Reflective Skills,Empathy,Wellbeing,and Resilience in Cognitive-Behavior Therapy Trainees Participating in Mindfulness-Based Self-Practice/Self-Reflection

Abstract

Self-Practice/Self-Reflection (SP/SR) is an aspect of therapist training and professional development aimed at enhancing therapy skills, empathy, wellbeing, and resilience in the ultimate furtherance of client outcomes. For many decades, intensive SP/SR has been a required part of therapist training in many countries but relatively little is known about the effect of SP/SR. Studies have found cognitive-behavior therapy (CBT) therapists trained under a Beckian CBT paradigm benefitted from more time limited Beckian SP/SR. Mindfulness-based CBT is a more recent third-wave CBT paradigm with psychological process aims similar to those of SP/SR. While training in mindfulness-based CBT often has prominent SP/SR aspects, and mindfulness practice has been shown to benefit health care providers personally and professionally, to date no evaluations have been reported specifically of effects of participation of CBT trainees in stand-alone mindfulness-based SP/SR that meets regulatory requirements for more intensive SP/SR. A study on SP/SR training meeting German requirements is reported here. Post-graduate CBT trainees (N = 95) were assigned to delayed or immediate SP/SR with those in the delayed SP/SR condition crossing-over into SP/SR training after two baseline evaluations on a variety of reflective skill, wellbeing, and resilience measures spaced six to 9 months apart before participating in 120–150 hours of stand-alone mindfulness-based SP/SR followed by a third reevaluation on all study measures. Participants assigned to the immediate SP/SR condition underwent identical SP/SR training with pre/post assessments. Results indicate participation in intensive stand-alone mindfulness-based SP/SR resulted in favorable changes in measures operationalizing all variables. Findings are discussed in terms of their implications for training and professional development of CBT therapists.

Keywords

self-practice self-reflection mindfulness based cognitive-behavior therapy therapy skills empathy wellbeing resilience

Introduction

Practitioners of Cognitive-Behavior Therapy (CBT) develop competencies as they progress throughout their training and later in their careers. These have been conceptualized as having declarative, procedural, and reflective components (Bennett-Levy, 2006). Declarative knowledge is factual information whether subject matter related or personal. Procedural skills are knowing how to do therapy, whether implicit or rule based. Reflective competencies are essentially a “… metacognitive skill which encompasses the observation, interpretation, and evaluation of one’s own thoughts, emotions and actions, and their outcomes.” (Bennett-Levy, 2006, p. 60). While training programs have traditionally placed considerable emphasis on declarative and procedural skills, attention on reflective skills has been more variable.

Several countries, including all Scandinavian countries, Germany and Austria have long legally required Self-Practice/Self-Reflection training (SP/SR) as part of training of therapists of various schools of psychotherapy including CBT to improve both professional competency and personal resilience (cf. Laireiter & Willutzki, 2003). In Germany, as of 2022, the requirement is for 120 hours SP/SR training for psychologists and counselors becoming licensed CBT therapists (cf. Laireiter & Willutzki, 2003). Similarly, 150 hours of CBT SP/SR training is mandatory for physicians choosing CBT training to qualify for independent practice in several mental-health-related medical subspecialties including psychiatry, psychosomatic medicine, and neurology (Bayrische Landesärztekammer, 2020).

SP/SR is a form of experiential learning (cf. Morris, 2020) with therapists-in-training as actively involved participants. Therapeutic techniques are self-practiced during workshops and home practice by applying them to common real-world psychological problems which trainees are themselves facing. This exposes trainees to novel experiences as they personally experience therapeutic techniques. As with other experiential learning, trainees may experience SP/SR as demanding and somewhat psychologically risky. This is why conducting SP/SR training typically requires prior disclosure and participant consent as, for example, called for under Section 7.04 of the Code of Conduct of the American Psychological Association (American Psychological Association, 2017). In addition to self-practice, SP/SR strategically employs critical self-reflection to engender and deepen meaningful learning (cf. Bennett-Levy, 2019; M. L. Davis et al., 2015; Laireiter & Willutzki, 2003).

Self-reflection is a critical element of SP/SR not only because it supports the development of procedural and declarative knowledge (Bennett-Levy et al., 2003; Rønnestad et al., 2019; Skovholt & Trotter-Mathison, 2016, p. 197), but more importantly because self-reflection is thought to be key to the development of the empathic skills underlying a strong therapeutic alliance which is the strongest non-specific determinant of psychotherapy outcome (Flückiger et al., 2018). SP/SR’s specific focus on reflective skills (cf. Bennett-Levy, 2019) has been associated with improvement in these skills among both early career and experienced CBT therapists (Bennett-Levy et al., 2003; M. L. Davis et al., 2015). However, due to lack of experimental control conditions, studies showing these effects often do not allow for such improvements to be unambiguously attributed to SP/SR participation versus general professional development factors (McGillivray et al., 2015; McGinn, 2015).

