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Developing clinical effectiveness in psychotherapytraining: Action researchBiljana Van Rijn a , Charlotte Sills a , Jill Hunt a , Suhith Shivanath a , KatarinaGildebrand a & Heather Fowlie aa Metanoia Institute , London, UKPublished online: 17 Nov 2008.

To cite this article: Biljana Van Rijn , Charlotte Sills , Jill Hunt , Suhith Shivanath , Katarina Gildebrand & Heather Fowlie(2008) Developing clinical effectiveness in psychotherapy training: Action research, Counselling and PsychotherapyResearch: Linking research with practice, 8:4, 261-268, DOI: 10.1080/14733140802305804

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RESEARCH ARTICLE

Developing clinical effectiveness in psychotherapy training:Action research

BILJANA VAN RIJN, CHARLOTTE SILLS, JILL HUNT, SUHITH SHIVANATH, KATARINA GILDEBRAND, &

HEATHER FOWLIE

Metanoia Institute, London, UK

AbstractThis study is an evaluation of a new approach to clinical training in Transactional Analysis using the methodology of actionresearch. The evaluation focuses on the second year of training and placement-based clinical practice at the Metanoia Institute,UK. The design of the training year was research-based and used the concept of an ‘internship’ year. The design aimed toclose the gaps between clinical practice, supervision and formal training; facilitate translation of theory into practice; andintegrate findings from the ‘common factors’ research into effectiveness of psychotherapy. Training and supervision methodswere linked and focused on emerging issues in clinical practice and the development of students’ capacity for critical reflectionand a research attitude to practice. The evaluation was a naturalistic study which used quantitative and qualitativemethodology within the action research framework to reflect on the impact of the training on the participants, theorganisation and the clinical practice. The quantitative outcomes show that the project developed the effectiveness ofstudents’ clinical practice and reflexivity. Qualitative analysis gives insight into the experiences of the participants and theemotional impact of the research process.

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

Introduction

This paper describes a year-long evaluative researchinto the new design for the second year training inTransactional Analysis, based on the doctoral researchby van Rijn (2005). Her concept of an ‘internship year’was central to this project; it positioned placementpractise at the heart of training as students started tosee clients. The internship approach aims to close thegaps between clinical practice, supervision and formaltraining, facilitate translation of theory into practiceand integrate findings from the ‘common factors’research into effectiveness in psychotherapy (Frank &Frank, 1991; Lambert & Bergin, 1994; Luborsky &Singer, 1975; Wampold, 2001).

A development group was formed to work on theyear’s training design � comprising several membersof the TA staff team and the researcher, who wasboth a tutor and a manager of the MetanoiaCounselling and Psychotherapy Service (MCPS),where students undertook placements within theinstitute. Later on, this group formed the researchteam. Each member had a different level of involve-ment within the programme and different roles in thewider team. As the manager of MCPS, the primaryresearcher regularly dealt with the interface betweenplacement practice, training and supervision, and was

motivated to improve it for the sake of clients, as wellas students. The training programme was based onher research and this increased her level of involve-ment with the programme. In this context, thecomposition of the research team and the members’inevitable investment in the project required particularattention to transparency and methods of qualitativeanalysis.

Training had previously been similar in structure toother programmes in the UK, containing formalteaching (didactic, experiential and skills practice),client work (normally in voluntary placements), andclinical supervision with a suitably qualified supervisorwho was not necessarily involved with the course.Other than supervision reports, there was no formalcontact between the institute and the supervisors,who were employed directly by the students and,unless there were difficulties, there was no formalcontact with the placement provider.

The development group focused on methods oflearning and assessment that allowed the challengesand questions relating to placement practice, stu-dents’ anxieties and their reflection on the therapeuticrelationship, to become the heart of the learningprocess. The redesigned training year was significantlydifferent from the established practice of TA (andother psychotherapy) training at Metanoia Institute,

Counselling and Psychotherapy Research, December 2008; 8(4): 261�268

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

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and evaluation of the programme was an importantpart of the development.

