Equipping students to be resourceful practitioners in community settings: A realist analysis

ABSTRACT

Training programmes for counsellors and psychotherapists comprise complex combinations of different types of learning activity. However, research into the process and outcomes of therapy training has almost entirely comprised investigations of specific training elements. In addition, studies of training have not taken account of the potential influence of the social and organisational context within which training is delivered. The present paper reports on a realist analysis of learning mechanisms within a professional counsellor training programme in pluralistic-integrative counselling, drawing on multiple sources of data collected over a ten-year period. Training outcomes were oriented toward preparing trainees to be flexible and resourceful practitioners in non-medicalised community settings. Core learning mechanisms included building on pre-existing skills, knowledge and awareness, and acquiring conceptual tools appropriate to a collaborative style of working, within an immersive learning environment that supported focused reflection and engagement with personally challenging learning tasks. Implications for further research on therapist training, and programme design, are discussed.

ABSTRAKT

Ausbildungsprogramme für Berater und Psychotherapeuten umfassen komplexe Kombinationen verschiedener Arten von Lernaktivitäten. Die Erforschung des Ablaufs und der Ergebnisse des Therapietrainings umfasst jedoch fast ausschließlich die Untersuchung spezifischer Trainingselemente. Darüber hinaus haben Studien zur Ausbildung den potenziellen Einfluss des sozialen und organisatorischen Kontexts, in dem die Ausbildung stattfindet, nicht berücksichtigt. Der vorliegende Beitrag berichtet über eine realistische Analyse von Lernmechanismen innerhalb eines professionellen Beraterausbildungsprogramms in pluralistisch-integrativer Beratung, die auf mehrere Datenquellen zurückgreift, die über einen Zeitraum von zehn Jahren gesammelt wurden. Die Trainingsergebnisse waren darauf ausgerichtet, die Auszubildenden zu flexiblen und einfallsreichen Praktikern in nicht-medizinischen Gemeinschaftseinrichtungen vorzubereiten. Zu den wichtigsten Lernmechanismen gehörten der Aufbau auf bereits vorhandenen Fähigkeiten, Kenntnissen und Bewusstsein sowie der Erwerb konzeptioneller Werkzeuge, die für einen kollaborativen Arbeitsstil geeignet sind, in einer immersiven Lernumgebung, die eine fokussierte Reflexion und Auseinandersetzung mit persönlich herausfordernden Lernaufgaben unterstützt. Implikationen für die weitere Forschung zur Therapeutenausbildung und Programmgestaltung werden diskutiert.

RESUMEN

Los programas de capacitación para consejeros y psicoterapeutas comprenden combinaciones complejas de diferentes tipos de actividades de aprendizaje. Sin embargo, la investigación sobre el proceso y los resultados del entrenamiento terapéutico ha comprendido casi en su totalidad investigaciones de elementos de entrenamiento específicos. Además, los estudios sobre la formación no han tenido en cuenta la influencia potencial del contexto social y organizativo en el que se imparte la formación. En el presente documento se informa sobre un análisis realista de los mecanismos de aprendizaje en el marco de un programa de formación de consejeros profesionales en asesoramiento pluralista e integrador, basándose en múltiples fuentes de datos recopilados durante un período de diez años. Los resultados de la capacitación se orientaron a preparar a los participantes para que sean profesionales flexibles e ingeniosos en entornos comunitarios no medicalizados. Los mecanismos básicos de aprendizaje incluyeron el desarrollo de habilidades, conocimientos y conciencia preexistentes, y la adquisición de herramientas conceptuales apropiadas para un estilo de trabajo colaborativo, dentro de un entorno de aprendizaje inmersivo que apoyaba la reflexión enfocada y el compromiso con tareas de aprendizaje personalmente desafiantes. Las implicaciones para la investigación adicional sobre el entrenamiento del therapist, y el diseño del programa, se discuten.

ABSTRAIT

Les programmes de formation pour les counsellors et les psychothérapeutes proposent des combinaisons complexes de différents types d’activités d’apprentissage. Cependant, les recherches examinant le processus et les résultats de la formation thérapeutique sont presque exclusivement constituées d’investigations quant à des éléments spécifiques de formation. Par ailleurs, les études sur la formation n’ont pas pris en compte l’influence potentielle du contexte social et organisationnel au sein duquel la formation est dispensée. Cet article fait le rapport d’une analyse réaliste des mécanismes d’apprentissage au sein d’un programme de formation professionnelle des counsellors dont l’orientation est pluraliste-intégrative, à partir de sources multiples de données collectées sur une période de dix ans.Les objectifs de la formation consistaient à préparer des apprenants à être des praticiens flexibles et ingénieux dans leur fonctionnement au sein d’un contexte de travail non-médicalisé. Les mécanismes d’apprentissages principaux incluaient le développement des compétences existantes, la connaissance et la prise de conscience, ainsi que l’acquisition d’outils conceptuels adaptés à une façon de travailler collaborative en immersion dans un environnement d’apprentissage soutenant la réflexion organisée et l’engagement avec des tâches d’apprentissage stimulantes. Les implications pour la recherche future quant à la formation des thérapeutes et à l’élaboration des programmes sont également abordées.

