(p. 93) Being and Becoming a Psychotherapist in Portugal: A Dialogue Between Personal and Professional Experiences1
As we strive to better serve our clients, we may find that we can learn important lessons from patterns and processes in our own lives.
Radeke and Mahoney (2000, p. 83)
Although the evolution of research in psychotherapy has proven fruitful with many methodological advances (Beutler et al., 2004; Hill & Lambert, 2004) and with a genuine concern for empirical validation of psychotherapeutic practice, studies concerning the psychotherapist as a person and implications for psychotherapy practice have been neglected. This chapter presents the results of a qualitative study conducted with 20 Portuguese psychotherapists regarding experiences and major changes in their professional development.
Despite the fact that the psychotherapist is considered an agent of paramount importance for the development of the psychotherapeutic process (Beutler et al., 2004; Norcross, 2002; Wampold, 2001, 2006) and the recognition by psychotherapists and researchers from different theoretical orientations that the psychotherapist brings more to therapy than his or her professional training (Reupert, 2006), the empirically supported treatments movement (EST) contributed to the devaluation of this component in research for several years due to studies primarily focused on therapeutic orientations (p. 94) (Beutler & Castonguay, 2006; Beutler et al., 2004). This may be due to the fact that EST research focuses on the study of therapies as a set of methods, procedures, and techniques that are per se effective in the treatment of psychological and psychiatric disorders (Orlinsky, 1989), and the subjective processes of human experience and relations are understood as a source of error to be eliminated or controlled in the research (Orlinsky & Rønnestad, 2005).
Nevertheless, this line of investigation has been disputed by studies that argue that the inter-therapist variability is a determining factor in the field of differential effectiveness, including the following:
1. Investigations that demonstrate that psychotherapists with the same theoretical orientation, using the same manualized therapy and trained, monitored, and supervised in the same context, produced different results (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Lambert, 1989)
2. Meta-analyses that show that the variability of psychotherapeutic results was better explained by the psychotherapist than by specific components of treatment, where the variability of psychotherapists explained 6–10% of the results (Ahn & Wampold, 2001; Del Re, Flückiger, Horvath, Symonds, & Wampold, 2012; Wampold, 2001; Wampold & Bolt, 2006)
3. Studies that identify psychotherapists who have consistently positive results and psychotherapists who have consistently negative results (Orlinsky & Howard, 1986)
4. Studies that identify psychotherapy iatrogenic effects as a result of the psychotherapists’ characteristics, such as lack of empathy, underestimation of the severity of the client’s problem, or negative countertransference and difficulties in managing countertransference (Hayes, Riker, & Ingram, 1997; Mohr, 1995)
5. Research and meta-analyses that support the implications of psychotherapist characteristics as important contributions to psychotherapy outcome (Beutler, Machado, & Neufeldt, 1994; Beutler et al., 2004; Laska, Smith, Wislocki, Minami, & Wampold, 2013; Luborsky, McLellan, Woody, Obrien, & Auerbach, 1985)2
Paradoxically, although Beutler et al. (2004) emphasize the importance of considering the characteristics of the psychotherapist other than theoretical orientations, these studies remain as an isolated island in the broad spectrum of psychotherapy research (Rønnestad & Orlinsky, 2005). In addition, these studies present several limitations (Gelso & Hayes, 2002; Lambert, 1989; Rønnestad & Orlinsky, 2005; Reupert, 2006), namely (1) most studies are limited to psychotherapists from the United States; (2) the samples are composed mostly of psychotherapists in training; (3) the range of variables studied focuses on characteristics such as age, social class, or personality type, neglecting internal and personal characteristics; and (4) the majority of studies on the self of the (p. 95) therapist focus on a theoretical perspective to the detriment of transtheoretical research. This last limitation is further supported by research showing that the choice of theoretical orientation is in itself inherent to the person of the psychotherapist and thus inseparable from his or her personality, experiences, values, and personal philosophy (Norcross & Prochaska, 1983; Vasco, 1992). This finding had already been stated by Strupp (1978):
The person of the therapist is far more important than his theoretical orientation … techniques are inert unless they form an integral part of the therapist as person. (p. 314)
In the end, each therapist develops his or her own style and the “theoretical orientation” fades into the background. What remains salient is a unique personality combining artistry and skill. (p. 317)
Conscious of the neglected role of the psychotherapist in the research field (Garfield, 1997) and the unavoidable finding that some psychotherapists are simply better than others (Gelso & Hayes, 2007), two main lines of research have developed focusing on the study of the psychotherapist’s development. The first concerns the international project organized by members of the Society for Psychotherapy Research (SPR Collaborative Research Network) that gathers research from almost 50 different countries (Rønnestad, Willutzki, & Tarragona, 2010). Using quantitative methodology, the study aims to examine the characteristics, practices, and experiences of psychotherapists from different countries and theoretical backgrounds. The second is based on qualitative methodology and has been developed by Skovholt and Rønnestad (1995), Jennings, Goh, Skovholt, Hanson, and Banerjee-Stevens (2003), and Sullivan, Skovholt, and Jennings (2005) in order to study representations of psychotherapists’ development with different levels of experience, different theoretical orientations, and with an emphasis on psychotherapy expertise.
These studies do not assess psychotherapy results. Instead, they stress the importance of the person of the psychotherapist by challenging the psychotherapist’s uniformity myth (Kiesler, 1966) underlying the continuities and discontinuities that occur in the professional development of psychotherapists. These studies do not intend to overlook the importance of other factors, such as the client’s characteristics or the contributions of different theoretical orientations, but strive to promote a holistic understanding of the psychotherapist’s effect on psychotherapy. In addition, the study of psychotherapists’ representations of their professional development seems to be one of the privileged ways to access the wisdom that often remains locked in the psychotherapy offices. Gelso and Hayes (2007) state,
Knowledge of how therapists’ backgrounds, personalities, and experiences affect their work with patients has been based almost exclusively on therapists’ personal reflections and anecdotes. Therapists often share their experiences and knowledge (p. 96) with trusted colleagues with whom they work closely, but much of this valuable clinical wisdom accrues, and atrophies, in the offices of individual therapists. It has been difficult to generate and retain a collective, cumulative wisdom about the person of the therapist because this information is transmitted so infrequently in public forums (e.g., symposia, workshops, and professional books and articles). (p. 113)
The study of the psychotherapist’s development can be crucial in comprehending the complexities inherent in psychotherapy effectiveness because it provides an understanding of the relational dynamics that may interfere with the development of the psychotherapeutic process. On the other hand, in the genesis of these studies is a genuine interest in the accumulated psychotherapist archetypes, whether as a mechanism for the progressive differentiation of the elements embodied in the psychotherapeutic process or as an understanding of the preferred path to becoming fully human and competent therapists (Skovholt, Jennings, & Mullenbach, 2004). Rønnestad and Skovholt (2003) state, “If a more accurate and comprehensive conceptualization of therapist counselor development is attained, we can better arrest the negative avenues of professional development such as incompetence, impairment, burnout, and disillusionment” (p. 6).
The pertinence of the current study is also due to the fact that to date, there have been no published studies in Portugal concerning psychotherapists’ representations of their own professional development. The results of the current study are discussed considering international psychotherapist development research.
The Current Study
The aim of this study was to analyze representations of psychotherapists from different theoretical and practical backgrounds who are recognized by their peers as experts and also to analyze the experiences perceived as being crucial to their professional development. Research suggests that experienced and recognized psychotherapists in different areas of mental health, the informant-rich cases, are an important source for identifying salient variables (Patton, 1990) that contribute to psychotherapeutic effectiveness (Jennings & Skovholt, 1999).
In the current study, we used qualitative methodology because it is considered a preferred method for exploratory phases of research and it allows in-depth study of complex phenomena such as the construction of meaning of the whole process that being and becoming a psychotherapist involves. The use of qualitative methods is especially relevant when we want to access the experiential world of individuals, through concepts, languages, and meanings, which are less likely to be captured by quantitative methodologies (Polkinghorne, 2005).
