Journal of Marital and Family Therapy doi: 10.1111/jmft.12051 April 2015, Vol. 41, No. 2, 163–176

PERCEIVED PROFESSIONAL GAINS OF MASTER’S LEVEL STUDENTS FOLLOWING A PERSON-OF-THETHERAPIST TRAINING PROGRAM: A RETROSPECTIVE CONTENT ANALYSIS Alba Ni~ no, Karni Kissil, and Florina L. Apolinar Claudio Drexel University

The Person-of-the-Therapist Training (POTT) is a program designed to facilitate clinicians’ ability to consciously and purposefully use themselves at the moment of contact with their clients in order to connect, assess, and intervene effectively. This qualitative study explored the experiences of 54 master’s-level students who were enrolled in an accredited marriage and family therapy program in the United States and examined their perceived professional gains following a 9-month POTT course. Content analysis of trainees’ reflections which they wrote at the end of the training revealed 6 primary themes: (a) increased awareness, (b) emotions, (c) improved clinical work, (d) humanity and woundedness, (e) meta-awareness, and (f) factors that contributed to the learning process. Findings suggest that key outcomes of this training curriculum are congruent with its stated goals. Clinical and training recommendations are additionally provided. The role of the therapist in therapeutic change has been an important topic since the beginning of the field of marriage and family therapy (MFT), with more or less salience depending on the authors and their conceptual frameworks. Several aspects regarding therapists and their centrality in clinical encounters have been considered, such as family of origin issues and levels of differentiation (Bowen, 1978; Titelman, 1995); capacity to be honest, congruent and whole (Satir, 1987; Lum, 2002); social location and dynamics of power and oppression (e.g., Bula, 2000; Hardy & Laszloffy, 2002; McDowell, Brown, Cullen, & Duyn, 2013); and congruence between personal characteristics/beliefs and therapeutic models (Goodell, Sudderth, & Allan, 2011; Simon, 2006), among others. Phrases such as “person of the therapist” or “self of the therapist” have been generically used in the field to refer to who the therapist is, his or her personal characteristics, and the role he or she plays in the delivery of therapy (e.g., Baldwin, 2000; Lum, 2002; Simon, 2006). The prominence given to the person of the therapist by different MFT models, authors, or schools of thought is reflected in their respective training methods. Some institutions or models make this area central in their training programs, whereas others consider it more tangentially. The inclusion of what is commonly referred to as “person/self-of-the-therapist work” in MFT training programs is based on the assumption that it will enhance the clinician’s therapeutic potential and directly benefit clients (e.g., Aponte et al., 2009; Satir, 1987). As noted by Blow, Sprenkle, and Davis (2007), despite the important role that the therapist plays in effecting therapeutic change, research literature on this topic is scarce. One area in which research is needed is in assessing whether the work that training programs are doing on the self of Alba Ni~ no, PhD, LCMFT, Assistant Professor in the Couple and Family Therapy Program, Alliant International University; Karni Kissil, PhD, LMFT, Private practice in Jupiter, FL; and Florina L. Apolinar Claudio., M.A, Doctoral candidate in the Couple and Family Therapy Department, Drexel University. We thank our trainees who showed courage and persistence going through the intense process of POTT and trusted us to help them grow. We admire them for stepping up to the plate when facing the challenge of embracing their humanity. We also thank Dr. Harry Aponte for the once in a lifetime opportunity to train with him and for his endless wisdom. We are grateful for his guidance and advice in developing this manuscript. Finally, we express our gratitude to Dr. Maureen Davey for her continuous support and her feedback on drafts of this manuscript. Address correspondence to Alba Ni~ no, Couple and Family Therapy Program, Alliant International University.10455 Pomerado Road. Daley Hall-206C. San Diego, CA 92131; E-mail: [email protected] or [email protected]

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the therapist is actually improving the therapist’s clinical outcomes. Our qualitative study was designed to begin filling in this gap in the MFT field. In this article, we present the results of a qualitative exploratory study that examined the professional gains reported by master’s level MFT students after participating in a 9-month POTT training curriculum designed to help them make purposeful use of who they are in their clinical work.

TRAINING OF USE OF SELF IN MFT: CURRENT ENVIRONMENT To understand the extent to which existing training programs incorporate person/self-of-thetherapist practices in their curricula, an informal poll was carried out. An e-mail was sent to the primary contacts of all Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) accredited master’s programs inquiring whether and how they incorporate selfof-the-therapist work in their MFT curricula. Of the 76 programs contacted, 24 responded (31.6%). All the responses came from training programs in the United States. Their responses suggest that personal work was an important part of these MFT programs either formally or informally. Some respondents described this type of work as “essential” or “integral” to their MFT training. Most respondents stated that work on the person of the therapist was woven or infused throughout their curricula, more specifically, in supervision, practicum, or class exercises within academic courses (e.g., reflective papers, journals, family of origin work). Three programs indicated that the work on the self of the therapist was addressed in a separate course. Based on these responses, self-of-the-therapist work seems to be implemented at least in the one-third of MFT programs who responded to our inquiry, although it may be operationalized differently depending on the mission and emphasis of the particular MFT program. Under the current accreditation standards defined by COAMFTE (2005), graduate and postgraduate programs are required to demonstrate that the training they provide helps students achieve the level of knowledge and skills required to become competent MFT professionals. Yet, “work on the self of the therapist” has not been specifically identified as one of these essential skills or required areas of knowledge. However, its importance for training master level family therapists is evident as noted by several guidelines that are part of the “Professional Marriage and Family Therapy Principles” (COAMFTE, 2005). For example, several competencies listed in the Marriage and Family Therapy Core Competencies (American Association for Marriage and Family Therapy [AAMFT], 2004) convey the importance of therapists’ own personal work in order to maintain a professional stance and prevent possible misconduct. Thus, some competencies (e.g., 3.4.5, 4.4.6, 5.5.2) refer to the need of MFTs to monitor and evaluate personal reactions to clients and treatment processes, and their possible effects on therapeutic effectiveness. Similar principles are found in the Code of Ethics (AAMFT, 2012). The output-based emphasis of the current accreditation standards (COAMFTE, 2005) now requires programs to clearly define the outcomes they are targeting and how those outcomes will be achieved, operationalized, and measured. In this article, we are describing one model of personof-the-therapist work that is currently being implemented in an MFT master’s program with the explicit purpose of increasing therapeutic effectiveness (Aponte et al., 2009). Most importantly, we are assessing the impact that this model has had on the clinical work of the students who completed it over a 9-month period during their first year of MFT training. This qualitative study, conducted to enhance the congruency between goals, methods and evaluation of self-of-the-therapist work, is timely and important in an academic environment that now requires that training programs show to key stakeholders in MFT education (especially those who are interested in becoming therapists) that they can indeed train competent professionals.