ΠΕΡΊΛΗΨΗ

Τα εκπαιδευτικά προγράμματα για σύμβουλους και ψυχοθεραπευτές περιλαμβάνουν σύνθετους συνδυασμούς διαφορετικών τύπων μαθησιακής δραστηριότητας. Ωστόσο, η έρευνα για τη διαδικασία και τα αποτελέσματα της θεραπευτικής εκπαίδευσης έχει σχεδόν εξ ολοκλήρου διερευνήσει συγκεκριμένα στοιχεία εκπαίδευσης. Επιπλέον, οι μελέτες σχετικά με τα εκπαιδευτικά προγράμματα δεν έλαβαν υπόψη την πιθανή επιρροή του κοινωνικού και οργανωτικού πλαισίου εντός του οποίου παρέχεται η κατάρτιση. Η παρούσα μελέτη αναφέρεται σε μια ρεαλιστική ανάλυση των μαθησιακών μηχανισμών στο πλαίσιο ενός προγράμματος κατάρτισης επαγγελματιών συμβούλων σε έναν πλουραλιστικό-συνθετικό τύπο συμβουλευτικής, που βασίζεται σε πολλαπλές πηγές δεδομένων που συλλέχθηκαν σε μια δεκαετία. Τα αποτελέσματα της εκπαίδευσης ήταν προσανατολισμένα στην προετοιμασία των εκπαιδευόμενων να είναι ευέλικτοι και επινοητικοί επαγγελματίες σε μη ιατρικοποιημένα κοινοτικά πλαίσια. Οι βασικοί μηχανισμοί μάθησης περιλάμβαναν το χτίσιμο πάνω σε ήδη υπάρχουσες δεξιότητες, γνώση και αυτεπίγνωση και την απόκτηση εννοιολογικών εργαλείων κατάλληλων για ένα συνεργατικό στυλ εργασίας, μέσα σε ένα καθηλωτικό περιβάλλον μάθησης που υποστήριζε τον εστιασμένο αναστοχασμό και τη δέσμευση σε προσωπικά προκλητικές μαθησιακές εργασίες. Συζητούνται οι επιπτώσεις για περαιτέρω έρευνα σχετικά με την εκπαίδευση θεραπευτών και τον σχεδιασμό προγραμμάτων.

KEYWORDS:

• Case study
• counselling
• pluralistic therapy
• realist methodology
• training

SCHLÜSSELWÖRTER:

• Fallstudie
• Beratung
• pluralistische Therapie
• realistische Methodik
• Training

PALABRAS CLAVE:

• caso práctico
• consejeria
• terapia pluralista
• metodología realista
• formación

MOTS-CLÉS:

• étude de cas
• counselling
• thérapie pluraliste
• méthodologie réaliste
• formation

ΛΈΞΕΙΣ-ΚΛΕΙΔΙΆ:

• μελέτη περίπτωσης
• συμβουλευτική
• πλουραλιστική θεραπεία
• ρεαλιστική μεθοδολογία
• εκπαίδευση

Following the pioneering work of Carl Rogers and his colleagues into the process of training in client-centred therapy (Grummon & Gordon, 1948; Rogers, 1951), the quest to establish an appropriate pedagogy for training in counselling and psychotherapy has represented a central focus of interest in the professional literature (Callahan & Watkins, 2018a, 2018b, 2018c; McAuliffe & Eriksen, 2011). The impact of a wide range of training activities within programmes has been examined, including micro-skills labs (Baker et al., 1990; Hill & Lent, 2006), self-practice (Bennett-Levy, 2019), deliberate practice (Hill et al., 2020), and mandatory personal therapy (Edwards, 2018). Research has also investigated processes of trainee development both during training (Kanazawa & Iwakabe, 2016; Wagner & Hill, 2015), and beyond its end-point (Carlsson, 2012; Carlsson et al., 2011; Rønnestad & Skovholt, 2013). Important generic aspects of effective training have been identified, such as the development of interpersonal skills (Anderson et al., 2016; Schöttke et al., 2017) and engagement in critical reflection (Wigg et al., 2011).

Designing and implementing effective training experiences requires an understanding of the ways in which specific training elements and activities can be successfully combined within an overall training programme, and how training trajectories and practices are shaped by cultural, socio-economic, organisational and other contextual factors. The distinction between ‘medicalised’ and ‘non-medicalised’ forms of practice comprises a potentially relevant contextual influence on therapy training (Strong, 2017; Strong et al., 2018). Therapy provision located in medicalised, health service settings comprises a domain of state-regulated therapy practice, characterised by nationally agreed career and salary structures, clinician adherence to treatment manuals and clinical guidelines (Gyani et al., 2014; Kalogeropoulos et al., 2018), and access to treatment mediated through medical referral pathways (Kalogeropoulos et al., 2018). By contrast, non-medicalised practice exists within such settings as student counselling, voluntary sector services (e.g. bereavement counselling, relationship/marital counselling, rape crisis centres, etc.), workplace counselling services, and private/independent practice. Non-medicalised practice constitutes a cluster of therapy environments that are much more diverse in terms of employment patterns, payment rates, and flexibility of service provision, and comprising counsellors working institutionally autonomous small or medium-sized community-based organisational units (Cornforth & Sewell, 2004). Clients do not typically access such services through a medical referral.