A phenomenological approach was also used because it privileged the procedural construction of meanings of the psychotherapist’s development. In this analysis, we do not intend to draw a developmental trajectory of psychotherapists but, rather, to analyze (p. 97) the perceived contribution of therapeutic as well as extratherapeutic experiences on the psychotherapist’s professional development.
The sample selection strategy is considered purposeful. In order to identify information-rich cases (Patton, 1990), we used the peer-nomination technique, in which nine psychotherapists from different orientations identified colleagues who they considered good psychotherapists and who they would consult for personal psychotherapy. Twenty-three therapists gathered more consensus among their peers. Some of these therapists were also engaged in teaching and/or supervision activities as faculty and in psychotherapy associations or societies.
Participants were recruited through telephone contact and via e-mail. From a total of 23 contacted psychotherapists, 20 agreed to participate in the study. The ages ranged from 35 to 77 years (M = 50.35 years, SD = 9.95), and years of experience ranged between 10 and 44 years (M = 21.4 years, SD = 8.79). Eleven therapists were female, and 9 were male. With regard to professional background, 16 were psychologists, 3 were psychiatrists, and 1 was a general practitioner. Regarding theoretical orientations, 4 were identified predominantly with the cognitive–behavioral model (cb), 5 with the constructivist model (c), 3 with the humanist approach (h), 4 with the psychoanalytic approach (p), and 4 with the systemic approach (s).
Instruments and Procedure
For the construction of the interview guide, we used a specific type of semistructured interview, conceptualized as expert interview (Flick, 1998). This type of interview restricts its focus to thematic analysis in which the individual is clearly recognized. The semistructured interview is a flexible and detailed data collection method (McLeod, 1995) that allows a deeper exploration of themes and to monitor the relevance of content. The interview developed is composed of 16 open-ended questions, grouped into the following eight main themes (Carvalho & Matos, 2006):
1. Motivations to choose psychology/psychiatry as a career
2. Motivations to become a psychotherapist
3. Development as a psychotherapist (major changes, change agents, personal style, and characteristics that remain stable)
4. Current conceptualization of the process of therapeutic change and the main characteristics of the psychotherapist that best contribute to the psychotherapeutic process and the promotion of change in psychotherapy (p. 98)
5. Impact of being a psychotherapist on private and relational life
6. Impact of personal and relational experiences on psychotherapeutic practice
7. Current difficulties in practice
8. Future aspirations as a psychotherapist
The interviews were conducted in psychotherapists’ work contexts (except two interviews) and were on average 50 minutes in duration. At the beginning of the interview, the general purpose of the study was explained, participation was consented to, and consent for audio recording of the interview was requested. The interviews were then transcribed taking into account the discursive nature of the narratives.
During data collection, interviews were successively transcribed and then pre-analyzed by both authors of the study. This procedure allowed a reflection of questions that could be included or reformulated so as to collect important data that spontaneously emerged in previous interviews. Data analysis was conducted using the grounded theory method (Glaser & Strauss, 1967; Strauss & Corbin, 1990). Grounded theory, as the name implies, is a method of qualitative analysis, which aims at the construction of theory based on data through the use of a set of systematic and inductive procedures (Strauss & Corbin, 1990). This procedure allowed, at first, to collect sections of text that expressed different meanings and stages of the psychotherapist’s development because participants could explore the same theme in different questions. Then these sections were organized into descriptive categories and emerging themes. The categories were titled according to the description made by the participants in the study. This nomination process is referred to as the in vivo coding method (Glaser, 1978) and is encouraged to maintain proximity to the data. Throughout the process of analysis, higher ranking categories emerged according to their ability to group the concepts and categories previously defined. It is a method of increasing complexity and abstraction because the grounded theory comparative method (Glaser & Strauss, 1967; Strauss & Corbin, 1990) requires continuous reflection and reformulation of previously analyzed data. However, data analysis did not entail an inductive linear perspective from concrete to abstract but, rather, a cyclic perspective, which entails a return to the data until the construction of the participants’ narrative essence, designated the core story (Charmaz, 2000; Strauss & Corbin, 1990). The adopted methodology was based on a constructivist perspective of grounded theory because the analytical process reflects the construction of meanings that therapists ascribe to their experiences, as opposed to a positivist perspective of discovering truth (Charmaz, 2000). This process is not free from the subjectivity of the investigator; therefore, strategies were adopted for conducting cross-validation analysis. The first strategy relates to the need to include a peer debriefer (Creswell, 2003), who reviews the entire analysis process, from the organization of the coding themes, categories, and subcategories to the interpretation and discussion of results. The entire process of encoding and data interpretation was (p. 99) carried out in partnership by the authors, with the supervisor of the study being assigned to the study as peer debriefer. The second strategy relates to actively seeking to maintain closeness to the data by in vivo coding, graphic representation of the results, or via the use of the psychotherapists’ narratives in the presentation of results. The third strategy involves constant reflection and dialectical analysis of data through the use of the bracketing technique. These strategies are considered by different researchers and methodologists as important techniques to validate data in scientific qualitative research (Creswell, 2003; Fischer, 2009; Flick, 1998; Williams & Morrow, 2009).
Two major themes emerged from the analysis: (1) relational experiences in psychotherapist development and (2) phases and changes of the psychotherapists’ development. The first theme is organized into two subthemes, namely relational experiences in the professional domain and relational experiences in the personal domain, which contributed to the development of psychotherapists. The second theme is also divided into professional domain and personal domain. Finally, the core story (Charmaz, 2000; Strauss & Corbin, 1990) is identified because it is the element that emerges from the narratives as being more representative of how psychotherapists attributed meaning to their experiences and their developmental process. Furthermore, being transversal in the analysis, it represents a synthesis and integration of the two aforementioned themes of the development of the psychotherapist.
Given that the qualitative analysis does not end at the categorization and codification of the data but also extends to the writing process, we seek to present this co-constructed narrative of the experiences of psychotherapists.
Theme 1: Relational Experiences of Psychotherapist Development
Subtheme 1: Relational Experiences in the Professional Domain That Contributed to the Psychotherapist’s Development
In psychotherapeutic practice, experiences signifying as being the most striking ones arise in the context of interaction with clients. The relational nature of psychotherapy is understood by psychotherapists as educational and transformative in the sense that the shared experience of the psychotherapeutic situation is constituted as a privileged space for professional development. In this theme, three categories emerged: (1) experiences with positive impact on the psychotherapeutic practice; (2) experiences with negative impact on the psychotherapeutic practice; and (3) factors validated by the psychotherapeutic experience, considered crucial in the psychotherapeutic process. (p. 100)
Experiences with Positive Impact on the Psychotherapeutic Practice
The following are understood as having a positive and reinforcing impact on the practice of psychotherapy: (1) experiences that promote a feeling of gratification for the help provided in situations of great suffering and in which the psychotherapist perceives a sense of usefulness, (2) experiences of access to privileged dimensions of human experience through the clients, and (3) the nature of the emotional bond.
The perception of success in following difficult cases that provoke high emotional activation in psychotherapists (among other processes, due to the vicarious experience of suffering) is felt as reinforcing psychological commitment to clinical practice, particularly in the early stages of psychotherapeutic practice. These experiences come to be so significant that they can determine the preference of the psychotherapist for certain clinical populations and even the decision of continuing as a psychotherapist. One interviewee referred to a difficult case as a central marker of the resolution of his distress. It was based on inappropriate expectations in his role as a psychotherapist and made him question whether he should continue his clinical practice (c1m)3. Some processes are represented as milestones in transitions of the developmental phase. Consider, for example, the case of a (p. 101) psychotherapist who has in her bag photographs from a client whose process represented a milestone in the therapist’s ability to establish the psychotherapeutic relationship (s1f), or the case of another psychotherapist who keeps a drawing on his office wall concerning a difficult process of great emotional activation (c1m).