PERSON-OF-THE-THERAPIST TRAINING The Person-of-the-Therapist Training (POTT) was developed by Dr. Harry Aponte (Aponte, 1992; Aponte & Winter, 2000; Aponte et al., 2009) with the goal of enhancing the therapeutic effectiveness of clinicians by helping them purposefully use all of who they are, both strengths and weaknesses, in their clinical work. Rather than emphasizing the resolution of the clinician’s personal struggles as a condition for conducting effective therapy, POTT encourages therapists to 164

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make use of who they are in the moment of the therapeutic encounter, while they continue working on resolving their personal issues, or grappling with issues that may have no resolution. In fact, special attention is placed in POTT on these lifelong unresolvable struggles, and the hurts, disappointments and losses that are at their core. These ongoing struggles are known in POTT as signature themes (Aponte et al., 2009; Aponte & Kissil, 2014). POTT assumes that by identifying their signature themes and better understanding their effects on relationships (most importantly, the therapeutic relationship), therapists not only increase personal awareness of their shortcomings and vulnerabilities but also can learn how to use them proactively during their clinical work. A premise of POTT is that we are all wounded healers (Nouwen, 1979), and that it is through the experience, understanding and acceptance of our own woundedness and vulnerability that we can better understand and accept the woundedness and struggles that others are facing (Aponte et al., 2009; Ni~ no, Kissil, & Aponte, in press). To the extent that therapists are grounded in the journey of understanding and tackling their own signature themes, they can differentiate themselves from their clients and their clients’ issues. This differentiation allows them to simultaneously relate intimately to their client’s experience while standing outside of their engagement with the client, with relative freedom to observe the interaction and draw both insight and the ability to maneuver therapeutically (Aponte & Kissil, 2014). Therefore, therapists can relate to and appreciate their clients’ difficult journeys without over-identifying or suffering from compassion fatigue (Negash & Sahin, 2011). Although signature themes are at the center of POTT, many other personal factors are also examined during this training, including personal and spiritual values, personal characteristics (e.g., being outgoing vs. being reserved) and cultural backgrounds. For approximately three decades, POTT had been used in clinical supervision and during clinical consultations prior to its formal integration into a couple and family therapy accredited master’s program (Aponte et al., 2009; Lutz & Spell Irizarry, 2009). In this particular academic setting, POTT has been implemented as a two-hour weekly experiential class that runs through the first academic year (nine months, 60 hours of class time) of the master’s program. This class is taught by two instructors, one of whom is Dr. Harry Aponte, the developer of POTT. Next, we present a brief outline of the POTT program.1 POTT includes several stages. First, students familiarize themselves with the main organizing principles of POTT by reading published journal articles on the topic. They then begin their own experiential work by identifying and understanding their signature themes (e.g., origins, manifestations in their personal and professional functioning, patterns of coping with these issues in their lives). The training is then directly applied to the clinical realm by discussing actual cases that the students are seeing, and examining how personal factors can be used to enhance therapeutic effectiveness. Additionally, each student receives a live supervision session of a simulated case performed by actors. During these simulated laboratory experiences or simlabs, the effects of the signature themes and other personal factors are directly observed in the student’s interaction with clients and feedback is provided to the trainee in real time by the instructors. Discussions about signature themes, clinical cases and simlab experiences are led by the trainers who work with one student at a time. Simultaneously, the rest of the class members observe the process. It is expected that by being exposed to the stories and experiences of their fellow classmates, students learn to empathize with their plight and become more accepting of the normalcy of their own human struggles, which in turn serves as a prelude to gaining the ability to empathize with their clients’ issues. At the end of each class, the forum is opened up for student observers to share how the experience resonated with them. In every step of the process, students are required to write a paper describing their insights during the experience. Students also write weekly journals to continue reflecting on their personal and professional processes. The year of POTT ends with a final reflection paper and class discussion of the professional and personal gains that students have achieved during the 9-month training period. These final reflections are the data that were qualitatively analyzed in this exploratory study of the perceptions of POTT trainees regarding the professional changes they experienced as a result of their participation in the training. April 2015

