Counselling and Psychotherapy Research, December 2008; 8(4): 261268

RESEARCH ARTICLE

Developing clinical effectiveness in psychotherapy training: Action research

BILJANA VAN RIJN, CHARLOTTE SILLS, JILL HUNT, SUHITH SHIVANATH, KATARINA GILDEBRAND, & HEATHER FOWLIE
Metanoia Institute, London, UK

Abstract This study is an evaluation of a new approach to clinical training in Transactional Analysis using the methodology of action research. The evaluation focuses on the second year of training and placement-based clinical practice at the Metanoia Institute, UK. The design of the training year was research-based and used the concept of an internship year. The design aimed to close the gaps between clinical practice, supervision and formal training; facilitate translation of theory into practice; and integrate findings from the common factors research into effectiveness of psychotherapy. Training and supervision methods were linked and focused on emerging issues in clinical practice and the development of students capacity for critical reflection and a research attitude to practice. The evaluation was a naturalistic study which used quantitative and qualitative methodology within the action research framework to reflect on the impact of the training on the participants, the organisation and the clinical practice. The quantitative outcomes show that the project developed the effectiveness of students clinical practice and reflexivity. Qualitative analysis gives insight into the experiences of the participants and the emotional impact of the research process.

Keywords: Psychotherapy training, action research, evaluation, internship, transactional analysis

Introduction This paper describes a year-long evaluative research into the new design for the second year training in Transactional Analysis, based on the doctoral research by van Rijn (2005). Her concept of an internship year was central to this project; it positioned placement practise at the heart of training as students started to see clients. The internship approach aims to close the gaps between clinical practice, supervision and formal training, facilitate translation of theory into practice and integrate findings from the common factors research into effectiveness in psychotherapy (Frank & Frank, 1991; Lambert & Bergin, 1994; Luborsky & Singer, 1975; Wampold, 2001). A development group was formed to work on the years training design comprising several members of the TA staff team and the researcher, who was both a tutor and a manager of the Metanoia Counselling and Psychotherapy Service (MCPS), where students undertook placements within the institute. Later on, this group formed the research team. Each member had a different level of involvement within the programme and different roles in the wider team. As the manager of MCPS, the primary researcher regularly dealt with the interface between placement practice, training and supervision, and was

motivated to improve it for the sake of clients, as well as students. The training programme was based on her research and this increased her level of involvement with the programme. In this context, the composition of the research team and the members inevitable investment in the project required particular attention to transparency and methods of qualitative analysis. Training had previously been similar in structure to other programmes in the UK, containing formal teaching (didactic, experiential and skills practice), client work (normally in voluntary placements), and clinical supervision with a suitably qualified supervisor who was not necessarily involved with the course. Other than supervision reports, there was no formal contact between the institute and the supervisors, who were employed directly by the students and, unless there were difficulties, there was no formal contact with the placement provider. The development group focused on methods of learning and assessment that allowed the challenges and questions relating to placement practice, students anxieties and their reflection on the therapeutic relationship, to become the heart of the learning process. The redesigned training year was significantly different from the established practice of TA (and other psychotherapy) training at Metanoia Institute,

1473-3145 (print)/1746-1405 (online) 2008 British Association for Counselling and Psychotherapy DOI: 10.1080/14733140802305804

262

B. van Rijn et al.

ship between training and clinical practice and use action research to develop reflective judgement in the early stages of clinical training. The Internship Training Programme

