Intern counselling psychologists' perceptions of therapeutic change and the role of supervision SM Nel orcid.org / 0000-0002-0039-4391 Mini-Dissertation submitted in fulfilment of the requirements for the degree Master of Arts in Counselling Psychology at the North-West University Supervisor: Dr R Kok Examination: May 2021 Student number: 22136355 ACKNOWLEDGEMENTS It has been a long journey to finally get to this point, and I have so many to thank for their part in my life. I would like to take the time to express my gratitude and thanks specifically to the following people:  My study leader, Dr Rümando Kok, for your patience, willingness, diligence and motivation in helping me to complete this mini-dissertation. Your work ethic, knowledge about the topic, professionalism, and the manner in which you treat others is admirable, and I thank you for everything you did during this time.  My faith has always grounded me and, therefore, I thank my heavenly Father for giving me the strength, serenity, calmness, perseverance, humility, and ability to work in this field.  To my parents and to my brother in heaven, a word of thanks and heart-filled gratitude for inspiring me since a young age to always give everything my all, to live up to my full potential, and for providing well in advance for me to be able to pursue my dream.  To the rest of my family, but especially my eldest brother, sister-in-law, and grandmother, thank you for lending a hand where needed, for comfort in times of distress, for embarking on this journey with me and not allowing me to lose sight of the bigger picture, and for supporting and loving me unconditionally.  Corrie, Anretha, and Petro, the impact you made on my life and my psychology journey has been exceptional. I can’t thank you enough for your words of encouragement and motivation when I needed it most, for always looking out for me, never losing faith in me, and for caring without asking for anything in return.  To each and every one of my colleagues at the Centre for Health and Human Performance, thank you for the opportunity to be part of such a remarkable team. Your support and encouragement have made such a difference.  To the North-West University and the Psychology Department, thank you for giving me the opportunity to pursue my dreams.  A huge thank you to my independent person, language editor and co-coder for your perseverance and work ethic. i  Lastly, but definitely not the least, thank you to my participants for willingly taking part in the research process. ii SUMMARY Keywords: Intern counselling psychologist, psychotherapy effectiveness, supervision, supervisor, therapeutic change There has been an ongoing debate over what brings about therapeutic change concerning the therapeutic relationship and the techniques used in psychotherapy. The effectiveness of psychotherapy has been established but, to an extent, it is still unclear what exactly brings about change within psychotherapy. This study served as an explorative study with the aim of introducing a topic that provides a basis for future research studies. Furthermore, this study aimed to explore how intern counselling psychologists perceive therapeutic change and what role supervision plays in their perception of therapeutic change by answering the following questions: 1) How do intern counselling psychologists perceive therapeutic change? and 2) What role does supervision play in the intern counselling psychologists’ perceptions of therapeutic change? An explorative study with a qualitative research approach and a qualitative descriptive research design was used to determine the participants’ perceptions about the topic, and the data was gathered using narrative inquiry through qualitative questionnaires. The data was analysed by means of thematic analysis. More insight and a better understanding of the process of therapeutic change was gained from the perceptions of intern counselling psychologists as well as the role of supervision. The participants in this study only recently completed their academic training and as such have limited practical experience, so they work under supervision. After their limited practical experience and recent registration as independent practice counselling psychologists, the intern psychologists are expected to provide iii evidence-based psychotherapy to a broad range of clients who present a diversity of problems. A total of twelve participants were included in this study. The participants took part in narrative inquiry through qualitative questionnaires. Each participant received a questionnaire that they were asked to complete within a two-week timeframe at a place and time that were most convenient for them, after which the questionnaire would be sent back to an independent person. Two main themes were identified that best fit both therapeutic change and the role of supervision. Appropriate sub-themes were identified from each theme. The main themes were: 1) factors that are helpful to the process of therapeutic change and the role of supervision, and 2) factors that hinder the process of therapeutic change and the role of supervision. Both themes revealed that therapeutic change is a multifaceted process with numerous factors that contribute to the outcome. It appears that a holistic consideration of the different variables is what ultimately leads to therapeutic change. Thus, to better understand therapeutic change, it is necessary to consider all the variables. This study provided a voice to the intern counselling psychologists, who received an opportunity to reflect on their perception of therapeutic change and the role of supervision. Ultimately, the aim would be to bridge the gap between training and practice and also to enhance the quality of supervision practice. iv PREFACE Article format  This mini-dissertation is typed in United Kingdom English for examination purposes. After examination it will be translated to American English for publication purposes.  This mini-dissertation forms part of the requirements for the completion of the Master of Arts degree in Counselling Psychology. It has been prepared in article format in adherence to rule A.5.4.2.7 of the North-West University Potchefstroom campus yearbook.  This article will be submitted for possible publishing in The Journal of Psychology accordance with the journals’ specific criteria.  This manuscript was prepared according to the author guidelines of the journal. The rest of the documents were prepared according to the North- West University guidelines.  Consent for submission of this mini-dissertation for examination purposes has been given by the research supervisor, Dr Rümando Kok, in fulfilment of requirements of the Master’s degree in Counselling Psychology.  The Afrikaans quotes from the participants were also translated to English by a qualified language practitioner.  For examination purposes, the pages are numbered from the title page and proceed from there onwards. v GUIDELINES FOR AUTHORS The Journal of Psychology About the Journal The Journal of Psychology is an international, peer-reviewed journal publishing high-quality, original research. Please see the journal's Aims & Scope for information about its focus and peer-review policy. Please note that this journal only publishes manuscripts in English. The Journal of Psychology accepts the following types of article: original articles. 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Here are some tips and ideas on how you can work with us to promote your research. xiii Article Reprints You will be sent a link to order article reprints via your account in our production system. For enquiries about reprints, please contact the Taylor & Francis Author Services team at reprints@tandf.co.uk. You can also order print copies of the journal issue in which your article appears. Queries Should you have any queries, please visit our Author Services website or contact us here. xiv PERMISSION TO SUBMIT ARTICLE FOR EXAMINATION PURPOSES I, Dr. Rümando Kok, the supervisor of this study, hereby declare that the mini- dissertation entitled “Intern counselling psychologists’ perceptions of therapeutic change and the role of supervision”, written by Susanna Maria Nel, reflects the research regarding the subject matter. I hereby grant permission that she may submit the article for examination purposes and I confirm that the mini-dissertation submitted is in fulfilment of the requirements for the degree Master of Arts in Counselling Psychology at the Potchefstroom campus of the North-West University. The article may also be sent to The Journal of Psychology for publication purposes. I can also confirm that the mini-dissertation was submitted to Turnitin and a similarity index of 3% was obtained. _______________________________ Dr Rümando Kok xv Table of Contents ACKNOWLEDGEMENTS ...................................................................................................... i SUMMARY ........................................................................................................................... iii PREFACE ............................................................................................................................. v GUIDELINES FOR AUTHORS ............................................................................................. vi The Journal of Psychology ................................................................................................ vi About the Journal ........................................................................................................... vi Peer Review and Ethics ................................................................................................. vi Preparing Your Paper .................................................................................................... vi Structure ..................................................................................................................... vi Style Guidelines ........................................................................................................ vii Formatting and Templates ......................................................................................... vii References ................................................................................................................ vii Taylor & Francis Editing Services .......................................................................... vii Checklist: What to Include ........................................................................................ viii Using Third-Party Material in your Paper .................................................................... x Submitting Your Paper ............................................................................................... x Data Sharing Policy .................................................................................................... xi Publication Charges .................................................................................................. xii Copyright Options ...................................................................................................... xii Complying with Funding Agencies ............................................................................. xii Open Access ............................................................................................................ xiii My Authored Works .................................................................................................. xiii Article Reprints ......................................................................................................... xiv Queries..................................................................................................................... xiv PERMISSION TO SUBMIT ARTICLE FOR EXAMINATION PURPOSES ............................ xv LIST OF TABLES ................................................................................................................ xix LIST OF FIGURES ............................................................................................................. xix Section 1: Introduction ...................................................................................................... 1 Introduction ....................................................................................................................... 1 Literature overview ............................................................................................................ 3 Psychotherapy effectiveness.......................................................................................... 3 Therapeutic change ....................................................................................................... 5 Intern counselling psychologist ...................................................................................... 6 Supervisor ...................................................................................................................... 7 Supervision .................................................................................................................... 8 xvi Problem statement .......................................................................................................... 10 Aim of the study ............................................................................................................... 11 References ...................................................................................................................... 13 Section 2: Manuscript ..................................................................................................... 16 Abstract ........................................................................................................................... 17 Orientation and problem statement .................................................................................. 18 Research method ............................................................................................................ 23 Research design .......................................................................................................... 24 Participants and research context ................................................................................ 24 Data collection ............................................................................................................. 27 Data analysis ............................................................................................................... 29 Trustworthiness............................................................................................................ 31 Ethical considerations .................................................................................................. 33 Findings ........................................................................................................................... 35 Therapeutic change ..................................................................................................... 37 Theme one: Helpful factors ....................................................................................... 37 Client variables ..................................................................................................... 38 Therapist variables ................................................................................................ 40 Therapeutic relationship variables ......................................................................... 41 Other variables ..................................................................................................... 44 Theme two: Hindering factors ................................................................................... 45 Client variables ..................................................................................................... 45 Therapist variables ................................................................................................ 47 Therapeutic relationship variables ......................................................................... 49 Other variables ..................................................................................................... 49 Supervision .................................................................................................................. 50 Theme one: Helpful factors ....................................................................................... 50 Developmental role ............................................................................................... 51 Increased awareness ............................................................................................ 53 Therapist responsiveness. .................................................................................... 54 Normalisation ........................................................................................................ 55 Supervisor-supervisee relationship ....................................................................... 56 Peer-supervision ................................................................................................... 57 Distinguishing between relational variables ........................................................... 58 Change process constructs ................................................................................... 58 Theme two: Hindering factors ................................................................................... 59 Supervisor being overworked ................................................................................ 60 xvii Supervisee feeling misunderstood by the supervisor ............................................ 60 Supervision as a punitive space ............................................................................ 60 Supervision as a space of labelling ....................................................................... 61 Power dynamics ................................................................................................... 