Literature

There is a paucity of research into psychotherapytraining and a lack of clear evidence that professionaltraining ensures effective clinical practice. Trainingcourses in the UK use competencies and methods ofassessment approved by universities and umbrellabodies, such as the United Kingdom Council forPsychotherapy (UKCP) and the British Association forCounselling and Psychotherapy (BACP) to monitortheir quality, but these do not answer questions abouttheir impact on effective clinical practice.

Beutler, Machado and Neudfelt (1994) reviewedstudies relating ‘therapist variables’, such as levels ofprofessional training and experience to clinical effec-tiveness and found that they were often confounded,making it difficult to separate the effects of trainingfrom other influences. Consequently, research studiesreviewed produced contradictory results. Some sug-gested experience or the level of training has littleimpact on effectiveness (Auerbach & Johnson, 1977;Beutler et al., 1986; Stein & Lambert, 1984); however,others suggested that experienced therapists producebetter results (Luborsky, Chandler, Auerbach, Cohen& Bachrach, 1971). Others argued that paraprofes-sionals perform better than professional therapists(Durlak, 1979, 1981; Hattie, Sharpley & Rogers,1984). Meta-analysis by Berman and Norton (1985)and Weisz et al. (1987) did not demonstrate a linkbetween training and effectiveness.

These studies give rise to questions such as, what isthe role of theory and how does it relate to clinicalknowledge and effective practice? Polkinghorne andHoshmand (1992) suggest that both theoretical andclinical sources of knowledge are essential in thedevelopment of clinical ability, and need to be unitedinto an interactive cycle of enquiry and action withintraining. In the UK, clinical practice during trainingmostly takes place in external counselling agencies.Knowledge emerging from this clinical practice rarelyfinds its way into the formal teaching environments,and this can be a challenge in developing the theory�practise relationship suggested by Polkinghorne andHoshmand (1992).

Whilst making a case for integration betweendifferent sources of knowledge within training, theseauthors also looked at the knowledge processes andattitudes involved in effective clinical practice. Dreyfusand Dreyfus (1986) and Schon (1987) (both cited inHoshmand and Polkinghorne, 1992) suggest thatprofessional education should be focused on devel-oping reflective judgement recognised in the contextof ‘expert practice’, by using the model of actionresearch. Schon (1987) defined reflective judgementas a capacity to engage in reflection in action, keepingalive a multiplicity of views of a situation. This model iscentral to the development of the ‘internship’ ap-proach in training, which aims to address the relation-

ship between training and clinical practice and useaction research to develop reflective judgement in theearly stages of clinical training.

The Internship Training Programme

Background

The research enquiry, underpinning the developmentof the internship year (Van Rijn, 2005), suggested thatin order to achieve the above stated aims it wasimportant to:

. develop effective communication between prac-tice placements and training institutions;

. integrate clinical supervision into the trainingprocess; and

. structure the internship in the early stages ofclinical training so that it could offer containmentto students at the time when they needed themost as they start to see clients.

Teaching aims and methods

The design of the programme focused on developingclinical practice within training content, structure,teaching methods and assessment.

The content of training units focused on thefollowing.

. Generic clinical issues: development and use oftherapeutic contracts, treatment planning anddirection, focus on issues of diversity and ethicsas they emerged in clinical practice, introductionto supervision and the use of the CORE-OMSystem in evaluation.

. Transactional Analysis techniques such as: ‘de-contamination’ (developing ego strength), work-ing with the Adult ego state, working withdevelopmental processes contained in archaicego states.

. The placement context.

. Practice-based research skills: developing anddeepening the capacity for reflection. Studentswere required to use quantitative evaluationmethods in their practice and enquire into theirlearning by engaging with the research question‘How do I become an effective practitioner?’

Training methodology was designed by tutors to belearner-centred and process-oriented. This entailed theshift from emphasis on content (i.e. didactic input alongwith exercises and discussions to consolidate learning),to a ‘learner-oriented’ approach, i.e. identification oflearners’ needs and supported reflection on practice.Students were given relevant material to read prior tothe training, and encouraged to consider the implica-tions for their practice as well as any critiques they mayhave. The theoretical input by the tutors was based onthe questions, musings and considerations that stu-dents brought with them. The aim was to giveinformation, and deepen their understanding of theory

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through experience. To this end, experiential andreflective exercises were used more and didacticteaching methods were kept to a minimum.