In addition to reflective and empathic skills, therapists’ own wellbeing and resilience have been shown to affect the quality of their therapeutic work (Nissen-Lie et al., 2013, 2017). While wellbeing always appears to have a positive effect on therapeutic competencies (Nissen-Lie et al., 2013), the role of resilience-related coping skills is less straight forward. Here, a certain amount of self-doubt (Nissen-Lie et al., 2013), including an ability to tolerate uncertainty appears to be beneficial (Strout et al., 2018; Turner et al., 2014). However, while SP/SR training has well documented benefits for CBT therapists’ reflective (McGillivray et al., 2015) as well as declarative and procedural skills (M. L. Davis et al., 2015), its effects on general wellbeing and tolerance of uncertainty are less known.

Despite having been required for many decades in many countries, specific therapist and therapy-related outcomes of SP/SR training have only recently been put to empirical tests, at least in English language publications (cf. Bennett-Levy, 2019; examples are: M. L. Davis et al., 2015; Haarhoff et al., 2011). Furthermore, the extant empirical literature, SP/SR has been mostly approached from a traditional Beckian approach (M. L. Davis et al., 2015, p. 182). A more recent third-wave CBT treatment paradigm with a considerable evidence base employs mindfulness-based interventions such as Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 2013; Santorelli et al., 2017) and Mindfulness-based Cognitive Therapy (MBCT; Segal et al., 2002, 2013). Mindfulness-based meditation interventions have been shown to improve emotion regulation skills, resilience, and psychological well-being (Birtwell et al., 2019; Godfrin & van Heeringen, 2010). Specific mechanisms of action responsible for its effects likely include improved self-reflective skills (Gu et al., 2015, 2016; Lutz et al., 2016), improved resilience by way of enhanced tolerance of cognitive and emotional processes (Farb et al., 2012; Herwig et al., 2010), and improved self-esteem (Morley & Fulton, 2020). Of these the role of self-esteem as a mechanism of action in mindfulness is least well understood because self-acceptance but not self-esteem is specifically targeted the practice of mindfulness (Thompson & Waltz, 2008). However mindfulness practices have often been found to result in increased self-esteem (Morley & Fulton, 2020; Pepping et al., 2013) and may mediate its beneficial effects (Bajaj et al., 2019).

Study Aims

The study aimed to examine quantitative evidence of effects of comprehensive mindfulness-based SP/SR on self-reflection, empathy, psychological wellness, and resilience, among CBT trainees of various health service professions.

Hypotheses

Based on the prior literature on the benefits of SP/SR training for CBT therapists and the effects of mindfulness-based interventions on psychological wellbeing and resilience, participation in mindfulness-based SP/SR training was hypothesized to be associated with improvements in (i) self-reflection and empathy and (ii) psychological wellbeing and resilience.

Method

Design

The study employed a controlled experimental design with cross-over. Participants were arbitrarily assigned in blocks of six to eight to either the delayed-SP/SR condition or the immediate-SP/SR condition (See Table 1 for design). Group assignment was arbitrary and depended on the availability of administrative staff to administer Time 1 measures to participants in the delayed-SP/SR condition. Participants in the delayed-SP/SR condition completed baseline assessment at Time 1 on all study variables, followed by a reassessment on all study variables at Time 2. Delayed-SP/SR participants then crossed over into SP/SR training followed by a post-SP/SR assessment at Time 3. Participants assigned to the immediate-SP/SR condition received pre-SP/SR assessment on all study variables at Time 1 before they underwent SP/SR training followed by a post-SP/SR assessment on all study variables at Time 2. Latency between Time 1 and Time 2 was approximately 6–9 months in the Delayed-SP/SR condition and 15 months in the Immediate-SP/SR condition.

Table 1.

Study Design Showing Timing of Assessments and of Self-Practice/Self-Reflection (SP/SR) Training.

Condition	Time 1 Assessment	SP/SR Training	Time 2 Assessment	SP/SR Training	Time 3 Assessment
Delayed-SP/SR	X		X (pre-SP/SR)	X	X (post-SP/SR)
Immediate-SP/SR	X (pre-SP/SR)	X	X (post-SP/SR)

Participants

All 105 participants initially approached for participation consented in compliance with German research ethics guidelines, and n = 27 participants were assigned to the delayed-SP/SR condition. There was no attrition from measurement across the three measurement times among delayed-SP/SR participants. Of the n = 78 participants assigned to the immediate-SP/SR condition, n = 10 were not available for data collection at Time 2 (post-SP/SR). Attrition analysis showed participant loss in the immediate-SP-SR group was unrelated to demographics (age, gender, professional discipline, employment status) and Time 1 scores on all study variables except for the “empathic concern” subscale on the Interpersonal Reactivity Index where lost participants scored higher (t (74) = 2.46; p = .016; d = .85) and the “general life satisfaction” subscale of the Habitual Subjective Wellbeing Scale where lost participants scored lower (t (74) = −2.31; p = .024; d = .72). Descriptive statistics taken at Time 1 for delayed-SP/SR participants (n = 27) and immediate-SP/SR participants with complete data sets (n = 68) can be found in Table 2. Analysis with χ² for categorical variables and t-test for age revealed no differences on demographics by SP/SR condition except for professional discipline due to the presence of physicians in the immediate-SP/SR condition only. Due to this, a plan was made to examine whether professional discipline interacted with SP/SR in causing outcome differences.

Table 2.

Participant (N= 95) Demographics.