The access to privileged dimensions of human experience is also regarded by the participants as having a positive impact on psychotherapeutic practice, particularly witnessing the client’s fighting capacity, as well as the interest aroused by the idiosyncratic philosophizing of the client (h1m):
The more charming side of psychotherapy is that you have windows to the most interesting aspects of people—that is, the ability to face and fight against an extremely adverse situation. (c2m)
The nature of the emotional connection that psychotherapists establish with certain clients and access to significant material of the client’s experience is also considered a turning point in their history as psychotherapists:
The [most striking] moments are the ones of patients or people with deprivation histories or disorganized attachment to close figures that become emotionally activated, and attach to us in a very particular way while having great esteem toward us. These patients then allow themselves, the remembering and activation of certain memories, and we try to work with them through these life events. It is a privilege to have access to such stories. (cb2m)
Experiences with Negative Impact on the Psychotherapeutic Practice
On the other hand, other dimensions are regarded as having a negative impact on the psychotherapeutic practice and in the development of the psychotherapist, insofar as they may compromise the practice, namely the perception of inability to help, particularly when associated with high expectations of the power of the psychotherapist to provide help; dropouts from psychotherapy when they are unexpected and are represented as a threat to the ability of assessment of the psychotherapeutic progress; and difficulties in establishing the psychotherapeutic relationship with certain clients with certain problems (issues), described by a psychotherapist as a terrible event (cb1f) and expressed in the following statement:
To feel that they [the clients] needed to be helped, but, on the other hand, to wish they did not return because it was too hard for me … some sessions are too painful from the human point of view, because we are not able to distance ourselves, we are always very attentive to any phrase or any words that we can say that can be interpreted in the wrong way and throw everything away [risk everything]. (s2f)
(p. 102) Other experiences believed by psychotherapists as having a negative impact on the psychotherapeutic practice and on the development of the psychotherapist are the difficulties in managing the limits (boundaries) of psychotherapy with clients, particularly in situations of harassment, stalking, or approach beyond the limits of psychotherapy and attempts at manipulating, especially in marital psychotherapy; and the emotional burden that the relational experience involving dramatic situations and the experiencing of human suffering at its limit may cause in the psychotherapist, which is reflected in the following narrative:
We have to absorb a lot of negative emotionality, that passes through us. … We carry the voice of patients with us, emotions are with us and it takes hours to drain out of the body, hours. … We touch the absurdity of life, we are there with the absurd in our arms and, sometimes, it takes hours to free ourselves of this. (c2m)
These experiences are perceived as being negative due to the difficulty in managing emotions, particularly in the early stages of practice. Supervision and peer discussion are represented as being optimal moments because they offer the security and tranquility necessary for the exercise of clinical practice, particularly through the confrontation with new perspectives on intervention. Moreover, they help psychotherapists in the management of the emotional charge raised in confrontation with situations/limits of human suffering. These ideas are expressed in the following statement:
That sharing is almost like a catharsis, ready ok, lets unload … we bring that emotional charge, so we have a colleague with whom we will unload and we’ll talk about what we feel, what we think, and the doubts that we have. … This helps a lot, it seems that. …Phew, it took a weight off my back. (s2f)
Factors Validated by Psychotherapeutic Experience Considered Crucial in the Psychotherapeutic Process
Synthesis and integration of experiences arising from the psychotherapeutic practice contribute to the validation of the determinants of the psychotherapeutic change process. Some of them are already addressed in theoretical training, but they are reinforced by accumulated practice, particularly (1) the importance of clients’ personal meaning (sense) of their problems, which brings us to a collaborative understanding of the psychotherapeutic process well expressed in the statement, “the good hypothesis is the useful hypothesis, not necessarily the true hypothesis!” (s3f); and (2) the importance of the quality of the psychotherapeutic relationship as a determining factor of the process.
Another factor that emerges from accumulated and reflexive practice is the pragmatic awareness of help—that is, the emerging knowledge from meeting multiple clients and their stories that are preserved in the memory of the psychotherapist, becoming important resources in conducting new processes: (p. 103)
I’ve done very complicated crossings with other people, and so I’ve been the boatman to many people. And I can tell many stories that have a lot of clinical validity, which help a lot of people to realize their experiences and feel validated in their difficulties, so this is in fact an important added value and that doesn’t come in the manuals, it is the learning of the pragmatics of clinical intervention. (c2m)
Subtheme 2: Relational Experiences in the Personal Domain That Contributed to the Development of the Psychotherapist
Regarding personal experiences of the psychotherapist, events underlying normative and non-normative transitions were signaled as formative in becoming and being a psychotherapist. In this subtheme, two categories emerged: implications for psychotherapeutic choices and implications for psychotherapeutic relationship.
As one participant told us, these are the “lights and shadows” of the personal trajectory (s4f) that are projected in the psychotherapeutic setting:
The person matures, will pass important phases of the life cycle, in personal, marital, and family terms. Clearly, I think that is a very important factor in the maturation of a psychotherapist and the growth of a psychotherapist. (s4f)
Implications for Psychotherapeutic Choices
The permeability between personal and cultural life events and decisions in the professional sphere is represented in the vocational choice of psychotherapy and in the preference for certain intervention models and clinical populations.
Regarding the vocational decision for psychotherapy, experiences in the context of peers and family that promoted reflection and questioning as well as events that triggered personal crises (e.g., relational disruptions and losses) were cited as motivating the interest in and motivation for understanding human behavior:
I had a period of personal crisis, I was very depressed, my relationship ended, anyway it was a pretty difficult phase for me, it was a period of questioning and, suddenly, I found that I became fascinated with how people function. (c1m)
In Portugal, the April Revolution in 1974 marked the overthrow of the dictatorial regime and the establishment of democracy. The revolution also signified a cultural and political shift that enhanced creative questions, debates, and concerns of social intervention and was represented by some psychotherapists as a context favorable to the emergence of interest in the social sciences and humanities.
Personal experiences had an impact on the preference for certain theoretical models, populations, and problems. A psychotherapist reported the impact of the birth of his (p. 104) daughter on his willingness to continue to assist children in a more analogical way (c1m). Another psychotherapist told us about the relationship between the death of his father and his interest in existential issues (cb3m).
Implications for the Psychotherapeutic Relationship
Interviewees also signaled the impact that certain life experiences had in the construction and meaning of the psychotherapeutic relationship, particularly with regard to empathy and building hope:
With age and time, life brings us things that helps us to better understand the world of other people. (h3m)
I went through various tragedies in life, maybe the fact that I have always managed to deal with things in a more constructive, positive way and with a smile, I think it helps when I watch others in their suffering. … My competencies, my strengths helped me to understand others, to support them to discover their own strengths and skills and, perhaps, to be more convincing in the transmission of these strengths and skills. (s1f)
Theme 2: Phases and Changes of the Psychotherapist’s Development
Subtheme 1: Phases and Changes in the Development of the Psychotherapist in the Professional Domain
Psychotherapists said that in the course of their development, they built different representations about psychotherapy and their role as psychotherapists. These changes are perceived as being significant and in sharp contrast to previous representations. These changes are present in the expression mentioned by two of the respondents as night and day (p1m and cb2m). The representations of the main changes were organized into five categories.