61 Discussion ....................................................................................................................... 61 Limitations and recommendations ................................................................................... 74 Conclusion ...................................................................................................................... 75 References ...................................................................................................................... 78 Section 3: Critical reflection ........................................................................................... 85 Data collection ................................................................................................................. 86 Data analysis and interpretation ...................................................................................... 87 Findings ........................................................................................................................... 88 Addendums ......................................................................................................................... 89 Addendum A: Informed consent ...................................................................................... 89 Addendum B: Ethical approval for this study ................................................................... 94 ........................................................................................................................................ 95 Addendum C: Proof of language editing .......................................................................... 97 Addendum D: Turnitin report ........................................................................................... 98 ........................................................................................................................................ 99 xviii LIST OF TABLES Table 1: Demographic information of participants ............................................................... 26 Table 2: Themes and sub-themes regarding therapeutic change ........................................ 36 Table 3: Themes and sub-themes regarding supervision .................................................... 36 LIST OF FIGURES Figure 1: Supervisor – Skill, relationship and personhood pyramid ..................................... 67 Figure 2: Roleplayers – Client, supervisor and psychotherapist pyramid ............................. 73 xix Section 1: Introduction Introduction Section 1 of this study offers the reader an in-depth literature overview and the opportunity to gain a better understanding of the core theoretical concepts relevant to the proposed study. Throughout history, there has been an ongoing debate about what factors bring about therapeutic change in psychotherapy. Goldfried (2013) states that research exploring change processes in psychotherapy has developed over three generations. The first generation, during the 1950s, was characterised by the realisation of the significance of evidence supporting whether psychotherapy is effective. However, psychodynamic therapy was the main focus of studies during this time, and the outcomes of such research studies were to an extent generalised and vague; although, it did spark interest in the direction toward which the field of psychology would head (Goldfried, 2013). During the 1960s and 1970s, the second generation marked the onset of research that focused more on the effectiveness of various specific interventions in an attempt to address specific problem areas that were identified (Goldfried, 2013). This gave rise to a methodological advantage over research conducted during the first generation; however, the inclusion criteria were, unfortunately, limited mainly to graduate tertiary students who served as psychotherapists (Goldfried, 2013). Hereafter, the third generation of research emerged during the 1980s, with several improvements having been made with regards to research methodology, which led to randomised controlled trials (RCTs) (Goldfried, 2013). This opened the door for the shift from what was once termed 1 ’psychological problems’ to ‘clinical disorders’ with the further aim of advancing the field of psychology and its effectiveness (Goldfried, 2013). Goldfried (2013) further mentions that, across three generations of research and to this day, the therapeutic relationship is implemented in various ways while making use of different techniques, depending on the therapeutic modality of the psychotherapist, with the aim of promoting therapeutic change. Numerous studies have focused on investigating the therapeutic relationship and the various techniques used in psychotherapy. Although the effectiveness of psychotherapy has been recognised, as mentioned above, there is still a lack of clarity regarding what ultimately results in change in psychotherapy, despite decades of research. The literature overview in this mini-dissertation provides a brief history of how therapeutic change has been recognised in the past and further explores current potential possibilities for gaining a better understanding of what brings about change in the context of psychotherapy. Furthermore, the literature overview considers the role that supervision plays in therapeutic change. The literature review is followed by the problem statement of the proposed study and the study aims. This study might benefit the field of psychology by providing a better understanding of the process of change for psychologists still in training and those working under supervision. Given the vital role that supervision plays in the training of psychotherapists as well as in this component in the research study, this study aims to gather more information from findings to possibly provide guidelines for supervision. The supervisor’s role includes promoting best practices within the field of psychology and enhancing the delivery of competent psychotherapeutic services (Hendricks & Cartwright, 2018). In addition, the findings of this study might also 2 potentially improve the quality and/or training of future psychologists. The abovementioned ultimately aim to enhance the vital duty of each psychotherapist to fulfil their role in safeguarding the public from harm and improving social wellbeing (Falender, 2014). Literature overview A literature overview is presented in section one of this mini-dissertation on the following aspects: the effectiveness of psychotherapy; therapeutic change; the intern counselling psychologist; supervision; and the supervisor. Various databases were used to research the terms, including Google Scholar, EBSCOhost and JSTOR. Psychotherapy effectiveness Effectively addressing mental health concerns through psychotherapeutic interventions has been the focus of numerous research over several decades (Ajaelu et al., 2018). Numerous findings have proven psychotherapy to be an effective intervention (Ajaelu et al., 2018; Campbell et al., 2013). According to Lambert (2013), a journal search engine was conducted which revealed that in the past 30 years, about 60 000 academic articles had been published on the topic of psychotherapy. Mulder et al. (2017) mention a greatly cited review from 2002 where 17 meta-analyses were compared regarding the effectiveness of various psychotherapy treatments, thus emphasising the great significance of promoting the field of psychology by better understanding what contributes to effective psychotherapy. 3 Today, psychotherapy is performed by registered psychologists who all have a shared interest in, firstly, ensuring that each client receives the best treatment supported by evidence from research and, secondly, providing the best training to the future generation (Campbell et al., 2013). Although all psychologists have this common ground, many still differ on the term psychotherapy and how it is implemented (Campbell et al., 2013). The term psychotherapy is derived from two ancient Greek words, namely psyche, which refers in its translation to mind or soul, and therepeia, which refers to treatment or restoring (Ajaelu et al., 2018). Combining these words in one term embodies the goal of psychotherapy, which is to restore distress and/or decrease the intensity of distress that an individual experiences and increase individual and relational wellbeing throughout a persons’ lifespan. In essence, Neto et al. (2015) explain that the important goal of psychotherapy is for the psychologist to encourage change within the client through a process. Before this process can begin, there are certain important factors that set the stage for what is to come. In essence, the first encounter between a client and a psychologist encompasses a meeting between two strangers. The client will evaluate whether the psychologist is trustworthy, competent, and capable of prioritising the client priority in understanding why they sought psychotherapy (Wampold, 2015). The psychotherapeutic relationship relies heavily on this initial relational connection. Clients enter psychotherapy with certain expectations, which makes the first interaction between client and psychologist especially critical for the process of psychotherapy to achieve its desired goal (Wampold, 2015). In general, psychotherapy is studied as a treatment modality within a therapeutic setting that revolves around personal skills and the relationship between the psychologist and their client (Ajaelu et al., 2018). The treatment 4 modality of psychotherapy consists of various techniques with various underlying clinical theories (psychoanalytic, humanistic and/or cognitive-behavioural) that create an inventory from which the psychologist can choose within the therapeutic setting to encourage the principle of change (Oddli et al., 2016; David & Cristea, 2018). The psychologist’s competency in applying these techniques in psychotherapy is assessed by how their client displays progress (Budge et al., 2012) or experiences what is otherwise known as therapeutic change. Donald et al. (2014) describe therapeutic change (and thus progress made) as a noticeable improvement of symptoms experienced by an individual. Therapeutic change Goldfried (2013) further comments on the great therapeutic debate in the field when describing that researchers and psychotherapists revealed how techniques and the relationship between the psychologist and their client can be seen as components that enhance the occurrence of therapeutic change; however, the question of which factor is primarily responsible for this change remains (ibid.). Hendriksen et al. (2014) also emphasise that even with significant research and evidence for the effectiveness of both the techniques and the therapeutic relationship within psychotherapy, questions surrounding whether it is the therapeutic relationship that leads to change or whether it merely regulates change by means of the techniques used remain. Donald et al. (2014) also explain that it is important to distinguish between change that occurs abruptly or change that occurs gradually and whether the change relates to a single factor or multiple factors. The general aim is to better understand and distinguish between a sustainable abrupt change and a gradual change (Donald 5 et al., 2014). Thus, a clear picture of how and where the change occurs is, to a large extent, still lacking. A better understanding of the how of effective psychotherapy is crucial in the field of psychology because it enables the field to provide important recommendations that can enhance the outcome of psychotherapy (Donald et al., 2014). This supports one of the core views emphasised in the HPCSA guidelines, namely, beneficence. Beneficence refers to psychologists striving to do no harm but rather to do good by acting professionally, ethically, and in the best interest of the client (HPCSA, 2006). In the training of new psychotherapists, demonstrating the principle of beneficence highlights the unique and key role that psychologists have in addressing mental health concerns (Barlow, 2004). Intern counselling psychologist In light of the above, it is also important to keep in mind the process that must be followed for one to be allowed to register as a psychologist and practise psychotherapy. Formal training programmes with accredited internships in psychology were first implemented in South Africa during the 1970s (Pillay & Johnston, 2011). It was also during this time that the specific category of counselling psychologist was first documented within the South African context (Bantjes et al., 2016). Cooper and Nicholas (2012) explain how the psychology profession is a very popular field of study at universities; however, registering as a psychologist is only possible after the completion of a master’s degree, and admission into training programmes is deemed extremely competitive, since only a limited number of candidates is chosen (Cooper & Nicholas, 2012). 6 An essential part of becoming a psychologist involves obtaining specific requirements and knowledge regarding psychological theories and ideologies, skills in applying techniques and procedures regarding diagnoses, the ability to conduct a clinical interview, develop a treatment plan, conceptualise a client, and be oriented with scientific developments and progress in the field (Ajaelu et al., 2018). Pillay and Johnston (2011) explain how, in the South African context, training programmes for psychologists are accredited by the Health Professions Council of South Africa [HPCSA], which conducts assessments at all training institutions to ensure that they comply with the prescribed minimum standards and to gain insight from intern psychologists who are currently registered in specific training programmes. Furthermore, according to Hendricks and Cartwright (2018), it is a mandatory requirement of the HPCSA that a psychologist in training receives two hours of supervised practice per week. This emphasises the important role of supervision in ensuring that the psychology profession is safeguarded in the correct principles and maintains service delivery of the highest possible standard. Supervisor Therefore, Nel and Fouche (2017) state how previously mentioned training programmes together with supervision are fundamental factors in preparing a psychologist in training. Supervisors play a crucial role in both protecting the client who enters psychotherapy and the profession of psychology through training competent individuals to conduct psychotherapy (Falender, 2014; Falender et al., 2014). 7 Falender (2014) defines supervision as a professional motion where teaching and training take place with the aim of developing a science-orientated practice facilitated by a cooperative interpersonal process. As part of internship training, it is important to keep in mind the intern psychologists’ relationship with his or her supervisor (Wulf & Nelson, 2000). Rønnestad and Skovholt (2003) attest that supervisors have a remarkable impact despite various influences. Feelings of dependency and vulnerability as a result of still being in training makes the intern counselling psychologist more appreciative of the support and reassurance of experienced professionals (Rønnestad & Skovholt, 2003). The intern counselling psychologist relies heavily on their relationship with their supervisor as they strive to get more training and guidance to further shape their personal and professional development (Ramos-Sánchez et al., 2002). Thus, the importance of considering the impact and the role of the supervisor within supervision on the intern counselling psychologist’s perceptions is highlighted, of which a better understanding is still needed in this regard. Supervision Supervision is marked as a standard competency area in psychology, especially for psychologists in training (American Psychological Association [APA], 2015). Research findings indicate that psychotherapy without supervision, in the context of psychologists in training is compromising to the field of psychotherapy for several reasons (Rønnestad & Skovholt, 2003). This is further supported by Watkins (2014), who is of opinion that supervision is vital whenever psychotherapy is conducted. Supervision takes the central position in the training of competent 8 psychologists, with the supervisor being primarily responsible for each supervisee and client the supervisee sees (Falender et al., 2014). Israelstam (2014) emphasises that there is an essential need for ongoing training in supervision and that gaining more knowledge about supervision should not be disregarded or neglected. McIntosh and Phelps (2000) mention that supervision in psychology has been researched since the 1980s with the aim of developing a better understanding of the role within the profession but that this research is still in its early developmental stages. The topic of supervision as a mandatory requirement in training programmes, especially concerning the gaps in research regarding what essentially brings about therapeutic change and the role of supervision, could potentially influence the effectiveness of psychotherapy for intern counselling psychologists, which has possible immediate and/or long term implications. By including interns as participants in this study, the researcher will be able to gather the perception of participants who recently completed one year of practical experience within the context of conducting psychotherapy under supervision. These participants, who have little experience, rely greatly on supervision for guidance and support in enhancing competency standards and shaping their personal and professional development as psychologists of the future. As such, understanding the perceptions of intern counselling psychologists will contribute greatly to the body of knowledge in psychology, especially with regard to training and yielding even more competent psychotherapists. 