skills, whereas modelling, role play, lectures and reading were seen as enhancing technical knowledge and skills. Interpersonal skills were seen as being best enhanced by reflective practice, self-experiential work and role play.

Interpersonal skills are undoubtedly important to the successful conduct of all psychotherapies. This intentional use of one’s personal characteristics is sometimes known as the practitioner’s therapeutic use of the self, a term that was originally proposed by Jerome Frank (1958). Subsequently, there have been a great many different ways to represent the use of the self, which has been developed extensively in particular in clinical social work in the United States (Taylor, 2008). Taylor identifies a range of definitions used by a variety of authors, and cited the following: “the ability to deliberately use one’s own responses to clients as part of the therapy” (Mosey, 1981); “conveying an attitude of respect and acceptance to clients so self-esteem could be restored” and “modeling characteristics of a mature, competent, and admirable person for the client” (Denton, 1987); “remaining neutral but engaged, accepting the client as he or she is, being tolerant and interested in the client’s painful emotions, and being able to interpret the client’s expectations of therapy accurately” (Schwartzberg, 1993); “the artful, selective, or intuitive use of personal attributes to enhance therapy” by “selecting aspects of one’s own personality, attitudes, values, or responses that were predicted to be relevant or helpful” (Hagedorn, 1995); and “developing an individual style that promotes change and growth in clients and helps furnish them with a corrective emotional experience” (Cara & MacRae, 1998) (all cited in Taylor, 2008, p. 5).

This range of possible definitions suggests that the concept when described in such broad terms lacks a certain rigour, but nonetheless seems to capture something of the intentional nature of using one’s interpersonal characteristics to influence the outcome of therapy. For the purposes of teaching, the following three definitions have been found most useful:

  • A “practitioner’s planned use of his or her personality, insights, perceptions and judgments as part of the therapeutic process.” (Punwar & Peloquin, 2000, p.285)
  • A way to “link the concepts of self-awareness, perceptions, choices and actions as the fundamental building blocks of our capacities to be effective agents of change” (Seashore et al., 2004, p. 42)
  • Purposefully and intentionally using one’s “motivation and capacity to communicate and interact with others in ways that facilitate change” (Sheafor & Horejsi, 2003, p. 69)

These definitions have been translated by the author into a self-reflective exercise that focuses on trainees’ personality, insights, perceptions, and judgments; self-awareness, motivation and capacity to communicate and interact; and perceptions, choices and actions (Table 6).

Table 6: self-reflective questions for trainees on the intentional use of self

Knight (2012), writing from the perspective of clinical social work, locates the theoretical rationale for therapeutic use of self in three traditions: Rogers’ person-centred therapy and the concept of congruence or genuineness; Shulman’s Interactional Model and the role of genuineness in helping create and sustain the working alliance as a necessary but insufficient aspect of interventions; and, attachment and relational theories that hypothesise that the therapist’s therapeutically appropriate relational genuineness is experienced as affirming by the client and can be internalised and applied by the client in other relationships. Knight points out that the therapeutic use of self has been operationalised in two specific ways: 1) the use of “there and then” self-disclosures of aspects of the therapist’s life outside of therapy; and 2) as “here and now” disclosures using immediacy, for example, disclosing that one has been moved by the client’s story. Knight’s review of the empirical evidence suggests that both forms of disclosure have the potential to enhance trust and deepen the working alliance but that “here and now” disclosures are generally experienced as more helpful. Under all circumstances, the intentional therapeutic use of self needs to be used with care and sensitivity for the person of the client, their difficulties and sensitivities, and the stage of therapy.

It seems to the author that the most parsimonious view of the intentional use of self might usefully be conceptualised as a process of social influence. Psychotherapy more generally has sometimes been described as an interpersonal process that relies on the credibility and social influence of the practitioner (Frank & Frank, 1993). Therapists, it is hypothesised, firstly need to establish themselves as a useful resource to the client in terms of their expertise, attractiveness and trustworthiness, and then use those characteristics to influence clients to engage with change processes (Strong, 1968). As such, the intentional therapeutic use of self might best be conceived of as a motivational tool to influence engagement with and understanding of therapeutic tasks.