	Delayed-SP/SR (n = 27)	Immediate-SP/SR (n = 68)
Gender	21F, 6M	53 F, 14M
Mean age (SD, range)	31 years (5.73, 24–43)	33 years (6.67, 25–54)
Professional discipline	Clinical psychologist (n = 22)	Clinical psychologist (n = 29)
	Counselor (n = 5)	Counselor (n = 14)
		Physician (n = 18)
Employment status	Part-time practicum (n = 5)	Part-time practicum (n = 8)
	Full-time practicum (n = 5)	Full-time practicum (n = 10)
	Part-time paid (n = 1)	Part-time paid (n = 10)
	Full-time paid (n = 14)	Full-time paid (n = 36)

Note. ns in some categories do not add up to Study N due to missing data; SP/SR = Self-Practice/Self-Reflection.

Mindfulness-Based Self-Practice/Self-Reflection Training

In compliance with German regulations, mindfulness-Based SP/SR was delivered over a 120–150 hours broken into a series of six or seven two-to three-day workshops spaced one to 3 months apart with participants required to spend approximately 10 hours between workshops for written self-reflection and meditation exercises. Throughout all workshop and home exercises, equal emphasis was placed on the personal and professional practice dimensions of SP/SR (cf. Bennett-Levy, 2019).

The particular SP/SR implemented in the present study followed the curriculum for mindfulness-based SP/SR groups (German: Achtsamkeitsbasierte Gruppenselbsterfahrung) developed by Mösler and Poppek (2016). This manualized SP/SR protocol mainly includes elements of MBSR and MBCT, including both guided and self-practice mindfulness mediation. Training additionally incorporates major elements of Nonviolent Communication (Rosenberg, 2003), and Naikan compassion training (Chervenkova, 2017; Krech, 2010). When used as freestanding interventions, these additional elements have been shown to improve self-reflection, and empathy (Shantha, 2019; Wacker & Dziobek, 2018) and they are philosophically highly compatible with mindfulness-based approaches. Workshops were co-led by a team of one male identified and one female identified facilitator and had between 6 and 10 participants. Workshops alternate individual and shared group activities including reflection, skills practice, meditation, exercises, and discussion. A detailed session-by-session manual including verbatim facilitator instructions for exercises, discussions, and home practice instructions together with related visual media is available (Mösler & Poppek; 2016, p. 101–172). A week-by-week outline of the SP/SR workshops appears in Table 3.

Table 3.

Week-By-Week Outline of Mindfulness based Self-Practice/Self-Reflection (Mösler & Poppek, 2016, p. 130–143).

Meeting Number	Activities – Note: A self- and other-directed compassion focus is the context of all work. Discussions include exploration of applicability to participants’ personal lives as well as to their psychotherapeutic work. Participants complete approximately 10 hours of self-reflection and meditation between meetings
1	Participant introductions.Meditation on the topic of ‘when I first fell in love’.Facilitated group sharing and discussion of experiences during the exercise
2	Meditation on the topic of ‘how I might experience my own death’.Facilitated group sharing and discussion of experiences during the exercise
3–5	Meditations and exercises on various topics related to families of origin, including related Naikan meditations Krech (2010).Facilitated group sharing and discussions of participants’ experiences during the exercises and group work
6	Facilitated group sharing and discussions of participant’ experiences during the preceding five meetings with special emphasis on nonviolent communication (cf. Rosenberg (2003) and compassion

Measures

Participants completed a brief sociodemographic survey to indicate their age, gender, professional discipline, and employments status.

The German version of the Clinical Psychological Diagnostic System 38 (CPDS-38; Forschungsstelle für Psychotherapie Universitätsklinikum Heidelberg, 2020; Percevic et al., 2005) was used to estimate subjective distress. It consists of 38 self-rated items rated on a four-point Likert scale (“doesn’t apply”, “applies a little”, “applies quite a bit”, and “applies exactly”. It yields a total score and six subscale scores based on 2 to 14 items in the following domains: Physical concerns, psychological concerns, social problems, self-efficacy, general life satisfaction, and social support. Subscale structure was confirmed through factor analysis. It was normed on a representative sample of the German population (N = 2066) with internal consistency for the six subscales ranging from α =. 71 (self-efficacy) to .91 (social support). Lower scores reflect fewer problems.

The German version of the Habitual Subjective Wellbeing Scale (HSWS; Dalbert, 1992, 2002a) was used to evaluate subjective wellbeing. The HSWS is based on the Mood Survey (Underwood & Froming, 1980) and consists of 13 self-rated items rated on a six-point Likert scale ranging from “applies exactly” to “does not apply at all”. It yields two subscale scores based on six and seven items respectively that are labelled “Mood Level” and “General Life Satisfaction”. The two-factor structure has been confirmed through factor analysis. Internal consistency is reportedly good, varying between α = .82 and α = .88. Higher scores reflect more wellbeing.

The German version of the Uncertainty Tolerance Scale (Dalbert, 2002b) was used to evaluate participants’ ability to tolerate ambiguity/uncertainty in stressful situations, a quality considered to be a resilience factor. The scale has eight self-rated items scored on a six-point Likert scale ranging from “strongly agree” (score = 6) to “strongly disagree” (score = 1). Its single factor structure has been confirmed through factor analysis. Prior studies have found a Cronbach’s α’s ranging from .66 to .72. Higher scores indicate greater tolerance for uncertainty.