and evaluation of the programme was an important part of the development. Literature There is a paucity of research into psychotherapy training and a lack of clear evidence that professional training ensures effective clinical practice. Training courses in the UK use competencies and methods of assessment approved by universities and umbrella bodies, such as the United Kingdom Council for Psychotherapy (UKCP) and the British Association for Counselling and Psychotherapy (BACP) to monitor their quality, but these do not answer questions about their impact on effective clinical practice. Beutler, Machado and Neudfelt (1994) reviewed studies relating therapist variables, such as levels of professional training and experience to clinical effectiveness and found that they were often confounded, making it difficult to separate the effects of training from other influences. Consequently, research studies reviewed produced contradictory results. Some suggested experience or the level of training has little impact on effectiveness (Auerbach & Johnson, 1977; Beutler et al., 1986; Stein & Lambert, 1984); however, others suggested that experienced therapists produce better results (Luborsky, Chandler, Auerbach, Cohen & Bachrach, 1971). Others argued that paraprofessionals perform better than professional therapists (Durlak, 1979, 1981; Hattie, Sharpley & Rogers, 1984). Meta-analysis by Berman and Norton (1985) and Weisz et al. (1987) did not demonstrate a link between training and effectiveness. These studies give rise to questions such as, what is the role of theory and how does it relate to clinical knowledge and effective practice? Polkinghorne and Hoshmand (1992) suggest that both theoretical and clinical sources of knowledge are essential in the development of clinical ability, and need to be united into an interactive cycle of enquiry and action within training. In the UK, clinical practice during training mostly takes place in external counselling agencies. Knowledge emerging from this clinical practice rarely finds its way into the formal teaching environments, and this can be a challenge in developing the theory practise relationship suggested by Polkinghorne and Hoshmand (1992). Whilst making a case for integration between different sources of knowledge within training, these authors also looked at the knowledge processes and attitudes involved in effective clinical practice. Dreyfus and Dreyfus (1986) and Schon (1987) (both cited in Hoshmand and Polkinghorne, 1992) suggest that professional education should be focused on developing reflective judgement recognised in the context of expert practice, by using the model of action research. Schon (1987) defined reflective judgement as a capacity to engage in reflection in action, keeping alive a multiplicity of views of a situation. This model is central to the development of the internship approach in training, which aims to address the relation-

Background
The research enquiry, underpinning the development of the internship year (Van Rijn, 2005), suggested that in order to achieve the above stated aims it was important to: . develop effective communication between practice placements and training institutions; . integrate clinical supervision into the training process; and . structure the internship in the early stages of clinical training so that it could offer containment to students at the time when they needed the most as they start to see clients.

Teaching aims and methods

The design of the programme focused on developing clinical practice within training content, structure, teaching methods and assessment. The content of training units focused on the following. . Generic clinical issues: development and use of therapeutic contracts, treatment planning and direction, focus on issues of diversity and ethics as they emerged in clinical practice, introduction to supervision and the use of the CORE-OM System in evaluation. . Transactional Analysis techniques such as: decontamination (developing ego strength), working with the Adult ego state, working with developmental processes contained in archaic ego states. . The placement context. . Practice-based research skills: developing and deepening the capacity for reflection. Students were required to use quantitative evaluation methods in their practice and enquire into their learning by engaging with the research question How do I become an effective practitioner? Training methodology was designed by tutors to be learner-centred and process-oriented. This entailed the shift from emphasis on content (i.e. didactic input along with exercises and discussions to consolidate learning), to a learner-oriented approach, i.e. identification of learners needs and supported reflection on practice. Students were given relevant material to read prior to the training, and encouraged to consider the implications for their practice as well as any critiques they may have. The theoretical input by the tutors was based on the questions, musings and considerations that students brought with them. The aim was to give information, and deepen their understanding of theory

Action research 263

through experience. To this end, experiential and reflective exercises were used more and didactic teaching methods were kept to a minimum. the participants within the training system. Continuing the research enquiry by developing ongoing cycles of reflection and action within the organisation, aimed to build theories of practice within a professional system and create communities of enquiry within communities of practice (Friedman, 2001). The participants were students and the research (development) team.

Clinical supervision
Clinical supervision was integrated into the training and took place in small groups. Students also had clinical supervision, outside of these sessions, in between the training units, and were encouraged to stay with the same supervisors, for continuity and containment. Supervision methods mirrored the teaching style and focused on developing insight and the ability to think through clinical problems as well as awareness of ones own emotional responses. The integration of teaching, practise and supervision is illustrated in Figure 1.

Methods of enquiry and analysis

The research process entailed: . monthly research meetings between researcher, tutors and the supervisor; and . monthly research meetings between researcher and students. All meetings were recorded and transcribed. Transcripts were shared with the participants, who were also offered an opportunity to make ongoing changes to the programme and thus shape the cycles of reflection, observation and action. Qualitative analysis by the research team took place at the end of the project and was shared with students before completion. The analysis of the project took place in three parts. . Quantitative analysis of the effectiveness of students clinical practice. . Qualitative analysis of portfolios: giving insight into development of clinical and research skills. . Qualitative analysis of the research process: developing insight into the process and dynamics of the research.

Placement practise
Students were all practising in placements, and the majority worked within the internal service (MCPS) at Metanoia Institute. This service offered low-cost, time-limited (to a maximum of 6 months) treatment to the general public. Students used quantitative methods of evaluation, primarily the CORE-OM System (CORE System Group, 1998) in their practice.