Because the intentional use of self is realised through the interpersonal process of psychotherapy to influence the content of the client’s affects, cognitions and behaviour, it is in essence a relational process that draws on both the everyday interpersonal skilfulness of practitioners and their more specific technical and conceptual knowledge. Bennett-Levy and Thwaites (2007) suggest that there are four elements to interpersonal skills, within the context of the DPR model: they are interpersonal perceptual skills, therapist attitude, interpersonal relational skills, and interpersonal knowledge. While interpersonal perceptual skills are some of the most important skills that a therapist possesses, they are some of the least researched, acknowledged or understood (Bennett-Levy, 2006). Perceptual skills depend not just on observation of the client and inference about the client’s internal (i.e. “in-process”) state but the therapist’s ability to perceive their own in-process state as a result of sensitivity acquired through personal development and experience.

In terms of the DPR model, Bennett-Levy states that this implies a close link between the therapist’s self-schema and their perceptual skills such that the self-schema functions as an “emotional barometer” of the client’s in-process state. This can create a conflict for a therapist whose procedural skills are not yet sufficiently automated, or who lacks the confidence in their skills to free up attention to focus on the client, when they may be using working memory capacity to rehearse mentally their next intervention or to try to make sense of what the client is telling them. These difficulties can sometimes be exacerbated by the process of assessment. In the author’s experience, interpersonal skills tend to suffer when, for example, recording a session because the prospect of later evaluation can lead to performance anxiety and self-consciousness. With repeated use of recording, one might expect habituation to take place, but it appears that for some practitioners this process can increasingly sensitise them to potential negative judgement, especially in people who are particularly sensitive to criticism or have high standards for personal performance.

Therapist attitudes may be more or less helpful in the therapeutic process, in particular as they influence both perceptual skills (what is attended to and what client communications are taken to mean) and relational (communication) skills. Interpersonal relational skills are the communication skills required to communicate empathy, warmth, and compassion. Interpersonal declarative knowledge is a more conceptual understanding, for example of the rationale for collaboration or for seeking feedback from clients.

Interpersonal relational skills have been linked to the person of the therapist, or the therapist’s self-schema. Haarhoff (2006) identified three therapist schemas that could unhelpfully interfere with therapeutic practice: “demanding standards”, “special superior person”, and “excessive self-sacrifice”. Because schemas affect the therapist in terms of perception, appraisal, affect and behaviour, they can lead to unhelpful therapeutic behaviour.  Where the unhelpful impact of these beliefs becomes evident, for example in reviewing a recording in supervision, self-reflection and the application of structured CBT tasks on oneself can help to raise the therapist’s awareness and encourage them to carry out their own behavioural experiments, for example taking the calculated therapeutic risk of prescribing more challenging homework tasks (Haarhoff & Kazantzis, 2007).

Bennett-Levy (2006) reports that some authors consider interpersonal relational skills to be less open to change and development than technical skills because they are derived from aspects of the self in relationship that are part of one’s personal self, i.e. that they generalise across social settings and interpersonal encounters. To the extent that interpersonal skills and personal process issues are able to be improved in supervision or training, as Bennett-Levy and Thwaites (2007) point out, they can be sensitive areas to address because they are tied so inexorably to the self-schema. In other words, if one feels criticised in the technical or conceptual domain it can be rationalised as being part of one’s specialist, professional development – we couldn’t reasonably be expected to have known. To feel criticised for one’s interpersonal skills feels a more stinging personal criticism that could embarrass us or activate shame-based schemas of defectiveness.

Bennett-Levy and Thwaites suggest that creating a sense of safety in the supervision relationship is essential to facilitate disclosure of therapists’ therapy-interfering behaviours, for example by the supervisor or trainer using self-disclosure to normalise interpersonal or counter-transference problems. It might be that personal experiential work is one route to enhanced perceptual and interpersonal effectiveness. For example, Bennett-Levy suggests that when CBT is practised on oneself, as in SP/SR tasks, the skills are processed at greater depth and available for retrieval from separate but linked memory systems.