9 Problem statement The literature review has highlighted that there is still a significant lack of research on the topic of therapeutic change within psychotherapy. Completing undergraduate studies and postgraduate studies in psychology – which includes an honours degree and acceptance into a master’s degree in psychology – as well as the successful completion of the prescribed hours of internship, passing the board exam, and registering as a psychologist in a certain registration category, are all part of the journey of becoming a registered psychologist. While numerous research has focused on several of the above aspects regarding psychotherapeutic training, what makes this study unique is its focus on the experiences of intern counselling psychologists who are still on their journey to becoming registered psychologists. In this regard, the study attempts to bridge the gap between training and practice by providing more insight into and a better understanding of how intern counselling psychologists experience therapeutic change and the role of the supervision they have received in this regard. In light of the above, the problem statement for the proposed study is: There is a need to explore the role that supervision plays in how intern psychologists (who were recently still in training under supervision) perceive change that occurs during the process of psychotherapy. In support of this statement, Flückiger et al. (2019) propose that more research is required in order to better understand how psychologists, in this case intern counselling psychologists, perceive change occurring during psychotherapy. To this end, conducting this proposed study will provide a better description and understanding of how intern counselling 10 psychologists perceive therapeutic change within the context of conducting psychotherapy under supervision. Aim of the study This study aims to explore how intern counselling psychologists perceive therapeutic change and what role supervision plays in their perception of therapeutic change. A better understanding of the intern counselling psychologists’ perceptions of therapeutic change and the role of supervision in therapeutic change will give more depth to the process of effective psychotherapy. Intern counselling psychologists who recently completed their academic training only have limited practical experience while working under supervision, after which they are expected to practise independently and provide evidence-based psychotherapy to a wide range of clients who present diverse problems. Thus, the focus of this study is to gather information that can be beneficial in filling the gaps in research on therapeutic change and obtaining a better understanding of what brings about therapeutic change. Filling this gap can also assist psychologists with limited experience, such as intern counselling psychologists, in providing more effective psychotherapy, with the added potential of improving supervision practices. Considering the aim of this study, a qualitative descriptive research design will form the basis from which to explore intern counselling psychologists’ perceptions of therapeutic change and the role of supervision. This study is an explorative study that introduces a new topic, since, to the best of the researchers’ knowledge, there is no previous research on this exact topic. Data about the topic will be gathered using a narrative inquiry through qualitative questionnaires. After gathering the data, it will be analysed by means of thematic analysis. 11 The researcher will adhere to the ethical rules as stipulated by the HPCSA when conducting research, and in particular, the principles of beneficence and non- maleficence. She will aim to ensure that she maintains confidentiality, anonymity, and the privacy of each participant. This study will be conducted under the supervision of a registered senior clinical psychologist who will serve as study leader of this study. The researcher will keep ongoing contact with an independent person throughout the research to remain updated regarding the implementation and progress of the recruitment, informed consent, and data collection process. After meeting the study’s aim, a better understanding will have been gained of the perceptions held by intern counselling psychologists’ on therapeutic change. This understanding will help to better prepare intern counselling psychologists who recently completed their academic training and only have limited practical experience working under supervision and yet, after having registered as independent practice counselling psychologists, are expected to provide evidence-based psychotherapy to a broad range of clients that present diverse problems. Further, this study is foreseen to provide information that can be beneficial for improving supervision practice and possibly also the evidence-based nature of psychotherapy, especially for newly registered psychologists. 12 References Ajaelu, C. C., Walker, D., & Atalor, A. (2018). The effectiveness of psychotherapy: Assessing evidence-based practice in treatment of psychiatric patients. Journal of Clinical Behavioral Health, 12(3), 1-13. 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J. (2013). Outcome in Psychotherapy: The past and important advances. Psychotherapy, 50(1), 42-51. doi:10.1037/a0030682 McIntosh, D. E., & Phelps, L. (2000). Supervision in school psychology: Where will the future take us? Psychology in the Schools, 37(1). Mulder, R., Murray, G., & Rucklidge, J. (2017). Common versus specific factors in psychotherapy: Opening the black box. Lancet Psychiatry. http://dx.doi.org/10.1016/S2215-0366(17)30100-1 14 Nel, L., & Fouche, P. (2017). Experience of master’s students regarding clinical supervision in an applied psychology programme in South Africa. Teaching in Higher Education, 22(1), 30-43. doi: 10.1080/13562517.2016.1213230 Neto, D. D., Baptista, T. M., & Dent-Brown, K. (2015). Development and validation of a system of assimilation indices: A mixed method approach to understand change in psychotherapy. British Journal of Clinical Psychology, 54, 147-162. Oddli, H. W., Nissen-Lie, H. A., & Halvorsen, M. S. (2016). Common therapeutic change principles as “sensitizing concepts”: A key perspective in psychotherapy integration and clinical research. Journal of Psychotherapy Integration, 26(2), 160-171. Pillay, A. L., & Johnston, E. R. (2011). Intern clinical psychologists’ experiences of their training and internship placements. South African Journal of Psychology, 41(1), 47-82. Ramos-Sánchez, L., Esnil, E., Riggs, S., Wright, L. K., Goodwin, A., Touster, L. O., Ratanasiripong, P., & Rodolfa, E. (2002). Negative supervisory events: Effects on supervision satisfaction and supervisory alliance. Professional Psychology: Research and Practice, 33(2), 197-202. doi: 10.1037//0735-7028.33.2.197 Rønnestad, M. H., & Skovholt, T. M. (2003). The journey of the counsellor and therapist: Research findings and perspectives on professional development. Journal of Career Development, 30(1), 5-44. Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277. doi: 10.1002/wps.20238 Watkins, C. E. (2014). Clinical supervision in the 21st Century: Revisiting pressing needs and impressing possibilities. American Journal of Psychotherapy, 68(2). Wulf, J., & Nelson, M. L. (2000). Experienced psychologists’ recollections of internship supervision and its contributions to their development. The Clinical Supervisor, 19(2), 123-145. 15 Section 2: Manuscript Intern counselling psychologists’ perceptions of therapeutic change and the role of supervision Susanna Maria Nel *Dr Rümando Kok Centre for Health & Human Performance (CHHP), Institute of Psychology & Wellbeing (IPW), Community Psychosocial Research (COMPRES), North-West University, South Africa. *Corresponding author: Dr Rümando Kok 16 Abstract Over many decades, there has been an ongoing debate in the field of psychology regarding what brings about therapeutic change, specifically with respect to the therapeutic relationship and therapeutic techniques. The effectiveness of psychotherapy has been established but, to an extent, it is still unclear what exactly brings about change within psychotherapy. This study aimed to explore how intern counselling psychologists perceived therapeutic change and what role supervision played in their perception of such therapeutic change. An explorative study with a qualitative research approach and a qualitative descriptive research design was used to determine the participants’ perception regarding this topic. All data was gathered using narrative inquiry through qualitative questionnaires, and the data was analysed according to thematic analysis, from which the following two main themes emerged, namely 1) factors that are helpful to the process of therapeutic change and the role of supervision, and 2) factors that hinder the process of therapeutic change and the role of supervision. The findings revealed that therapeutic change is multifaceted, with numerous factors that contribute to the outcome. This study, through its results, aimed to bridge the gap between training and practice and also contribute to making supervision practice more effective. Keywords: Intern counselling psychologist, psychotherapy effectiveness, therapeutic change, supervision, supervisor 17 Orientation and problem statement As a discipline, psychology is one of the most popular fields of study at tertiary institutions; however, it is greatly competitive at master’s level, which is a requirement that includes an internship for registering as a psychologist in South Africa (Cooper & Nicholas, 2012). Psychologists are confronted daily with the complexity of human behaviour and are required to conduct effective psychotherapy (Gaines et al., 2020; Goldfried et al., 2014). Yet, psychotherapy has been a subject of debate amongst psychologists for decades, in which some advocate for the therapeutic relationship as the leading factor that brings about therapeutic change, while others argue that change results from the therapeutic techniques used during psychotherapy (Goldfried, 2013). Despite decades of debate, what all psychologists do agree on is the aim of ensuring that their clients receive the best treatment and providing the best training (and supervision) to future generations of psychologists (Campbell et al., 2013). This corroborates what Castonguay et al. (2010) emphasise as the focus on preventing potential hindering factors and enhancing what is regarded as helpful in psychotherapy, which also extends to training practices (including supervision). Generally, psychotherapy is studied as a treatment modality centring on personal skills and the relationship between psychologists and their clients within a therapeutic setting (Ajaelu et al., 2018). The treatment modality of psychotherapy consists of various techniques. These techniques are underpinned by clinical theories which serve as an inventory from which the psychologist can choose within the therapeutic setting in order to promote the principles of change (Oddli et al., 2016). The psychologists’ competency in applying these techniques is assessed by 18 how their clients progress (Budge et al., 2012) or, put differently, experience therapeutic change. Goldfried (2013) further comments on the continuing debate within the field of psychology, as mentioned previously, where researchers and practitioners explain how therapeutic techniques and the therapeutic relationship can both be seen as important components for change to occur. Yet, the question remains of which (therapeutic techniques or the therapeutic relationship) is primarily responsible for the change that occurs. Despite numerous research that has been conducted which support and establish that psychotherapy is effective (Ajaelu et al., 2018; Campbell et al., 2013), a clear picture of how and where change occurs is to a large extent still lacking (Donald et al., 2014). Understanding the how of effective psychotherapy is crucial, seeing that it can provide important recommendations for enhancing the outcome of psychotherapy (Donald et al., 2014). In addition, Donald et al. (2014) emphasise that it is important to distinguish between change that occurs abruptly and change that occurs gradually and to establish whether change relates to a single factor or multiple factors. Answering these questions will help identify factors to consider in understanding how therapeutic change occurs. The Health Professions Council of South Africa (HPCSA) provides the framework and requirements for registering as a psychologist in South Africa (Hendrick & Cartwright, 2018). The framework includes accrediting the training programmes offered by institutions, who thus have to adhere to specific guidelines. The aim of accreditation is to ensure that all training institutes uphold the same minimum standards (Pillay & Johnston, 2011). Further concerning this framework, the registered psychologist must have acquired a wide range of knowledge, skills 19 and values during training (Ajaelu et al., 2018). These knowledge, skills, and values should manifest in the ability to acquire a good theoretical foundation, conduct a clinical interview, develop good diagnostic skills, conceptualise clients, and effectively apply techniques as part of developing a treatment plan (Ajaelu et al., 2018). Training programmes include a specific process that must be followed for an individual to be allowed to register within a certain scope of practice within the field of psychology. The process includes an internship with specific requirements regarding content and prescribed hours. Hendricks and Cartwright (2018) highlight the mandatory requirement of the HPCSA, namely that intern psychologists must receive two hours of supervised practice per week. As such, supervisors play a crucial role both in safeguarding the client in psychotherapy and the profession of psychology through training individuals to become competent professionals in conducting psychotherapy (Falender, 2014). Falender (2014) defines supervision as a professional motion where teaching and training take place with the aim of developing science-orientated practice which is facilitated by a cooperative interpersonal process. As part of internship training, it is important to keep in mind the relationships between the intern psychologist and their supervisor (Wulf & Nelson, 2000). According to Rønnestad and Skovholt (2003), supervisors make a remarkable impact in light of providing the necessary guidance and assistance as well as of various external influences. Various factors have the potential to influence the intern psychologist, which can become overwhelming, especially in the period from theoretical training to seeing their first client in psychotherapy. These factors include influences from their personal lives, 20 peers, and colleagues, as well as their cultural and religious environments (Rønnestad & Skovholt, 2003). Feelings of dependency and vulnerability as result of still being in training makes the intern psychologist more appreciative of the support and reassurance of experienced professionals. Furthermore, research has shown that psychotherapy without supervision, in the context of psychologists in training, can compromise the profession and field of psychology and the various stakeholders in various regards (Rønnestad & Skovholt, 2003). Israelstam (2014) emphasises that there is a great need for ongoing training in supervision and that the importance of gaining more knowledge about supervision and the further development of the supervisory skills should not be underestimated or neglected. Falender (2014) agrees when stating that supervision is considered crucial in protecting the public by enhancing the standards of competency and further contributing to the personal and professional development of psychologists in training. In essence, supervision also plays a crucial role in terms of training the following generation of supervisors, which in turn is important for enhancing good practice within the field of psychology (Simon et al., 2014). By including interns in a research study, the researcher has the opportunity to discover the perceptions and experiences of intern counselling psychologist participants who recently completed a year of practical experience within the context of conducting psychotherapy under supervision. These interns, who have limited experience, rely greatly on supervision for guidance and support in enhancing their competency standards and shaping their personal and professional development as future psychologists. Therefore, the outcome of a study such as this can assist in bridging the gap between training and practice and, in so doing, improve the field 21 and practice of psychology by yielding even more competent and better-prepared psychologists. The various scopes of practice within psychology have all been well acknowledged. However, the aforementioned ongoing debate in the field of psychology has given rise to research inquiries that focus on and explore one scope of practice at a time. To this end, this study aimed, firstly, to gain a better understanding of the perceptions of therapeutic change by analysing and comparing data from participants within the same scope of practice who are able to register and practice independently after completion of their internship year. The study aimed, secondly, to look at the role that supervision plays in how the intern counselling psychologist (who was recently still in training under supervision) perceives change that occurs during the process of psychotherapy. Focusing on the intern counselling psychologists’ perceptions of therapeutic change and the role their supervisor played in this regard helped us to provide information that could better describe therapeutic change within the context of conducting psychotherapy under supervision. Achieving these aims ultimately contribute to bridging the gap between training and practice. The study’s overall aim can therefore be summarised as identifying the intern counselling psychologists’ perceptions of therapeutic change and the role their supervisor played in this regard. In achieving this aim, this study provides qualitative data from questionnaires completed by participants that was analysed through thematic analysis, which enabled comparisons to be made between relevant themes. The obtained information, which was then linked to the aim, was used to provide a 22 better understanding of how intern counselling psychologists perceive therapeutic change and the potential role of supervision in this regard. Research method This study focused on gaining a better understanding of intern counselling psychologists’ perceptions of therapeutic change and the potential role of supervision in this regard. Although numerous studies have been conducted to determine what brings about therapeutic change, it is still to a large extent unclear what exactly brings about therapeutic change; no studies that addressed the influence of supervision on intern counselling psychologists’ perception of therapeutic change could be found. A qualitative study was chosen to gather specific information regarding the participants’ perceptions (Polkinghorne, 2005). Furthermore, qualitative research was used in the attempt to explore, study and define participants within their environments (Orb et al., 2000), thus providing detailed insight into the experiences and understandings of each participant (Creswell, 2012). Jackson et al. (2007) explain that qualitative research provides the opportunity for each participant to offer responses to questions that are more comprehensive because they are based on the individual’s perception and experiences within the context of working under supervision. The qualitative nature of this research approach assisted the researcher in obtaining an in-depth understanding of the phenomena (namely, intern counselling psychologist perception of therapeutic change and the role of supervision). 