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METHOD Participants Participants included 54 first year master’s level students enrolled in a COAMFTE accredited marriage and family therapy program in a northeastern U.S. city. This sample of students completed the Person-of-the-Therapist Training (POTT) program between 2010 and 2012. Fifty-two participants were females and 2 were males. Ages ranged from 23 to 51 years old with the average age 27 years old. Half of the participants were between the ages of 23 and 25. Seventeen participants identified as Black or African American, 27 identified as White, 3 as Asian, 1 as American Indian or Alaska Native and the remaining 6 participants identified as mixed raced or other. Regarding ethnicity, 49 participants identified as non-Hispanic, 4 identified as Hispanic or Latino, and 1 participant identified as Asian or Pacific Islander. Participants were part of two cohorts of first-year MFT students. Each of these two cohorts was divided in two sections. Both sections had Dr. Harry Aponte as one of the instructors. The first author was the co-instructor of one of the sections and the second author was the co-instructor of the other one. The two sections had the same syllabi, assignments, schedule, teaching methodology, and grading system. Additionally, the three instructors met regularly to ensure the consistency and uniformity between the two sections. Procedure This study was based on archival data from two cohorts of the Person-of-the-Therapist Training (POTT) program. The final reflection papers that students wrote at the end of the 9-month training were the source of the qualitative data for this study. In these papers, students were asked the following two questions: (1) What personal changes have taken place in you and in your relationships as a result of the experiences that you had in this class? and (2) How have your clinical practice and your perception of yourself as a therapist changed as a result of the experiences that you had in this class? Even though the first of these two questions is related to personal changes and the second directly asks about professional gains, while reading the papers it became clear that answers to the first question also included statements about professional growth. Therefore, the responses to both questions were included in this qualitative study. After receiving approval for this study from the University’s Institutional Review Board, the authors compiled two documents, one included the 54 responses to question 1 and the other the 54 responses to question 2. Names of the students, names of third parties and all other identifying information were deleted. These documents were then sent to a person not familiar with the training program or the students to further de-identify the data by removing any other demographic information (e.g., ages, places, names of institutions, gender). Finally, the order of the entries was randomized in each of the two documents. The resulting documents were then qualitatively analyzed. Analysis A conventional content analysis method (Hsieh & Shannon, 2005) was used to identify frequent and notable themes. In this type of analysis, researchers allow the codes and themes to emerge from the data, rather than using preconceived categories. To increase the trustworthiness of this study via triangulation of investigators (Lincoln & Guba, 1985), three coders independently analyzed the data. Two of the coders were class instructors, whereas the third was not familiar with the course premises or materials, thus providing a fresh perspective for the data analysis. During the initial stage of open coding, the three coders independently analyzed the data by reading every sentence in the two documents and deriving labels and codes from the participants’ ideas. Then, each coder organized these codes in a provisional hierarchy of themes and subthemes related to professional growth. During the second stage, the coders discussed the subthemes and themes they had independently identified, and by consensus created a master list that only included those that all coders agreed upon. During the third stage, the coders went back to the two documents, counted the number of students who mentioned each of the agreed

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upon themes to reach an estimate of the prevalence and importance of each theme among the 54 participants. In this study, all the stages of the process were documented, generating an audit trail (Lincoln & Guba, 1985) that is open to scrutiny. This includes the two documents with the de-identified responses from the students, records of the initial coding and provisional hierarchies of the three coders, the master list of agreed upon themes and subthemes, memos and meeting agendas. Another strategy used to increase trustworthiness in this study was member checking (Newman, 2003). An e-mail was sent to four participants with a copy of the study results, for their response regarding whether they felt that the findings reflected their experiences. Three participants responded to this request and expressed that the results reflected their experiences.

RESULTS Six dominant themes emerged from participants’ reflections: (a) increased awareness, (b) emotions, (c) improved clinical work, (d) humanity and woundedness, (e) meta-awareness, and (f) factors that contributed to the learning process. Below, we describe these findings with illustrative quotes from the trainees’ reflection papers. In order to maintain anonymity of all participants, no identifying information will be provided for the illustrative quotes. Increased Awareness A salient area of growth, reported by 48 of 54 participants, was increased awareness. This was described as a twofold gain. First, students described getting used to practicing self-observation as an ongoing task while performing their clinical work. Students mentioned becoming “more conscious,” “insightful,” or improving their capacities for self-exploration. Second, students noted many areas that they became more aware of during the Person-of-the-Therapist Training (POTT). These included strengths, values, limitations, and the manifestations of all these factors in their work as therapists. An additional area of heightened awareness mentioned by most participants was emotions and emotional processes. Given the salience of this theme, it is described in a separate segment below. Regarding strengths, students reported becoming more aware of personal characteristics that served them during clinical encounters with their clients, for example, being “caring”, “compassionate”, or “committed.” Even while discussing their ongoing struggles, students recognized their tenacity and determination to overcome their fears and “continue to push rather than back down.” Participants also reported becoming more aware that they were “strong enough” to carry the task of being therapists. As stated by one student “I have a core of strength inside me which I am learning to tap into at will.” Participants also reported reaching a higher level of awareness regarding their own personal and cultural values, and how they manifested in the way they perceived and related to clients. Students reported realizing that things “do not mean the same for everyone” and that “to be curious and ask more questions” helped them to avoid imposing their values or to draw conclusions about the clients based on their own frame of reference. Students additionally described becoming more aware of their limitations, including their signature themes. Some examples of signature themes that students identified were as follows: feeling inadequate or incapable, inability to trust others, need for approval, fear of failure, and fear of not being taken seriously. In addition, students reported an increased understanding of how they protected themselves or coped with their own shortcomings in relationships. For example, students mentioned using “fake smiles,” pretending not to care, avoiding taking risks, being perfectionists, becoming peacemakers, or needing to be always in control. Furthermore, students described being able to recognize the specific ways that their own limitations and signature themes manifested in their relationships with their clients. The following are a few of the many quotes that illustrate the level of awareness that students reached in this area: In the last POTT simlab, I was told I was ‘doing too much work.’ This is part of my ‘overfunctioning in order to survive’ signature theme. I could not sit back and allow others to do the work.