Assessment
Academic assessment was portfolio-based. Students were asked to use their research question How do I become an effective practitioner? to reflect on their learning and structure their portfolios. Although it contained obligatory elements, the portfolio also offered an opportunity for individual exploration, structure and presentation. Methodology Within this naturalistic study, the methodology of action research was used as the most suitable for the setting, the background of the project and its philosophy and aims. The project took place within a complex organisational setting and aimed to develop practical knowledge in collaboration with all

Ethical issues
The project aimed to widen collaboration and participation within the training process in the structure of training and the process of assessment. Individual confidentiality was addressed at the beginning and within the enquiry process. Participants signed a consent form which ensured their confidentiality in transcripts and publications. Additionally, participants in the enquiry were asked for consent regarding their participation, and were free to withdraw from the enquiry. All the participants had ongoing access to the transcripts of research meetings and full access to any analysis of the findings. Metanoia Institute did not have a formal Research Committee at the time, and approval was granted by the existing Academic Committee.

THEORETICAL TEACHING Based on Clinical Practice

EXPERIENTIAL LEARNING and Development of Personal Awareness

Quantitative analysis
PREPARATORY READING APPLICATION OF LEARNING Triads and Supervision

Figure 1. The integration of teaching, practise and supervision.

Quantitative analysis of the clinical data offered a descriptive comparison between the internship and two comparative groups. First, other students at the same stage of training working within the MCPS and second, the CORE-OM national benchmarks which measure effectiveness of qualified practitioners. This

264

B. van Rijn et al.

ness of her own biases. Her role also heightened the impact of transference projected on her. Collegial and personal relationships within the research team were also a subject for reflection. Feelings of anxiety about the outcomes, fears of failure, need for support, anger about the amount of work involved and impact of loyalty to each other were all voiced in the research meetings. The continuity of this personal reflection in the monthly research meetings helped to understand and voice personal biases and develop transparency. When, at one point during the year, the research team became stuck in the group process with students, they used the wider TA tutor team for consultancy. This gave them a perspective which facilitated the research team through the difficulties they were experiencing. Results

analysis is particularly relevant, as the main aim of the programme was to increase effectiveness of early clinical practice and students ability to establish and maintain a therapeutic relationship.

Research meetings: methods of analysis

All members of the research team were involved in analysing transcripts. Meetings between the researcher, tutors and the supervisor were not structured. Participants were invited to discuss issues related to the process and content of training and reflect upon themes emerging from the research. The researcher loosely structured the framework of transcript analysis into areas of training content and structure. In coding terms, these fields were primarily descriptive (Miles & Huberman, 1994). Emergent themes were also identified. These were more interpretative, using respondents subjective experience and their ability as psychotherapists to analyse unconscious and group processes. They were interpretative and pattern codes (Miles & Huberman, 1994). Meetings with students were semi-structured. They were invited to give feedback on training structures and content as well as share their experiences. The content analysis focused on different aspects of training (descriptive codes). Emerging themes were identified in the same way as the tutor transcripts. To minimise bias, each member of the research team analysed transcripts individually. The researcher did her own analysis and then compiled all the responses and themes. The final conclusions were discussed and agreed in the group. This analysis was disseminated to students. Descriptive categories of structure, content of training, feedback on theory and supervision were interconnected within the training process and overlapped in the final analysis. The impact of this was that different enquirers could categorise their responses in different ways. To deal with this in the final analysis, summary tables were created for each training module. Feedback from each respondent was grouped into intuitive process themes for each training module. Finally different respondents were compared in terms of similarities and differences in the themes they identified, in relation to their role in training and the research process. Based on the methodology of action science (Argyris, Putnam, & Smith, 1985), all the participants in the enquiry were part of the system and also collaborators in the research process. In recognition of her own bias and involvement and to ensure validity, the researcher involved the whole team in the analysis of transcripts, and formulation of conclusions. The outcome of this was that respondents frequently allocated feedback to different categories (content or structure). The researchers role in the organisation was an advantage because of the degree of knowledge and involvement she held, and a disadvantage because she was continuously challenged to maintain aware-

Quantitative analysis
One of the aims of the internship-based training was to help students develop the ability to evaluate their practice using both qualitative and quantitative methods. In comparison to other students within the same organisation, outcomes suggested that internship students used the CORE-OM System were more fully to evaluate their practice, were able to work with more distressed clients for longer and were on the whole more effective. The relatively high percentage of complete data sets indicates that this aim of training was largely successful. The completion of 41.67% ranks in the above average category. This indicates that students have become involved in the process of evaluation and started to develop a research attitude to practice. See Table I.