Trainees being prepared to work in the medicalised sector, for example, as clinical or counselling psychologists, are likely to be younger (age 20–30) on entry to training, have limited prior occupational experience, and to be taught in classes consisting of students with a single discipline background (psychology) (Ameen et al., 2021). By contrast, counsellors and psychotherapists being trained to work in community agencies and private practice are usually older (age 30–50 on entering training) with considerable previous occupational experience in health, social care or educational settings (Coldridge & Mickelborough, 2003; Cornforth & Sewell, 2004; King, 2007; Messina et al., 2018). Medicalised clinical psychology programmes tend to be at Doctoral level, with a strong research emphasis linked to a training curriculum defined within a narrow band of empirically-validated models of therapy, primarily CBT (Heatherington et al., 2012; Jaimes et al., 2015; Levy & Anderson, 2013), while non-medicalised counsellor and psychotherapist training programmes are more likely to be at undergraduate or Masters level and based in integrative and collaborative models of therapy practice (Strong, 2017).

A defining feature of medicalised therapy practice is that it is standardised and operates in response to various forms of centralised control. By contrast, a defining feature of community-based non-medicalised counselling and psychotherapy services is its flexible responsiveness to local needs and social change. Being an effective therapist in a community context requires training that provides a capacity for creativity and capacity to engage constructively with ambiguity (Nicolaides & Marsick, 2016).

Realist evaluation offers a methodological approach that is appropriate to the task of analysing how training programmes operate within specific contexts. From a realist perspective, an intervention programme is viewed as functioning as a complex, open system that operates across both micro (individual action and experience) and macro (organisational and societal structure) levels (Pawson & Tilley, 1997). Realist analysis synthesises all available information to generate a ‘programme theory’ that makes links between contextual conditions, change mechanisms, and outcomes. Psychosocial mechanisms (M) represent the key processes through which an intervention has an effect. Mechanisms are conceptualised as actions and choices undertaken by participants in specific contexts (C), that lead to intervention outcomes (O). In many realist evaluation studies, configurations are presented in the form of ‘if-then-because” summaries. Pawson and Tilley (1997) developed realist analysis in the belief that the development of effective psychosocial interventions and programmes required more than evaluating effectiveness or understanding participant experience. Instead, in order to design and implement effective interventions, they suggested that it was crucial to examine ‘what works for whom, in what context, to what extent, how and why’. A programme theory has the potential to inform practice by clarifying what participants can do to achieve particular outcomes in particular contexts, and to learn from the operation of similar configurations in other practice domains. The establishment of a programme theory also opens up the possibility of further research that yields more fine-grained analyses of configurations, or examines how configurations interact with each other within a programme system. Realist analysis has been extensively applied in research in fields such as health, social care, management, education, and international development.

The aim of the present study was to use realist methodology to explore learning mechanisms and outcomes associated with counsellor training within a specific societal and organisational context. There were two main research questions that we sought to explore in the present study: What are the skills and training outcomes associated with effective therapeutic work in non-medicalised community practice contexts? How does a counsellor training programme equip and support trainees to work in such contexts?

Methods

A realist case-study approach was used to analyse documentary evidence relating to the operation of a counsellor training course over a 10-year period.

The training programme

The study was based in a university MSc in Counselling programme validated by the British Association for Counselling and Psychotherapy (BACP) as an approved training route leading to professional accreditation as a counsellor. In the period covered by the present case study, the programme comprised a series of three linked qualifications. Stage 1 (Graduate Certificate in Counselling Skills; 120 class contact hours over 9 months) focused on the development of counselling skills and self-awareness, with additional lecture and workshop inputs on theory and professional issues (additionally validated by COSCA: Counselling in Scotland). Skills practice was conducted in triads in which students acted as clients for each other; self-awareness and personal development was facilitated through participation in collaborative, manual-based experiential groups (10–12 participants). Stage 1 was open to practitioners in occupations such as nursing, social work and teaching, seeking to develop work-related skills and competencies, as well as those aiming to progress to a qualification as a professional counsellor. In Stage 2 (Postgraduate Diploma in Counselling; 420 class contact hours; validated by BACP), students entered supervised practice (100 client contact hours) in a wide range of community counselling agencies, and attended classes on theory and professional issues, received individual and group case supervision, and continued their experiential learning in personal and professional development groups. Stage 3 (MSc Counselling) comprised an opportunity to carry out a piece of research.

Assignment tasks throughout the programme consisted of essays, case studies, process analysis of recordings of therapy sessions, supervision reports, and observation of skills. Students attended part-time (one day per week) and were able to leave with a qualification, or pause their studies, at the end of each stage of the programme. All entrants to the programme were interviewed, assessed for interpersonal skills competence, and required to demonstrate previous experience in a helping role.

The programme provided training in an integrative pluralistic approach to therapy that emphasised client-therapist collaboration, dialogue and shared decision-making (Cooper & McLeod, 2011; McLeod, 2017). Students received training in specific pluralistic competencies such as goal agreement, collaborative case formulation, exploration of client preferences, metacommunication, using feedback tools, and activating client strengths and cultural resources. Training also covered use of concepts and interventions from person-centred, psychodynamic, CBT, Transactional Analysis, narrative therapy and existential therapy. Principles of research-informed practice were introduced at the start of the programme, and reinforced through sessions on critical analysis of research papers, use of feedback tools, a practical workshop on case study methodology, and a research conference.