Each category is defined by bipolar dimensions, which describe a movement of change underlying the development of the psychotherapists’ representations. However, these dimensions do not imply a static and exclusive developmental state or phase but, rather, are represented by psychotherapists as developmental paths of an erratic and constant dialogue of personal and professional structures of the psychotherapist’s self. Thus, they are dialectic categories looking for consistency between the challenges offered by the practice and the sense of identity of the psychotherapist. These domains are spontaneous references in the narrative of the participants when questioned about their changes as psychotherapists and about their views of psychotherapy. The following categories were identified:
1. Potentialities and limitations of psychotherapy and psychotherapists: Super Psychotherapist versus Human Psychotherapist
2. Attentional focus on the evaluation of the psychotherapist’s performance: Psychotherapist Auto versus Psychotherapist Inter (p. 105)
3. Management of emotional involvement: Client’s Shoes versus Shoes of the Psychotherapist
4. Role of psychotherapist and client in defining the goals of therapy: Psychotherapist Author versus Psychotherapist Coauthor
5. Factors underlying the intervention (external and internal focus): Styles of Psychotherapy and Stylish Psychotherapist versus Personal Style of Psychotherapist
Potentialities and Limitations of Psychotherapy and Psychotherapists: Super Psychotherapist Versus Human Psychotherapist
The potentialities and limitations of psychotherapy and psychotherapists are, at the beginning of clinical practice, represented by an idealized fantasy (p1m) of naive omnipotence (c1m) and salvation of the other (c1m):
It’s like a very, very strong illusion that we are going to change the world, or that we change people, we have a fabulous arsenal, or we have fabulous nuclear weapons to change people. (c2m)
(p. 106) There is very much the myth of psychotherapy, as if a person possesses magic, a bright crown around the head that distinguishes them from others! (c3f).
These initial representations emerge in the context of either internal expectations about the psychotherapeutic role or external and sociocultural expectations about psychotherapeutic practice. The psychotherapist incorporates what we call the Super Psychotherapist, and clinical practice is mythologized in terms of the ability to help and promote change in clients.
These expectations promote high anxiety and insecurity, especially in the face of non-immediate results socially imposed on the psychotherapist. In the course of clinical practice, the progressive realization of the limited nature of psychotherapeutic help, the construction of what we call the Human Psychotherapist, is seized by the growing complexity of the possibilities of psychotherapeutic space and the role of the psychotherapist in the process. Two of the interviewees refer to this change as follows:
In the beginning I had a somewhat idealized vision, a little more omnipotent. … I thought that psychotherapy could solve all the ills of a person and, today, I don’t think any of that. … Psychotherapy is like yeast in cakes, if the eggs are not there, if the flour is not there, if the ingredients are not there, you can put the yeast in and the cake will not be as it could be, and this limitation of reality, I guess I started to accept, integrate and know that the contribution I can give is limited. (p3f)
Nowadays, I have a lot more security because I don’t feel pressed to solve the world’s problems, and I think that the problem of youth is that we think we can help people and that everything will be resolved. … Today I don’t have this weight on my shoulders. (cb1f)
A magical definition of psychotherapy, the psychotherapist’s superhuman power, and the underlying distress of the illusions of salvation are progressively replaced by the awareness of the possibilities and limitations of psychotherapy and the humanization of the psychotherapist as a provider of help. The understanding of the limits of psychotherapy results from (1) the acceptance that some problems fall outside of the psychological domain of intervention and that clients may benefit from a referral to other professionals or even to other psychotherapists, (2) the understanding of suffering as inevitable in life and human existence, and (3) the acceptance of uncertainty and ambiguity in the psychotherapeutic process. Understanding the limits is particularly expressed in the following statements by a psychotherapist:
I better accept suffering in the lives of people and in my own life. Lives are suffered, there is no going back to it, we are not going to [take it away]. Suffering will continue to exist, whether there are psychotherapists or not. (c1m)
(p. 107) I am less rushed than I was 10 years ago also … I think that I dealt less with the ambiguity; therapy involves us dealing with the ambiguity, not realizing what is ahead, unable to make sense of the case and to be able to deal with this ambiguity. (c1m)
Fundamental characteristics of a psychotherapist? Humility regarding own knowledge and the ability to help the other to create change. (s3f)
Attentional Focus in the Assessment of the Psychotherapist’s Performance: Psychotherapist Auto Versus Psychotherapist Inter
Continuing a perception of unlimited power in psychotherapeutic help in the beginning of practice, characterized by Super Psychotherapist, produces what we call the Psychotherapist Auto, self-centered on his or her abilities and competencies to promote help in psychotherapy. Gains and setbacks in the process are primarily attributed to the psychotherapist’s own performance. This self-focus is felt as promoting high anxiety, distress, and fear of making mistakes that have iatrogenic implications. These emotional reactions inhibit a holistic and relational understanding of the psychotherapeutic process. The following statements exemplify this attentional focus:
At the beginning, I was so scared and had so much fear of not being able to do things well, I was so worried about what I was saying, what I did, what I thought, what I felt, basically there was a giant eye on myself that did not let me be available to others. (p3f)
I lived with an intense anxiety, that is, for me it was highly uncomfortable. … There was a time when I considered quitting, I suffered a lot from therapy. Imagine, the day before therapy I began to get tense. (c1m)
Progressively psychotherapeutic effectiveness is no longer understood as being exclusively dependent on the performance of the psychotherapist and on the theoretical models, and a relational understanding of psychotherapy emerges. The attentional focus of the psychotherapist turns to the dialogical interaction in psychotherapy. A movement to what we call the Psychotherapist Inter is in progress.
A sense of greater security and serenity in the management of errors and psychotherapeutic impasses is increasingly developed with experience and a continuous reflexive stance. Psychotherapists perceive self-efficacy particularly in challenging therapeutic processes. The progressive decentering of the Psychotherapist Auto toward the Psychotherapist Inter extends the psychotherapeutic space. Psychotherapy becomes more complex, and the psychotherapist discovers the client and his or her importance in the evolution of the process. Within a broader and relational conception of change, the Psychotherapist Inter has more room to allow him- or herself to improvise and to risk innovation/creativity. Clients become important agents of learning, (p. 108) and the psychotherapeutic relationship becomes an important indicator of psychotherapeutic progress. The Psychotherapist Inter is now more available to the other and to the complex sphere of psychotherapeutic relationships:
I actually had a lot of fear of not being up to the situation, which ended by not being available for the relationship, I was more concerned with me than with the person and with the relationship, and I think that it passed, fortunately! … I think now I can take pleasure in the situation, which at the time I could not because of fear. (p3f)
Managing Emotional Involvement and Proximity: Client’s Shoes Versus Shoes of Psychotherapist
One of the factors that psychotherapists consensually indicated as being more influential in psychotherapeutic success is empathy. As an essential quality of the psychotherapeutic relationship, empathy is characterized as a difficult and complex process, given the encounter between two epistemic realities, client and psychotherapist; the management of emotional charge potentiated by the vicarious experience of suffering; and the difficulty establishing a genuine relationship of unconditional support:
Am I really able to understand this person? I think that is one of the hardest things to do … understanding, empathy. There aren’t many encounters with others that are genuinely open, with a total availability to others, it happens few times … to be unconditionally on the side of people is not something so easy, we are accustomed to believe very conditionally. (cb3m)
The polarization of this category, Client’s Shoes versus Shoes of Psychotherapist, emerges from the definition of empathy as a metaphor for the capacity of the psychotherapist to put him- or herself in the shoes of the client knowing that the shoes are not his or her own, meaning not to lose his or her own references (Rogers, 1975; Skovholt & Rønnestad, 1995). To wear the “shoes of the client” as an empathic exercise without the “as if” condition can lead to identification with the client and projection of own experiences. This is perceived as problematic, either because of the impact it can have on the quality of emotional support provided to clients or because of the effect on psychotherapists’ personal lives.
“Absorbing negative emotionality” (c2m), the “weight of the stories” (c4f), and “sleeping with the cases” (c3f) are statements that point to the risk of overidentification—that is, to permanently wearing the client’s shoes, which can contaminate other contexts of psychotherapists’ personal experience.