23 Research design Considering the aim of this proposed study, a qualitative descriptive research design formed the basis of exploring the perception of the intern counselling psychologists’ (the participants’) perceptions of therapeutic change and the role of supervision (the phenomenon). Colorafi and Evans (2016) state that a qualitative descriptive research design is particularly found in research related to health settings, as it provides genuine answers to questions asked. Questions asked within a qualitative descriptive design relate to how participants’ feel about a specific situation and place, what are their main reasons for finding themselves in that specific situation and place, who makes use of this specific situation and place, and what are some of the elements that enable or impede participants (Colorafi & Evans, 2016). In this study, the questions asked related to how participants (intern counselling psychologist) perceived therapeutic change and the potential role that supervision has on their perception of therapeutic change. The answers provided explain the phenomenon of interest in a straightforward language (Colorafi & Evans, 2016). The phenomenon in this study is intern counselling psychologists’ perceptions of therapeutic change and the potential role that supervision has in how they perceive therapeutic change. Participants and research context To meet the aim of the research, all participants had to meet the terms of the specific criteria. The researcher formulated inclusion and exclusion criteria for including participants that were able to provide information relevant to the research 24 topic. The inclusion criteria for the target population were participants who were registered with the HPCSA as intern counselling psychologists in the past 24 months, completed the prescribed hours for their internship and their Masters-related research and were no longer registered as students at a university. The exclusion criteria excluded the following participants: intern counselling psychologists registered for more than 24 months, intern research psychologists, intern educational psychologists, intern clinical psychologists, clinical psychologists, educational psychologists, registered counsellors, research psychologists, and industrial psychologists. The HPCSA acted as gatekeeper and was contacted to assist with the recruitment of the participants for this study. Due to the POPI act, only information from the names of registered practitioners found on websites was allowed to be distributed. After receiving a list from the HPCSA, an independent person made initial contact with the potential participants. For recruitment purposes, the independent person (an intern research psychologist) drafted a research information letter to email to the list of possible participants received by the HPCSA. The independent person was responsible for establishing contact with the participants and was primarily responsible for the informed consent process. As part of the informed consent process, an informed consent form (ICF; see Addendum A) was send to the prospective participants, who were given sufficient time (namely 24 hours) to make an informed decision on whether they were willing to voluntarily participate in this study. To adhere to the ethical requirements, the informed consent process was electronic (via Skype). The consent was recorded – the minimum 25 requirement for the consent to be valid was that a witness had to be present on the side of the independent person as well as on the side of the participant. An electronic version of the ICF in the form of a fillable PDF document was used to ensure that the process of completing the form and providing signatures was also recorded. Upon completion of the informed consent process, each consenting participant received a document to complete at a time convenient to them. This document contained questions to gather basic demographic information and two qualitative questions that the participants were requested to complete. The participants received two weeks to complete and return the document in order to ensure that they had sufficient time. Each participant was reminded and reassured that their participation was voluntary and that they could withdraw from the study at any point prior to data analysis. Some basic demographic data was collected from the participants, which is displayed below (see Table 1). Table 1: Demographic information of participants Participant number Gender Ethnicity Home language P1 Male Caucasian Afrikaans P2 Female White Afrikaans P3 Female White Afrikaans P4 Male White English P5 Female White English P6 Male Black Ndebele P7 Female White English 26 P8 Male White English P9 Female White English P10 Female White English P11 Female White English P12 Female Indian English Of the twelve participants that participated in the study, eight participants were female and the remaining four were male. All the participants, with the exception of one, completed their internship at only one internship site. The one participants’ (who did not complete her internship at only one internship site) internship was divided into a six-month placement at one internship site and the remaining six months at another internship site. Data collection As stated previously, a qualitative descriptive approach was used for this research study. Qualitative research strives to better understand human experiences within various settings (Fossey et al., 2002). For the proposed study, the data was collected by using a demographic questionnaire and narrative inquiry through qualitative questionnaires that were appropriate for the proposed topic. The demographic questions that the participants were requested to complete were included in the document they received before being sent the qualitative questions that they had to answer. This demographic questionnaire included details such as home language, ethnicity, and gender. This information was valuable for 27 guiding future research on this specific topic, especially given that this study is explorative in nature. Next, the participants received a document with the qualitative questions to complete and were asked to submit their answers either in written or typed form on the document below the questions. The participants could complete this at a place and time that were most convenient to them and were given a two-week timeframe to complete and send back the document via email. The independent person was responsible for the data collection process. The next step in the process entailed the narrative inquiry. Connelly and Clandinin (1990) explain that all participants lead a life of which stories can be told. Therefore, through narrative inquiry, the researcher aimed to define such lives through collecting and writing about their experiences. McGannon and Smith (2015) describe that telling stories through narrative inquiry is an effective way of communicating meaning, ideas, feelings and inspiration to enable a better understanding of how the participant views and experiences his or her world. Narrative inquiry enabled the researcher to understand the participants’ point of view by writing their stories regarding the phenomenon of interest (Patsiopoulos & Buchanan, 2011). This study focused on the narrative of the intern counselling psychologists’ perceptions of therapeutic change and the potential role of supervision in this regard. The narrative inquiry template that each participant received contained two main questions. The questions were compiled through collaboration between the researcher and the study leader and were structured with the study’s aim in mind. The two questions were: 1. Write a short narrative of how you perceived therapeutic 28 change – in other words, based on your experience as an intern counselling psychologist and in particular your experience in working with clients, how do you perceive therapeutic change? and 2. What role did supervision play in your perception of therapeutic change? The researcher was able to start with thematic analysis immediately upon receiving the answers, as the verbatim answers of each participant were already in written or typed form. A limitation of the data collection method used in this study is that the researcher was not able to ask any probing questions to gather information. Further research studies are recommended that consider in-depth interviews where it would be possible to ask follow-up questions. The findings of this explorative study can be used as a guideline to formulate possible questions for in-depth interviews in future studies on a similar topic. Data analysis The responses of each participant were coded according to themes that frequently occurred by means of thematic analysis. Clarke and Braun (2013) explain that thematic analysis is a method used in arranging data in a way that enables the researcher to derive specific themes. This enables the researcher to find similarities and differences amongst participants’ responses. A minimum of 12 qualitative questionnaires was analysed using thematic analysis. On the point of data saturation, Fusch and Ness (2015) comment that data saturation is not necessarily bound by numbers but rather by thickness and richness of data when it comes to a narrative inquiry. Guest et al. (2006) and Ando et al. (2014) found that, for thematic analysis, it is satisfactory to create from the data of 12 participants. 29 Clarke and Braun (2013) recommend six phases for conducting thematic analysis. The first phase involves becoming familiar with the data through repetitive reading and establishing ideas that stand out. The second phase entails creating primary codes and linking the data with the relevant primary codes. In the third phase, the researcher looks for themes that stand out and assigns relevant information previously written down next to each theme. In the fourth phase, each theme is revised to ensure that each theme is effective in correlation with its code. The fifth phase involves describing (detailed description) and giving specific names to each theme to ensure that the content is clear. In the sixth and final phase, the researcher derives a well-structured report in concluding the data analysis process by producing a synthesis of the results obtained from the data. The thematic analysis process was completed by both the researcher and an independent co-coder, respectively. The independent co-coder was regarded as suitable because she completed her master’s degree in counselling psychology. She also received research training during her undergraduate and post-graduate studies in psychology. Furthermore, during 2019 she attended the Basics of Health Research Ethics training hosted at the North-West University: Potchefstroom campus. Thereafter, the researcher and independent co-coder compared their findings to reach consensus. Only after a thorough discussion of the findings was an agreement reached, and the final themes were reported in writing. In addition, the study leader also monitored the process of thematic analysis and the write-up of the themes. 30 Trustworthiness Trustworthiness builds confidence in the findings of a study under the readers; therefore; it is important to explain how this study ensured trustworthiness (Connelly, 2016). For this study, trustworthiness was ensured by following Guba’s model as stipulated in a research article by Krefting (1991). Krefting (1991) focuses on four aspects, which is truth value, applicability, consistency, and neutrality. Truth value describes the researcher’s level of confidence in the findings of the research as obtained from the participants (Krefting, 1991). Krefting (1991) is further of the opinion that truth value could be considered as a critical criterion in assessing trustworthiness. The researcher ensured the truth value by honestly and accurately writing up the research findings and not leaving out any information relevant to the research. Since the participants wrote or typed their responses, verbatim recordings of their responses were readily available in hard and soft copy to ensure truth value. A second measure of ensuring truth value was based on actively participating in the data analysis process by completing thematic analysis personally, as stipulated by Clarke and Braun (2013), and including an independent co-coder, who conducted a separate thematic analysis of the data. Finally, frequent research supervision meetings were scheduled throughout the research process. Applicability aims to better explain to what extent the findings are applicable to other settings and groups and to what extent the findings can be generalised (Krefting, 1991). To enable future studies on similar topics, the researcher aimed to provide rich detail and a thorough representation of the entire research process. With this, researchers will be able to implement the same research design and approach 31 in other similar studies – for example, conducting similar research with a different group who also has to complete an internship under supervision. Krefting (1991) describes consistency as the way in which the replication of research with the same participants or the same context can produce similar findings. All participants received the same set of questions with exactly the same instructions, namely to complete the demographic questionnaire and the two questions formulated thereafter. In addition, all the data gathered was analysed by following the same data analysis approach, which comprises the steps set out for thematic analysis as stipulated by Clarke and Braun (2013). Working with an independent co-coder also ensured consistency in that both the researcher and independent co-coder completed the thematic analysis separately, compared their analyses and reached consensus. The final criterion is neutrality, which refers to the researcher’s objectivity and strategies used to reduce bias (Krefting, 1991). As the researcher is also an intern counselling psychologist at the time of conducting this study, it was vital that the researcher consciously set aside any personal feelings and personal experiences. The researcher strived to maintain focus on the data collected and its relevance to gaining a better understanding of the participants’ perceptions. Including bracketing enabled the researcher to take the stance of an observer in an attempt to remain objective in research findings (Hopkins et al., 2017). Bracketing is where the researcher sets aside their own perceptions about the topic, which enables them to be open to acquire new information about the perception of the participants (ibid.). Therefore, bracketing also refers to a way for the researcher to be aware of their own 32 prejudices regarding the research topic so that they are able to remain objective (Tufford & Newman, 2012). Keeping records of the verbatim documents from each participant in hard and soft copy and working under strict supervision of the research supervisor also ensured that the researcher remained objective and minimised potential bias. Ethical considerations Orb et al. (2000) state that the researcher should always aim to avoid causing harm (non-maleficence) and act in the best interest of each participant (beneficence). In adherence to these principles, ethical approval for this study was obtained from the Health Research Ethics Committee (HREC) of the North-West University (NWU-00310-20-A1; see Addendum B). The HPCSA acted as gatekeeper and provided the independent person with a list of psychologists who met the inclusion criteria. Thereafter, the independent person contacted all available participants, and all those who voluntarily and willingly decided to participate in the study were provided with an ICF to complete. The ICF described all relevant information regarding the research together with all ethical considerations. The participants signed the ICF and emailed it back to the independent person. The process of informed consent was recorded and adhered to the strict ethical regulations of the HREC. Due to the high emphasis on confidentiality, which entails not disclosing any recognisable information of participants or their supervisors (Wiles et al., 2008), the researcher opted to make use of questionnaires that were not only convenient for the participants to complete but also offered them the opportunity to voluntarily answer the questions posed to them and email their responses to the independent person. 