Participants were encouraged to adopt a lifelong learning perspective that acknowledged skills and competencies arising from prior occupational and life experience, and viewed training as providing a practice framework that built on pre-existing knowledge. All assignments included requirements to ground critical reflection in awareness of relevant pre-existing experience and learning, and identify future learning goals. The programme as whole operated as a learning community that encouraged mutual support and constructive challenge. Students were not required to be in personal therapy during the programme, but were encouraged to do so. Students kept reflective learning journals, and submited reflective personal development reports at the end of each year, documenting and commenting on feedback from peers, tutors and clients. The key ideas of a pluralistic approach to therapy (e.g. open-ness to different perspectives, shared decision-making, use of feedback) were embodied within the operation of the programme.

The time-span covered by the current case study (2006–17) was selected on the basis that it represented a stable period in the operation of the programme within the institution. In the period 2000–2005 the course had been based in a different theoretical model (person-centred), while in 2016 the structure of the programme had been significantly revised in response to a shift in university policy. Between 2006 and 2017, a total of 515 students completed at least one stage of the programme. Most students were female (84%), mature learners (average age 36.2 years at point of entry; age range 22–76 years); and ethnic white (96%). Disability status was recorded for 10% of students, and 43% had a home address in an area with a high deprivation index.

Data collection

All available programme documents covering the period covered by the case study were consulted, including validation reports and reviews, Programme Handbooks prepared for students, Personal and Professional Development manuals, student feedback forms, annual reports, quality enhancement proposals, External Examiner reports, and staff-student liaison meeting notes. Evidence from previous studies of specific aspects of the programme were also considered (details omitted to enable anonymous review), including an on-line student survey designed for the purpose of programme development and administered in 2018. Survey items covered satisfaction with the programme, career trajectory and current occupational role, impact of training on personal development and employability, value of specific aspects of the course, a description of an example of a practice development with which they had been involved, and suggestions for improving the course. The survey had been distributed to 410 individuals for whom contact details were available, with 192 useable returns (response rate 48%). Qualitative comments were received from all participants who completed the survey.

Philosophical perspective

The design of this study was informed by a realist approach to the development of practical, societally-relevant knowledge regarding the effectiveness of behavioural interventions (Emmett et al., 2018; Pawson & Tilley, 1997). Realist evaluation is part of a broad methodological tradition influenced by a philosophical stance of critical realism (Maxwell, 2012; Sayer, 2000) that assumes that there exists a reality ‘out there’ that is independent of our capacity to know it. This position differs from the naïve realism that underpins the positivist approach to knowledge espoused with the natural sciences, that assumes that this reality can be directly accessed through observation and measurement. By contrast, a critical realist perspective acknowledges that our knowledge of reality is socially constructed. Realist inquiry differs from constructivist and interpretative approaches to research, such as grounded theory, Interpretative Phenomenological Analysis and reflexive thematic analysis, which focus primarily on how participants make sense of lived experience (Levitt et al., 2021). Realist research seeks to describe and analyse relevant characteristics of the actual social world, as well as how individuals and groups make sense of that world. An important aspect of realist research is an assumption that the world is differentiated and stratified, including objects and structures that have powers capable of generating events (Sayer, 2000). For example, the realist evaluation methodology developed by Pawson and Tilley (1997) and utilised in the present study, is based on an assumption that the social world is structured in terms of contexts, mechanisms and outcomes. Those running counselling and psychotherapy training programmes generally espouse a realist perspective that regards the learner as actively engaged in constructive processes of reflection, meaning-making and self-appraisal, while at the same time needing to function within a real-world context defined by the curriculum, the characteristics and membership of a learning community, job opportunities, and other factors (McAuliffe & Eriksen, 2011). A realist perspective therefore offers a methodological approach that shows fidelity to the subject matter of therapist training and development (Levitt et al., 2020).

Data analysis

Realist research seeks to generate practical, societally-relevant knowledge regarding the effectiveness of behavioural interventions (Emmett et al., 2018). Rather than conceptualising participants as a passive recipients of interventions, they are regarded as purposefully and selectively engaging with opportunities afforded by interventions available to them in a particular context. Realist analysis aims to build a programme theory that accounts for programme effectiveness in terms of context-mechanism-outcome configurations attributed by informants or inferred from analysis of available data (Westhorp, 2018). Realist analysis seeks to use all possible sources of evidence that may be available regarding the operation of a programme, including archive data, published reports, and data collected within a specific project (see, for example, De Brún & McAuliffe, 2020). Data analysis comprises the identification of potential Context-Mechanism-Outcome (CMO) configurations within the evidence base. Emergent configurations are viewed as ‘working hypotheses’ to be refined in further cycles of inquiry.

In addition to principles of realist evaluation, the approach to data analysis in the present study was informed by the practitioner research approach developed by Levitan et al. (2020). This methodological stance highlights the potential value for practice-bases inquiry of analysis of routine organisational archive data, not initially collected for research purposes, as a basis for developing new theoretical understanding through critical and systematic re-examination of practice. Data analysis was further influenced by an affordances perspective: the idea that an intervention or resource affords opportunities for learning to those who choose to engage with it (Coulson, 2017).