Clinical supervision

Clinical supervision was integrated into the trainingand took place in small groups. Students also hadclinical supervision, outside of these sessions, inbetween the training units, and were encouraged tostay with the same supervisors, for continuity andcontainment. Supervision methods mirrored theteaching style and focused on developing insightand the ability to think through clinical problems aswell as awareness of one’s own emotional responses.The integration of teaching, practise and supervisionis illustrated in Figure 1.

Placement practise

Students were all practising in placements, and themajority worked within the internal service (MCPS) atMetanoia Institute. This service offered low-cost,time-limited (to a maximum of 6 months) treatmentto the general public. Students used quantitativemethods of evaluation, primarily the CORE-OM Sys-tem (CORE System Group, 1998) in their practice.

Assessment

Academic assessment was portfolio-based. Studentswere asked to use their research question ‘How do Ibecome an effective practitioner?’ to reflect on theirlearning and structure their portfolios. Although itcontained obligatory elements, the portfolio alsooffered an opportunity for individual exploration,structure and presentation.

Methodology

Within this naturalistic study, the methodology ofaction research was used as the most suitable for thesetting, the background of the project and itsphilosophy and aims. The project took place withina complex organisational setting and aimed todevelop practical knowledge in collaboration with all

the participants within the training system. Continu-ing the research enquiry by developing ongoing cyclesof reflection and action within the organisation,aimed to build theories of practice within a profes-sional system and create communities of enquirywithin communities of practice (Friedman, 2001).The participants were students and the research(development) team.

Methods of enquiry and analysis

The research process entailed:

. monthly research meetings between researcher,tutors and the supervisor; and

. monthly research meetings between researcherand students.

All meetings were recorded and transcribed. Tran-scripts were shared with the participants, who werealso offered an opportunity to make ongoing changesto the programme and thus shape the cycles ofreflection, observation and action. Qualitative analysisby the research team took place at the end of theproject and was shared with students before comple-tion.

The analysis of the project took place in three parts.

. Quantitative analysis of the effectiveness ofstudents’ clinical practice.

. Qualitative analysis of portfolios: giving insightinto development of clinical and research skills.

. Qualitative analysis of the research process:developing insight into the process and dynamicsof the research.

Ethical issues

The project aimed to widen collaboration and parti-cipation within the training process in the structure oftraining and the process of assessment. Individualconfidentiality was addressed at the beginning andwithin the enquiry process. Participants signed aconsent form which ensured their confidentiality intranscripts and publications. Additionally, participantsin the enquiry were asked for consent regarding theirparticipation, and were free to withdraw from theenquiry. All the participants had ongoing access to thetranscripts of research meetings and full access to anyanalysis of the findings. Metanoia Institute did nothave a formal Research Committee at the time, andapproval was granted by the existing AcademicCommittee.

Quantitative analysis

Quantitative analysis of the clinical data offered adescriptive comparison between the internship andtwo comparative groups. First, other students at thesame stage of training working within the MCPS andsecond, the CORE-OM national benchmarks whichmeasure effectiveness of qualified practitioners. This

EXPERIENTIALLEARNING

and Developmentof PersonalAwareness

APPLICATIONOF LEARNING

Triads andSupervision

THEORETICALTEACHING

Based on ClinicalPractice

PREPARATORYREADING

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

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analysis is particularly relevant, as the main aim of theprogramme was to increase effectiveness of earlyclinical practice and students’ ability to establish andmaintain a therapeutic relationship.

Research meetings: methods of analysis

All members of the research team were involved inanalysing transcripts. Meetings between the re-searcher, tutors and the supervisor were not struc-tured. Participants were invited to discuss issuesrelated to the process and content of training andreflect upon themes emerging from the research. Theresearcher loosely structured the framework of tran-script analysis into areas of training content andstructure. In coding terms, these fields were primarilydescriptive (Miles & Huberman, 1994). Emergentthemes were also identified. These were more inter-pretative, using respondents’ subjective experienceand their ability as psychotherapists to analyse un-conscious and group processes. They were interpre-tative and pattern codes (Miles & Huberman, 1994).

