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 i 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. ii  Lastly, but definitely not the least, thank you to my participants for willingly taking part in the research process. iii 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 iv 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. v 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. vi 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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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. mailto:reprints@tandf.co.uk?subject=Author%20reprints%20(IFA%20link) http://authorservices.taylorandfrancis.com/ordering-print-copies-of-your-article/ http://authorservices.taylorandfrancis.com/ordering-print-copies-of-your-article/ http://authorservices.taylorandfrancis.com/ http://authorservices.taylorandfrancis.com/contact/ xv 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 xvi 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 xvii 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 xviii 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 xix 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 1 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 2 ’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 3 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. 4 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 5 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 6 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). 7 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). 8 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 9 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. 10 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 11 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. 12 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. 13 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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The new great psychotherapy debate: Scientific integrated psychotherapy vs. plurality. Why cognitive-behavior therapy is the gold standard in psychotherapy and a platform for scientific integrated psychotherapy. Journal of Evidence-based Psychotherapies, 18(2), 1-17. Donald, I. N., Rickwood, D. J., & Carey, T. A. (2014). Understanding therapeutic change in young people: A pressing research agenda. Journal of Psychotherapy Integration, 24(4), 313-322. Falender, C. A. (2014). Clinical supervision in a competency-based era. South African Journal of Psychology, 44(1), 6-17. 14 Falender, C. A., Shafranske, E. P., & Ofek, A. (2014). Competent clinical supervision: Emerging effective practices. Counselling Psychology Quarterly, 27(4), 393-408. doi: 10.1080/09515070.2014.934785 Flückiger, C., Hilpert, P., Goldberg, S. B., Caspar, F., Wolfer, C., Held, J., & Vîslă, A. (2019). Investigating the impact of early alliance on predicting subjective change at post-treatment: An evidence-based souvenir of overlooked clinical practice. Journal of Counselling Psychology. http://dx.doi.org/10.1037/cou0000336 Goldfried, M. R. (2013). What should we expect from psychotherapy? Clinical Psychology Review, 33, 862-869. Hendricks, S., & Cartwright, J. (2018). A cross-sectional survey of South African psychology interns’ perceptions of negative supervision events. South African Journal of Psychology, 48(1), 86-98 Hendriksen, M., Peen, J., Van, R., Barber, J. P., & Dekker, J. (2014). Is the alliance always a predictor of change in psychotherapy for depression? Psychotherapy Research, 24(2), 160-170. doi: 10.1080/10503307.2013.847987 HPCSA. (2006). Guidelines on keeping patient records. Pretoria: Health Professions Council of South Africa. Israelstam, K. (2014). Discussion (I): Never ever stop learning more about supervision. Psychoanalytic Inquiry, 34, 634-641. Lambert, M. 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 15 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. 16 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 17 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 18 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 19 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 20 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, 21 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 22 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 23 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). 24 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 25 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 26 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 27 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 28 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 29 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. 30 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. 31 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 32 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 33 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. 34 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 35 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. 36 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 37 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. 38 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”. 39 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 cha