Bennett-Levy and Thwaites (2007) propose that some attitudinal or relational problems stem from a simple lack of knowledge about interpersonal processes. They suggest that interpersonal knowledge can be enhanced through increased understanding of interpersonal process issues from a theoretical standpoint that will transfer into skilled interpersonal behaviour when enacted and practised.

Bennett-Levy and Thwaites (2007) have described both a model for processing interpersonal difficulties in supervision and a range of self-supervision, supervision and training strategies to address difficulties with interpersonal processes. The supervision model has six components. It is closely mapped on to the ways in which the reflective system is thought to work while also integrating the declarative and procedural systems. The six stages are: 1) focus attention on the supervision question that relates to an interpersonal difficulty; 2) reconstruct the problem experientially through mental representation; 3) clarify the experience using cognitive operations so that it can be better understood; 4) conceptualise the problem using interpersonal, technical and conceptual knowledge; 5) role play strategies to refine the procedural skills needed; and 6) enact the new strategy with the client (Figure 12). While the six-stage process model is a useful conceptual model it might benefit from making more explicit the importance of reflecting on the outcome of reflection, perhaps as a separate seventh stage, which is to review the effectiveness of the strategy in a subsequent supervision session using the kind of bridging process that is often used with clients in CBT to consolidate learning between sessions (Beck, 2011).

Figure 12: The six-stage process model for addressing therapeutic relationship difficulties (solid arrows indicate progression through the stages; broken arrows are reflective processes) (Bennett-Levy & Thwaites, 2007)

Haarhoff and Kazantzis (2007) have developed a complementary model of supervision that focuses on improving the use of homework in CBT practice, especially with CBT trainees. The approach uses self-practice of CBT techniques (SP/SR) in supervision in order to identify and modify therapists’ interpersonal therapy-interfering schemas and behaviour. For example, Haarhoff and Kazantzis identify common, potentially therapy-interfering cognitions, such as “Homework assignments will be overwhelming for patients who are distressed” (p. 326) that can lead either to avoidance of, or poorly executed, homework-setting. The authors suggest using CBT conceptualisations, such as the five-part model, and CBT techniques, such as an automatic thought record, to help practitioners understand the relationships between their thoughts, emotions and behaviour and its consequences for effective treatment according to best practice guidelines that emphasise the importance of homework. Grimmer (2013) has also written about how in supervision the use of Interacting five areas models (termed a nine-part model) can be used in supervision to explore therapist assumptions about the way that client cognitions and emotions might affect therapist behaviour.

In so far as it is useful for trainees, qualified practitioners, and supervisors to be able to make explicit links between technical, conceptual and interpersonal skills, or between declarative, procedural and reflective knowledge and skills, the author would suggest that it might be useful to link them to specific competences from the Cognitive Therapy Rating Scale-Revised (CTS-R). For example, the author has used in training the following example of the CTS-R competence of eliciting key cognitions as an essential skill in CBT. In terms of declarative knowledge, trainees need to understand the cognitive rationale that links “hot thoughts” to the emotional intensity associated with experiences; that skill in the use of guided discovery is a key procedural competence to elicit key thoughts; that an attitude of respect for the client’s autonomy and lived experience reflects both important personal and therapeutic values; that, in terms of declarative interpersonal knowledge, accurate empathy is likely to enhance the disclosure of affect-laden relevant therapy material; that perceptually, it is important to be attuned to shifts in the client’s affect; and that these affect shifts need to be handled with sensitive interpersonal relational skills, such as the use of immediacy to enhance the client’s awareness and understanding of the significance of the thoughts they are disclosing.

The interpersonal skills described above that form part of the intentional use of self, rely on the therapist having sufficient self-awareness to recognise their therapy-enhancing and interfering interpersonal behaviours and attitudes. From a clinical social work perspective, Heydt and Sherman (2005) point out that self-awareness requires ongoing monitoring, such that:

“Just as artists clean their paintbrushes and fire fighters inspect their equipment to keep their instruments in perfect working order, every social worker needs to examine his or her own attitudes, personal habits, and interactional patterns in order to enhance the conscious use of self and become the most effective instrument of change possible for as many of their clients as possible.” (p. 28)