Client profile. The client profile used in this analysis refers to the clinical cut-off point at the start of therapy. This report shows that in the internship, the percentage of clients inside the clinical population is within the average in comparison with the national benchmarks. In comparison to that, the percentage of clients above the clinical cut-off (74.95%) at MCPS is below the CORE-OM benchmark. This suggests that internship students worked with a more distressed group of clients within the service. See Table II. Number of sessions. The number of sessions relates to students developing ability to establish and maintain the therapeutic relationship. This developmental task is often a struggle for beginning practitioners, and represents a stage in developing therapeutic skills (van Rijn, 2005). One of the aims of internship was to address this training need through the particular
Table I. Validity. Internship students Comparative data (other MCPS) CORE benchmark 41.67% 28.71% 39%

Action research 265

Table II. Client prole with respect to CORE clinical cut-offs. Percentage of clients above the clinical cut-off Internship MCPS CORE benchmark 80.77 74.95 80.00

combination of training and supervision within the programme. Within a service like MCPS (that allows an average of six months of therapy) our comparative group engaged in an average of 14.36 sessions. The internship group engaged in an average of 21.5 sessions, demonstrating a considerable improvement in the ability to establish and maintain a therapeutic relationship.

The portfolios were primarily structured as descriptive narratives and focused on the components of the training year contained in the student handbook. This did not demonstrate individual learning processes but a gathering of evidence. Despite that, the content demonstrated ability for critical analysis and familiarity with quantitative methods of evaluation. Qualitative evaluation (contained in essays and reflection on supervision) demonstrates considerable ability for reflexivity. Students have learned to reflect on their practice and use this reflection to modify their responses to clients.

Clinical and reliable change. Clinical and reliable change is an indicator of effectiveness, based on the statistical analysis of differences between OM1 and OM2 (questionnaires completed by clients at the beginning and the end of therapy). These outcomes show a considerable difference in effectiveness in students going through the internship-based training. Even though they have worked with clients whose scores were higher than the average MCPS client, there is no deterioration, the overall improvement is above the average, when compared to the CORE-OM benchmarks (Mullin, Barkham, Mothersole, Berwick & Kinder, 2006), and far higher than the average for MCPS. In comparison to CORE-OM benchmarks, their practice was overall in line with the performance of other, NHS-based services, unlike that of other students at the same stage of training, and well beyond expectations. These outcomes demonstrated that students developed an increased evaluative attitude to clinical practice while becoming more able to sustain a therapeutic relationship and develop well in effectiveness on par with qualified practitioners. Qualitative analysis Portfolios. All of the 11 portfolios submitted met the criteria and learning objectives for the year. Particular focus of analysis was the development of research skills. The researcher hypothesised that engagement with the research question How do I become an effective practitioner would be reflected in students individual learning process, critical analysis of their clinical work and an understanding of qualitative and quantitative aspects of research evidence.
Table III. Clinical and reliable change. Health outcomes Deterioration Unchanged Overall improvement Internship Other CORE benchmarks (%) MCPS (%) (%) 0 25 75 3.11 31.56 65.33 1.8 26.1 72.2

Emerging themes and group dynamic. Over the first six training units the impact of systemic factors was translated into confusion about leadership and dissatisfaction and splitting between the two parallel student groups. This process was initially vocalised in the research meetings, rather than the training groups, which delayed its being adequately addressed. Although the purpose of the research meeting was not to deal with the group process, it became an opportunity for students to communicate their difficulties, not just to tutors, but also to the researcher and Metanoia Institute. Over the same period, tutors dealt with the intensity of the programme and their own needs for support by refining and streamlining their training designs, but felt rushed, unsupported and resentful. The stress seemed to arise from the difference in new teaching methods and a lack of familiarity with the process of assessment and research. Additionally the anxiety, stress and pressure were generated within the training groups by starting to see clients for the first time in their placements. In this period both students and tutors expressed anger and frustration with the research process. The transparency of the process, which meant that students had access to transcripts of the tutor meetings, initially increased students anxiety because it showed tutors uncertainty. Later on, as the process evolved, this was experienced as a permission to be vulnerable and human. The primary researcher became the point of connection and communication between the students and the tutors, but without the power to affect change. She felt helpless and angry and experienced a pull of split loyalties between the students and the tutor groups. The apparent destructiveness of the group process became a concern and she questioned whether the research should continue in these circumstances. This was an important ethical systemic intervention. The process was brought up to the wider group of the tutor team, who acted as consultants to the research group. This intervention modelled integration and enabled communication, both between the members of the research team and with the wider tutor team, and the impact of the research process on the training groups was addressed in a training unit (three months before the end of the training year). This countered the process