Data analysis was conducted by a team of three researchers (the co-authors). A series of initial meetings were held to agree the aims and scope of the study and collate the available evidence. In order to sensitise themselves to the use of an analytic frame organised around concepts of context, mechanism and outcome, and as a means of externalising pre-understandings and areas of potential bias, research team members began by independently writing about their own personal experiences as trainers (and in two cases, programme participants) in relation to these themes. Research team members then took part in a further three half-day meetings at which each member presented their coding of salient context-mechanism-outcome configurations observed in the entire data set. These meetings adhered to the Ward method of consensual data analysis (Schielke et al., 2009), in which each contributor separately presented (orally and in writing) their analysis in turn, without discussion. The aim of such a procedure is to create an environment in which co-researchers are able to be as open as possible to the ideas of each other, in a situation where there is no pressure to agree. Following each meeting, each member independently reflected on what they had heard, and worked to integrate these additional perspectives into a revised version of their own analysis. This process invariably required further engagement with data. Convergence across separate analyses, in terms of key context-mechanism-outcome configurations, was achieved following three meetings. In line with other realist studies, CMO configurations were summarised in the form of ‘if-then-because’ statements. A draft report was compiled by the first author, which was then circulated for comment to other colleagues in the programme teaching team and to programme graduates who had agreed to be consultants to the project. Suggestions, feedback and further observations from these sources were incorporated into the final version of the findings.

Ethical consent

Ethical approval for the on-line survey, published studies and documentary analysis was granted by the Research Ethics Committee, Abertay University. Programme documents analysed in the study did not include information that might enable identification of specific staff or students.

Researchers

The study was carried out by three members of the staff team delivering the programme being studied. JMcL had trained in person-centred counselling and transactional analysis psychotherapy and has worked as a counsellor in student counselling, health and private practice settings. They had over 30 years experience as a counselling educator in different colleagues and universities, and has been a member of the Abertay staff team since 2003. SL trained at Abertay as a pluralistic counsellor and had managed the community counselling clinic operated by the University since 2014. They are a qualified counselling supervisor and have been a member of the staff team since 2016. KS trained at Abertay as a pluralistic counsellor and had been a member of the staff team since 2012, and management lead for the tutor team since 2019. They have published in the field of pedagogical practice in mental health and the pluralistic framework for counselling and psychotherapy.

Findings

Findings are presented in two main sections. First, an analysis is offered relating to context-programme-outcome configurations specifically relevant to the operation of the programme as a means of equipping students to work in non-medicalised community settings. This section begins by describing the real-world context within which the training programme operated, then offers an analysis of two core context-programme-outcome configurations: building on, and adapting, pre-existing skills, knowledge and awareness, and acquiring a collaborative model of practice appropriate to the demands of working as a counsellor in a community setting. In the second main section, a more limited analysis is provided of configurations relating to how the programme functioned in order to support the development of generic therapeutic competencies.

Equipping students to work in community settings

For participants in the programme, the general context for their learning and development was grounded in the various elements of the structure and operation of the programme, described above. Specific contextual factors that were salient in relation to working in community settings existed in terms of the social and institutional positioning of the course, and trainee life context.

Social and institutional positioning of the course

Social and institutional positioning of the course Abertay University is located in a largely culturally homogeneous (white Scottish/European) city with historic high levels of economic deprivation. At the time covered by the present case study, all counselling and psychological therapy agencies (including medicalised NHS services) operating in the city and surrounding area had substantial waiting lists. There was a limited private practice therapy sector, and high rates of use of anti-depressant medication. In Scotland, the community sector comprises a major provider of counselling and psychotherapy, in the form of a wide range of local and national agencies, with extensive opportunities for employment in non-medicalised community-oriented services. The University was teaching-oriented, small (6000 students), and located in an inner-city campus. The counselling programme was based in a department of health studies and nursing. Counselling tutors possessed knowledge, skills and practical experience in providing therapy in non-medicalised community settings, while also able to drawn on medicalised therapeutic perspectives represented by colleague with mental health nursing backgrounds.

Readiness to learn

The characteristics of programme participants represented a significant source of contextual influence. Students were mainly mature learners with previous experience and qualifications in occupations such as teaching, nursing, medicine, community work, the ministry, criminal justice, and business, with 20% having completed prior postgraduate study (Masters or Doctoral) in these disciplines. Within their previous occupational and voluntary work roles, 40% reported having had no prior experience of training in counselling skills, with 10% having undergone brief skills training of less than 12 hours duration, and 50% having completed longer skills training courses. Although very few (<5%) had worked as counsellors before entering the programme, all had previous experience of using interpersonal skills in some kind of helping role. As a group, programme participants possessed considerable experience, knowledge and skill around mental health issues and therapeutic processes, along with first-hand understanding of emotional support services in the local area. Prior to entering the programme, 70% had received personal therapy at an earlier point in their lives. The majority of students maintained either paid work or carer responsibilities (or both) alongside their studies. Taken as a whole, these contextual factors represented a high level of readiness to learn, comprising a combination of (i) personal self-awareness and emotional maturity, (ii) capacity for conceptualisation and reflection, curiosity, openness to learning; (iii) ability to use interpersonal skills in helping/caring situations, and (iv) being at a stage of personal and professional life where becoming a counsellor as a considered decision, based on reflection on experience and an informed appreciation of the nature of therapeutic work. Participation in the training programme was part of a longer developmental journey, many years in the making.