The movement that allows the psychotherapist to understand the frame of reference of the client requires the learning of an optimal emotional distancing in the (p. 109) psychotherapeutic relationship. “Close the door, remove the client’s shoes” protects the psychotherapist from emotional overinvolvement and appears to be an important achievement in obtaining security in the role of a psychotherapist, as expressed in the following statements:
It seems that this is an achievement to not to be afflicted with, to not be anxious with the anxiety of our patients, not to get depressed with the depressions of the clients, but still stay attuned. … Empathize with the person, without letting us invade. (p2f)
From an early age, I learned that I can’t take things home, and this causes the person to have to set limits … and it is the only way that I have to continue to enthuse myself and be touched by the situations, but without getting depressed or carrying it for the rest of my life. … To continue to be there one hundred percent we have to protect ourselves somehow. (cb1f)
Role of the Psychotherapist and Client in Defining the Goals of Therapy: Psychotherapist Author Versus Psychotherapist Coauthor
At the beginning of practice, the definition of the aims of therapy tends to be paradoxically imposed by psychotherapists. We say “paradoxically” because it is precisely at the beginning of practice, with less experience, that psychotherapists need to lead therapy and to have certainty in the intervention and the results to be achieved. Although, as one of the participants mentioned, if dealing with fragile and misleading representations,
When I entered the first session, I soon had all the responses. … I think that because of this felt omnipotence in the first session ……, “I know what I will do next time,” but in fact do not know. (c1m)
Thus, the search for objectivity and safety of practice, validated by personal and cultural expectations of the unlimited power of the psychotherapist, underlies the emergence of what we call the Psychotherapist Author. The Psychotherapist Author is characterized by a unified definition of the aims of therapy, namely
(1) by a concern with diagnosis and rapid identification of the problem; (2) by the need to observe rapid changes and to “see things work” (cb2m); (3) by the directivity and imposition in conducting the psychotherapeutic process; and (4) by the structuring and programming of the practice, particularly by referencing textbook treatments and structured and planned interventions:
In the beginning, it was a little more rigid, one thing you learn in a certain way, leads to the first interview, looking to follow those steps, the person is very attached to a script in the beginning, it is for the sake of safety and security. … Then the person (p. 110) forgets them, but integrates them in such a way that they seem to arise naturally, I can’t think “Now I will use a paradoxical strategy!” (s4f)
[In the beginning] maybe I was more involved in the desire to heal, inhibited less my desire to steer the situation a little, and I have learned to be more silent, more able to accept that one has to do more internal work, more slowly, and therefore greater tolerance. … The young often get anxious, because results fail, or strive so much that it seems that they want to be the authors of the improvement of the patients, who after all have to learn to manage their conflicts themselves, to understand what is happening with them. (p2f)
With the expansion of the role of the client, a collaborative and shared definition of psychotherapy comes about through what we call Psychotherapist Coauthor: This movement is characterized by the reinvention of variables such as timing and client’s alternative contexts of change and by relinquishing the total and absolute control of the psychotherapeutic journey, considered erratic, undefined, and endowed with a dialogical complexity, evident in the following statement:
We get out of that attitude in which we have the knowledge that the other person lacks. … We enter a more collaborative one, to know each other and help each other to achieve what you want, and not what I think he should reach, is a colossal shift. … It gives us a whole way of being with the person that is totally different and I think more rewarding for me in this case … to be open to each other, to the phenomenological experience that the other person brings. (cb1f)
The Psychotherapist Coauthor is also defined by epistemic opening and humility. Finally, the Psychotherapist Coauthor distributes the power in therapy and considers the client as an essential agent in the definition of psychotherapeutic success:
There was another thing that came later; which was that I started to become aware of things that clients themselves taught me. … I think at the beginning I did not even let them teach me. (s3f)
Underlying Factors to the Psychotherapist’s Intervention: Styles of Psychotherapy and Psychotherapists Stylish Versus Personal Style of Psychotherapist
Throughout their training, psychotherapists have access to ways of thinking about psychotherapy, either through theoretical models or through senior psychotherapists and trainers. This is represented by psychotherapists in the beginning of clinical practice as being of conceptual and theoretical clarity. They tend to become fascinated with the models that give a sense of apparent security in the face of the initial chaos fostered by the complexity of the psychotherapeutic intervention: (p. 111)
Let’s say that I believed in the model in a very naive way, for three, four years. It was nice, it gave me that fantasy, that innocent security of the early years, convinced that I could do anything, that I had solutions for everything, so it helped me in that sense, it gave me a certain determination in the intervention that helped. (c2m)
I think there is a phase of a certain initial fascination with the model, with the theory, with the possibilities, seeing senior people speak to us of their work, after that there comes the awareness that this is not as easy as it seems. . . to be with a client is a difficult thing, which requires a lot of training, requires a personal reflection on how we are and how we behave, the felt difficulties … there is an awareness of a personal path that has to be completed [executed]. (h2m)
The guiding factors of intervention at the beginning of psychotherapeutic practice are initially inspired by the use of theoretical models and textbook practices due to the structure they provide (Psychotherapy Styles) and the simulation of senior psychotherapists and in questioning before difficulties or impasses (Psychotherapists Stylish).
Given the adoption of external references in the definition of authenticity, the practice is increasingly felt as stiff and uncomfortable, formatted, and with the feeling of “performing a role” (cb3m). The progressive awareness of (1) the nonlinear character of the psychotherapeutic process and (2) the diversification of theoretical models, in terms of trainers, models, and intervention strategies and techniques more in line with the psychotherapist’s genuine self, allow a more spontaneous, flexible, and individualized therapy.
The Personal Style of the Psychotherapist appears to result, thus, from the synthesis and integration of theoretical influences and personal styles of the psychotherapists observed, as well as from the use of personal characteristics in practice, such as the use of humor, metaphors, and self-disclosure:
I was indoctrinated with self-control and the absence of complete openness on the part of the psychotherapist, the total absence of transfer and countertransference and indoctrinated with the manual that is “you have to be the manual and not yourself.” The big difference in principle from that time to now is that I’m much more at ease being myself and saying what I feel and what I think, as an important factor in the psychotherapeutic relationship and change, in favor of the patient, not for my well-being. (c2m)
The genuineness and authenticity arise as a corollary of integration and search for congruence between personal and professional experiences, and they inspire creativity and satisfaction with the challenge that the permanent attempt to understand the other demands. Consider the following descriptions:
It’s funny … I was remembering an expression that Figo [soccer player] has used, that maybe is similar to what I feel at this moment … [when he] was asked if (p. 112) he was going to play that game being angry or afraid he responded in a way that I think is very funny: “No I’ll play as I always play the game, for enjoyment.” … This is how I play, that’s how I like to play and I’m going to play like that and that gives me pleasure, in fact, to do psychotherapy today! It is curious because it is a radical change from six or seven years ago, it gives me joy, sometimes I even forget myself! … I would like to be able to see me ten years ago, because … WOW! (c1m)
On the other hand, when we want someone to find himself and pop out of the internal packages that limit, meaning that their identity comes to the surface, we also have to be ourselves, despite the technique. Pretense, hypocrisy, patting yourself on the back, do not fit in this relationship. (p4m)
Finally, the psychotherapist has space to reinvent him- or herself and to be there 100% (cb1f), being able to be with his or her client in a true way, “without masks, without being artificial and … without defenses, fears” (h2).
Subtheme 2: Phases and Changes of the Psychotherapist’s Development in the Personal Domain
For psychotherapists, the nature of change does not take place only in the professional field but also in the personal domain. This subtheme is organized into three categories that represent precisely the implications that the practice takes on: representations of the self, representations of the other, and representations of the world.