266

B. van Rijn et al.

its consistent challenge of in-depth personal reflection, brought up early developmental issues and primitive processes in the group, but also enabled the students to increase their effective relational depth, evident in the quantitative analysis. This raises questions about balance between the safety of holding in the process at that stage of training and the challenge of personal reflection and self-responsibility. The research methods were used in different ways: quantitative for evaluation, qualitative in the training process and action research as a framework for reflection on learning.

of splitting, and met some of the unaddressed leadership needs. Both helped the groups to identify and move through the dynamic they experienced. The impact of the combination of research and training was addressed with the students and in the tutor team. It was acknowledged that the involvement of the research team unconsciously communicated the narcissistic message of you are special to students. This was an understandable side-effect of doing naturalistic research. These student groups were the first ones to experience the new training programme and all the members of the research team devoted inordinate amounts of time and effort to dealing with the programme and issues arising from it. However, the narcissistic dynamic also contained the accompanying shadow at two significant levels. The first was communicating the message of not being good enough, by not fully hearing the individuals. The second was somehow making students feel used for someone elses needs (i.e. Metanoias research). This was the classic narcissistic injury special but used and not seen. In response, students seemed to demand more and more from tutors, supervisor and researcher and continue to feel unmet. Both groups experienced not being good enough and not being given enough. The TA concept of psychological games (Berne, 1964) and the Drama Triangle (Karpman, 1971) helps to explain this process in which students moved from the role of Victim to Persecutor and tutors from the role of Rescuer to Victim. Addressing the unconscious processes in tutor and student groups facilitated both through the unconscious Game process and organisational change. Finally, students felt able to feel excited by the programme and their own achievements within it. Tutors became able to enjoy the development of the students as well as the emergence of the new project. The end-of-year reflection on the research process by the students described it as safe and successful. Discussion Themes emerging from this enquiry highlight the psychological and unconscious group processes related to the impact of the new training approach, the research process on the training department, and a new approach. This new training approach emphasised coordination of clinical practice, supervision and formal teaching, and involved students overtly in becoming proactive in all aspects of their learning. Although the aim was to contain students at this early stage of clinical practice, the new approach was a significant contributor to feelings of anxiety in both students and tutors. Most of the anxiety centred on the teaching approach, and while going through the difficulties of implementing this new strategy, tutors distanced themselves from the authorship of the design for a time. In looking back at the process of training, the research team wondered whether this approach with

Impact of the research process on the training department

Engaging with questions develops human narratives and often leads into the process of change. This is evident in psychotherapy, as questioning facilitates the development of personal narratives, in neuroscience (Cozolino, 2002), as well as fields of organisation consultancy and action research (Schein, 2001). Within this process in organisations, a researcher is likely to be seen as an agent of change and feelings of helplessness and anger often focus on whoever is seen to be in this role. In this case, it could be the tutors and Metanoia Institute, as well as the researcher. The process of change completes a cycle when an organisation finds a way of dealing with and sustaining change (Rashford & Coghlan, 1989). An important systemic intervention within this enquiry was a meeting between the research and the TA tutor teams, which helped to communicate feelings and personal experiences and reflect on the dynamic of the process. The methodology of action research, with its emphasis on the process, transparency and involvement of all participants, highlighted the process of change as well as enriching the analysis of how the change happened. Qualitative analysis shows that the research process was not just the evaluation of the course but that, as expected within action research enquiry (Schein, 2001), it also formed part of the organisational and training dynamics. The process of research in itself was new to both tutors and students and an emotional response to this became part of the overall group process. What is more, taking part in the new training programme and research created considerable anxiety in the tutors who then struggled to offer potency and containment to the groups, resulting in the parallel group process in both tutor and student groups, ultimately reaching the point of conflict when it was overtly addressed and managed. The tutors paralleled the students contradiction between effectiveness and distress process in that they had developed, managed and delivered a complex new training programme but felt unrecognised and overwhelmed much of the time. The celebration and recognition of these achievements only became possible when the unconscious processes were addressed