33 Besides confidentiality, Orb et al. (2000) stress that there should be thorough awareness regarding the role of autonomy, beneficence, and justice in qualitative research. Autonomy emphasised that each participant had the right to choose whether they wanted to participate in this study – with beneficence again stressing the importance of not doing any harm during the research process and justice stressing that each participant was treated equally and fairly (Orb et al., 2000). Keeping the above principles in mind, the researcher continuously made it a top priority to treat each participant the same, to be just and fair, and to give each participant the choice to partake in this study. Privacy, confidentiality and anonymity are crucial considering the nature of the research. In order to protect the privacy of each participant, all documents were sent with password protection and the participants were advised to complete the questions in a secure space where only the participants were present. Confidentiality is critical and should always be adhered to, as stipulated in the HPCSA guidelines. The independent person encouraged each participant to refrain from revealing identifying information regarding their clients as well as the role of supervision to keep the supervisor anonymous. Lastly, anonymity was ensured by the independent person ensuring that no findings could be linked to a specific participant. The independent person created an email account that only she had access to and for the sole use of this research, which was stored on a password-protected computer, and the email address was deleted after all data had been transferred. Furthermore, the independent person removed all identifying information of participants before providing the researcher 34 with the data for the purpose of coding to ensure that no participant could be identified. Each completed questionnaire was saved as a PDF document and printed; therefore, all PDF documents were transferred to a memory stick, and the memory stick, as well as the printed documents, were locked in a secure cabinet at the North- West University Potchefstroom campus. The participants also had the right to withdraw from the research at any given moment before data analysis. Findings Themes capture the essence of the data and provide the best narrative in relation to the research question (Clarke & Braun, 2013). Through thematic analysis, two main themes were identified as being associated with both therapeutic change (see Table 2) and the role of supervision (see Table 3). Appropriate sub-themes were identified with each theme, which are discussed together with the main themes. The main themes are: 1) factors that are helpful to the process of therapeutic change and the role of supervision, and 2) factors that hinder the process of therapeutic change and the role of supervision. 35 Table 2: Themes and sub-themes regarding therapeutic change: Theme one: Helpful factors Sub-themes: 1.1 Client variables 1.2 Therapist variables 1.3 Therapeutic relationship 1.4 Other variables Theme two: Hindering factors Sub-themes: 1.1 Client variables 1.2 Therapist variables 1.3 Therapeutic relationship 1.4 Other variables Table 3: Themes and sub-themes regarding supervision Theme one: Helpful factors Sub-themes: 1.1 Developmental role 1.2 Increased awareness 1.3 Enhance therapist responsiveness 1.4 Normalisations 1.5 Supervisor-supervisee relationship 36 1.6 Peer-supervision 1.7 Distinguishing between relational variables 1.8 Change process constructs Theme two: Hindering factors Sub-themes: 1.1 Supervisor being overworked 1.2 Supervisee feeling misunderstood by supervisor 1.3 Supervision as a punitive space 1.4 Supervision as a space of labelling 1.5 Power dynamics Appropriate verbatim quotations from the transcripts support how themes were attained. Therapeutic change Theme one: Helpful factors Whilst reading through each transcript of data, it became apparent that the intern counselling psychologists continuously referred to various factors that they found helpful. These helpful factors refer to variables they perceived as contributing to therapeutic change. Four main sub-themes stemmed from the analysis, namely: client variables, therapist variables, therapeutic relationship, and other variables. Each sub-category is unpacked and explained below. 37 Client variables Numerous client variables were reported as playing a vital role in therapeutic change. P3 stated that the amount of responsibility a client assumes in the therapeutic process also plays a role in terms of therapeutic change. The clients’ contribution to the process was significant and is captured through the following: Change process constructs came to light where P2 mentioned that “client factors, for example, the client’s readiness for change and their commitment, for example, missing a session or not completing therapeutic homework also play a role in therapeutic change”. P2 also stated: “I have realised that it is impossible for a therapist to force change when the client is not yet ready”. Furthermore, P3 added to the change process constructs in saying that “from my experience, one of the most important factors is the client's willingness to change along with the phase of change they are currently in (e.g. pre-contemplation phase, contemplation phase, etc.)”. Both responses imply that a client’s readiness to change and commitment to change are perceived as contributing to the process of change and that “[…] it is impossible for a therapist to force change when the client is not yet ready” (P2). Mechanisms of change were also highlighted among the participants; P4 explained that “the client is encouraged […] to be truthful and congruent […] the process leads to vulnerability, which, in turn, generates awareness from which the therapeutic change emerges”. 38 A clients’ internal locus of control during the process came to light in P3’s statement on how “[…] one of the most important factors is the client's willingness […] as well as […] the amount of responsibility that a client assumes for the therapeutic process that plays a role in terms of therapeutic change”. Thus, it seems that mechanisms of change further include an increased awareness and acceptance, as stated by P9: “therapeutic change really only occurred when the clients I worked with became aware of and accepted their current circumstances […] and their role in that they “[…] may choose to make (or choose not to make) conscious changes in their lives and relationships […]”. According to P5, “[…] when clients experience all their emotions to the fullest regardless of how distressing, frustrating or uncomfortable, clients in the midst of experiencing therapeutic change are able to identify and name their emotions, and ultimately gain insight from these experiences into what they are experiencing in their daily lives as well as more clarity on what they need ‘now’”. P9 further shared how “I came to see that people can really only start to alter their behaviour/feelings/thoughts when they became aware of any maladaptive functioning and its origins/causes”. From the data collected it appears that the participants perceive change as something that occurs holistically and not just in one area of a client’s life. 39 Therapist variables This sub-theme focuses on the other roleplayers in the process of psychotherapy, which P9 described as the “[…] tool in the room […] for therapeutic change”. This sub-theme highlights how each participant perceived their own process and their role as therapist in therapeutic change. According to P4, “Person-centred therapy (PCT)-principles were emphasised as P2 explained how […] client-centred principles, unconditional positive regard, empathy and congruence are essential for therapeutic change”. P4 added by saying that “the therapist should conduct themselves in a manner that suggests to the client that they are unconditionally accepted in the space, that the therapist wants to understand them, that they are provided empathy and that the therapist has acted in a congruent manner with the client”. The therapists’ view of change is also important, as stated by P2: “[…] therapy is not about me and that change cannot be forced, as well as the realisation that change happens at different paces for different clients”. The therapists’ understanding of change appears to be that change is complex, fluid, and a circular process – P11 explained how “[…] therapeutic change can take many shapes and forms and mean different things for different people […] as this participant compares the process of change to […] an ever-changing chameleon, does take time and is not something that occurs overnight”. 40 The implementation of evidence-based treatment was also highlighted by P11: “[…] the therapist’s ability to demonstrate unconditional positive regard and acceptance, to be responsively attuned to the client’s interpersonal, cognitive and affective world, and to use evidence-based interventions”. P2 further explained the important variable of the therapist’s ability to be flexible and to customise the process to the needs of their clients in saying, “I realised that different therapeutic modalities will work better for different clients and that there is no ‘one-size-fits-all’ approach in therapy. The importance of the therapist to be flexible in approach”. The competency of the therapist to adapt seems to lead to corrective experiences, according to P11, who felt that “[…] people tend to feel unseen and unheard […] therefore making it a priority […] to create a space where clients could feel seen, heard and most importantly, accepted”. P4 commented on the belief in the process by saying that “at the basis of all psychological intervention, is the belief that clients can shift and change”. Therapeutic relationship variables The third sub-theme placed emphasis on the therapeutic relationship. P1 reflected on therapeutic change within the therapeutic relationship by saying that 41 “[…] I developed an appreciation for the relational aspects involved in the psychotherapeutic process, and how being responsive to these elements (and the needs of the client), form an important part of the change process”. P2 said that “I believe that it is necessary to foster a warm, safe and understanding environment”. Also emphasising the importance of the therapeutic relationship, P11 described that “the therapeutic relationship, I believe, is an important mechanism in therapeutic change; it allows a space for the client to experience a new and different way of interacting, of seeing themselves, others and the world”. P2 is of the opinion that “the ability to form a positive therapeutic relationship with a client stands central to therapeutic change”. This participant also stated: “I believe that without a warm therapeutic relationship, the techniques and procedures of specific modalities are unlikely to be effective. It is my experience that the therapeutic relationship is the medium through which the work (e.g. techniques) take place”. P3 goes on to say that “clients who are accepted unconditionally and trust their therapist may experience therapeutic change sooner in the process […]”. Thus, the therapeutic relationship is perceived as vital for corrective experiences. P9 explained how, within this therapeutic relationship and process between client and therapist, they “[…] came to see that people can really only start to alter their behaviour/feelings/thoughts when they became aware of any maladaptive 42 functioning and its origins/causes. If you don’t know why you do the things you do, it is harder to change them to have healthier habits and relationships”. The process of therapeutic change is a “[…] process through which client and therapist work towards achieving the goals and expectations formulated during the psychotherapeutic process” (P1) and thus “[…] therapeutic change is therefore the shift that occurs in the life of client/s due to their interaction with the therapist” (P4). P8 explained this corrective experience: “[…] furthermore, corrective emotional experiences occur within the therapeutic relationship, allowing for clients to re-experience holding, containing and being known. This experience may result in an unconscious ‘change’ in the way that clients perceive relationships and themselves within relationships. It also brings to light patterns of relating, allowing for these to be challenged in the space and allowing different ways of relating to be explored and experienced within the space”. The therapeutic relationship also contributed to the realisation of the belief that change is possible once the therapist believes that change is possible, resulting in a shift in expectations. P12 shared that “it is only now as a qualified professional can I look back on it, but when I was in the thick of it, it was really hard for me. I had to be in my own personal therapy and work through my own process in order to feel better as a therapist and intern. Therefore, there had to be change within me in order for me to see change in my clients”. In highlighting that change results from a working relationship as part of the process, P6 explained that 43 “therapeutic change could also be perceived in the change in the working relationship between the client and the therapist – when a client shows increased comfort, confidence, and trust with the therapist. In other words, an enriched and ever-growing client-therapist relationship”. Other variables This sub-theme refers to different levels of change. P1 explained how, during their year of internship, they got “[…] to develop the skill of reflecting on the micro-processes within a session”. Furthermore. P12 explained: “I perceive therapeutic change as many things, but often it can be as simple as my client being able to sleep better or even leave their house. It is often relative and through small shifts I think my clients gain momentum and are better able to encounter the more challenging parts of therapy […] I now have an appreciation for small changes and not to put too much pressure on the therapeutic space to have large, big moments or shifts, as these can happen organically over time”. P8 explained how “[…] clients may experience therapeutic change on two levels. They may choose to make (or choose not to make) conscious changes in their lives and relationships based on what is uncovered in therapy. They may also have more unconscious changes based on their experience of a ‘different’ kind of relationship which is experienced with the therapist. Again, the hope is that this results in a reduction in symptoms”. 44 Other variables also reiterated by P11 included “[…] therapeutic change can take may shapes and forms and mean different things for different people”, which link back to change being a process that is complex. Theme two: Hindering factors Theme two, still focusing on therapeutic change, refers mainly to what the participants perceived as hindering factors in the client’s process of change. Hindering factors refer to those factors that the participants deemed as delaying or preventing therapeutic change to occur. From theme two, four apparent sub-themes emerged (similar to helpful factors), namely client variables, therapist variables, therapeutic relationship, and other variables. Client variables This sub-theme refers to factors that, mainly on the client’s part, had an effect on the process of change. The first point raised was a lack of consistent and active participation, on which P2 explained “[…] missing session or not completing therapeutic homework also play a role in therapeutic change […]” and how readiness for change is important because “[…] it is impossible for a therapist to force change when the client is not yet ready” (P2). Some external locus of control were also mentioned as P12 explained how the 45 “[…] setting brought about significant challenges for me in therapeutic change […] because of the community I was working with […] holding clients and having clients that were consistent was difficult”. P9 commented on factors such as lack of insight, maladaptive coping, and premature termination in saying that “I came to see that people can really only start to alter their behaviour/feelings/thoughts when they became aware of any maladaptive functioning and its origins/causes. If you don’t know why you do the things you do, it is harder to change them to have healthier habits and relationships”. This also emphasises the role of the client’s responsibility in the process. P12 further commented on the client variables by saying that “being in an internship is difficult because of the endings. I was only at my respective placements for a limited time, and just as I felt I was getting a firmer better foot in my confidence and competency the relationship had to end”. P3 added by stating that another hindering factor was when “clients who only show up for therapy and do not have to pay for it due to a free service that e.g. the university offers and do not really set goals experience little or no therapeutic change”. P3 elaborated by saying “if therapeutic change did not occur at times, they could also always point out possible reasons for it in terms of the client's process of change, possible pathology, or that no responsibility was accepted for the process”. 46 Therapist variables As much as certain therapist variables that were deemed helpful, the participants also noted some therapist variables as hindering to the process of change and the therapeutic relationship. For one, P2 commented that “clients are not likely to cooperate with a therapist who impose their authority or therapists who are too directive [sic.]”