Representations of the Self
The trips that the psychotherapy takes to the world of others, embodied in the process of empathy present during the psychotherapeutic encounter, seem to promote the development of a sense of tolerance, “a less superficial and deeper understanding” (h1m) of the human being, which is reflected in the self through self-knowledge and acceptance of the psychotherapist’s personal characteristics. A psychotherapist describes the impact of being a psychotherapist on her personal life as follows:
From the personal point of view, I feel that therapy [being a therapist] helped me to grow and live in a more peaceful, more serene, less troubled, less anxious way. Here’s a question that I think is very important, to be aware of my own inner world, of my own fears, anguishes, concerns, not to escape it, to take it as mine. (h2m)
It is interesting to note that the understanding and acceptance of the therapist by the client constitutes one of the objectives to promote in psychotherapeutic help, and it seems to be a spontaneous result in the development of the psychotherapist. Despite the client’s role being clearly differentiated from the role of the psychotherapist, the relational (p. 113) dialectic seems to constitute itself as an opportunity for a deep knowledge of self in relationship. As a psychotherapist told us, “We’re doing a psychotherapeutic process with our clients and we are ourselves doing [receiving] psychotherapy” (s2f).
Vicarious experience of suffering and of human limits also has implications for the relativization of priorities and the devaluation of what some psychotherapists have defined as “trivial” problems (s2f and cb3m). Putting their own personal experience in contrast with the experiences of some clients triggers, somehow, a sense of privilege and of relief and an appreciation of significant relationships such as family and friends:
To perceive that life story, that person’s problems and to feel selfishly well about my family, with the story that I have. … Sometimes, I really don’t recognize what I have around me, for example. If you want, the effect it can have is of valuing. (c4f)
Representations of Other
With regard to the representations of the other, the main changes mentioned by the psychotherapists are the deep respect and admiration for the idiosyncrasies of the human being, so well expressed in the following statement:
We think, before studying these things a little bit, we know some determinants and we are able to predict the behavior of people, and in fact it is not so! …We are dealing with a person we see as unique and unrepeatable, there is no equal in the world, and this I think is a challenge, it’s exciting. (s4f)
This admiration for the human being has at least three implications for the personal experience of the psychotherapist. The first refers to a less rigid, more open and complex stance when encountering behavior that is in dissonance with his or her personal experience:
Therapy [being a psychotherapist] ultimately influences our way of being in life, our values, philosophies, even existential aspects, choices that are made, the profound respect for people, and even a more comprehensive approach to certain behavior, which could sometimes be seen as shocking, strange, bizarre. But we get to look at them in another way, have a certain tolerance and understanding, this might be the great influence of therapy. Accept the diversity of people and recognize that people have a right to make choices in their lives and this is something that concerns them, and that I don’t have to have an influence, or even often, an opinion. (h2m)
The second implication deals with a constructive approach to people’s capacities for resilience, emotional survival, and the process of making sense of disruptive experiences:
I worked with victims of torture … it has been a fantastic learning experience … because it showed me the extent of almost human limit, that is one (p. 114) thing that interests me, they amazed me! How do people who we imagine are totally destroyed by the most blatant and the most terrible things—and, in fact, the side of torture is one side of an unimaginable violence, and how people are able to survive this, and to restructure and to live well, is a remarkable thing. (cb3m)
The third implication concerns the sense of hope and tolerance vis-à-vis others believing in the resolution of the problems:
I think the big change that was taking place in me, in my personal relationships, was in acceptance. … I’m a very tolerant person. … I think that tolerance, tolerance for others, appears as a corollary of this whole process, this slow therapeutic relations broth. (h1m)
However, this same complexity inherent to the understanding of the other, “this deeper evaluation of psychological things” (h1m), is likely to promote anxiety and uncertainty:
I like to feel that the complexity with which we can see things—on the one hand sometimes we feel anguish, but on the other hand there is a feeling of fullness, that we do not give interpretations to the banal or everyday or superficial things, that we seek to understand the logic of things, how people function and its complexity, that sometimes is distressing because we are powerless to change a number of things, even of people who are by our side, but that, on the other hand, … gives the notion that we are seeing things in some depth. (cb2m)
Participants also mentioned professional learnings that were felt as positive experiences as psychotherapists in their relationships, namely in marriage, divorce, and remarriage and in parenting, because they contributed to a less dramatic and more creative experience of emotional challenges. Negative impacts on the emotional availability to others were also reported, notably the most close and significant ones, due to the implications of emotional wear of the psychotherapeutic relationship:
I think that during my divorce process, I managed to avoid a number of mistakes, I am absolutely sure, because theoretically I knew a lot about divorce and I think I managed to do a good job there. In terms of remarriage, there are many issues that arise and are unavoidable, and because I know they are unavoidable, I don’t dramatize, therefore, any other person who does not know that a particular conflict is inevitable, can dramatize. (s1f)
Representations of the World
To be a psychotherapist has implications in the form of shaping the world. The contact with a variety of worlds, arising from clinical practice, promotes a more flexible view and perspective on the world: (p. 115)
This access to people’s lives, that they allow naturally, is extremely beneficial … gives me a variability over the world, gives me flexibility, because people sometimes are in the same place, they live with the same people all the time, are at the same age, they become boring and extremely cynical. I think this is the natural antidote, I mean I somehow know that the world is diverse and that’s good, it’s nice, it’s interesting and I prepare myself for this world. (cb3m)
This diversity also appears to promote a sense of acceptance of the imperfect and absurd nature of human existence:
And life also has very absurd things, very violent things, very terrible things that have no explanation in the sense that they happen, we have to prepare ourselves for these things … life is not fair, there is nothing productive in many things. (cb3m)
The interviewees also referred to social concerns, expressed by the problems reported in psychotherapy and that seem to constitute important information about the state of the world for some psychotherapists:
Maybe the biggest impact is to think of society in these recent years, I am thinking “In which society do I live, which brings these problems?” … “Why is it that people are like that?” “What is it that brings this transformation?” “What are we making of ourselves, of society and of the world, in the small portion that I can contribute?” (cb1f)
For other psychotherapists, worldviews are inspired by their theoretical models, and this sense of understanding goes beyond the psychotherapeutic setting and is part of the more general domain of personal experience, as expressed in the following statement:
Through psychoanalysis, I realized what civilization was in general and how badly we comply. I noticed also the wars in which we live and how we could improve our own groups. It gave me opportunities for observation and understanding that I find very good. (p4m)
Core Story—Development of Psychotherapist: Dialogue and Coherence Between Personal and Professional Self
The core story unfolding in the interviews is the development of the psychotherapist as a progressive process of searching for consistency and coherence between personal and professional experiences. The professional development of a psychotherapist is intimately (p. 116) related to his or her construction as a person. This seems to be the most explicit representation by psychotherapists interviewed about their professional development:
I don’t see psychotherapy as having, psychotherapy is being. It’s a process of incorporation, we have to breathe this … because, it is also our own personal development. We also are very involved in the things that we have within ourselves, who we are, in the understanding of what we are, and in using that same understanding. (p1m)
The psychotherapist is a professional of the relationship and as one psychotherapist said, “It is a matter of fundamental research, knowing the [self of the] psychotherapist, because we are the main tool of our work” (cb1f). This tool (psychotherapist) is embedded within relational stories, memories, constructions of realities, meanings, and idiosyncrasies, which are inevitably a part of how psychotherapists practice psychotherapy.