The German version of the Self-efficacy Expectations Scale (SEES; Schwarzer & Jerusalem, 1999) was used to evaluate participants’ self-efficacy beliefs considered to be resilience factor. The SEES has 10 items rated on a four-point Likert scale (“does not apply”, “applies somewhat”, “applies quite a bit”, “applies perfectly”). Its single factor structure has been confirmed through factor analyses. Internal consistency has been estimated at α = .79. Higher scores indicate greater self-efficacy expectations.

The German version of the Interpersonal Reactivity Index (IRI; M. H. Davis, 1980, 1983) was used to measure participants’ self-reported empathic abilities. The IRI consists of 28 items broken down into four subscales (Perspective Taking, Fantasy, Empathic Concern, and Personal Distress) of seven items each. Items are self-rated on a 5-point Likert scale ranging from “does not describe me well” (score = 0) to “describes me very well” (score = 4). All four subscales have satisfactory internal consistency with Cronbach's α ranging from .71 to .77. Higher scores reflect more empathy but also more personal distress.

Finally, participants answered three self-evaluation questions (SEQs) to elicit subjective ratings of reflective habits. These items were: “I know myself well”, “I do self-reflection”, “I am able to examine myself from a distance”. Items were rated on a four-point Likert scale ranging from “not at all how I see myself” to “very much how I see myself”. These items had originally been suggested by (Greve, 2007; p. 285) and were pilot tested in the present study based on their face validity. Their psychometric properties were unknown. Higher scores reflect a greater self-rating of reflectiveness.

Procedure

After providing consent, participants in both conditions completed the sociodemographic survey and all study measures. Participants in the immediate SP/SR condition then commenced 120–150 hours mindfulness-based SP/SR training over six to seven two-to three-day long workshops followed by post-SP/SR assessment on all study variables. Participants in the delayed-SP/SR condition waited 6–9 months before completing all measures again followed by immediately commencing identical SP/SR training followed by a third completion of all study measures. Total duration of SP/SR training in both conditions was dependent on availability of staff to run workshops and on participants’ personal issues, such as birth of a child or illness and averaged 15.03 months (SD = 4.50).

Results

Plan for Analyses

Data were analyzed in two phases. In Phase I, to see if SP/SR conditions affected study variables while controlling for threats to internal conclusion validity of history and maturation (Kazdin, 2017, p. 17), the interaction of time (Time 1 vs. Time 2) and condition (Delayed-SP/SR vs. Immediate-SP/SR) was analyzed using a mixed within-between two-way ANOVA. In the Phase I analysis delayed-SP/SR participants served as the no-intervention control and their post-SP/SR scores did not participate. Power to find a small to medium time by condition effect $(η_{p}^{2} = .03)$ in Phase I was 1.0. A significant time by condition effect would mean that SP/SR significantly affected study variables. A significant main effect for time in Phase I would signify that the passage of time (history or maturation), rather than SP/SR were responsible for changes in study variables. A significant main effect for condition would mean lack of group equivalency on study variables.

For the subsequent Phase II analysis, groups were combined to take advantage of the additional power due to delayed-SP/SR participants crossing over into the SP/SR intervention after Time 2. Only study variables found to be significantly impacted by treatment in Phase I were examined as outcome variables in Phase II to examine if effects found in Phase I would replicate when delayed-SP/SR participants were included in the analysis and to examine possible moderation of SP/SR effects by participants’ professional discipline. These analyses employed mixed within-between two-way ANOVAs using pre-SP/SR/post-SP/SR score pairs as the within subjects’ independent variable and SP/SR condition (delayed vs. immediate) as the between subjects’ independent variable. The first baseline measurement in the delayed-SP/SR condition did not participate. Power was equivalent to that in Phase I. A significant interaction of time by condition in Phase II would mean that SP/SR groups did not respond to SP/SR in the same fashion. A significant main effect for condition would mean a failure of group assignment to conditions to yield equivalent groups. A significant main effect for time would mean that participation in SP/SR training affected outcome variables in both groups and would thus potentially replicate Phase I results.

Finally, because professional discipline of participants varied across SP/SR conditions because there were no physicians in the delayed-SP/SR condition, mixed within-between two-way ANOVAs were run with pre-SP/SR/post-SP/SR as the within subjects’ independent variable, professional discipline (psychologist, counselor, physician) as the between subjects’ independent variable, and all outcome variables that showed replicated effects as dependent variables. In this analysis a significant time by professional discipline interaction would signify that members of different professions responded differently to SP/SR training.

Phase I Analysis: Empathic and Reflective Skills

Descriptive statistics and Phase I ANOVA results for empathic and reflective skills variables can be found in Table 4. Mixed within/between two-way ANOVAs were conducted with SP/SR condition as the between subjects’ independent variable, Time 1/Time 2 as the within subjects’ independent variable, and all psychological empathic and reflective scales as dependent variables. Note that participants in the immediate SP/SR condition underwent SP/SR training between Time 1 and Time 2, those in the delayed-SP/SR condition did not (see Table 1). No ANOVA showed significant main effects for condition, suggesting that assignment of participants to SP/SR conditions had generated comparable groups. Significant SP/SR condition by time interaction effects suggest SP/SR training significantly improved scores on the IRI perspective taking and fantasy subscales. There was also a significant main effect for time on the IRI empathic concern subscale suggesting scores improved across time but unrelated to SP/SR participation. The three items of the SEQ were not affected either by SP/SR condition, time, or their interaction.