. P1 further reflected on the therapists’ view of change: “I started off with an understanding of change that is largely theory driven. I remember thinking that if a client presents with A, and the evidence indicates that we should do B, then C should follow. This changed to understanding psychotherapeutic change as a more fluid, and less deterministic process. […] I see it now as the process through which client and psychotherapist moved from point A to point C”. The person-of-the-psychotherapist (POTP) places emphasis on the important role of the psychotherapist. This refers to the values and boundaries of the psychotherapist that have an impact on the process of psychotherapy, thus taking the abovementioned view of change into account but also other professional and personal influential factors. P12 explained how “I had to be in my own personal therapy and work through my own process in order to feel better as a therapist and intern. Therefore, there had to be change within me in order for me to see change in my clients”. 47 Furthermore, P2 explained how “supervision emphasised that therapy is not about me and that change cannot be forced, as well as the realisation that change happens at different paces for different clients”. Another participant, P5, explained how “therapeutic change therefore, often does not appear as one would expect or as the client expects, as the opposite of what they are feeling, or the absence of the distressing emotion but rather the acceptance of the distressing, uncomfortable experience”. The realisation of the therapists’ own processes thus also seemed to make a difference in the therapeutic change experienced by the clients in psychotherapy. The role of parents, when working with children, was also included under the sub-theme of hindering factors. P12 mentioned how “[…] the role of parents was integral to perceived therapeutic change and […] I was therefore able to see some small changes but these were not significant as the therapy process often felt interrupted and did not have substantial buy-in from the parents”. Parents will always play an important role that will either help or hinder the therapeutic process of children, as the parents cannot be separated from the process. 48 Therapeutic relationship variables Important factors such as misunderstandings, cultural factors, and language barriers played a role in therapeutic change. P2 said, “I have realised that a misunderstanding of the client’s problem, a lack of consideration of cultural factors and language barriers are factors that hinder therapeutic change and that these factors should be highlighted in therapy (e.g. the therapist asking for clarity when unsure)”. P2 also shared that “I believe that without a warm therapeutic relationship, the techniques and procedures of specific modalities are unlikely to be effective”. P12 explained that “there were a number of socio-economic, class, racial, and gendered obstacles that did impact upon therapeutic change. Often with our therapeutic space there was the idea that the community presented its own difficulties that was always felt heavily in therapy. For children and adults alike, there were some cultural norms that were hard to challenge, and with my own identity as an outsider and often of a different ethnicity this did seem to play a role in clients coming back. Consequently, the community my clients came from had an impact upon therapeutic change [sic]”. Other variables Finally, other variables also emerged as another sub-theme under hindering factors related to therapeutic change. Other extra-therapeutic factors that had an influence, according to P12, the following: 49 “I think I might have at times underestimated what the space provided for some clients. There was a sense that there not often spaces like this in the community where people could go with their trauma, pain, emotions and experiences where they could be heard and held”. P12 also said “there were practical obstacles such as money for transport, changing and chaotic schedules of the parents or clients, or traumatic events that seem to disrupt the therapy process […] there were a number of socio-economic, class, racial, and gendered obstacles that did impact upon therapeutic change. Often with our therapeutic space there was the idea that the community presented its own difficulties that was always felt heavily in therapy. For children and adults alike, there some cultural norms that were hard to challenge, and with my own identity as an outsider and often of a different ethnicity this did seem to play a role in clients coming back”. These responses serve as reminders that there are more factors that form part of other systems to consider or be mindful of when working with individuals. Supervision Theme one: Helpful factors The second research question focused on how the role of supervision influenced the intern counselling psychologists’ perceptions of therapeutic change. Two main themes with sub-themes emerged. Theme one refers to the helpful factors related to the supervision that the intern counselling psychologists’ received. As a mandatory requirement, an intern 50 counselling psychologist must receive weekly supervision. The supervisor’s role is highlighted by unpacking how they influenced the intern counselling psychologists’ perceptions of therapeutic change. Eight sub-themes emerged under the heading of helpful factors, namely: developmental role, increased awareness, therapist responsiveness, normalisation, supervisor-supervisee relationship, peer supervision, distinguishing between relational variables, and change process constructs. Developmental role On a developmental level, it became apparent from the data collected that the supervisor played a significant role in moulding/shaping the professional, as well as the personal development and growth of the intern counselling psychologist. P1 described that “my experience of supervision is that it felt tailored to what I needed as a developing psychotherapist, at that stage”. P2 also stated that “supervision for me was a positive experience where my supervisor and I could work together to develop the efficacy of the therapist and client relationship as well as assist in my personal growth as a psychologist”. P2 continued by saying that “my supervisor assisted me to gain a greater understanding of therapy, my work with clients and about myself as a therapist”. Another participant, P5, stated that “supervision is a vital part of the process of ‘becoming’ a competent therapist, and continues to be”. Furthermore, P1 added how supervisors assisted in internalisations that occurred for the new therapist to “find their own voice” and also to challenge themselves: 51 “supervision also helped me to find my feet within a theoretical framework, and to develop the skill of reflecting on the micro-processes within a session. This was really instrumental to me finding myself as a psychotherapist and gaining a sense of belief and confidence in the psychotherapy process”. P9 stated how their supervisor “was unlike any psychologist or supervisor that I had encountered in my M1 and personal life. He pushed me to find my own voice in the therapy room and bring pieces of myself into the process as well instead of remaining a ‘copy- and-paste’ psychologist”. P8 explained that, “in a way, the experiences and way of thinking that happens within supervision becomes somewhat internalised and is held within the room in order to best serve my clients”. P5 also commented by saying that “supervision taught me to sit with my own discomfort of not initially seeing change, relief or improvement in my clients. Supervision helped me question myself, why did I need to see change, and was change as important to my clients as it was to me?”. P6 said that “moreover, understanding my role as a therapist also assisted greatly e.g., my strengths, shortcomings, vulnerabilities, beliefs, and values that may positively or negatively affect the therapeutic processes”, thus, creating a sense of understanding your sense of responsibility and limits to responsibility as a psychotherapist. In support of this, P9 mentioned: “my supervision was powerful in aiding me to have a clear understanding of what therapeutic change actually is and what it needs, in understanding my impact on the therapeutic change through using myself as a tool in the room, 52 and finally in understanding my responsibility (and thus my limits to responsibility) for therapeutic change”. Enhancing the therapists’ competence was also noted in the words of P11, who said that “without the outsider perspective and guidance of an experienced professional, it is difficult, as an intern, to effectively conceptualise clients, become aware of your own pitfalls and shadow, to recognise areas of development or understand your therapeutic performance at all”. Lastly, the developmental role was summarised in the words of P6: “In short, supervision assisted in the perception of the therapeutic change by helping me understand a) the client and their presenting problems, b) understanding myself as a therapist, as well as c) understanding the client- therapist relationship”. Increased awareness Supervision assisted in increasing awareness, as it highlighted important aspects such as the importance of timing, allowing clients to work at their own pace, and the importance of being a medium for exploration. P8 explained how “supervision has allowed me space to step out of what is happening in-front of me, to explore what is happening within the relationship and to then place this in the context of a client’s perception of the world. This creates a space where corrective emotional experiences can take place and such internal perceptions can be challenged”. 53 Also commenting on this was P5, by saying that “through supervision I realised that sitting with clients and holding a non- judgmental space is precisely what would lead to change, insight and improved mental health and well-being”. P5 also stated that “supervision made me question and rethink my role as a therapist. Initially I wanted to be an agent of change, but currently I am satisfied with just being a medium for exploration”. Lastly, P11 commented on increased awareness by saying that “while supervision is not therapy, it too has processes of interactions and I feel that, as it allows you to build your own awareness of these processes both between yourself and the client and between yourself and the supervisor, it does provide something of a model of therapeutic change”. Therapist responsiveness. P1 commented by saying that “through this [supervision], I developed an appreciation for the relational aspects involved in the psychotherapeutic process, and how being responsive to these elements (and the needs of the client), form an important part of the change process”. P1 also added: “through focusing on these micro-processes, I started to realise (and experience in-session), how these relational elements, and especially being responsive to the client, impacts the entire process of psychotherapeutic change”. P5 further added that “helping clients to tell their stories and revisit 54 important moments in their lives is more important than reaching the finish line of improved mental health” and P2 said that “supervision for me was a positive experience where my supervisor and I could work together to develop the efficacy of the therapist and client relationship as well as assist in my personal growth as a psychologist”. From the abovementioned, it is clear that supervision proved to be helpful in enhancing therapist responsiveness of the participants (while they were psychologists in training during their internship year). Normalisation Supervisors seemed to add to normalising certain expectations for the intern counselling psychologists. P9 explained how “my supervision was powerful in aiding me to have a clear understanding of what therapeutic change actually is and what it needs, in understanding my impact on the therapeutic change through using myself as a tool in the room, and finally in understanding my responsibility (and thus my limits to responsibility) for therapeutic change”. Another participant, P2, explained how the assistance of a supervisor contributed to the above factor by saying that “supervision emphasised that therapy is not about me and that change cannot be forced, as well as the realisation that change happens at different paces for different clients”. 55 Supervisor-supervisee relationship The supervisor-supervisee relationship also came to light from the data that was collected. Factors such as receiving support and guidance, being offered different perspectives, providing practical examples, and supervision as a holding space stood out. P8 explained how “most importantly for me, [supervision] provided me with an ability to nurture and trust my feelings and intuition (countertransference). This has played a vital role in allowing me to both pick up and trust when and how to act on my own feelings with a client”. P12 stated that “because the unit was not as punitive I felt more adult and I was allowed more space and control over how I wished to structure and plan my internship. There were certain rules and parameters I had to follow but I felt that our supervisors trusted us more, and allowed us more room to breathe. As long as we met targets, I felt more able to manage my own schedule and therefore more competent. This allowed for more therapeutic change in my clients”. Other helpful factors were noted by P2, who stated that “my supervisor used practical examples from some of her cases to demonstrate how therapeutic change occurred over time, this was very helpful and made me realise that therapeutic change can take time and is different for each client”. 56 P9 further stated how “in my observation of him in group sessions during training, it became clear that he used humour, metaphors, and strategic self-disclosure to connect with his clients in such a way that the therapeutic relationship was strong enough to build awareness and acceptance very quickly to facilitate that change. In supervision he pushed me to use my own critical thinking in problem solving and in understanding where I needed to focus to achieve therapeutic change with my clients. He also assisted me in creating boundaries and understanding my sense of responsibility when clients did not achieve any therapeutic change at all. That was very important too, knowing where my responsibility for therapeutic change started and where it ended”. Again, this emphasises the important role of supervision in the development and growth, as previously stated, of the intern counselling psychologist. Peer-supervision Some data reflected how peer supervision, received from fellow-interns, played an important role in their perception of therapeutic change to the extent that it was deemed to be helpful. P4 explained how “there were moments when my supervisor offered decent advice on how to develop my character through mindfulness, but overall, I believe my colleagues offered me greater supervision than many of the supervisors I met along my path”. 57 Distinguishing between relational variables Important relational variables stood out with regard to client variables, therapist variables, and client-therapist variables. P1 stated that “through [supervision], I developed an appreciation for the relational aspects involved in the psychotherapeutic process, and how being responsive to these elements (and the needs of the client), form an important part of the change process”. P8 explained that “supervision has allowed me space to step out of what is happening in-front of me, to explore what is happening within the relationship and to then place this in the context of a client’s perception of the world. This creates a space where corrective emotional experiences can take place and such internal perceptions can be challenged”. All the variables were summarised according to the words of P11: “while supervision is not therapy, it too has processes of interactions and I feel that, as it allows you to build your own awareness of these processes both between yourself and the client and between yourself and the supervisor, it does provide something of a model of therapeutic change”. Change process constructs P11 commented on change process constructs in saying that “with input from the supervisor, you can further determine how you can continue to or better facilitate 58 therapeutic change or what you may be doing to hinder that process”. P3 also commented on this when saying that “my supervisors have definitely influenced how I experience therapeutic change. They taught me that the client should always work harder in the session than the therapist and that the client should take responsibility for their own process. Without the latter, one cannot go far and expect therapeutic change”. Furthermore, P6 elaborated by saying that “supervision played a great role in my perception of therapeutic change through understanding the stages and processes of therapy – initial assessment, feedback, formulation of goals, psychoeducation, etc. until consolidation of the process, and termination”. Evidently, supervision adds greatly to the perception of change for the intern counselling psychologist and also helps them to better understand how theory and practice align. Theme two: Hindering factors The final theme focused on what factors the participants perceived as hindering in terms of the supervision they received and how the supervision shaped or informed their perception of therapeutic change. Starting with the words of P4, the following theme emerged: “I did not have a great experience of supervision”. The first sub-theme relates to the supervisor being overworked. Sub-themes two, three and four offer more insight into how participants experienced the supervision space. Sub- theme two refers to the supervisee feeling misunderstood by the supervisor, sub- 59 theme three refers to supervision being experienced as a punitive space, and sub- theme four to supervision as a labelling space. The final sub-theme sheds light on the experience of power dynamics in the context of supervision. Finally, the abovementioned sub-themes are linked to how supervision plays a role in the perception of therapeutic change from the perspective of the intern counselling psychologist in this study. Supervisor being overworked P4 explained how “[…] I can appreciate that supervisors seek to help shift supervisees and shape their understanding of therapeutic change. However, my experience taught me that supervisers often fail to reach this standard”. Further, P4 explained, “my supervisor was over worked and it came through in her own sessions with me”. Supervisee feeling misunderstood by the supervisor P4 explained, “I felt misunderstood […]” – a short but important statement, as the supervisee relies greatly on the supervisor for guidance, support, and assistance when experiencing possible feelings of uncertainty. Supervision as a punitive space P12 stated that “some supervision spaces felt quite punitive and challenging which did not help me develop as I might have wanted. However, I do not wish to discredit 60 these spaces as often the supervisors who held these spaces were incredibly knowledgeable and experienced, and their thinking were really helpful in getting me to think about my clients. However, because of the approach it did not always build my confidence and did not help me implement meaningful change in my clients [sic.]”