Configuration 1. Building on, and adapting, pre-existing skills, knowledge and awareness

Summary: In a programme that aims to equip counsellors to work in community settings, if participants are already competent helpers/practitioners in health, social care or educational settings, then they are capable of reviewing and where necessary adapting the interpersonal and helping skills they already possess, in order to become able to facilitate counselling processes, because (i) they are making use of existing knowledge and strengths; and (ii) they are able to appreciate the practical relevance of the therapeutic skills and theories that are taught in the training programme. As a result, graduates of the programme are empowered and motivate to engage with the programme, and to go on to become effective and employable counsellors in community agencies.

The initial stage of training included learning tasks in which participants described and critically reflected on their prior use of helping skills, in terms of how aspects of these competencies were either well-suited to a counselling relationship, or needed to be modified. Frequent examples of this type of learning mechanism occurred in relation to skills such as listening, questioning, use of silence, challenging, and therapist self-disclosure. For instance, a student might realise that their previous work experience and personal life circumstances had made them uncomfortable with any occurrence of silence within in a therapy session. By contrast, the process of learning how to facilitate a counselling interaction would lead to an awareness that moments of silence might be extremely helpful in enabling the client an opportunity for deeper personal reflection. Within the course, the trainee would be encouraged to see their pervious attitude to silence as valuable in respect of appreciating possible client awkwardness around silence, while acquiring new strategies for making effective use of episodes of silence. Other training activities focused on skills such as metacommunication or eliciting feedback that may have been less fully developed in their previous work roles, or deployed in different ways. At later stages of the programme, participants drew on pre-existing knowledge in relation to their understanding of the social context of their clients’ lives, the involvement of other agencies and services, and the cultural resources available to clients.

The process of building on, and adapting, pre-existing skills, knowledge and awareness involved mechanisms based on practical integration of counselling skills and knowledge into current professional roles. The survey questionnaire had asked graduates of the course to map the development of their career pathway. The overall survey sample (192) included 55 participants who had paused their study after stage 1 (basic skills training). All of these informants used counselling skills and theory in other work roles, with some reporting that they contemplated returning to complete their professional training at a future date. A second group (73 participants) had recently completed stage 2 training, and were gaining further practical experience. A third group (64 participants) comprised those who were three or more years beyond the end of training, and had established a career as a counsellor.

Examples of integration of counselling skills and perspectives into pre-existing work roles included:

I work as a housing caretaker … .90% of the time been using everything you taught in class. Working with everyday people, who just at times need a wee chat. Many ranges of needs but all worth an ear ….there was a young mum felt as if she had enough of life and didn’t want to be here anymore. Talked a lot with her over time … .

[As a teacher] it has helped me build, maintain and nurture relationships with students better within the educational environment, my skills learned from counselling really helped me out here and it has been such a privilege to see them flourish and become more confident in their educational abilities … I know when to stay silent with a student, let them talk, I know when to ask open questions … . I know when to support and to take a step back.

The experiences described above quoted above were typical of participants in the early stage of the programme – both those who proceeded to Stage 2 as well as those who stopped or took time out at that point. Counselling skills, theory and awareness were regarded as competencies that could complement on-going paid work as a teacher, nurse or other practitioner. In the period during and immediately following the end of Stage 2, the majority of participants reported that they continued to use counselling skills in their pre-existing work settings, while gaining more experience as counsellors, typically in a voluntary sector community agency or a student counselling service.

Information about employment outcomes was available from survey data on 64 programme graduates who had accumulated 3 or more years post-qualification experience (Table 1). In terms of primary work roles, two-thirds were engaged in paid counselling work in community settings (counselling services and private practice). Another 19% had paid work that was linked to specific non-medical organisational settings (universities and other workplaces).

Table 1. Main counselling occupation at three years post-training

Occupational role	N	%
Community-based counselling service	27	42
Generic	9
Women survivors of violence	4
Young people	3
Addictions	3
Other (health, criminal justice, bereavement, carers, hospice)	8
Private practice	10	16
Counselling tutor/lecturer	6	9
Use skills in other work role (family, social work, midwife)	6	9
Student counselling	5	8
National Health Service	4	6
Improving Access to Psychological Therapies (IAPT)	2
Patient support	2
Employee/workplace service	3	5
Other (retired, unemployed)	3	5
Total	64	100

The configuration described in this section can be characterised as representing a career pathway available to programme participants, in which counselling skills and knowledge are integrated into pre-existing capabilities developed within earlier life and work contexts, then deployed alongside these other capabilities, gradually becoming a set of specialist counselling capabilities that make it possible to enter new roles within such work contexts.

Configuration 2. Acquiring a collaborative model of practice appropriate to the demands of working as a counsellor in a community setting

Summary: If participants are already competent and experienced helpers/practitioners (in non-counselling roles) in community settings, then it makes intuitive sense to them to be offered an understanding of counselling that allows them to work collaboratively with client using a range of implicit and formal theories, because (i) such a model is similar to how they already work with service users; and (ii) the rationales for manualised and single-theory approaches to therapy are not convincing to them. As a result, programme participants with this profile are able to conceptualise therapy in ways that take account of complex intersecting client and institutional concepts of mental health and healing, co-occurrence of adversities and life issues, and an array of resources for engaging in therapeutic work. By contrast, some participants who entered the programme with a pre-existing adherence to a single model of therapy (e.g. person-centred or psychodynamic) or who had completed a psychology degree that led them to believe in the validity of empirically validated and manualised approaches to therapy, struggled to come to terms with a collaborative pluralistic approach to counselling or the challenges of practicing in community settings.