Table 4.

Phase I Analysis: Means Standard Deviations, and Two-Way ANOVA Statistics for Empathic and Reflective Skills Variables.

Variable	Delayed-SP/SR^a		Immediate SP/SR		ANOVA
	M	SD	M	SD	Effect	F ratio	df ^b	p	$η_{p}^{2}$
IRI: Perspective taking					C	.58	1,91	.451	.01
Time 1	3.94	.56	3.71	.52	T	.08	1,91	.773	.00
Time 2	3.80	.50	3.88	.53	C x T	7.26	1,91	.008	.07
IRI: Fantasy					C	.01	1,91	.944	.00
Time 1	3.25	.68	3.35	.61	T	1.02	1,91	.316	.01
Time 2	3.41	.64	3.30	.64	C x T	4.29	1,91	.041	.05
IRI: Empathic concern					C	.58	1,91	.450	.01
Time 1	3.85	.44	3.88	.48	T	5.29	1,91	.024	.06
Time 2	3.91	.58	4.03	.41	C x T	1.22	1,91	.273	.01
IRI: Personal distress					C	.26	1,90	.614	.00
Time 1	2.30	.47	2.43	.58	T	.98	1,90	.324	.01
Time 2	2.31	.57	2.30	.59	C x T	1.11	1,90	.296	.01
SEQ1: “I know myself well”					C	1.52	1,91	.221	.02
Time 1	3.33	.62	3.17	.65	T	.05	1,91	.829	.00
Time 2	3.30	.54	3.17	.69	C x T	.05	1,91	.829	.00
SEQ2: “I do self-reflection”					C	.01	1,90	.155	.00
Time 1	3.26	.66	3.45	.73	T	.01	1,90	.926	.00
Time 2	3.26	.56	3.46	.71	C x T	.01	1,90	.926	.00
SEQ3 “I am able to self-examine”					C	.01	1,89	.910	.00
Time 1	2.37	.74	2.36	.72	T	.69	1,89	.408	.01
Time 2	2.44	.70	2.43	.75	C x T	.01	1,89	.944	.00

Note. SP/SR = Self-Practice/Self-Reflection; IRI = Interpersonal Reactivity Index; SEQ = Self-Evaluation Question; C = Condition; T = Time.

^aSP/SR not provided to participants in this condition until after Time 2.

^bper-comparison dfs vary due to missing data.

Phase I Analysis: Psychological Wellness and Resilience

Descriptive statistics and Phase I ANOVA results for psychological wellbeing and resilience variables can be found in Table 5. Mixed within/between two-way ANOVAs were conducted with SP/SR condition as the between subjects’ independent variable, Time 1/Time 2 as the within subjects’ independent variable, and all psychological wellness and resilience scales as dependent variables. Note that participants in the immediate SP/SR condition underwent SP/SR training between Time 1 and Time 2, those in the delayed-SP/SR condition did not (see Table 1). Because neither CPDS-38 total score nor any of the CPDS-38 subscales showed any effects, only CPDS-38 total scores are shown in Table 5, descriptive and ANOVA statistics for all CPDS-38 subscales can be found in the Supplemental Appendix. Again, no ANOVA showed significant main effects for condition on any variable, suggesting assignment of participants to SP/SR conditions had created comparable groups. There were also no significant main effects for time, suggesting any changes in study variables could not be attributed to the passage of time alone. There were significant SP/SR condition by time interaction effects showing improvements attributable to participation in SP/SR for HSWS total score, HSWS mood, and SEES. The SP/SR condition by time interaction effect was closely missed the significance cutoff (p < .05) at p = .061 for HSWS general life satisfaction. However, due to how closely p < .05 was missed, this subscale was also included in the replication analysis in Phase II and the analysis of possible professional discipline confounds.

Table 5.

Phase I Analysis: Means Standard Deviations, and Two-Way ANOVA Statistics for Psychological Wellbeing and Resilience Variables.

Variable	Delayed-SP/SR^a		Immediate SP/SR		ANOVA
Variable	M	SD	M	SD	Effect	F ratio	df ^b	p	$η_{p}^{2}$
CPDS-38^c					C	.22	1,89	.641	.00
Time 1	1,91	.34	1,99	.40	T	.11	1,89	.916	.00
Time 2	1,97	.38	1,95	.39	C x T	1.85	1,89	.178	.02
HSWS: total scale					C	.01	1,91	.925	.00
Time 1	4.74	.57	4.59	.57	T	.21	1,91	.647	.00
Time 2	4.63	.57	4.75	.68	C x T	6.02	1,91	.016	.06
HSWS: Mood level					C	.37	1,91	.925	.00
Time 1	4.48	.67	4.20	.87	T	.49	1,91	.486	.01
Time 2	4.35	.70	4.43	.79	C x T	5.02	1,91	.027	.05
HSWS: General life satisfaction					C	.31	1,91	.581	.00
Time 1	5.01	.53	4.98	.57	T	.00	1,91	.954	.00
Time 2	4.90	.57	5.08	.69	C x T	3.59	1,91	.061	.04
Uncertainty tolerance scale					C	.08	1,90	.775	.00
Time 1	27.59	5.43	27.21	6.32	T	.16	1,90	.694	.00
Time 2	27.37	6.18	27.02	5.93	C x T	.00	1,90	.983	.00
Self-efficacy expectations scale					C	.26	1,89	.611	.00
Time 1	3.04	.24	2.93	.37	T	.02	1,89	.901	.00
Time 2	2.97	.23	3.01	.40	C x T	4.22	1,89	.043	.05