Meetings with students were semi-structured. Theywere invited to give feedback on training structuresand content as well as share their experiences. Thecontent analysis focused on different aspects oftraining (descriptive codes). Emerging themes wereidentified in the same way as the tutor transcripts.

To minimise bias, each member of the researchteam analysed transcripts individually. The researcherdid her own analysis and then compiled all theresponses and themes. The final conclusions werediscussed and agreed in the group. This analysis wasdisseminated to students. Descriptive categories ofstructure, content of training, feedback on theory andsupervision were interconnected within the trainingprocess and overlapped in the final analysis. Theimpact of this was that different enquirers couldcategorise their responses in different ways. To dealwith this in the final analysis, summary tables werecreated for each training module. Feedback fromeach respondent was grouped into intuitive processthemes for each training module. Finally differentrespondents were compared in terms of similaritiesand differences in the themes they identified, inrelation to their role in training and the researchprocess.

Based on the methodology of action science(Argyris, Putnam, & Smith, 1985), all the participantsin the enquiry were part of the system and alsocollaborators in the research process. In recognition ofher own bias and involvement and to ensure validity,the researcher involved the whole team in the analysisof transcripts, and formulation of conclusions. Theoutcome of this was that respondents frequentlyallocated feedback to different categories (contentor structure).

The researcher’s role in the organisation was anadvantage because of the degree of knowledge andinvolvement she held, and a disadvantage becauseshe was continuously challenged to maintain aware-

ness of her own biases. Her role also heightened theimpact of transference projected on her. Collegial andpersonal relationships within the research team werealso a subject for reflection. Feelings of anxiety aboutthe outcomes, fears of failure, need for support,anger about the amount of work involved and impactof loyalty to each other were all voiced in the researchmeetings. The continuity of this personal reflection inthe monthly research meetings helped to understandand voice personal biases and develop transparency.When, at one point during the year, the researchteam became stuck in the group process withstudents, they used the wider TA tutor team forconsultancy. This gave them a perspective whichfacilitated the research team through the difficultiesthey were experiencing.

Results

Quantitative analysis

One of the aims of the internship-based training wasto help students develop the ability to evaluate theirpractice using both qualitative and quantitative meth-ods. In comparison to other students within the sameorganisation, outcomes suggested that internshipstudents used the CORE-OM System were more fullyto evaluate their practice, were able to work withmore distressed clients for longer and were on thewhole more effective. The relatively high percentageof complete data sets indicates that this aim oftraining was largely successful. The completion of41.67% ranks in the ‘above average category’. Thisindicates that students have become involved in theprocess of evaluation and started to develop aresearch attitude to practice. See Table I.

Client profile. The client profile used in this analysisrefers to the clinical cut-off point at the start oftherapy. This report shows that in the internship, thepercentage of clients inside the clinical population iswithin the average in comparison with the nationalbenchmarks. In comparison to that, the percentage ofclients above the clinical cut-off (74.95%) at MCPS isbelow the CORE-OM benchmark. This suggests thatinternship students worked with a more distressedgroup of clients within the service. See Table II.

Number of sessions. The number of sessions relates tostudents’ developing ability to establish and maintainthe therapeutic relationship. This developmental taskis often a struggle for beginning practitioners, andrepresents a stage in developing therapeutic skills (vanRijn, 2005). One of the aims of internship was toaddress this training need through the particular

Table I. Validity.

Internship students 41.67%Comparative data (other MCPS) 28.71%CORE benchmark 39%

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combination of training and supervision within theprogramme.

Within a service like MCPS (that allows an averageof six months of therapy) our comparative groupengaged in an average of 14.36 sessions. The intern-ship group engaged in an average of 21.5 sessions,demonstrating a considerable improvement in theability to establish and maintain a therapeutic rela-tionship.