. Supervision as a space of labelling P12 noted that “the supervision space formed a significant part of my internship experience. I think my experience of the label [of] intern made me feel a little more apprehensive”. This possibly also links with the next sub-theme, namely power dynamics. Power dynamics From the data, power dynamics were apparent, particularly in P4’s explanation: “I felt misunderstood by her and that she, and the rest of the supervision team, saw themselves as some sort of “gift” to their supervisees”. This also links with P12, who stated that “I think my experience of the label intern made me feel a little more apprehensive”. This possibly created a sense of lack of trust and confidence in the level of competency of the intern counselling psychologists. Discussion This explorative study, with a qualitative research approach and a qualitative descriptive research design, aimed to answer the following research questions: 1) How do intern counselling psychologists perceive therapeutic change? and 2) What role does supervision play in the intern counselling psychologists’ perceptions of therapeutic change? 61 Gaines et al. (2020) is of the opinion that what psychotherapists would agree on is the complexity of individuals and thus also psychotherapy and the process of change. Mulder et al. (2017) applaud the fact that research in psychotherapy has come a long way with some significant improvements in the field. This study agrees with this notion, but a lot still remains to be further explored and discovered concerning what brings about therapeutic change, particularly by focusing on specific scopes of practice in the field of psychology, to gain better understanding. These better understandings can be derived from narratives from different participants. The participants, with limited experience in terms of psychotherapy, are expected to conduct psychotherapy while working under supervision. In this study, participants reflected on several factors that stood out with regards to therapeutic change and the role that supervision had in shaping or influencing their perception of therapeutic change. The most prominent finding was that the data collected in this study naturally fell under two main themes, namely 1) factors that are helpful to the process of therapeutic change and the role of supervision, and 2) factors that hinder the process of therapeutic change and the role of supervision. Drawing upon the words of P5 “I wanted to be an agent of change, but currently I am satisfied with just being a medium for exploration”, this study sheds light on the journeys of intern counselling psychologists’ and their experience of helpful and hindering factors while also considering the role that supervision plays in this regard. Willis-O’Connor et al. (2016) describe helpful factors as those factors that contribute to the client experiencing higher levels of comfort and support, resulting in clients feeling better understood by their psychotherapists. The findings of this study 62 revealed that the participants identified client variables, therapist variables, the therapeutic relationship, and other variables as important helpful factors with regards to therapeutic change. These four variables emerged strongly as prominent sub- themes. Despite the different theoretical orientations of psychotherapy that the participants have, it was evident that therapeutic change is dependent on the client’s stage in or readiness to change, the clients’ level of awareness and insight into the psychotherapeutic process, and to what extent they acknowledged and take responsibility for their own psychotherapy processes. Feinstein et al. (2015) argue that how ready a client is for change is a significant factor, which is often not considered enough during the course of psychotherapy. However, the findings portrayed here emphasise how clients’ readiness for change needs to be a prominent consideration during psychotherapy. In addition, it would be beneficial if supervisors could highlight the clients’ readiness to change and their stage of change during discussions in supervision as important points for consideration. The participants’ feedback strongly corroborate the findings of Krebs et al. (2018), who argue that all psychotherapists readily recognise the profound impact of a client’s readiness to change on the effectiveness of therapeutic change. Moldovan and Pintea (2015) refer to processes that take place where one factor leads to another to ultimately result in therapeutic change as mechanisms of change. From the findings of this study, these mechanisms of change are synonymous with the themes reported under helpful factors that potentially result in therapeutic change. In addition to the readiness to change and the stages of change being regarded as mechanisms of change, other important mechanisms of change noted are increased awareness and insight. Increased awareness and insight are also mentioned by Jennissen et al. (2018) as mechanisms of change and important 63 helpful factors in the context of psychotherapy. Perrotta (2020) comments that awareness is a deeper level of consciousness, which implies that a client is present, has the capacity to make decisions, accepts what lies ahead, and intimately desires to make changes with the aim to be free of their maladaptive ways. This corroborates with findings that if a client truly becomes aware of their maladaptive ways in thinking, behaving and coping and they gain insight, change will most likely occur. In particular, from their findings Jennissen et al. (2018) stress, that insight is a process that involves cognitive and affective elements. Jennissen et al. (2018) further state that insight refers to self-understanding and describe the term as the occurrence of realisation and understanding of the links between past events and present experiences, relational patterns, as well as interpersonal, emotional and psychological difficulties. Furthermore, the findings strongly suggested that increased awareness and insight seemingly had a ripple effect that led to corrective experiences. The psychotherapist as a helpful factor was just as prominent. Levitt and Pomerville (2016) are of the opinion that factors related to the psychotherapist are some of the most favourable contributors of therapeutic change. Castonguay et al. (2010) further add that, keeping in mind the complexity of individuals and how people differ, being able to adapt the process to the clients’ needs is simply inevitable. Norcross and Wampold (2011) addressed this same topic by also stressing the importance of tailoring the psychotherapy to the client as well as their context. Thus, it would seem that the above support the findings from this study regarding the psychotherapists’ ability to be flexible and competent. Duarte et al. (2019) add to the findings by stressing the importance of the actions of the psychotherapist, in particular being flexible, reliable, authentic, considerate, and receptive to the needs 64 of each client. The first two variables (namely: client variables and therapist variables) looked individually at the two role-players in the therapeutic process. The third variable focused on the interaction between the psychotherapist and the client – referred to as the therapeutic relationship. Feinstein et al (2015), Corey (2014), and Nienhuis et al. (2018) argue that all diverse psychotherapy schools stress the importance of a strong therapeutic relationship. The participants likewise described the importance of the therapeutic relationship as central to therapeutic change, as being more important than any specific modality, and as the medium through which therapeutic change takes place. Furthermore, what mainly stood out in the findings is the role of the therapeutic relationship in enhancing the occurrence of corrective experiences. Corrective experiences were initially introduced by Alexander and French in 1946 (as cited in Gülüm & Soygüt, 2021). It is defined as re-experiencing the past in the present without the negative association (Gülüm & Soygüt, 2021). Furthermore, Gülüm and Soygüt (2021) explain how a corrective experience can lead to positive outcomes on an intrapersonal level (namely, emotionally, cognitively, and behaviourally) as well as on an interpersonal level (namely, relationally). The linking of different types of corrective experiences are associated with different schools of thought. The first introduction to corrective experience was linked to psychodynamic therapy in which corrective experience occurred when clients corrected their maladaptive relational patterns through transference in the relationship with their psychotherapist (Khattra et al., 2017; Roussos et al., 2017). Schema therapy would emphasise the importance of a corrective emotional experience as being of the highest significance, since it aims to correct a clients’ 65 early maladaptive schemas (Gülüm & Soygüt, 2021), while cognitive behaviour therapy would emphasise the importance of addressing cognitive distortions or negative biases (Rnic et al., 2016). Lane et al. (2015) argue that therapeutic change, no matter the theoretical orientation, occurs through reconsolidation of old emotional memories (past experiences) with new emotional experiences (present). Furthermore, they argue that it also results in changing schemas on a cognitive level (ibid.). Goldfried (2019) summarises how the process of change occurs when clients are motivated, willing to work with their psychotherapist, have insight into current problems, take action to change, and experience corrective experiences on different levels, namely interpersonally (relationally) and intrapersonal levels (cognitively, emotionally and behaviourally). The findings, as mentioned previously, strongly correlate with what other authors have reported on corrective experience. One participant especially highlighted this corrective experience within the therapeutic relationship by describing how this change brings to light patterns of relating, which can be understood by relating with interpersonal and intrapersonal levels – thus, how clients think, feel and behave in different contexts. This is in line with the fourth sub-theme, namely other variables, which refers to change that occurs on different levels. The data from this study suggests that change occurs on different levels. The participants reported how change occurs through relational aspects (changes in healthier relationships), the recognition, reflection and experiencing of all their emotions, and altering maladaptive behaviour and thought patterns. These four 66 variables contribute strongly to what the participants experience as important in terms of therapeutic change. The second research question helped the research to arrive at helpful factors that serve as a prominent theme in the role of supervision in therapeutic change. Fernández-Alvarez (2016) define supervision as falling halfway between training and treatment, which supports Falender et al. (2014), who place supervision as central to the development of a competent counselling psychologist. Thus, from the findings of this study, supervision can be described as the bridge between professional and personal development in the journey of becoming a registered psychologist. Watkins (2018) describe supervision as a pyramid that highlights the skills of the supervisor, the relationship between the supervisor and supervisee, and the personhood of the supervisor. Findings from the data place helpful factors well within this pyramid. See Figure 1 for a visual illustration of this pyramid. Skills of supervisor Therapeutic change Relationship between Personhood supervisee of supervisor and supervisor Figure 1: Supervisor – Skill, relationship and personhood pyramid 67 The skills of the supervisor came to light in the sub-themes of the developmental role, increased awareness, therapist responsiveness, normalisation, distinguishing between relational variables, and change process constructs. The personhood of the supervisor was evident in the supervisor-supervisee relationship. The participants’ reflection on their perception of the role of supervision strongly agrees with what Watkins (2018) explained in saying that effective supervision comes down to what supervisors do, who they are as supervisors, and how supervisors regard their supervisees. The participants stated how supervision assisted in growth on a personal and professional level (skills), how supervision helped gain a better understanding of psychotherapy (skills and relational), how readiness of change is important (skills), and how to become psychotherapists in their own right (personhood) instead of being a “copy-and-paste” psychotherapist. A mandatory requirement of the HPCSA is that an intern counselling psychologist must have supervision. Therefore, when studying intern counselling psychologists’ perception of therapeutic change, it is deemed as important to also strongly consider the role of supervision when venturing into this domain of research. This serves as an additional motivation for including the context of supervision in the current study. This link was also evident in the importance of insight and awareness, the relationship, and the different variables that were prominent from the data in both research questions. The findings thus reiterate how important and interlinked these factors are in understanding therapeutic change from the perspective of intern counselling psychologists (or any psychologists in training for that matter). 68 The opposite is when clients experienced factors that hindered their process and caused them to experience discomfort, feel misunderstood, or not supported (Willis-O’Connor et al., 2016). Hindering factors was a prominent theme that stood out in both research questions. With regard to therapeutic change, the four variables were the same hindering factors that stood out, namely client variables, therapist variables, the therapeutic relationship and other variables. Thus, findings strongly support Kleiven et al. (2020) who explained that intrapsychic (client variables and therapist variables) and interpersonal (therapeutic relationship and extra-therapeutic factors) processes contribute to hindering factors. A very important ethical guideline from the HPCSA is that the psychologist must strive to always ensure ethical practice and act in a way that prevents harm (HPCSA, 2006). This is commonly known as the ethical principles of beneficence and non-maleficence. The findings of this study highlight possible factors that can potentially contribute to harm if these principles are not included in the training of psychologists. Costanguay et al. (2010) emphasise that awareness of potential hindering factors should be mandatory in the training of psychologists to prevent possible harmful outcomes. A prominent finding reported under client variables was how premature termination, lack of insight, and not taking responsibility (missing sessions) hinder the therapeutic process, which links strongly with the therapist variables of being aware of the stage or readiness of change at which the client finds themself. Although client variables are seldom within the control of the psychotherapist, they are important factors to consider when reflecting on a process and during case conceptualisations. Bucci et al (2016) state how case conceptualisation is a core 69 competency and central to the psychotherapy process. As this is such a central competency and it is well known that case conceptualisation forms an integral part of a psychotherapeutic process, not only in the context of psychotherapy but also in the context of supervision, one can argue that for the intern counselling psychologist this is a vital part of training and supervision. However, it was surprising that it did not feature strongly as part of the data collected, as only one participant mentioned how supervision assisted them in conceptualising clients. Being overly authoritative and directive were described as potential hindering factors in the data, as this does not create a space that promotes understanding and support. The participants referred to the psychotherapist as being an important ‘tool’; therefore, considering the person-of-the-psychotherapist (POTP) is vital. If the ‘tool’ is ineffective, it could greatly hinder the therapeutic process. The ripple effect thereof could lead to a possible therapeutic rupture, which Feinstein et al. (2015) define as the breakdown within the relationship between client and psychotherapist. They further argue that it can result in termination of therapy and prevent progress, resulting in psychotherapy not achieving the desired outcome (ibid.). Johnston (2015) and Pillay et al. (2013) comment on the cultural diversity within the South African context and its influence on psychotherapy. This diversity includes 11 official languages, among others (Johnston, 2015), thus emphasising that there are numerous factors to consider, which indicates just how vital training and supervision are for the intern counselling psychologist working in such a culturally diverse country. The findings reiterated the challenges of working within the South African context that is so diverse, where misunderstandings that result from cultural factors and language barriers had a significant impact on the process. 