Action research 267

and the level of anxiety lessened. This dynamic shows the complexity of research in naturalistic settings and processes of organisational (departmental) change it sets off. More research is needed into what made the training successful, and the possible relevance of the emotional challenges. Limitations and implications for practice Action research as the chosen methodology had limitations as well as strengths in this project. The study took place within a single organisation, and only two training groups, limiting both the generalisability of the findings and the quantitative analysis. The depth of involvement of the research team with the project posed a challenge to validity. Whether this was sufficiently addressed by the research team can only be answered through further evaluation and replication. The intensity of the research process created a dynamic of change, which challenged all the participants and nearly destroyed the project. Looking back, the extent of this might have been avoided by giving tutors more grounding in action research and having fewer research meetings, and at different times to the training programme. However, this organisation has managed to sustain the change. The new training programme continues with ongoing evaluation. The impact has been felt within the whole department and action research, evaluation of clinical practice and development of reflective practice have now been implemented in all the training years, and integrated into the culture of training. This demonstrates the wider impact and potential of action research to create reflexivity within an organisational system. This study demonstrates the apparent link between the development of personal reflexivity, evaluative attitude to practice and effectiveness. It also offers a structure of training, which can be adapted, used and evaluated in different training settings. Although this particular project takes place within the theoretical orientation of Transactional Analysis, the training structure is not orientation-specific and can be used within different theoretical approaches. Conclusion This paper offers insight into the live process of development and evaluation of a psychotherapy training programme. In doing so, it offers suggestions and raises questions about the development and training of effective practitioners. It also demonstrates the complexity and challenges of evaluating psychotherapy training in all its subtleties. Biographical notes Dr Biljana van Rijn: DPsych, Teaching and Supervising Transactional Analyst (Psychotherapy), MSc in Transactional Analysis, Certified Transactional Analyst (Psychotherapy), BACP accredited and UKCP registered. As well as being a psychotherapist and supervisor in private practice, Biljana van Rijn is a Head of Clinical Services at Metanoia Institute and tutor. Professor Charlotte Sills: Teaching and Supervising Transactional Analyst (Psychotherapy), MSc in Transactional Analysis, Certified Transactional Analyst (Psychotherapy), BACP accredited and UKCP registered. At the time of this research Charlotte Sills was a Head of Transactional Analysis Department at Metanoia Institute. She is a tutor, psychotherapist, supervisor and a widely published author in the field of psychotherapy. Jill Hunt: Provisional Teaching and Supervising Transactional Analyst (Psychotherapy), MSc in Transactional Analysis, Certified Transactional Analyst (Psychotherapy), UKCP registered and BACP-accredited supervisor. Jill Hunt is a psychotherapist in private practice, supervisor and tutor in psychotherapy, counselling and supervision. Suhith Shivanath: Provisional Teaching and Supervising Transactional Analyst (Psychotherapy), MSc in Transactional Analysis, Certified Transactional Analyst (Psychotherapy), BACP accredited and UKCP registered. Suhith Shivanath is a psychotherapist in private practice, supervisor and tutor at Metanoia Institute and other counselling training establishments. Katarina Gildebrand: Provisional Teaching and Supervising Transactional Analyst (Psychotherapy), MSc in Transactional Analysis, Certified Transactional Analyst (Psychotherapy), BACP accredited and UKCP registered. Katarina Gildebrand is a psychotherapist and supervisor in private practice. At the time of this research she was a long-standing tutor at Metanoia Institute. Heather Fowlie: Provisional Teaching and Supervising Transactional Analyst (Psychotherapy), MSc in Transactional Analysis, Certified Transactional Analyst (Psychotherapy), BACP accredited and UKCP registered. Heather Fowlie is a psychotherapist and supervisor in private practice. As well as being a tutor, at the time of this research she was also a Co-coordinator of Transactional Analysis counselling programme at Metanoia Institute. References
Argyris, C., Putnam, R., & Smith, D. (1985). Action science: concepts, methods, and skills for research and intervention. San Francisco, CA: Jossey-Bass. Auerbach, A.H., & Johnson, M. (1977). Research on the therapists level of experience. In A.S. Gurman & A.M. Rzin (Eds), Effective psychotherapy: A handbook of Research (pp. 84102). Elmsford, NY: Pergamon. Berman, J.S., & Norton, N.C. (1985). Does professional training make a therapist more effective? Psychological Bulletin, 97, 401407. Berne, E. (1964). Games people play. London: Penguin. Beutler, L.E., Machado, P.P.P., & Neufeldt, S. (1994). Therapist variables. In A.E. Bergin & S.L. Gareld (Eds.), Handbook of psychotherapy and behaviour change (4th ed) (pp. 229269). Oxford: Wiley. Core System Group (1998). CORE System information management handbook. Counselling and Psychotherapy Research, 6, 1.