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By recognizing my signature themes, I have become more aware of why I may push my clients when they are not ready. I had a difficult time challenging my clients to the point of intensity because of my theme of caring [about] what others think of me. At times, my fear of ‘messing up’ overwhelmed me. I would not be myself in sessions and appear too serious. Reaching this level of awareness about their internal and relational processes helped students respond with less reactivity and in a more purposeful way during their therapeutic encounters, which increased their confidence about their clinical actions and decisions. As one participant wrote: “understanding myself and sorting out what emotions are reactions to my own, and not the client has made me more confident in the decisions I make regarding interventions and formulating hypotheses”. Participants reported that this class offered a safe place to explore their “blind spots” and “confront them in a healthy way.” A few students reported having negative reactions to the training. One student reported feeling “overwhelmed” upon realizing the effects of her signature themes on her clinical interactions. Another student mentioned feeling “defeated” at some point during the POTT program. Emotions Most participants (50 of 54 students) reported gains regarding the emotional aspects of their therapeutic work. Students reported becoming more at ease with experiencing and acknowledging their own emotions, thus normalizing having feelings as an essential and natural part of their clinical work. In the words of one of the trainees: “The first learning experience was that I do have emotions come up during the session and it is ok to acknowledge them.” Students also mentioned achieving a deeper understanding of the triggers of those emotions, especially in relation to their signature themes. For example, one student wrote “my fear of being wrong comes from my signature theme of being critical of myself”, while another trainee mentioned “My fear of challenging [name of client] was related to my need to be viewed as perfect.” These statements reflect an experiential understanding of the emotional manifestations of their signature themes in the therapeutic relationship. Being able to track their emotions in the session and not only in retrospect was also identified as a professional gain due to POTT. Participants reported, for example, being able to better recognize in the moment when they were resonating with the pain expressed by the clients, or recognizing the care and compassion that they developed toward them. Additionally, students mentioned becoming keener at noticing the mechanisms that they use to deal with their own emotional reactivity. In relation to this, one student stated “I have found it extremely difficult to connect to my clients emotionally, because when I feel their pain, I put a wall up after a certain point and distract them from their hurt.” By having more clarity about their own emotional processes, students reported being more capable of distinguishing between what they and what their clients brought to clinical encounters. This enabled students to take greater responsibility for their own contributions to the therapeutic process. As one student described: I can catch my feelings of anger, resentment, or annoyance when speaking to a client who reminds me of everything I dislike in [name of person]. Being able to catch these feelings allows me to acknowledge what is going on inside of me and how I need to change my attitude or behavior toward the client. The client has not wronged me; they are not making it personal. I am making it personal because they remind me of someone who has hurt me. Having better management of their emotional responses in therapy was also mentioned by many participants as an important professional gain. This refers to the delicate task of connecting with their emotions, while at the same time preventing their reactivity to take over. This helped

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students feel more at ease with the intensity in the room, to “get in that dirty bath water,” and to not feel “sucked in by the drama.” Additionally, this helped students feel more present and genuine during their sessions. As one participant stated: I feel more and more comfortable asking my clients what they are feeling and recognizing it because I am getting more comfortable in doing it with myself. I have allowed myself to be more open with myself and others and it has allowed me to make more human connections with my clients. Acknowledging their own emotions, tracking them while with clients and better managing emotions during their clinical work seems to be the foundation for using their own emotional experiences during clinical encounters more purposefully; another professional gain reported by students. For example, participants reported making use of their emotional experience in session as a guide during the process, and as a way to inform their assessment and their interventions. They also reported making use of their emotions to make therapy more human and genuine. As reported by a student “I can pause and address the emotional atmosphere as I am observing it, without sounding clinical or superficial, but coming from a place of felt emotion”. Students most frequently used their own emotions to connect with their clients. They reported using their emotions to understand the depth of the clients’ experience and struggle. They also described tapping into their own experiences of anger, joy, loss, frustration, hope, or abandonment to better understand their clients’ situation. As stated by one of the participants: My client was feeling very betrayed and was getting very worked up. I found myself, even though I had never been through something like that, being able to tap into my own feelings and intuition. I was able to connect to his feelings of betrayal and his feelings of being powerless and losing control. Improved Clinical Work The third area of professional growth, reported by 34 students, was improved clinical work, which included the development of their clinical identity. In relation to this, participants reported trusting themselves more, increased self-confidence and higher sense of preparedness within their role as therapists. In the words of one participant: “Surprisingly enough, I feel ready and prepared. I think that is what I got most from POTT as far as professional growth. I feel confident in who I am as a therapist, flaws and all.” Another key aspect of improved clinical work described by participants was learning new skills and techniques. For example, one student said “I do see my clinical skills improving tremendously with regards to assessment and intervention”. More specifically, students mentioned better conceptualization of cases, requesting feedback from clients at the end of the sessions, or switching communication styles according to the needs of the clients. Taking control of the session, being vocal, and having more authority were also mentioned by several participants in the study as examples of their improved clinical work. Participants realized that as therapists, their role was to challenge clients by being “more assertive and willing to suggest things.” As stated by one of the students: “I went from not speaking and interacting in my sessions to taking control of the sessions and having true interactions with my clients.” Participants also reported being better able to distinguish between process and content. In relation to this, one student explained the following: I give clients the opportunity to “feel heard” by their sharing the content, but I do not get overwhelmed by or swamped in detail. It is this increasing ability to separate content from process that is helping me become a therapist rather than just a person who has always been “a good listener and easy to talk to. More differentiation and better professional boundaries with clients and coworkers was an additional aspect of improved clinical work mentioned by the students. Not only did students state that they were able to identify and connect with clients but they were also able to differentiate from them. This allowed students to be present during emotionally charged therapeutic moments while maintaining a distinction from their clients, as evidenced by this student: April 2015