70 Other variables which Feinstein et al. (2015) refer to as extra-therapeutic factors or life events are believed to have a greater impact on psychotherapy outcome than any or all of the other factors. Research from Paley and Lawton (2001) stated how forty percent of change processes are determined by these variables. Feinstein et al. (2015) further argue that extra-therapeutic factors are the most important factors to reflect on when reporting outcomes in the context of psychotherapy. However, this contradicts findings from this study. Extra therapeutic factors such as trauma occurrence, parental involvement, and socio-economic challenges were significant in the data but, although they did not stand out solely as the most important factors. They were mentioned to have a significant enough impact to form part of the findings, but not as significant in that it outweighs the other factors. Referring back to the context of psychologists in training and in an attempt to prevent hindering factors, the role of the supervisor is of particular importance. The intern counselling psychologist relies greatly on the input from supervision as part of their journey. From the findings of this study, the hindering factors were again a prominent theme; however, it seemed that in this regard to lean to the one side of the pyramid, which is the personhood of the supervisor (Watkins, 2018). Participants noted the impact of being in supervision where the supervisor was overworked and where the supervision space was a punitive space, a space of labelling and a space in which clear power dynamics were present. The power dynamics refer to the supervisor being in the so-called ‘one-up’ position (authority figure) with the intern counselling psychologist being in the so-called ‘one-down’ position (submissive/compliant figure). This links with what Cook et al. (2018) describe to as the hierarchical structure. 71 The power dynamic can be either healthy or unhealthy, depending on the context (Cook et al., 2018). In supervision, the supervisor is more knowledgeable and skilful than the supervisee, based on the difference in years of experience within the field of psychology, in particular (De Stefano et al., 2017). The power difference is expressed in the way in which the supervisor conducts themselves given their power in this position. De Stefano et al. (2017) describe that the supervisor has the potential to create a space that is either positive or negative and can therefore be categorised as either a helpful or a hindering factor. In the context of this study, unfortunately, it appears that some participants perceived their supervisors to incline more towards the unhealthy (hindering) side of the power relationship, resulting in potentially harmful effects for the participants (and consequently, also for the clients of the participants). Participants also reported feeling misunderstood in supervision. Nel and Fouche (2017) argue that supervision is regarded as the most important and fundamental contributor in the training of the novice psychologist (or the psychologist in training). The findings support this notion; however, not all the participants shared in the positive experiences that should have been contributed by supervision. However, all the participants did agree on the important influence of supervision, where for some it entailed an experience of assisting in their personal and professional growth, becoming a competent psychotherapist, and acquiring great insight and realisation, while for others it left them feeling apprehensive and the supervision failed to assist in helping them develop in the way they would have wanted. 72 Although discussed as four separate themes under two research questions, the findings support how these themes come together – in other words, there is a clear link between the findings gathered through the two research questions. Intern counselling psychologists are in the position to work daily with clinical challenges and are thought of as problem seekers and observers of behaviour and change processes. Therefore, Goldfried et al. (2014), refer to education and training as being inseparable in promoting and shaping the profession. Supervision should be a space that assists intern psychologists in understanding therapeutic change on affective, behavioural, cognitive, and interpersonal levels. Duarte et al. (2019) are in agreement in explaining that psychotherapy is better understood as a complex, dynamic, and a diverse phenomenon. The prominent features of this research are that the participant(s), even working individually within a session with a client, actually do so in collaboration with their supervisor(s). This can also be conceptualised as a pyramid (see Figure 2) of client, psychotherapist and supervisor, which links all the above variables in order to better understand therapeutic change. Client Therapeutic change Supervisor Psychotherapist Figure 2: Roleplayers – Client, supervisor and psychotherapist pyramid 73 Limitations and recommendations What was initially thought to not be a limitation ended up becoming one due to unforeseen circumstances – one of the main limitations in this study is the number of participants. The pool of participants shrunk as a result of an international pandemic (with very clear nationwide implications). Although including only intern counselling psychologists could be considered a limitation, this research study was purposeful in looking at one scope within the psychology profession, namely one in which individuals will be required to start practising directly after having completed their internship and passing the HPCSA board exam, in contrast to clinical psychologists who are required to complete an additional community service year. All the other registration categories are acknowledged and it is highly recommended to conduct similar studies under each registration category in order to obtain a more balanced view based on all the findings, which can then be generalised. Another limitation is that the participants in this study had experience in different theoretical paradigms (or schools of thought). Even though the different theoretical paradigms emerged during the data analysis, they were not specifically asked for; this might limit the options available in terms of data analysis. Different theoretical paradigms could have an impact on the perceptions of therapeutic change. If the specific paradigms were all they knew and had to work from, it makes one wonder about the impact on the personhood and becoming psychotherapists. The limitation is thus that this study could have asked specifically for the participant’s preferred theoretical paradigms, which could have offered other options in terms of data analysis. This being said, this was an exploratory study. 74 This study recommends follow-up interviews on this topic to gain a more in- depth understanding of therapeutic change and the role of supervision in this regard. This could possibly include a better understanding of training programmes, theoretical paradigms of training, the internship site, as well as the theoretical framework from which supervision occured. Finally, although it can be regarded as a limitation in that the researcher was not able to ask follow up questions, the findings from this explorative study can be used as a guideline to formulate possible questions for in-depth interviews in future studies. Therefore, it is recommended to also do a follow-up study to further explore, in a year or two after these participants have been practising as counselling psychologists’, how they view therapeutic change then with a view to bridging the gap between education, training, and practice. Such longitudinal study designs would yield interesting findings, which, to the best of the researchers’ knowledge, are currently not yet available for this specific research topic. Doing so would ultimately contribute to the field of psychology regarding the way in which psychologists are trained in the South African context. Conclusion This study aimed to explore intern counselling psychologists’ perceptions of therapeutic change and the role of supervision. The data analysis revealed that therapeutic change is a constant, multifaceted process with numerous factors that contribute to the outcome. The participants contributed significantly in sharing their perception of change and also honestly reporting on their experiences with working under supervision. Two prominent themes were highlighted that featured prominently in both research questions and the study as a whole. 75 Understanding helpful and hindering factors to therapeutic change were prominent themes. From grouping the findings into hindering and helpful factors, it appears that considering the variables holistically is what ultimately brings about therapeutic change. The role of supervision was highlighted by all participants as an important contributor to change in therapy. This contradicts the notion that one is more important than the other when referring back to the longstanding debate in psychotherapy of which is the most important factor that leads to change (Goldfried, 2013). From the findings it is learnt that, in order to understand therapeutic change, all the variables need to be considered and unpacked. Understanding your clients’ variables – among others readiness to change, internal locus of control, responsibility, insight and awareness – contributes meaningfully as either helpful or hindering factors in the context of therapeutic change. The therapist variables came to light secondly, which could either be helpful or hindering to the psychotherapists’ view of change. These factors include knowledge of when you are too authorative or directive in your approach. Furthermore, the understanding of the notion that there is no one-size-fits-all approach, and having the necessary skills. It also includes fundamental factors such as being congruent, showing unconditional positive regard and acceptance. When psychotherapists and clients come together, it is important to consider the therapeutic relationship as an important variable in the occurrence to therapeutic change. The importance of the therapeutic relationship is emphasised, as it fosters a safe, working relationship and medium through which therapeutic techniques take 76 place. Misunderstandings and important cultural and language barriers can play a significant role in the outcome and success of psychotherapy. Lastly, other variables as well as external factors play a part in understanding and experiencing change on different levels, which has an impact on therapeutic change. The second research question helped to gain a better understanding from the findings of the role of supervision in the perception of therapeutic change. Helpful factors were the shaping or forming in respect of both professional and personal development. What stood out as hindering factors were approaches to supervision that were viewed as punitive and where labelling and dysfunctional or unhealthy power dynamics were prominent. Cases of an overworked supervisor and where the supervisee felt misunderstood were also regarded as hindering factors. If the road to better understanding therapeutic change comes down to helpful and hindering factors, then the words of participant five are suitable: becoming a competent psychotherapist who is “satisfied with just being a medium for exploration” is a good starting point. 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We are always connected to others, and it is through relationships with others that we also get the chance to really learn about ourselves, about others, the world and important life lessons. Shared joy, shared anxiety, shared sorrow, and shared laughter – all is better in collaboration. I appreciate that I have people who hold me accountable for what I do and say, people who really know me and my potential and who always reflect authentically and honestly on what I do. The past two and a half years have confirmed yet again the importance of having people in your life who truly care and who are with you through it all. This has also been something highlighted throughout the research process. To me, this journey is like playing various rounds of cards. I was handed different cards – some challenging, some good, some frustrating, and some that left me speechless for a moment. Yet every card was needed, and now, with all the cards on the table, I have a definite feeling of winning this time around. The first round of cards handed to me was entering the programme, finding a study leader and deciding on the topic. With my research topic having been accepted, the various people who would also be a part of this round entered. The process of obtaining approval to conduct the study went relatively well, and I received clearance from the scientific committee (COMPRES) and ethics (HREC) 85 within a year. When the Covid-19 pandemic struck, it threw all my cards off the table, putting all qualitative research on hold for a few months and in the process also reducing the number of participants due to the change in board exams at the HPCSA. After having been cleared to conduct research again, HREC dealt us a very different, unexpected set of cards this time that would have an impact on each element discussed below. Data collection Given that I had to be cautious about my role as researcher whilst being an intern counselling psychologist myself at the time, this round rendered me an observer, as I had to watch how the other role players had to execute their tasks with the hands they were dealt. I had to rely on an independent person to assist with recruitment and data collection which at times was frustrating – having to wait and rely on others to get things done while keeping in mind those individuals also had other responsibilities and work to do. Then came the change in the informed consent process that had to be done virtually, which had a significant impact on the data collection process. There was a huge delay in getting the informed consent documents from HREC, which negatively impacted my research timeline. Thereafter, five participants who had been eager to complete the questionnaire withdrew from my study, mainly due to the change in the informed consent process, which they regarded as inconvenient, and they didn’t have the time to set aside for it. This took some cards off the table, and my independent person had to start again. Moving into 2021, my independent person managed to get more participants and the data was collected. I remember how, with 86 each set of data that came in, it felt like I picked up the Joker card, meaning that all things went. Throughout this process, I learned a lot about patience and relying on relationships with others. I had to remind myself that I needed to trust the process and do what I could to the best of my ability while being aware of my own limitations. I had to trust and have faith in my independent person to adhere to all the ethical rules while recruiting participants, getting informed consent, and collecting the data. The exciting part was that no transcribing was necessary, which saved time, as the data we received was already typed verbatim from each participant. Data analysis and interpretation The next round of cards dealt was having to work with each set of data obtained and also working with a co-coder in analysing the data. At the onset, I had to familiarise myself with the data by reading through it various times. This process was very exciting, as the data was clear, to the point, and so rich in quality. The data produced made it easier to remain unbiased, as I did not have to wonder about what a participant wanted to say or imply; each participant expressed themselves well and highlighted certain themes. It was interesting to see how my co-coder and I worked independently from one another yet we both got to similar themes, which emphasising again how good the data was. I think also having knowledge about the topic from my studies and working with my study leader who is extremely familiar with the content of the topic made this process very interesting, exciting, enjoyable, and also a great learning opportunity. 87 Findings While analysing the data and discussing it with my study leader, it was very exciting to find a range of literature that confirmed these findings. All the themes are so relevant to me as a soon-to-be counselling psychologist in realising again how important factors should be kept in such as acting in the best interest of each client. I have so much respect for each participant who shared their narrative with us and gave a voice to the unvoiced, all with the aim also of benefitting the field of psychology. My hope is, even if the participants had negative experiences, that they learned valuable lessons of what not to do when they find themselves in a similar role and that they will feel heard and valued for their contribution. On a personal level, this research study expanded my knowledge on therapeutic change and the role of supervision. It certainly challenged me in many ways, some more than I had hoped for, but in the end, it was all worth it. 88 Addendums Addendum A: Informed consent 89 90 91 92 93 Addendum B: Ethical approval for this study 94 95 96 Addendum C: Proof of language editing 97 Addendum D: Turnitin report 98 99