Note. N=95; ANOVA = analysis of variance; SP/SR = Self-Practice/Self-Reflection; CPDS-38 = Clinical Psychological Diagnostic System 38; HSWS: Habitual Subjective Wellbeing Scale; C = condition; T = time.

^aSP/SR not provided to participants in this condition until after Time 2.

^bper-comparison dfs vary due to missing data; ^c Phase I ANOVA results for CPDS-38 subscales can be found in the Supplemental Appendix.

Phase II Analysis: Replication of Significant Interaction Effects from Phase I

For Phase II analyses, data from all participants was pooled to analyze the effects of SP/SR conditions on all pre-SP/SR and post-SP/SR outcome variables which were found in Phase I to be affected by SP/SR condition. This was possible because participants in the delayed-SP/SR group crossed over into SP/SR training after their Time 2 assessment. Descriptive and ANOVA statistics for this replication analysis can be found in Table 6. Mixed within/between two-way ANOVAs were conducted with SP/SR condition as the between subjects’ independent variable, pre-SP/SR/post-SP/SR as the within subjects’ independent variable, and all SP/SR training effects found in Phase I as dependent variables. There were no significant main effects for condition or for time by condition interactions indicating that both groups were affected by SP/SR training in substantially comparable ways. Neither the significant time effect from phase I for the IRI empathic concern subscale, nor the effect on the IRI fantasy subscale replicated. As indicated by significant main effects for time, all other Phase I SP/SR training effects replicated. There was a medium to large improvement for IRI perspective taking

(η_{p}^{2} = .12)

, and small to medium effects on HSWS total scale

(η_{p}^{2} = .09)

, HSWS mood level

(η_{p}^{2} = .04)

, HSWS general life satisfaction

(η_{p}^{2} = .11)

, and for the SEES

(η_{p}^{2} = .08)

Table 6.

Phase II Analysis: Means Standard Deviations, and Two-Way ANOVA Statistics for Variables Found to be Affected by SP/SR in the Phase I Analysis.

Variable	Delayed-SP/SR^a		Immediate SP/SR^a		ANOVA
Variable	M	SD	M	SD	Effect	F ratio	df ^b	p	$η_{p}^{2}$
IRI: Perspective taking					C	1.30	1,91	.257	.01
Pre-SP/SR	3.80	.50	3.71	.52	T	12.91	1,91	.001	.12
Post-SP/SR	4.02	.47	3.88	.53	C x T	.18	1,91	.676	.00
IRI: Fantasy					C	.82	1,91	.368	.01
Pre-SP/SR	3.41	.64	3.35	.61	T	.01	1,91	.929	.00
Post-SP/SR	3.48	.70	3.30	.64	C x T	1.15	1,91	.287	.01
IRI: Empathic concern					C	.19	1,91	.664	.00
Pre-SP/SR	3.91	.58	3.88	.48	T	3.03	1,91	.085	.03
Post-SP/SR	3.92	.39	4.03	.41	C x T	2.39	1,91	.126	.03
HSWS: total scale					C	.16	1,91	.693	.00
Pre-SP/SR	4.63	.57	4.59	.69	T	8.58	1,91	.004	.09
Post-SP/SR	4.82	.65	4.75	.68	C x T	.61	1,91	.805	.01
HSWS: Mood level					C	.30	1,91	.583	.00
Pre-SP/SR	4.35	.70	4.20	.87	T	4.11	1,91	.046	.04
Post-SP/SR	4.46	.92	4.43	.79	C x T	.53	1,91	.469	.01
HSWS: General life satisfaction					C	.16	1,91	.900	.00
Pre-SP/SR	4.90	.57	4.98	.62	T	11.15	1,91	.001	.11
Post-SP/SR	5.19	.49	5.08	.69	C x T	2.60	1,91	.110	.03
Self-efficacy expectations scale					C	.84	1,89	.361	.01
Pre-SP/SR	2.97	.23	2.93	.34	T	7.20	1,89	.009	.08
Post-SP/SR	3.10	.33	3.01	.40	C x T	.50	1,89	.480	.01

Note. N = 95; ANOVA = analysis of variance; SP/SR = Self-Practice/Self-Reflection; IRI = Interpersonal Reactivity Index; HSWS: Habitual Subjective Wellbeing Scale; C = condition; T = time.

^aSP/SR provided to participants in this condition between pre- and post-measures.

^bper-comparison dfs vary due to missing data.