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I am learning to differentiate from my clients, it was hard for me at first not to draw on the similarities between my family of origin and my clients and therefore make conclusions about the people based on my own upbringing. Some students reported being better able to take risks or try new things in session as another gain resulting from participating in POTT. For example, a student stated that she was previously worried about making mistakes but later realized that “therapists make wrong suggestions all the time” and “just have to keep trying.” It was this ability to take risks that allowed the therapist to challenge the clients, while understanding that this process takes practice. Lastly, students also perceived themselves as being more authentic with their clients. Participants stated that they originally struggled with wanting to be seen as “professional” but realized that being authentic resulted in being able to relate to their clients’ pain and problems. Students found that being authentic was a skill that improved clinical work. In relation to this, one participant stated the following: Not only has this helped me to work more effectively but it has also helped me to become more confident with trusting my instincts because they are coming from a genuine place. In fact, I have found that it is appropriate and in many ways beneficial to simply be myself and utilize what I offer naturally. Humanity and Woundedness The fourth most common theme, mentioned by 27 of 54 students was humanity and woundedness. Students wrote about acknowledging their flaws, accepting their painful life struggles, and seeing their shortcomings as a normal aspect of being human. They noted that being imperfect was a thought that they could bear, and the desire to hide their own shortcomings from the world or to pretend they never existed decreased after completing POTT. They accepted that being human meant having weaknesses or vulnerabilities, and that this was something they shared with others. In the words of one student, “I no longer see myself as an awful therapist in training. I have begun to forgive myself for not being perfect, and I am beginning to comprehend my strength.” Another student wrote “I think that this whole process has all in all helped me finally feel comfortable in my own skin.” Students also reported having more empathy toward their own vulnerabilities and humanity, which in turn, allowed them to humanize their clients. As a result, trainees were better able to empathize with their clients and their ongoing struggles. Furthermore, students began perceiving their own emotional wounds as assets that could help them become more effective therapists by connecting better with their clients. One student, for example, wrote “It never crossed my mind that I can use my life experiences to emotionally walk with someone and experience in some way the hurt and pain someone else felt.” Another trainee stated the following: I have been deeply hurt, but all my pain is a wondrous tool because my clients have been deeply hurt as well. Every bad experience in my life can be turned around and made into a tool for healing others. As students became more comfortable experiencing their own humanity and woundedness, they described actively using their vulnerabilities in their clinical work. One student wrote about her experiences with a specific client, “When I started to look at him (my client) with empathy, compassion and reaching into the scared, abandoned part in me I begun to relate to him in a different way.” Another student wrote the following: My journey throughout this course helped me understand that everyone experiences some type of loss, trauma and happiness, but in various forms. And as a therapist it is up to me to challenge myself to find that moment in my life that will allow me to join with my clients because progress begins with joining. Students reported that the ability to reach into their painful experiences enabled them to better connect with clients from various backgrounds. Even though their clients may have stories that were very different from their own, below the surface, their clients were struggling with similar

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emotional pains and difficulties. Students reported experiencing themselves connecting to their clients through their “shared humanity.” One of the students stated the following: I know that I can connect with clients whatever their story is. It is through POTT that I have realized that “our shared humanity is what connects us.” So regardless of content I can connect with the client’s pain. Even if I do not agree with them I can use my own experience of hurt, pain, anger to connect with the client and what they are feeling. Meta-Awareness The fifth theme, mentioned by 17 students was meta-awareness. Students wrote about developing an ability to observe the therapy process from outside and to more clearly observe themselves in this process. In addition, they wrote about an evolving understanding of what therapy was and what the therapist’s role was. At the end of the training they perceived therapy as a process which is meant to empower people, to help them take charge of their lives and to free themselves from self-imposed burdens, rather than a process aiming at “fixing” people and solving their problems. One of the students wrote the following: I no longer perceive myself as a therapist who needs to save people from their problems because now I understand that problems are always going to exist. At this point in my journey as a therapist, I no longer seek to save people, but empower them. Another student wrote the following: I realize I do not have to do the work for the clients but to be there for them to guide them and to coach them. I am there to facilitate the process, be understanding and to remain open and nonjudgmental. Students also described a different understanding of their roles as therapists. They conveyed an understanding of the importance of being versus doing, realizing that being fully present and engaged with the client is more important than what they do or say, as one of them related: Now I understand that therapy is not about doing. It is about being. When confronted with pain I still have an overwhelming urge to make the pain go away, but I own that response, understanding that the aversion and tending is my response to my own pain as it is being triggered by my client’s pain. Furthermore, students reported acknowledging and accepting that the work on the self of the therapist is important and experiencing a clear connection between this work and their effectiveness as therapists. They indicated understanding that this is a life-long process, but that being in the process and continuing to struggle with their issues can potentially help them become better therapists. One of the students wrote the following: That process was influential to me because it helped me realize that I will continue to struggle with my signature theme, but that the struggle does not have to keep me from being a good therapist. I came to realize how my continuing struggle will only help me to empathize more with my clients’ own struggles. In addition, students commented on realizing that there was a reciprocal relationship between their professional selves and personal selves and they reported noticing the interplay between the two. One of the students wrote the following: “I think that because of this class, I learned that who I am as a person greatly affects who I am as a therapist.” Another one stated the following: “My professional growth is interrelated to my personal growth.” Factors that Contributed to the Learning Process Although the two questions students were given did not specifically ask about aspects of the training that facilitated their learning process, several students spontaneously wrote about factors that helped them reach the reported professional growth. Participation in the simlab was reported by 12 students as being an experience that helped them clearly see the effects of their signature themes and other personal factors on their therapeutic work. By receiving direct feedback from the April 2015