268

B. van Rijn et al.

Mullin, T., Barkham, M., Mothersole, G., Bewick, B.M., & Kinder, A. (2006). Recovery and improvement benchmarks in routine primary care mental health settings. Counselling & Psychotherapy Research, 6, 6880. Rashford, N.S., & Coghlan, D. (1989). Phases and levels of organisational change. Journal of Managerial Psychology, 4 (3), 1731. Reason, P. & Bradbury, H. (2001). Introduction: inquiry and participation in search of a world worthy of human aspiration. In P. Reason & H. Bradbury (Eds.). Handbook of action research: participative inquiry and practice (4th ed.) (pp. 115). London: Sage. Schein, E.H. (2001). Clinical inquiry/research. In P. Reason & H. Bradbury (Eds.), Handbook of action research: participative inquiry and practice (4th ed) (pp. 228238). London: Sage. Smith, M.L., Glass, G.V. & Miller, T.I. (1980). Meta-analyses of psychotherapy outcome studies. Baltimore, MD: The Johns Hopkins University Press. Stein, D.M. & Lambert, M.J. (1984). On the relationship between therapist experience and psychotherapy outcome. Clinical Psychology Review, 4, 127142. Van Rijn, B. (2005). An enquiry into psychotherapy training. Challenges to developing a generic foundation year and links to clinical practice training. Unpublished D.Psych. Metanoia Institute and Middlesex University. Wampold, B.E. (2001). The great psychotherapy debate. New Jersey: Lawrence Erlbaum Associates. Weisz, J.R., Weiss, B., Alicke, M.D., & Klotz, M.L. (1987). Effectiveness of psychotherapy with children and adolescents: A metaanalysis for clinicians. Journal of Consulting and Clinical Psychology, 55, 542549.

Cozolino, L. (2002). The neuroscience of psychotherapy. New York: WW Norton & Company. Durlak, J.A. (1979). Comparative effectiveness of paraprofessionals and professional helpers. Psychological Bulletin, 86, 8092. Frank, J.D., & Frank, J.B. (1991). Persuasion and healing: a comparative study of psychotherapy. Baltimore, MD: John Hopkins University Press. Friedman, V.J. (2001). Action science: creating communities of inquiry in communities of practice. In P. Reason & H. Bradbury (Eds.), Handbook of action research: participative inquiry and practice (pp. 159171). London: Sage. Hattie, J.A., Sharpley, C.F., & Rodgers, H.J. (1984). Comparative effectiveness of professional and paraprofessional helpers. Psychological Bulletin, 95, 534541. Hoshmand, L.T. & Polkinghorne, D.E. (1992). Redening the sciencepractice relationship and professional training. American Psychologist, 47 (1), 66. Karpman, S. (1971). Options. Transactional Analysis Journal, 1 (1), 7987. Lambert, M.J., & Bergin, A.E. (1994). The effectiveness of psychotherapy. In S.L. Gareld & A.E. Bergin (Eds.), Handbook of psychotherapy and behaviour change (pp. 143190). Oxford: Wiley. Luborski, L., & Singer, B. (1975). Comparative studies of psychotherapies: is it true that Everyone has won and all must have prizes? Archives of General Psychiatry, 32, 9951008. Luborsky, L., Chanler, M., Auerbach, A.H., Cohen, J., & Bachrach, H.M. (1971). Factors inuencing the outcome of psychotherapy. Psychological Bulletin, 75, 145185. Metanoia Institute. (2005/2006). Transactional analysis counselling and psychotherapy. Clinical Practice Year Student Handbook. Miles, M.B., & Huberman, A.M (1994). An expanded sourcebook: qualitative data analysis. London: Sage.