The pluralistic approach to counselling on which the training programme was based, provides a framework for client-therapist shared decision-making that takes account of whatever ways of making sense of difficulties may be viewed as relevant by either participant, and any activities external to therapy (cultural resources) that the client regards as potentially helpful. The approach also incorporates practices that support joint working, such as diagrammatic collaborative case formulation and use of feedback, and agreement over therapy goals and how to make progress towards them. This framework aimed to enable trainees to harness their own pre-existing theories, new theories acquired during training and the implicit or explicit theories of clients, alongside personally meaningful meta-theoretical perspectives such as social justice, multiculturalism, feminism and environmental activism. The process of learning to use this conceptual framework was facilitated though a range of activities such as assignments, project work and case presentations, as well as being modelled by tutors. Medicalised perspectives on therapy, such as diagnostic categories, treatment protocols for specific disorders, and the use of medication, were taught by tutors who were not core staff, in formats that encouraged dialogue.

The following example, contributed as part of the student survey, shows how a graduate from the course used a pluralistic framework to guide their work with the kind of complex case presentation typical of front-line practice in a community voluntary sector generic counselling service:

… client trafficked as a teenager from Vietnam and came for counselling while waiting on an immigration tribunal … .There were issues of power to be understood and cultural influences both on the client and the counsellor.

I entered into relationship with this client with an attitude of curiosity and collaboration … . Whilst there was a shared faith between the young man and myself, the practice of belief [in his home country] was very different to my own. Working with difference and diversity, terms of reference continually needed to be explained and explored. No assumptions were possible. English as a second language created further challenges but also opportunities for care around words and what really needed to be said and heard. Pluralistic practice allowed me the freedom to relate to him in different ways: I mothered him through the trauma, I coached him through the tribunal, I nurtured him through the growth of his evolving identity. We made use of creative interventions introduced in the course which helped with communication and the forming of a shared understanding of client experience and goals. The client grew and thrived (outcome measures tracked the change as well as visual and verbal feedback) in a counselling setting where he was the expert. Having been without choice in his trafficking experience (and subsequent immigration process) he was now in control of the pacing and content of the counselling encounter.

This case provides evidence of how a course graduate with no prior specialist training or experience in working with refugees or victims of trafficking was able to use a pluralistic framework to assemble a helpful combination of relational, creative and behaviour change interventions, alongside reference to their own life experience and faith knowledge, in respect of therapeutic goals and tasks that encompassed emotional, interpersonal and socio-politicial (immigration tribunal) issues.

A significant outcome of training, highlighted by several respondents to the survey, was a capacity for practice innovation. Many of these graduates described situations in which community services in which they were employed were faced with challenges arising from emergent needs, gaps in provision and underserved client groups. Examples of this type of practice innovation included: a format for incorporating case formulation within the first session of brief therapy; the development of a collaborative strategies in work with clients with eating disorders; new formats for documenting and monitoring client goals and strengths; an ‘ecomap’ procedure to facilitate client exploration and activation of cultural resources; an on-line waiting time support tool; and making expressive-creative art materials available in counselling rooms. Participants also described areas of innovation informed by a capacity to draw on research evidence to inform their work with particular clients, for example, through literature searches around identifying feedback measures for specific issues, which were then incorporated into the therapy process. The following account illustrate how two programme graduates drew on previous knowledge and experience, alongside collaborative skills and perspectives acquired during training, to develop a new service:

I work in a health and wellbeing service for young people 11-25 years of age, that had been in existence in the city for several years. The service had been initiated as a response high levels of teenage pregnancy and provided holistic health care for some of the most vulnerable young people in the city. Central to the ethos of the service was that young people were involved in the design and running of the service through on-going consultation. As a health promotion worker, it became apparent that there was a link between poor mental health and unhealthy behaviours and actions. There was an increase in young people attending with mental health difficulties, but staff had limited skills in which to support this. It also became apparent that there were limited services [elsewhere in the city] that provided counselling for young people and often those services had long waiting times. My colleague and I both had an interest in counselling and could see the benefits that this would bring young people. However unfortunately our employers would not financially support this. In spite of this my colleague and I self-funded and in our own time completed the course. Throughout my training my colleague and I pushed for a counselling service to be introduced and after much persuasion we opened our counselling service on completion of my training. Having acquired the skills and education of pluralistic counselling I could put these skills into practice. Pluralism by its very nature fits well with working in this environment. Young people are often not asked what works for them and can be lumped in with younger children in terms of their understanding and their abilities to make decisions for themselves. … . The counselling service is now firmly established with yearly reviews that show high rates in terms of reducing distress, anxiety and low mood in young people. (Source: qualitative survey response).

Beyond the development of new services, other participants described contributing on a profession-wide level, through carrying out research, delivering training, and developing a professional network and website to support pluralistic practitioners.

Configuration 2 represents a set of conceptual tools, in the form of theoretical constructs, problem-solving routines and information search strategies, that harness the pre-existing curiosity, epistemic resources and learning skills of trainees in ways that provided them with the ability and confidence to handle the kind of multi-dimensional complex issues presented by clients in community contexts. An underlying theme within this configuration was the development of resourcefulness, in the sense of being able to use collaboration and shared decision-making to harness their own resources along with those of their clients.