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instructors in real time and processing this experience in class, students were able to see their clinical strengths, identify areas of improvement and learn ways to address them during the simlab itself and in their future clinical work. The second most frequently mentioned factor that contributed to students’ learning was the group context, which was mentioned by 10 students. In addition to feeling supported by their fellow classmates in this intense training process, students stated that hearing their classmates’ stories exposed them to a variety of experiences that in turn helped them to better connect with their clients’ diverse realities. Furthermore, watching classmates in the role of therapist allowed students to see different therapeutic techniques in action and assess whether these would fit in their actual work with clients. One student mentioned the following: “Watching my classmates hold sessions allowed me to see various styles and walk away with something new to add to my bag of tricks, or something to remind myself never to do.”

DISCUSSION The goal of this qualitative study was to explore the perceptions of first year master’s level marriage and family therapy students of professional gains following a 9-month Person-of-theTherapist Training (POTT) program. Our findings suggest that participants experienced significant transformation in several areas related to self, including self-knowledge and self-acceptance of struggles and vulnerabilities, access to self and increased ability to proactively use their selves in therapy to connect, assess, and intervene. All three areas of change (self- knowledge and acceptance, self-access, and proactive use of self in therapy) are directly targeted by POTT. These findings suggest congruency among the training stated goals, the methods used to facilitate these goals and the training outcomes, as perceived by the participants. At the end of the POTT program, students perceived themselves as being more self- aware and reported knowing themselves better both individually and interpersonally. Increased knowledge of self is a specific goal of the POTT model (Aponte et al., 2009). Our findings suggest that POTT has been successful in promoting increased levels of self-knowledge and self-awareness. Participants in our study not only reported better knowledge and understanding of themselves, but also wrote about the important changes in their level of self-acceptance. Students described having more empathy and understanding toward their own shortcomings and struggles in life. They accepted their own humanity and felt less ashamed of their own flaws and imperfections. They reported feeling more comfortable with who they were and a decreasing need to hide, deny, or reject parts of themselves they did not appreciate. Increased self-acceptance is viewed as an important part of the training, allowing therapists to use more of their selves in therapy. According to POTT, when the therapist accepts her vulnerable parts, she is then able to use experiences, memories and emotions related to these parts, as needed, in order to connect with her clients (Aponte & Kissil, 2014). Increased access to self is the second goal of the POTT training and participants in our training clearly reported feeling more comfortable accessing more of their selves as a result of accepting these unwanted and hidden parts of themselves. The third part of the POTT training focuses on participants’ abilities to use themselves in therapy, especially to tap into their own struggles and vulnerability, in order to connect, assess, and intervene with their clients (Aponte & Carlsen, 2009; Aponte & Kissil, 2014). The students in our program reported experiencing a clear connection between knowing and accepting themselves and using themselves in therapy. Participants could vividly describe how they were able to use themselves in therapy with specific examples from their cases. First, participants reported that their ability to connect to their own vulnerability has allowed them to be more present in their sessions, and has increased their ability to connect with clients from various backgrounds. Second, they reported that they were able to use themselves to intuit where the clients were and therefore better assess what the clients were struggling with, which then helped them to decide how to intervene. Developing this ability is the essence and the ultimate purpose of the POTT training. Our findings suggest that the POTT training has been effective in facilitating the development of this ability. Therapists’ self-awareness in general and during the therapeutic process in particular has been found to help them be more present in sessions and more engaged with clients, as reported by both therapists and clients (Fauth & Nutt-Williams, 2005). Therefore, by helping the therapists become 172