Phase II Analysis: Examination of the Effect of Professional Discipline SP/SR Training Outcomes

Mixed within/between two-way ANOVAs were run with professional discipline (psychologist, counselor, physician) as the between subjects’ variable, pre-SP/SR/post-SP/SR as the within subjects’ variable, and dependent variables IRI perspective taking (F (2,84) = 1.51; p = .23), HSWS total scale (F (2,84) = .35; p = .71), HSWS mood level (F (2,84) = .07; p = .93), and HSWS general life satisfaction (F (2,84) = .92; p = .40), and SEES (F (2,82) = .21; p = .81). These were the outcome variables where SP/SR effects found in Phase I, were replicated in Phase II. Because none of these effects were significant, participants’ professional discipline did not significantly impact how they responded to SP/SR training.

Discussion

As hypothesized, mindfulness-based SP/SR training had beneficial effects on empathy, reflective skills, wellbeing, and resilience of CBT trainees. Improvements in empathy and reflective skills were evident on the IRI subscale “perspective taking” but not on other IRI subscales or on the three SEQ items. Positive effects on wellbeing and resilience were found on HWBS, its mood level and general life satisfaction subscales, and on the SEES. There were no effects on CPDS-38 total scores, any CPDS-38 subscales, or on the UTS.

Changes in study variables were not evident due to time alone or due to whether SP/SR training was provided immediately or after a 6–9 months delay. This provides a good counter argument to threats to internal conclusion validity of natural psychological maturation across time or of extraneous events that may have coincidentally occurred while SP/SR was ongoing. This is important because these confounding factors might otherwise account for the observed changes rather than SP/SR training. However, alternative accounts for why changes were seen cannot be entirely ruled out, as participants had many other training experiences throughout the approximately one to two-year duration of the study which may have impacted study variables. For example, participants’ professional responsibilities and demands on their time typically increase later in CBT training, though it is unclear whether this might support or tax wellbeing and resilience. Similarly, CBT training and supervision may have primed the development of empathy late in training to potentiate the impact of SP/SR training. To control for these confounds, an extended no-SP/SR control group would be ideal, but such a group could not be formed due to the legal requirement in Germany that all CBT trainees participate in SP/SR training. Owing to these circumstances, obtaining a Time 1 measurement from the delayed-SP/SR group was a good way to address maturation and history threats to improve internal conclusion validity.

Similarly, threats to external validity could be ruled out reasonably well and results can be considered generalizable due to the low participant attrition rate and finding that training effects could not be attributed to participant’s professional discipline (psychologist, counselor, or physician) or to whether SP/SR began immediately or after a delay. The heterogeneous composition of both samples in terms of professional background, age, and gender further speak in favor of the generalizability of the present findings.

A limitation of the study was the lack of an implementation check. While all participants completed SP/SR training, it is unknown if all benefitted equally. Future studies may want to include a measure of mindfulness such as the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). Variations in FFMQ scores may also relate to individual differences in participant motivation and engagement, variables also not assessed in the present study which have previously been found to relate to the benefit of SP/SR (M. L. Davis et al., 2015). Inclusion of such measures may be particularly relevant when studies are conducted in countries such as Germany where SP/SR training is legally required.

Despite good power, SP/SR training effects were not found in uncertainty tolerance on the UTS, on the CPDS-38 and its subscales, and on the self-reflection items of the SEQ. As mindfulness practice is well known to improve distance from own thoughts and emotions (Herwig et al., 2010; Lutz et al., 2016), the lack of findings on the UTS is somewhat puzzling. This may have been due to this particular operationalization of tolerance of uncertainty (Dalbert, 2002b) which, while popular in Germany, may not be sensitive to changes in affect management due to mindfulness practices. However, it may also reflect variability in degree to which participants mastered mindfulness skills which is unknown due to the lack of an implementation check. Lack of findings on the CPDS-38 may be because the CPDS-38 is a pathology focused measure. With observed CPDS-38 scores in this study toward to bottom end of the scale, a pathology-oriented measure may have lacked the measurement sensitivity to detect more subtle changes in wellbeing among this group of overall psychologically well-adjusted CBT trainees. SEQ items were pilot tested in this study to see if these items with their good face validity could give a reliable read of participants’ self-rated reflective skills. However, it did not appear that merely asking participants self-reflection questions is a feasible way to detect any impact of SP/SR.

Findings of the present study regarding wellness and resilience replicate the prior literature on the personal benefits of mindfulness-based practice among a variety of health service providers (Conversano et al., 2020; Spinelli et al., 2019). Importantly, SP/SR equally emphasizes the application of self-practice and self-reflection to professional competencies (cf. Bennett-Levy, 2019). Here prior findings have also shown benefits, for example for increased empathy and reduced compassion fatigue among a variety of health care providers (Conversano et al., 2020). In contrast to the present study, however, efficacious mindfulness protocols from prior studies often only take just a few hours (Kriakous et al., 2021) or may be delivered virtually (e.g., Pflugeisen et al., 2016; Wen et al., 2017) versus the SP/SR protocol employed here which takes 120–150 hours plus additional time for home-based self-reflection and meditation. Future research may thus want to investigate what the optimal dose/response relationship for mindfulness-based SP/SR to engender both personal and professional outcomes.