The development of the psychotherapist does not apply exclusively to the professional domain of developing technical skills but also refers to the domain of self-knowledge and acceptance of personal characteristics as important resources for the development of a personalized practice of psychotherapy. Self-knowledge and self-acceptance are even considered as important resources in the acceptance and understanding of the other: “If the person is not capable of self-knowledge, he hardly gets to know the other, and if you can’t see the other, you are hardly able to be empathic” (s1f). One of the psychotherapists also told us about self-awareness present in the ability to read emotional resonances of the client:
I read better the discomfort in a relational mode, that is, when I feel uncomfortable, rather than thinking I’m inappropriate, I think “Why I’m feeling this, why is this person making me feel. …why is the relationship with this person making me feel uncomfortable, what is she trying to say to me?” (c1m)
The synthesis and integration of experiences from the personal and professional field, as well as the personal appropriation of the professional role, form part of the characteristics considered important in practice. The construction of a personal style of intervention and the legitimization of the person of the psychotherapist are viewed as central markers of the maturing and developmental process:
I’m much more myself [me] than I was in the past … and therefore, my well-being was legitimized in the relationship. My personal experience has been legitimized; the person who I am has become legitimized. (c2m)
The developmental process is represented as a lifelong process and what is considered vital is the curiosity, the openness to the phenomenological experience of the other. The fascination behind the understanding of the complexity and uniqueness of human (p. 117) primordial serves as gear lubricant of the unfinished development dynamics of the psychotherapist, as reported by one interviewee:
Psychotherapy is a phenomenon of humanity. … To be a psychotherapist is one path, and it is a path that never is, nor ever will be finished, it is a path to be carried on throughout experience, throughout life. (p1m)
The aim of this study was to analyze the representations of psychotherapists considered experts about the experiences perceived as being crucial to their professional development. It was not intended to draw developmental pathways but, rather, to analyze the variety of experience and changes that occur in therapeutic and nontherapeutic settings that contribute to the construction of being a psychotherapist. Two major themes emerged from the analysis: (1) relational experiences of psychotherapist development and (2) phases and changes of psychotherapist development.
The experiences that psychotherapists described as being more likely to promote change arise in interpersonal contexts in therapeutic or in personal relationships. This data is consistent with the findings from studies by Skovholt and Rønnestad (Rønnestad & Skovholt, 2003; Skovholt & Rønnestad, 1995), which claim that interpersonal experiences appear to be more important than impersonal sources of information such as seminars, work, and theories. Also, in Rønnestad and Orlinsky’s (2005) international study, clinical experience with clients is considered to be most crucial in psychotherapist development, followed by personal psychotherapy, supervision, courses and seminars, and experiences in the personal life of the psychotherapist. This finding does not mean, however, that compelling theoretical training and quality supervision are not important to psychotherapist development and to psychotherapy effectiveness.
In the first subtheme, relational experiences in the professional domain that contributed to psychotherapist development, we find that the experiences felt with a more intense emotional tone represent the most significant moments for psychotherapist development. On the one hand, we note that experiences represented as having a positive impact and that reinforce practice were the ones that return a sense of usefulness and effectiveness. These include experiences that restore a sense of gratification, experiences of access to privileged dimensions of clients’ experience, and emerging experiences that focus on the nature of the emotional bond that the psychotherapist develops with some clients. On the other hand, the sense of inability to help, unexpected client dropouts, difficulties in establishing the psychotherapeutic relationship, managing the limits of psychotherapy, and emotional distress caused by the practice seem to form developmental challenges that could trigger early withdrawal from practice or even psychotherapist (p. 118) burnout, which is a common professional hazard (Abreu, Stoll, Ramos, Baumgardt, & Kristensen, 2002).
Reflective and accumulated practice also seems to be represented as an important device for the validation of the determining factors in the psychotherapeutic process. The collaborative comprehension of the psychotherapeutic process, the importance of relationship quality, and pragmatic help, which is called context-sensitive knowledge (Rønnestad & Skovholt, 2003), are three of the characteristics identified by expert psychotherapists in the studies of Sullivan et al. (2005) and Rønnestad and Skovholt (2003). Because psychotherapy is a dialogic encounter between the psychotherapist’s and client’s realities, it is not surprising that the client is a mirror that constitutes the greatest reflection for the psychotherapist’s practice. It is precisely the understanding and integration of these dialogical moments that is the central catalyst of developing a sense of self and being in psychotherapy.
With regard to the second subtheme, relational experiences in the personal domain that contributed to psychotherapist development, we find that many of the choices made in the psychotherapists’ career, namely therapeutic orientations, preferred intervention populations, and the construction and meaning of the psychotherapeutic relationship (particularly with regard to empathy), were influenced by experiences in the personal domain. Rønnestad and Skovholt (2003) found that experienced psychotherapists reported a greater impact of personal life experiences on practice (namely experiences with a strong emotional tone, such as including stories of abandonment and also rigid and demanding family contexts). Although in the current study psychotherapists did not explicitly articulate which life events (particularly negative experiences) had implications for their practice, psychotherapists described how experiences that generate higher emotional stress in their personal life enhanced their psychotherapeutic practice and felt like gains, especially in terms of empathy and support.
In Rogers’ (1975) ironically titled article, “Empathic: An Unappreciated Way of Being,” he says that “the better integrated the therapist is within himself, the higher the degree of empathy he exhibits” (with clients) (p. 4). Being and becoming a psychotherapist is a process that goes beyond the realm of the theoretical models, techniques, and conceptual reading of psychotherapy, usually privileged in comparative studies (Reupert, 2006), and is part of a more complex domain of increasing differentiation and personalization of psychotherapeutic practice. Thus, this process is represented as continuing and unfinished because it draws on the dialectic between therapeutic and nontherapeutic experiences, the definition of psychotherapy, therapeutic change, the helping relationship, and the psychotherapist’s role being inherent to the psychotherapist’s developmental history. It seems, therefore, that the continued pursuit of coherence between the relational challenges of psychotherapeutic practice and the psychotherapist’s personal experience should be subjected to a deeper understanding, given its implications for clinical practice.
For the second theme, stages and changes in the development of psychotherapists, we present a figure that can help us analyze the categories along two main axes (p. 119) (Fig. 4.3), the diachronic and synchronic. The diachronic axis is implicit in the polarization of the categories and implies the temporality of change and the promoting factors. The synchronic axis emphasizes the importance of an integrated and inclusive understanding of the areas analyzed—for example, the categories constructed cannot be understood as developmental bumps but, rather, as salient representations of the development of the psychotherapist.
On the diachronic axis, a movement of progressive differentiation of the psychotherapists’ representations about their role in the psychotherapeutic space and process can be inferred. The supportive role of the psychotherapist is initially amplified, and the definition of psychotherapy effectiveness relies on technical expertise. This focus on the psychotherapist’s power goes through the hetero-imposition of therapy goals, means, and the processes underlying an idealized goal. The search for an objective and safe practice, validated by further personal and sociocultural expectations, underlies the emergence of Psychotherapist Author. Conflict between practice and the integration of experiences that challenge the initial definition of the psychotherapist role and of psychotherapy occurs with the progressive introduction of the client space and its contingencies in the process. This represents the core promoter of change in psychotherapy. The accumulated and reflected practice, and as was stated by one of the psychotherapists interviewed, “the broth of slow therapeutic relationships,” emerges as a challenging context for increasing complexity in the definition of help. The relational experiences and the cognitive and emotional movement that understanding clients demand appear to be agents for the differentiation of categories from a temporal perspective. The experience in itself is not a differentiating factor of the psychotherapist’s expertise. However, as mentioned by Goldberg (1992), experience is no guarantee of wisdom but constitutes itself as an excellent opportunity.
The conflict between psychotherapy and the psychotherapists’ limitations inherent to the movement of building a Psychotherapist Human implies the acceptance of uncertainty and ambiguity as well as the acceptance that professional practice does not exclusively depend on the psychotherapists’ technical and theoretical expertise (Matos, 2011). Rønnestad and Skovholt (1991, as cited in Skovholt, Hanson, Jennings, & Grier, 2004) reported that one of the mistakes of inexperienced psychotherapists is precisely premature closure—for example, when facing the ambiguity of psychotherapeutic (p. 120) practice, psychotherapists cling to simplistic solutions, theories, or frameworks in order to avoid feeling cognitively and emotionally overwhelmed. Although this strategy can inhibit anxiety and professional uncertainty, it appears that this same ambiguity and anxiety can induce reflection and opening. Neufeldt, Karno, and Nelson (1996) state that reflection is the enhancing of the conversion of experience into expertise.