Clinical and reliable change. Clinical and reliablechange is an indicator of effectiveness, based on thestatistical analysis of differences between OM1 andOM2 (questionnaires completed by clients at thebeginning and the end of therapy). These outcomesshow a considerable difference in effectiveness instudents going through the internship-based training.Even though they have worked with clients whosescores were higher than the average MCPS client,there is no deterioration, the overall improvement isabove the average, when compared to the CORE-OMbenchmarks (Mullin, Barkham, Mothersole, Berwick &Kinder, 2006), and far higher than the average forMCPS.

In comparison to CORE-OM benchmarks, theirpractice was overall in line with the performance ofother, NHS-based services, unlike that of otherstudents at the same stage of training, and wellbeyond expectations. These outcomes demonstratedthat students developed an increased evaluativeattitude to clinical practice while becoming moreable to sustain a therapeutic relationship and developwell in effectiveness on par with qualified practi-tioners.

Qualitative analysis

Portfolios. All of the 11 portfolios submitted met thecriteria and learning objectives for the year. Particularfocus of analysis was the development of researchskills. The researcher hypothesised that engagementwith the research question ‘How do I become aneffective practitioner’ would be reflected in students’individual learning process, critical analysis of theirclinical work and an understanding of qualitative andquantitative aspects of research evidence.

The portfolios were primarily structured as descrip-tive narratives and focused on the components of thetraining year contained in the student handbook. Thisdid not demonstrate individual learning processes buta gathering of evidence. Despite that, the contentdemonstrated ability for critical analysis and familiaritywith quantitative methods of evaluation. Qualitativeevaluation (contained in essays and reflection onsupervision) demonstrates considerable ability forreflexivity. Students have learned to reflect on theirpractice and use this reflection to modify theirresponses to clients.

Emerging themes and group dynamic. Over the firstsix training units the impact of systemic factors wastranslated into confusion about leadership and dis-satisfaction and splitting between the two parallelstudent groups. This process was initially vocalised inthe research meetings, rather than the traininggroups, which delayed its being adequately ad-dressed. Although the purpose of the research meet-ing was not to deal with the group process, it becamean opportunity for students to communicate theirdifficulties, not just to tutors, but also to theresearcher and Metanoia Institute.

Over the same period, tutors dealt with theintensity of the programme and their own needs forsupport by refining and streamlining their trainingdesigns, but felt rushed, unsupported and resentful.The stress seemed to arise from the difference in newteaching methods and a lack of familiarity with theprocess of assessment and research. Additionally theanxiety, stress and pressure were generated withinthe training groups by starting to see clients for thefirst time in their placements. In this period bothstudents and tutors expressed anger and frustrationwith the research process. The transparency of theprocess, which meant that students had access totranscripts of the tutor meetings, initially increasedstudents’ anxiety because it showed tutors’ uncer-tainty. Later on, as the process evolved, this wasexperienced as a permission to be vulnerable and‘human’.

The primary researcher became the point of con-nection and communication between the studentsand the tutors, but without the power to affectchange. She felt helpless and angry and experienced apull of split loyalties between the students’ and thetutor groups. The apparent destructiveness of thegroup process became a concern and she questionedwhether the research should continue in thesecircumstances. This was an important ethical systemicintervention. The process was brought up to thewider group of the tutor team, who acted asconsultants to the research group. This interventionmodelled integration and enabled communication,both between the members of the research team andwith the wider tutor team, and the impact of theresearch process on the training groups was ad-dressed in a training unit (three months before theend of the training year). This countered the process

Table II. Client profile with respect to CORE clinical cut-offs.

Percentage of clients above the clinical cut-off

Internship 80.77MCPS 74.95CORE benchmark 80.00

Table III. Clinical and reliable change.

Healthoutcomes

Internship(%)

OtherMCPS (%)

CORE benchmarks(%)

Deterioration 0 3.11 1.8Unchanged 25 31.56 26.1Overall improvement 75 65.33 72.2

Action research 265

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of splitting, and met some of the unaddressedleadership needs. Both helped the groups to identifyand move through the dynamic they experienced.

The impact of the combination of research andtraining was addressed with the students and in thetutor team. It was acknowledged that the involvementof the research team unconsciously communicatedthe narcissistic message of ‘you are special’ tostudents. This was an understandable side-effect ofdoing naturalistic research. These student groupswere the first ones to experience the new trainingprogramme and all the members of the research teamdevoted inordinate amounts of time and effort todealing with the programme and issues arising from it.