This commitment to self-awareness is potentially important given the literature showing that there are a number of therapist characteristics that may have a significant impact on therapeutic effectiveness (Bennett-Levy & Finlay-Jones, 2018). These include the following: personal distress; personal/professional wisdom; therapist attachment style; therapist burnout; and therapist mindfulness and resilience. Bennett-Levy and Finlay-Jones suggest that the presence of unhelpful characteristics may call for personal practice work such as personal therapy, or ultimately, a re-evaluation of the therapist’s suitability for the role (and the role’s suitability for the therapist), due to their potential negative impact on therapeutic effectiveness. In contrast, as we have seen, very effective therapists tend to be highly self-aware, reflective, non-defensive and mentally healthy and mature (Sullivan et al., 2005).

Despite the importance ascribed to self-reflective awareness (SRA) in highly effective therapists, Bennett-Levy and Finlay-Jones (2018) report that the relationship of self-awareness to therapist effectiveness and therapy outcomes is unclear. They state that, while the term has been poorly defined, its ubiquity in the personal practice literature for therapy of all modalities suggest it is relevant to a model of personal practice as a technique to improve therapeutic skilfulness. This ubiquity is reflected by Henriques (2016) who states that self-reflective awareness is “probably the single most important competency” (para. 1) that he teaches doctoral-level psychotherapy students, although it should be pointed out that this is anecdotal evidence rather than an empirically based finding.

Henriques describes SRA it as a metacognitive ability where the practitioner is able to generate and communicate a narrative of the self in practice that is “complex, clear and multifaceted” (2016, para. 2). Henriques states that it is a quality that is best cultivated firstly by valuing it, then by adopting an approach based on four characteristics that can be summarised using the acronym CALM: Curiosity (a questioning attitude), Acceptance (of experience, whether positive or negative), Loving compassion (acknowledging that we are doing the best we can), and Motivation (towards personal and professional growth). Henriques argues that, in order to acquire greater SRA, practitioners need to explore eight key domains:

  1. Know your family story and developmental history
  2. Understand your needs, motivations, and emotions
  3. Understand your psychological defences and how you handle criticism
  4. Understand your strengths and weaknesses
  5. Understand your beliefs/values and worldview
  6. Know your purpose in life and how you make meaning
  7. Know how others see you
  8. Know the “cultural bubble” that you live in

One potential method of improving therapist self-awareness and professional competence is the use of some form of personal practice (PP) in training. Bennett-Levy (2019) proposed that conventional training methods without a personal practice component could be expected to influence the therapists’ conceptual and technical skills and their interpersonal beliefs, attitudes and skills, but would be less likely to influence therapist self-awareness and the therapist’s personal development and wellbeing. Bennett-Levy and Finlay-Jones (2018) argue that developing a personal practice model could be useful to therapists in deciding what type of personal practice might be beneficial and under what circumstances. It could also benefit educators in deciding which personal practice, if any, to include in a training programme, and supervisors, as a way to identify new ways to improve supervisee competence.

Bennett-Levy and Finlay-Jones’s (2018) model of personal practice highlights a “reflective bridge” between personal self-reflection from the perspective of the personal self and professional self-reflection from the perspective of the professional self (Figure 13). This model draws on the existing theory behind the DPR model as well as the empirical literature on the impact of personal practice in therapist training, including personal therapy, meditation-based programmes and self-practice/self-reflection.

Figure 13: the personal practice model (Bennett-Levy & Finlay-Jones, 2018)

The model retains the idea of two selves – a personal and professional self –but also suggests four motivations to engage in personal practice: 1) therapist skill development, 2) personal problems, 3) personal growth, and 4) self-care. There are five potential outcomes of personal practice in terms of improvements in: 1) personal development and wellbeing; 2) self-awareness; 3) interpersonal beliefs, attitudes and skills; 4) conceptual and technical skills; and 5) reflective skills. The three elements of the reflective process consist of: 1) personal self-reflection, 2) therapist self-reflection and 3) the reflective bridge, which represents the ability to transition flexibly between personal and professional self-reflections. The model highlights the potential impact of positive or negative experiences in the therapist’s personal life on their professional capabilities, and of positive and negative professional experiences on their personal life, although this latter phenomenon, which has been reported by therapists over the course of their careers (Guy, 1987) is perhaps under-researched.