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more aware of themselves, POTT can contribute to strengthening the therapeutic relationship, which is turn facilitates better therapeutic outcomes (Norcross & Wampold, 2011; Sprenkle, Davis, & Lebow, 2009). Having more self-acceptance allows therapists to be more congruent and genuine while interacting with their clients, qualities that were also found to be associated with positive therapy outcomes (Kolden, Klein, Wang, & Austin, 2011). A primary premise of the POTT training is the belief that we are all “wounded healers” and our shared humanity is what enables us to connect to our clients. The POTT model emphasizes that our long lasting struggles may never be resolved. Thus, we will always be wounded healers and our work on our own self is a life-long process (Aponte et al., 2009). Being a wounded healer is not viewed as a hindrance to effective therapy but rather allows us to truly understand our clients’ struggles and the difficult processes of growth and change. Participants in our training reported realizing and accepting that becoming an effective therapist is a lengthy process that requires work on self. They reported being more comfortable with the idea that some of their issues will always be there to some extent and that the work on self is a never-ending process. They expressed commitment and willingness to continue to work on their selves because they understood and experienced the interconnection between their personal and professional identities. Realizing that being imperfect is part of being human, participants reported feeling more comfortable with uncertainty. They reported a shift in their understanding of the therapist’s role from the all-knowing expert, to a witness, facilitator, and co-participant in a journey. The students developed a more humble view of themselves and their role in the therapy process. They came to view the therapeutic encounter as a human-to-human authentic interaction and not as an encounter between a distant professional prescribing solutions to a helpless client. Consequently, some students experienced less pressure to perform and were more able to be authentically present in the moment and pay attention to the process in the room. The POTT model is based on two primary assumptions: one, that we all carry within us a psychological issue that is at the core of our human woundedness (signature theme/s); and two, that for therapists to be able to relate most effectively to their clients, they must learn to work with and through this core issue (Aponte & Kissil, 2014). The POTT model takes a unique stance regarding the value of these core psychological issues by first, suggesting that these signature themes are powerful resources that can significantly enhance therapists’ effectiveness, and second, by placing the importance of learning to work through these signature themes at the heart of the training of therapists in the use of self (Aponte & Kissil, 2014). Our findings suggest that working through the signature themes and helping trainees acknowledge, access and use these emotional issues increase their perceived effectiveness as therapists. The participants reported two aspects of the training especially helpful in promoting their perceived effectiveness; the opportunity to work with a simulated case and get live supervision, and the group context of the training. The importance of live supervision has been extensively addressed in the literature and is viewed by many in the field as an effective modality of supervision, allowing the acceleration of learning and performance (e.g., Storm, 1997). Our findings provide additional empirical evidence to the benefits of live supervision even with simulated clients. The other aspect of the training the participants viewed as beneficial is the group context. This finding supports our own anecdotal experience conducting the training. Although this training can be done in individual supervision, our experience has taught us that the group amplifies the power of the experience exponentially, a phenomenon recognized by many trainers: “The process of the training group must be considered and used in order to develop a context that can maximize the development of personal and interpersonal resources” (Haber, 1990, p. 4). The POTT class and the present study are examples of the type of work that we have to do as a profession in order to connect the goals, methods, and outcomes of MFT education. As the trainers of future generations of MFTs, it is our responsibility to our profession and our students to show that we are offering person/self-of-the-therapist training models that are effective, targeted, and have positive impact on therapeutic outcomes. The next step, following this study, will be to assess its efficacy in improving therapeutic outcomes. Our study shows that it is possible to reach higher levels of structure in the training of the person of the therapist, and at the same time humanize the profession by helping trainees use all of who they are as persons in the relationships that they establish with their clients. April 2015

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LIMITATIONS This qualitative study is based on the students’ perceptions about their own professional growth, and their attributions about what contributed to it, which presents two limitations for this study. Students were quite descriptive and profound in their written accounts of professional gains. However, the ultimate test of whether the Person-of-the-Therapist Training (POTT) helped students enhance their clinical effectiveness is to actually look at therapeutic outcomes for the clients, and to evaluate students before and after the POTT training to examine change over time. For that reason, future research needs to take into account the perspectives of clients and clinical supervisors, and consider whether or not the changes reported by the students are also perceived by clients and supervisors. Moreover, other research methodologies and sources of data should be included, most notably, the direct observation of therapy sessions. The second limitation of this study is that the methodology did not make it possible to clearly discern whether the professional changes that students attributed to participating in the POTT class are not due to other activities that promote personal and professional growth. Future research needs to be designed in ways to ensure that the professional growth that students are reporting is in fact due to the participation in POTT, and not related to other factors such as participating in therapy, other classes or supervision. This would require comparing the clinical performance of students before and after taking the POTT class, and having a comparison group that is not receiving this self-of-the-therapist training. In addition, the methodology employed in this study does not allow a determination of whether the reported changes will be sustained over time. Longitudinal research is necessary to answer the question of the long-term impact of POTT. When considering transferability of these findings (Lincoln & Guba, 1985), readers are advised to look at the description of the sample. Among the characteristics of the sample that need to be highlighted is the fact that these are MFT master level students, who are starting their careers, and who are mostly young adults. POTT might have different effects when implemented with more experienced clinicians or when the training is not taking place in an academic context. Also, the majority (52 of 54) of participants were women. It is possible that men or cohorts with a different women-to-men ratio will have different experiences in the POTT program.

IMPLICATIONS FOR TRAINING The results of this qualitative study have important implications for training therapists in marriage and family therapy programs. Since we evaluated the perceived effects of the program as a whole, we have no way of knowing whether adopting certain parts of the program, as opposed to implementing the whole training (e.g., using parts of the training in individual supervision), is likely to bring the same results. This study provides evidence that it is possible to implement a structured person/self-of-thetherapist class in a training program without sacrificing the genuineness, emotional connection, and the humanity for those involved. Similarly, the findings suggest that implementing a personof-the-therapist class that focuses on acknowledging, accepting, and using the students’ core personal struggles can have positive benefits in their professional development. In addition, students’ reports suggest that models of person-of-the-therapist work such as POTT can assist MFT programs in achieving several core competencies (AAMFT, 2004) that pertain to personal work to maintain professional competency and prevent misconduct. Therefore, training programs could incorporate a model like POTT that can assist in the student’s personal and professional growth while adhering to the professional marriage and family therapy principles and accreditation standards (COAMFTE, 2005). As the students indicated, there were aspects of the POTT format that assisted in promoting its effectiveness, especially live supervision and the group context. Training programs can potentiate the impact of self-of-the-therapist work by offering students the possibility of live supervised sessions with mock actors. In these sessions, the focus can be placed on the student’s clinical development, without concerns about the wellbeing of the “clients”. In addition, the supervisor can provide timely feedback that the trainee can immediately incorporate in his or her work.

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Participants indicated that being in a group setting was beneficial to their training, which could have further implication. Training programs or supervisors themselves can provide a group setting in which students can present, share, and receive feedback that focuses on personal issues. An intimate setting like this can allow trainees to hear others’ stories to which they can connect, providing the opportunity to connect to their own humanity, thereby promoting personal and professional growth.