However, the narcissistic dynamic also containedthe accompanying shadow at two significant levels.The first was communicating the message of notbeing ‘good enough’, by not fully hearing theindividuals. The second was somehow making stu-dents feel ‘used’ for someone else’s needs (i.e.Metanoia’s research). This was the classic ‘narcissisticinjury’ � special but used and not seen. In response,students seemed to demand more and more fromtutors, supervisor and researcher and continue to feelunmet. Both groups experienced not being goodenough and not being given enough. The TA conceptof psychological games (Berne, 1964) and the DramaTriangle (Karpman, 1971) helps to explain this processin which students moved from the role of Victim toPersecutor and tutors from the role of Rescuer toVictim.

Addressing the unconscious processes in tutor andstudent groups facilitated both through the uncon-scious Game process and organisational change.Finally, students felt able to feel excited by theprogramme and their own achievements within it.Tutors became able to enjoy the development of thestudents as well as the emergence of the new project.The end-of-year reflection on the research process bythe students described it as ‘safe and successful’.

Discussion

Themes emerging from this enquiry highlight thepsychological and unconscious group processes re-lated to the impact of the new training approach, theresearch process on the training department, and anew approach. This new training approach empha-sised coordination of clinical practice, supervision andformal teaching, and involved students overtly inbecoming proactive in all aspects of their learning.Although the aim was to contain students at this earlystage of clinical practice, the new approach was asignificant contributor to feelings of anxiety in bothstudents and tutors. Most of the anxiety centred onthe teaching approach, and while going through thedifficulties of implementing this new strategy, tutorsdistanced themselves from the authorship of thedesign for a time.

In looking back at the process of training, theresearch team wondered whether this approach with

its consistent challenge of in-depth personal reflec-tion, brought up early developmental issues andprimitive processes in the group, but also enabledthe students to increase their effective relationaldepth, evident in the quantitative analysis. This raisesquestions about balance between the safety of‘holding’ in the process at that stage of training andthe challenge of personal reflection and self-respon-sibility. The research methods were used in differentways: quantitative for evaluation, qualitative in thetraining process and action research as a frameworkfor reflection on learning.

Impact of the research process on the trainingdepartment

Engaging with questions develops human narrativesand often leads into the process of change. This isevident in psychotherapy, as questioning facilitatesthe development of personal narratives, in neu-roscience (Cozolino, 2002), as well as fields oforganisation consultancy and action research (Schein,2001). Within this process in organisations, a re-searcher is likely to be seen as an agent of change andfeelings of helplessness and anger often focus onwhoever is seen to be in this role. In this case, it couldbe the tutors and Metanoia Institute, as well as theresearcher. The process of change completes a cyclewhen an organisation finds a way of dealing with andsustaining change (Rashford & Coghlan, 1989). Animportant systemic intervention within this enquirywas a meeting between the research and the TA tutorteams, which helped to communicate feelings andpersonal experiences and reflect on the dynamic ofthe process.

The methodology of action research, with itsemphasis on the process, transparency and involve-ment of all participants, highlighted the process ofchange as well as enriching the analysis of how thechange happened. Qualitative analysis shows thatthe research process was not just the evaluation ofthe course but that, as expected within actionresearch enquiry (Schein, 2001), it also formed partof the organisational and training dynamics. Theprocess of research in itself was new to both tutorsand students and an emotional response to thisbecame part of the overall group process. What ismore, taking part in the new training programme andresearch created considerable anxiety in the tutorswho then struggled to offer potency and containmentto the groups, resulting in the parallel group processin both tutor and student groups, ultimately reachingthe point of conflict when it was overtly addressedand managed.

The tutors paralleled the students’ contradictionbetween effectiveness and distress process in that theyhad developed, managed and delivered a complexnew training programme but felt unrecognised andoverwhelmed much of the time. The celebration andrecognition of these achievements only became pos-sible when the unconscious processes were addressed

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and the level of anxiety lessened. This dynamic showsthe complexity of research in naturalistic settings andprocesses of organisational (departmental) change itsets off. More research is needed into what made thetraining successful, and the possible relevance of theemotional challenges.