Another important feature of psychotherapists in this study relates to the progressive learning of managing emotional involvement. These results are in line with the findings of Rønnestad and Skovholt (2003). The authors report that in the early stages of development, psychotherapists tend to overidentify themselves with clients, and this overinvolvement tends to block the construction of a helpful therapeutic relationship. Moreover, the authors report that learning how to manage emotional involvement is quite difficult but crucial in order to help psychotherapists deal with human suffering throughout their career. This developmental competence is called boundaried generosity (Skovholt et al., 2004).
As a corollary of learning obtained throughout training, mimicking the psychotherapist’s masters fosters the gradual learning of a personal style of intervention. The self-knowledge promoted in a relational context allows psychotherapists to be more spontaneous, with personal characteristics appearing to be indicators of genuineness and transparency in the psychotherapeutic relationship. As mentioned previously, we are not stating that psychotherapists do not need to learn techniques and theoretical models. However, as noted by Skovholt et al. (2004), training in technical skills, although constituting an important part of becoming an expert psychotherapist, is not enough. Also, as noted by Orlinsky and Rønnestad (2005), the conflict between more than one therapy and psychotherapeutic practice modalities at the beginning of training seems to be followed by a theoretical opening associated with representations of greater developmental progress in psychotherapeutic practice. Thus, the movement inherent in the development of the person of the psychotherapist looks beyond the technical domain and engages in the logic of human and humanized development.
From the synchronic standpoint, the categories inherent to the Human Psychotherapist, Inter Psychotherapist, the Client’s Shoes, the Psychotherapist Coauthor, and Psychotherapist’s Personal Style reflect a more limited power of the psychotherapist but also a broader image of the psychotherapist’s potentialities. The client shares this power. On the one hand, the relationship that the client establishes with the psychotherapist is an indicator of success. On the other hand, the relationship that the psychotherapist establishes with the client is a central promoter of development. It is also interesting to note that self-knowledge conveyed through psychotherapeutic practice, conflicts with uncertainty, openness to ambiguity, and the adoption of the other as internal reference expands to the psychotherapist’s personal life. This second subtheme, phases and changes of the psychotherapist’s development in the personal sphere, is an indicator of professional development as integral to the development of the psychotherapist as a person. The admiration of clients’ fighting capacities and clients’ resilience in the face of (p. 121) traumatic situations appears to enhance curiosity toward others and a sense of tolerance and genuine understanding. In the same sense, Rønnestad and Skovholt (2003) identified the extensive experience of suffering as a promoter of human variability recognition, acceptance, and appreciation. Throughout the analysis, from both a synchronic and a diachronic perspective, it can be seen that developmental experiences are more likely to happen on an inter- and intrapersonal logic, with the technical skills component being less emphasized.
Even in the psychotherapists’ training, it seems that the most obvious implications of this study relate to the need to promote openness to uncertainty and ambiguity and a reflective attitude toward the difficulties and challenges of psychotherapeutic practice among novice psychotherapists. Premature closure may interfere with the psychotherapist’s development, which, apart from losing the potential psychotherapeutic relationship, not only causes ineffective assistance but also causes iatrogenic consequences in the clients’ lives. The psychotherapists’ training should focus not only on the cognitive component but also on emotional and relational professional development because the relational component is the most determining factor of successful psychotherapy (Jennings & Skovholt, 1999). Given the challenging nature of psychotherapeutic experiences, practice can foster increasing levels of complexity during the integration of learning and, alternatively, may carry risks, given the vicarious experience of traumatic situations and the psychotherapist’s own personal challenges. The incorporation of professional experiences promoting reflection on practice, self-knowledge, and the integration of personal experiences in the curriculum could help psychotherapists to manage psychotherapeutic emotional experiences because these constitute unique opportunities to humanize psychotherapist training (Matos, 2011). In 1910, Freud recognized that no psychoanalyst would go further than what is allowed by his or her complexes and internal resistances (p. 145). Psychotherapy will always be a meeting of two or more selves, the world and the other’s; as Mahoney (1991) stated, our choices are neither random nor irrelevant, and we will be wise to examine the patterns and preferences of our own options. This implies the awareness, as much as possible, of the implications of the way psychotherapists give meaning to clients’ lives and to the psychotherapeutic process.
A second implication stresses the importance of the humanization of psychotherapists in psychotherapy research, particularly concerning the need to deepen the comprehension of the impact of the personal and relational story on how psychotherapists personalize their practice and signify their role. The introduction of personal characteristics as important variables in being and becoming a psychotherapist can help in understanding the complex interactions that are established between clients and psychotherapists, whether in research processes or in results. How psychotherapists regulate their personal relationships and attachments, how they regulate their emotions, how they perceive and manage countertransference behaviors, how they perceive their relational skills, and the degree of satisfaction in their most significant relational contexts may be important topics for further investigation of the association between the quality of relational experiences and (p. 122) events in personal experience (Barreto & Matos, 2012; Carvalho & Matos, 2010, 2012; Matos, 2011). This study also emphasizes the fact that being and becoming a psychotherapist is a lifelong process; therefore, this requires the existence of training devices that include both theoretical and technical updates and both personal development and supervision, according to the logic of integral development.
The results of this study should be evaluated in light of several limitations. The first limitation is that given the qualitative nature of the exploratory study presented, the data cannot be generalized to other psychotherapists. A second limitation relates to the process of identification of the sample. With the peer-nomination technique, we sought to minimize the effect of psychotherapists’ institutional knowledge by gathering consensus among nine key informants from different geographical points of the country; this is a not representative sample of psychotherapists recognized as experts in Portugal.
The delimitations of this study are associated with the qualitative methodology. We sought to adopt a critical, reflective hermeneutics and to reduce the subjective nature of the process involving the encoding and interpretation of data through the use of validation strategies. However, we are aware that the entire coding process could have undergone changes, and the emergence of new categories in another encoding process is likely. This is a limitation because the qualitative methodology is fundamentally interpretive (Creswell, 1998), which allows greater proximity and depth to more complex research topics but restricts and limits data replication.
To conclude, we stress the contribution of this study to highlight the synthesis of the personal and professional dimensions in understanding the complex task of being and becoming a psychotherapist; after all, as Skovholt et al. (2004) stated, “Expertise is not about narrow skill development. It is becoming, over a long time, fully human” (p. 140).
This research was partially supported by a PhD research grant of the first author (SFRH/BD/22333/2005), by a research project (PTDC/PSI/65416/2006), and by PEst-C/PSI/UI0050/2011 financed by the Portuguese Foundation for Science and Technology (FCT). This chapter was also supported by FEDER funds through the COMPETE program under the project FCOMP-01-0124-FEDER-022714.
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2. We highlight the central contribution of revisions to the main studies of the impact of characteristics of the psychotherapist in the results of different psychotherapies that have been published in the Handbook of Psychotherapy and Behavior Change during the past 30 years (Beutler, Crago, & Azrimendi, 1986; Beutler et al., 1994, 2004; Parloff, Waskow, & Wolf, 1978). However, (p. 123) despite the concern, especially referred to in the last two issues (Beutler et al., 1994, 2004) to include extratherapeutic characteristics (traits) and specific features (states) in the review, the authors concluded that in the past 20 years there has been a declining emphasis on investigations of the characteristics of the psychotherapist that are not associated with specific effects of treatment.
3. Each transcribed narrative was assigned a code that contains three types of information. The first is on the theoretical orientation (cb, cognitive–behavioral; c, constructivist; h, humanism; p, psychoanalytic/dynamic; s, systemic). The second piece of information concerns the number of interviews conducted within the same model. The third piece of information corresponds to the sex of the respondent (m, male; f, female). For example, in “p1m,” “p” corresponds to the psychoanalytic orientation, “1” to the number of the interview within the psychoanalytical model, and “m” to male.