Traditionally in psychotherapy training, personal practice has taken the form of personal therapy, which is sometimes a requirement of entry to and completion of training programmes.  This is a topic that is both contentious and has a huge literature with regard to its purported benefits and role in developing safe and effective practice. It is beyond the scope of this work to do it justice, but it is worth providing a brief summary of the main findings as it is an area that is generating increasing interest within CBT as a result of the inclusion of other PP activities within CBT training courses, such as self-practice/self-reflection and meditation programmes. Most recently, Bennett-Levy has published a review of the theoretical and empirical case for personal practice in therapist training and professional development that reviews the topic as it is currently understood (Bennett-Levy, 2019). It is also a topic on which the author has published both original research (Grimmer & Tribe, 2001) and several reviews of the literature (e.g. Grimmer, 2015).

There are a number of recurring rationales for personal therapy for practitioners (Norcoross et al., 1988) that are still influential today. These are:

  1. Improved emotional and mental functioning making the therapist’s life less neurotic and more gratifying.
  2. A more complete understanding of personal dynamics, interpersonal elicitations, use of self, and conflictual issues, that enables therapy to be conducted with clearer perceptions and reduced counter-transference potential.
  3. Alleviating emotional stresses and burdens, enabling practitioners to deal more successfully with challenging work.
  4. Providing a profound socialisation experience that establishes conviction about therapy’s effectiveness and facilitates internalisation of the healer role.
  5. Experience of being a client, which sensitises therapists to the interpersonal reactions and needs of their own clients.
  6. Direct modelling of clinical methods through first-hand, intensive experience.

Orlinsky et al. (2011) conclude that research generally supports the notion that personal therapy enhances professional development through a number of means that are reflected in the rationales cited above, including: increasing sensitivity and empathy; experiential learning of therapeutic skills; understanding one’s own conflicts, beliefs and values, and the ability to use self-awareness in therapy. Despite the assumption that personal therapy contributes to professional development, Macran and Shapiro (1998) state that three major reviews of the outcome literature all conclude: ‘There is no evidence that either receipt of personal therapy or length of personal therapy is positively related to various measures of client outcome” (p. 19). Bennett-Levy (2019) points out that this finding of a lack of evidence for improvements to client outcomes is unsurprising given that personal practice would need to enhance therapist skills, which themselves would need to improve client outcome.

In other words, we would need to know what the contribution of PP to the variance in therapist skills was, multiplied by the contribution of variance in therapist skills on client outcome. Bennett-Levy (2019) reports that the range of figures for the contribution of therapist factors lies between 3% and 8%, perhaps 10% for more complex clients. There is no quantitative data on the contribution of PP to therapist skills, and indeed that may be less relevant than knowing which therapists would benefit most from PP, at what point in their development, and with what form of PP.  Having said that, Bennett-Levy proposes that personal and interpersonal qualities of therapists play a key role in client outcomes; and personal practice is the most effective way to achieve changes in therapists’ personal and interpersonal qualities. This already complicated and unclear picture also needs to consider research cited by Bennett-Levy that the most effective 15-20% of therapists achieve recovery rates at approximately twice those of the bottom 15-20%. Perhaps PP would best be targeted at poorer performing therapists, in so far as their poorer recovery rates are a function of the kind of interpersonal skills that could be enhanced by PP, assuming they are willing to participate and capable of benefitting from it.

Aside from Bennett-Levy and Finlay-Jones’s (2018) PP model, there are other models drawn from different therapeutic traditions. Rizq and Target (2008) propose a mechanism of change linked to Fonagy and Target’s psychodynamic developmental model of mentalisation, which refers to the maturing child’s experience of, and capacity to tolerate, strong emotion that increases their ability to function interpersonally. They suggest that personal therapy can replicate this process. Through the experience of “being seen” and understood by their therapist, the capacity to see, identify and empathise with clients is developed through the recognition that “subjective experience is a representation of, rather than indistinguishable from, reality” (ibid. p. 43). They suggest that developing this mentalising stance is responsible for the perceived emotional resilience that participants attributed to personal therapy and that the effects of successful therapy may be seen most prominently when working with challenging clients who have the potential to elicit the greatest negative emotion.