Limitations and implications for practice

Action research as the chosen methodology hadlimitations as well as strengths in this project. Thestudy took place within a single organisation, and onlytwo training groups, limiting both the generalisabilityof the findings and the quantitative analysis. Thedepth of involvement of the research team with theproject posed a challenge to validity. Whether thiswas sufficiently addressed by the research team canonly be answered through further evaluation andreplication.

The intensity of the research process created adynamic of change, which challenged all the partici-pants and nearly destroyed the project. Looking back,the extent of this might have been avoided by givingtutors more grounding in action research and havingfewer research meetings, and at different times to thetraining programme.

However, this organisation has managed to sustainthe change. The new training programme continueswith ongoing evaluation. The impact has been feltwithin the whole department and action research,evaluation of clinical practice and development ofreflective practice have now been implemented in allthe training years, and integrated into the culture oftraining. This demonstrates the wider impact andpotential of action research to create reflexivity withinan organisational system.

This study demonstrates the apparent link betweenthe development of personal reflexivity, evaluativeattitude to practice and effectiveness. It also offers astructure of training, which can be adapted, used andevaluated in different training settings. Although thisparticular project takes place within the theoreticalorientation of Transactional Analysis, the trainingstructure is not orientation-specific and can be usedwithin different theoretical approaches.

Conclusion

This paper offers insight into the live process ofdevelopment and evaluation of a psychotherapytraining programme. In doing so, it offers suggestionsand raises questions about the development andtraining of effective practitioners. It also demonstratesthe complexity and challenges of evaluating psy-chotherapy training in all its subtleties.

Biographical notes

Dr Biljana van Rijn: DPsych, Teaching and Super-vising Transactional Analyst (Psychotherapy), MSc inTransactional Analysis, Certified Transactional Analyst

(Psychotherapy), BACP accredited and UKCP regis-tered. As well as being a psychotherapist and super-visor in private practice, Biljana van Rijn is a Head ofClinical Services at Metanoia Institute and tutor.Professor Charlotte Sills: Teaching and Super-vising Transactional Analyst (Psychotherapy), MSc inTransactional Analysis, Certified Transactional Analyst(Psychotherapy), BACP accredited and UKCP regis-tered. At the time of this research Charlotte Sills was aHead of Transactional Analysis Department at Meta-noia Institute. She is a tutor, psychotherapist, super-visor and a widely published author in the field ofpsychotherapy.Jill Hunt: Provisional Teaching and SupervisingTransactional Analyst (Psychotherapy), MSc in Trans-actional Analysis, Certified Transactional Analyst (Psy-chotherapy), UKCP registered and BACP-accreditedsupervisor. Jill Hunt is a psychotherapist in privatepractice, supervisor and tutor in psychotherapy,counselling and supervision.Suhith Shivanath: Provisional Teaching and Super-vising Transactional Analyst (Psychotherapy), MSc inTransactional Analysis, Certified Transactional Analyst(Psychotherapy), BACP accredited and UKCP regis-tered. Suhith Shivanath is a psychotherapist in privatepractice, supervisor and tutor at Metanoia Instituteand other counselling training establishments.Katarina Gildebrand: Provisional Teaching andSupervising Transactional Analyst (Psychotherapy),MSc in Transactional Analysis, Certified TransactionalAnalyst (Psychotherapy), BACP accredited and UKCPregistered. Katarina Gildebrand is a psychotherapistand supervisor in private practice. At the time of thisresearch she was a long-standing tutor at MetanoiaInstitute.Heather Fowlie: Provisional Teaching and Super-vising Transactional Analyst (Psychotherapy), MSc inTransactional Analysis, Certified Transactional Analyst(Psychotherapy), BACP accredited and UKCP regis-tered. Heather Fowlie is a psychotherapist and super-visor in private practice. As well as being a tutor, atthe time of this research she was also a Co-coordi-nator of Transactional Analysis counselling pro-gramme at Metanoia Institute.

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