For better comparability between present findings and prior work on the effects of Beckian-based SP/SR as developed by (Bennett-Levy et al., 2015), it would have been desirable also to include in this study outcome measures used in previous SP/SR research, such as the Cognitive Therapist Self-Monitoring Scale (CMSMS) (Thwaites et al., 2003) as cited in M. L. Davis et al., (2015) and the Cognitive Therapist Empathy Scale (CTES; (Thwaites et al., 2003) as cited in M. L. Davis et al., (2015). It is entirely possible, that despite the differences in paradigms between Beckian and mindfulness-based SP/SR, effects on therapists’ reflective competencies, wellbeing and resilience might be comparable. Present findings that self-efficacy improved following mindfulness-based SP/SR would be consistent with this. On the other hand, because mindfulness-based SP/SR does not include practice of specific cognitive-therapy (CT) skills, a mindfulness-based approach may not lead to improvements in CT-specific technical skills seen after Beckian SP/SR (cf. Haarhoff et al., 2011; Schneider & Rees, 2012). Such measurement of declarative and procedural CBT skills would also have been desirable to see if improvements seen here in empathy translate into better declarative and procedurals skills as prior research and theory would suggest (Bennett-Levy, 2006). Though it is possible there are paradigm specific SP/SR effects with mindfulness-based SP/SR specifically benefiting declarative and procedural skills related to mindfulness-based CBT but not to Beckian CBT.

Regardless of the paradigm they follow, all therapists aim to improve their clients’ mental health. However, similar to prior SP/SR studies (cf. McGillivray et al., 2015), the effect of SP/SR on ultimate client outcomes was not measured in this study and is therefore unknown. Because prior research has shown that when therapists’ empathy and skills improve, their well-being, coping skills, and reflective abilities also increase, it stands to reason clients would also benefit. Nevertheless, it would be desirable at least to show effects of SP/SR on clients’ experience while undergoing CBT, for example by evaluating possible changes the quality of the Helping Alliance (Luborsky et al., 1996) as their therapists participate in SP/SR.

Conclusion

SP/SR based on Beckian principles has been shown to have many promising benefits for the training and later professional development of CBT therapists practicing Beckian CBT. While empirically supported mindfulness-based therapies such as MBSR and MBCT have prominent experiential aspects that are also used in training therapists to implement them, there would not appear to have been prior studies on the effects of an organized course of mindfulness-based SP/SR training. Because SP/SR training is not only promising benefits for CBT trainees and their clients but is a legal requirement in many countries, the availability of empirically supported mindfulness-based SP/SR training as documented in this study is of benefit to training programs in such countries and elsewhere that seek an additional option to engage CBT trainees in SP/SR. The present findings are an important step in showing mindfulness-based SP/SR benefits CBT trainees’ self-reflective and empathic development, wellbeing, and resilience.

Supplemental Material

Supplemental Material - Reflective Skills, Empathy, Wellbeing, and Resilience in Cognitive-Behavior Therapy Trainees Participating in Mindfulness-Based Self-Practice/Self-Reflection

Supplemental Material for Reflective Skills, Empathy, Wellbeing, and Resilience in Cognitive-Behavior Therapy Trainees Participating in Mindfulness-Based Self-Practice/Self-Reflection by Thomas Mösler, Sandra Poppek, Christoph Leonhard, and Wilfried Collet in Psychological Reports

Footnotes

Author Contributions

TM and SP: Conceptualization, implementation, and manuscript editing. WC: Conceptualization, data analysis, and manuscript editing. CL: Conceptualization, data analysis, and manuscript preparation.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: TM and SP participate financially in book sales of the Self-Practice/Self-Reflection program that is the subject of this research and in workshops implementing the program.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data Availability Statement

Data are available for reanalysis contingent on IRB approval of proposed research.

ORCID iD

Christoph Leonhard

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Thomas Mösler, MD is board certified in diseases of the nervous system and in psychotherapeutic medicine. He is Director of the Institut für Verhaltenstherapie, Verhaltensmedizin und Sexuologie in Nuremberg/Fuerth. A faculty member of the University of Erlangen, Medical School, his research and professional work focuses on Self-Practice/Self-Reflection in the training of cognitive-behavior therapists, mindfulness-based educational and therapeutic techniques, and palliative and end-of-life care. He has published widely on these topics.

Sandra Poppek, MD, is board certified in psychotherapeutic medicine. She is Director of Education, Continuing Education, and Self-Practice/Self-Reflection at the Institut für Verhaltenstherapie, Verhaltensmedizin und Sexuologie in Nuremberg/Fuerth. Certified as a medical sexologist and sex therapist, her research and professional work focuses on sexual health and the training of cognitive-behavior therapists with special emphasis on mindfulness-based Self-Practice/Self-Reflection. She has widely published on these topics.

Christoph Leonhard, PhD is board certified in Behavior Therapy. He is a professor of clinical psychology at The Chicago School of Professional Psychology at Xavier University of Louisiana, a licensed psychologist in Louisiana, and a research consultant at the Institut für Verhaltenstherapie, Verhaltensmedizin und Sexuologie in Nuremberg/Fuerth. His research, teaching, and publications focus on multicultural psychology and health disparities, program development and evaluation, addictions, behavior therapy, and research methods.

Wilfried Collet, Dr. rer.nat, is a research consultant with the Institut für Verhaltenstherapie, Verhaltensmedizin und Sexuologie in Nuremberg/Fuerth. He has several decades experience with pharmaceutical and psychological research consultation.

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