Wigg et al. (2011) developed a model to describe how practitioners “progress to greater levels of reflexivity, assisted through the experience of personal therapy” (p. 354). Their reflective practice model notes the following themes across studies that focused on process issues: 1) personal reflections (processes that encourage personal growth and development to occur); 2) professional reflections (the development of greater skill and accuracy through the honing of the professional self as the tool of therapy); 3) extended reflections (the benefits of prolonged therapy as an ongoing process to meet different demands at different points in the professional life of the practitioner); and, 4) meta-reflections (a diverse category that encompasses the development of authenticity in the personal and professional selves along with self-acceptance, awareness and coherence). The model describes a process whereby each level of reflection builds on the former to produce increasingly abstract and thus generalizable principles that have applicability across a wide range of professional situations. The authors acknowledge that their proposal raises questions as to whether it is necessary to have reflected in a personal manner before reflecting in a professional manner, and whether therapists need to reflect personally, professionally, and over an extended period, before being able to reflect on their reflections.

Theories of the role of personal therapy suggest that reflection and self-reflection could be conceived of as the capacity to hold in awareness and evaluate multiple perspectives (client experience, self-experience, and contextual variables) while under emotional strain from the impact of client behaviour. The positive reciprocal influence of increased reflective capacity and emotional regulation skills could facilitate a non-defensive, empathic and inquisitive stance towards the client’s experience. This mechanism is implicit in some qualitative research, for example, increased capacity to tolerate a client being distressed and crying (Grimmer and Tribe, 2001).

It is worth noting that reactions to a personal practice requirement are diverse. Sanders and Bennett-Levy (2010) report that when Bennett-Levy taught his first CBT training programme and included a “personal experiential component” at least one participant was “appalled” at the idea. Happily, their opinion changed to one of enthusiasm, but this reaction also mirrors some of the ambivalence towards personal practice that the author reported in a qualitative study of mandatory personal therapy for counselling psychology trainees (Grimmer & Tribe, 2001). Indeed, the author would argue that there are ethical issues concerned with the use of any mandatory personal practice activities. Kottkamp (1990) points out that there is an often unstated assumption in all approaches to reflection as a device for training or professional development, which is that “The practitioner is in total control of deciding whether to reflect, and, as a result, whether and how to change his or her practice” and that we “cannot use it to change the recalcitrant, the malicious, the unmotivated or those who have given up all hope” (p. 199, italics in original). The author would argue that the trainee is always at a disadvantage with regard to the institutional power of the training institution and the whims and prejudices of individual trainers. This is particularly insidious, even cruel, when the person of the trainee is being judged on their fitness to practice, rather than their professional skills and knowledge.

In support of the relative imbalance of power between trainee and institution, Orlinksky et al. (2011) point out that there is a “small literature” (p. 831) concerning possible dangers of personal therapy, in particular, where there are ethical and health risks associated with a structural requirement for therapy in training. This possibility of inadvertent iatrogenic effects of personal practice for trainees taking part in mandatory personal practice (specifically mandatory personal therapy) was addressed by Murphy et al.’s (2018) metasynthesis and review of qualitative research into mandatory personal therapy during training. The authors concluded that ethical issues should be at the forefront of decision-making where personal therapy is mandatory and that it should not be used as a means to rectify perceived personality faults in trainees.

Bearing those caveats in mind, in the absence of a requirement for the personal therapy requirement that can be found in other therapeutic modalities, reflective practice activities, such as self-practice/self-reflection (SP/SR), now form part of the training for many trainee CBT therapists. In fact, there is research that shows that CBT therapists perceived SP/SR activities as more beneficial personally and professionally than counselling trainees found personal therapy, leading the authors to conclude that “it may be that, for trainees, SP/SR represents a more controlled and contained self-experiential method than personal therapy—especially when mandatory” (Chigwedere et al., 2020, p. 13).