REFERENCES American Association for Marriage and Family Therapy (2004). Marriage and family therapy core competencies. Retrieved from http://www.aamft.org/imis15/Documents/MFT_Core_Competencie.pdf American Association for Marriage and Family Therapy. (2012). AAMFT code of ethics. Retrieved from http://www. aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx Aponte, H. J. (1992). Training the person of the therapist in structural family therapy. Journal of Marital and Family Therapy, 18, 269–281. Aponte, H. J., & Carlsen, C. J. (2009). An instrument for person-of-the-therapist supervision. Journal of Marital and Family Therapy, 35, 395–405. Aponte, H. J., & Kissil, K. (2014). “‘If I can grapple with this I can truly be of use in the therapy room’: Using the therapist’s own emotional struggles to facilitate effective therapy. Journal of Marital and Family Therapy, 40, 152–164. Aponte, H. J., Powell, F. D., Brooks, S., Watson, M. F., Litzke, C., Lawless, J., et al. (2009). Training the person of the therapist in an academic setting. Journal of Marital and Family Therapy, 35, 381–394. Aponte, H. J., & Winter, J. E. (2000). The person and practice of the therapist: Treatment and training. In M. Baldwin (Ed.), The use of self in therapy (2nd ed.) (pp. 127–165). New York, NY: Routledge. Baldwin, M. (Ed.). (2000). The use of self in therapy. New York, NY: The Hartford Press. Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298–317. Bowen, M. (1978). Family therapy in clinical practice. New York, NY: Jason Aronson, Inc. Bula, J. F. (2000). Use of the multicultural self for effective practice. In M. Baldwin (Ed.), The use of self in therapy (pp. 167–189). New York, NY: The Hartford Press. Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) (2005). Accreditation standards: Graduate & post-graduate marriage and family therapy training programs version 11.0. Retrieved from http://www.aamft.org/imis15/Documents/Accreditation_Standards_Version_11.pdf Fauth, J., & Nutt-Williams, E. (2005). The in-session self-awareness of therapist-trainees: Hindering or helpful. Journal of Counseling Psychology, 52, 446–447 doi: 10.1037/0022-0167.52.3.443. Goodell, K. A., Sudderth, B. G., & Allan, C. D. (2011). The self of the therapist. In L. Metcalf (Ed.), Marriage and family therapy: A practice oriented approach (pp. 21–38). New York, NY: Springer. Haber, R. (1990). From handicap to handy capable: Training systemic therapists in use of self. Family Process, 29, 375–384. Hardy, K. V., & Laszloffy, T. A. (2002). Couple therapy using a multicultural perspective. In A. S. Gurman & N. S. Jacobsen (Eds.), Clinical handbook of couple therapy (pp. 569–593). New York, NY: The Guilford Press. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. Kissil, K., Ni~ no, A., & Aponte, H. (in press). The beginning of the person-of-the-therapist journey: Using signature themes to facilitate greater therapist’s effectiveness. In R. A. Bean, S. Davis & M. Davey (Eds), Clinical supervision activities for increasing competence and self-awareness. Hoboken, NJ: Wiley Press, Inc. Kolden, G. G., Klein, M. H., Wang, C. C., & Austin, S. B. (2011). Congruence/genuineness. Psychotherapy, 48(1), 65. Lincoln, Y. S., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA: Sage. Lum, W. (2002). The use of self of the therapist. Contemporary Family Therapy, 24, 181–197. Lutz, L., & Spell Irizarry, S. (2009). Reflections of two trainees: Person-of-the-therapist training for marriage and family therapists. Journal of Marital and Family Therapy, 35, 370–380 doi: 10.1111/j.1752-0606.2009.00126.x. McDowell, T., Brown, A. L., Cullen, N., & Duyn, A. (2013). Social class in family therapy education: Experiences of low SES students. Journal of Marital and Family Therapy, 39, 72–86 doi: 10.1111/j.1752-0606.2011.00281.x. Negash, S., & Sahin, S. (2011). Compassion fatigue in marriage and family therapy: Implications for therapists and clients. Journal of Marital and Family Therapy, 37, 1–13 doi: 10.1111/j.1752-0606.2009.00147.x.

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Newman, W. L. (2003). Social research methods: Qualitative and quantitative approaches. Boston, MA: Allyn and Bacon. Ni~ no, A., Kissil, K., & Aponte, H. (in press). The next step of the person-of-the-therapist journey: The clinical case instrument. In R. A. Bean, S. Davis & M. Davey (Eds), Clinical supervision activities for increasing competence and self-awareness. Hoboken, NJ: Wiley Press, Inc. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48, 90–102. doi: 10.1037/a0022161. Nouwen, H. J. M. (1979). The wounded healer. New York, NY: Doubleday. Satir, V. (1987). The therapist story. Journal of Psychotherapy and the Family, 3, 17–25. Simon, G. (2006). The heart of the matter: A proposal for placing the self of the therapist at the center of family therapy research and training. Family Process, 45, 331–344. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy. New York: Guilford. Storm, C. L. (1997). Live supervision revolutionizes the supervision process. In T. C. Todd & C. L. Storm (Eds). The complete systemic supervisor. Context, philosophy, and pragmatics. (pp. 195–216). Needham Heights, MA: Allyn & Bacon. Titelman, P. (Ed.). (1995). The therapist’s own family: Toward the differentiation of self. Lanham, MD: Jason Aronson, Inc.

NOTE 1

A more detailed description of this training can be found in Aponte et al. (2009). For descriptions of specific class exercises, please refer to Aponte and Carlsen (2009), Kissil, Ni~ no, and Aponte (in press), and Ni~ no et al. (in press). A manual detailing POTT, its principles, and procedures is currently being written.

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