Given that reflective practice including SP/SR is often mandatory in CBT training and the quality of trainees’ ability to demonstrate reflective practice is assessed, it is helpful to know what elements of SP/SR affect its perceived benefits.  Bennett-Levy & Lee (2014) reported that two mutually influencing outcomes were identified consisting of experience of benefit and engagement with the process, such that “the more motivated a trainee is, the more benefit s/he experiences; and the more benefit s/he experiences, the more s/he is engaged” (p. 54). Five other factors were also reported: 1) course structure and requirements, 2) expectation of benefit, 3) feeling of safety with the process, 4) group process, and, 5) available personal resources. These were functionally related to institutional parameters, preparation for the course, and experience during the course, as shown in Figure 14.

Figure 14: Factors influencing engagement and experience of benefit in SP/SR (Bennett-Levy & Lee, 2014)

The benefits of SP/SR have now been well documented. Early research with experienced therapists showed that SP/SR increased the “professional artistry” of experienced therapists. Benefits included: the refinement of specific CT skills; enriched communication of the conceptual framework of CBT; increased attention to the therapeutic relationship; empathic attunement; therapist self-reflection; and therapeutic flexibility (Bennett-Levy et al., 2003). A metasynthesis of qualitative studies of experiences of SP/SR in CBT published a decade later (Gale & Schröder, 2014) identified 14 constructs that were grouped in to three broad categories: 1) experience of SP/SR; 2) outcomes of SP/SR; and 3) implications for training. Experiences of SP/SR included five categories: 1) increased empathy through being in the client’s shoes; 2) increased self-awareness to understand better practitioners’ own problems and coping strategies; 3) increased awareness that therapy can be life changing, especially where therapists used themselves as a case study; 4) experiencing difficulties with techniques including a greater appreciation of the difficulties that clients might therefore face; and, 5) appreciating the potential for negative experiences, including the potentially unsettling and anxiety-provoking nature of self-disclosure. Five constructs were also identified in terms of outcomes of SP/SR: 1) a perceived increased empathy for clients; 2) a deeper level of knowing; 3) an increased capacity to understand and explain the model; 4) an increased understanding of the role of therapist as a guide; and, 5) increased confidence and competence. Four constructs were identified in terms of implications for training: 1) the importance of SP/SR as a training method; 2) the importance of other people to help reflect at a deeper level; 3) that written reflections are crucial; and, 4) that SP/SR can be lifelong.

Gale and Schröder concluded that there is a “line of argument” where 1) SP/SR leads to an experience that is analogous to being in the client’s shoes when it is used as a learning method that uses written reflections and draws on other people; 2) this experience of being in the client’s shoes increases self-awareness and socialises practitioners to the potentially life-changing impact of therapy, but with awareness also that techniques can be difficult and it is possible to have negative experiences; 3) that this awareness leads to increased empathy for clients that allows the transfer of knowledge gained in SP/SR to clinical practice, including an increased capacity to understand and explain the model and act as a therapeutic guide to the client, 4) and that overall this increases both confidence and competence and validates SP/SR as a lifelong process which results in enhanced motivation to continue such self-reflective methods. This hypothesised process is shown in Figure 15.

Figure 15: a “line of argument” demonstrating the relationship between constructs identified in a metasynthesis of qualitative studies on SP/SR (Gale & Schröder, 2014).

The author would conclude that, despite the lack of reliable evidence that personal practice improves client outcomes, positive therapeutic relationships and better therapeutic outcomes are more likely to be achieved by interpersonally sensitive, less distressed and more self-aware therapists who practice according to accepted guidelines that they have tried for themselves or seen modelled for them. These positive outcomes and processes are likely to reinforce a firm belief in the practitioner’s own competence and the efficacy of the treatment that increases allegiance to a model and confidence in the ability to practice it. Increased self-confidence potentially helps create powerful expectancy effects in clients that help to form a strong working alliance comprised of positive interpersonal bonds plus agreement on the tasks and goals of therapy. A sense of working together collaboratively on personally meaningful goals both helps motivate clients to disclose relevant experiences and engage more fully in therapy tasks. As facilitators of experiential learning in their clients, and as reflective practitioners themselves, capable and proficient therapists model an open-minded and reflective practice in the ways that they behave towards themselves and their clients that is congruent, compassionate and transformative.


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