Further configurations related the development of generic competencies

The process of realist analysis generated additional configurations that were not specifically linked to community outcomes, but instead comprised mechanisms that resulted in outcomes associated with generic competencies and developing a professional identity as a counsellor. These configurations are briefly described below.

Configuration 3. Engaging with personally challenging learning tasks

Summary: The programme required participants to adapt previous skills and knowledge to meet the demands of a new work role. They were then inevitably be faced with learning tasks that involved changing long held and deeply ingrained ways of being and relating, and were experienced as cognitively, emotionally or interpersonally threating and demanding. Student module feedback and survey comments indicated that engagement with emotionally and personally demanding learning was a central feature of their lived experience of the course. Evidence of the centrality of this aspect of the training was also apparent in the extent to which is was highlighted in information provided to participants: at interview, in the programme handbook, recommended reading, a requirement to report on personal learning within most assignments. The CMO configuration arising from this aspect of the programme could be summarised as: if participants have prior experience of making use of emotional support (e.g. prior personal therapy, successful resolution of difficult life events, etc.), and are offered a learning context that provides multiple sources of support (e.g. personal development groups, personal therapy, supportive reading, reflective writing, etc.), then they are able to make effective use of the learning opportunities afforded by the course, with the result that they are able to become effective counsellors.

Configuration 4. Confidence in the credibility of the programme

Summary: If participants believe that the approach to counselling that they are being taught is effective, grounded in evidence, and makes sense, then they are more likely to commit to learning, persevere in mastering new skills, and approach clients from a position of security of purpose, because they are (i) not unduly distracted by doubts, and (ii) are positively motivated by a sense of doing something of value. This mechanism was activated through introductory lectures and reading, reinforced throughout the programme, that portrayed the pluralistic approach to therapy as a research-informed strategy that addressed underlying tensions and contradictions within the field of psychotherapy. Participants viewed the professional reputation and accomplishments of tutors as positive evidence of credibility. Credibility was established was through transparency around pedagogy, in the form of detailed explanations of how assignments, learning tasks, modules, and programme stages contributed to the development of competence. Survey data showed that participants chose the course on the basis of its reputation (50%) and the validity of the pluralistic model (47%). A significant element of credibility was personal perception of compatibility between personal values and the principles of pluralistic counselling, and stance on active use of research evidence (source deleted for anonymous review).

Configuration 5. Participation in an immersive learning environment

Summary: If all aspects of a learning environment reflect the principles and concepts of the therapy model being taught, then participants are helped to acquire a flexible and personalised repertoire of skills, because they are being continually exposed to multiple ‘teachable moments’ in which they encounter different facets of the model at different levels of intensity and in different combinations, and are constantly engaging in practice of, and reflection on, their use of the model. Procedural aspects of the programme, such as how personal development groups and skills practice were structured, were based on collaborative decision-making around goals and tasks, drawing on transparent explanations of rationale and assumptions (decision ‘aids’). Tutors sought to model a collaborative, dialogical stance in all interactions with participants, who in turn were encouraged to respond to each other in similar fashion, and to be open to learning with, and from each other.

Configuration 6. Engaging in focused reflection

Summary: If participants engage in focused reflection on their use of counselling skills and concepts in helping/therapeutic relationships, then their practice becomes more effective, because they (i) construct a nuanced and differentiated appreciation of what they can do that is helpful/unhelpful for clients; (ii) are able to identify areas for further learning, and (iii) become able to able to demonstrate, model or facilitate reflective functioning in ways that enable clients to use this skill to resolve problems. This mechanism builds on the contextual factor of participant readiness: individuals entered the programme with a pre-existing capacity to reflect on experience (e.g. not only having experience of adversity in life, but having been able to learn from it). Principles of focused reflection on experience were taught to students and then reinforced throughout the programme. Guidelines for all programme assignments required participants to reflect on critical incidents (e.g. episodes in which use of a specific skill or intervention was either markedly successful or otherwise) in terms of both counselling theory and research, and personal meaning (e.g. how difficulties in using a skill could be understood in terms of early life experience or professional socialisation). Skills practice groups followed a format in which performance of a skill was followed by personal reflection, and reflective feedback from learning partners to support joint reflection. Journal writing was used as a means of reflection on practice. Lecture inputs were typically punctuated by brief reflection activities.

Configuration 7. Readjustment of programme elements in response to participant learning needs

Summary: If tutors engage in continually revising the programme in response to evidence about the effectiveness or relevance of activities and topics, then participant acquisition of skills and knowledge is enhanced, because (i) it is more likely that meaningful and transformative learning experience will occur; (ii) less time is lost on unhelpful or irrelevant activities; and, (iii) participant commitment to learning is maximised. Tutors held weekly meetings to review progress around the development of individual participants, if necessary leading to meetings with particular students to resolve issues. This developmental focus was also demonstrated in feedback on assignments, in which tutors identified potential future learning tasks and priorities tailored to the student. Tutors also adjusted the programme in response to general feedback from students, and scanning of broader professional horizons. Annual reports and minutes of liaison meetings included many examples of responsiveness to student feedback. An area of that received attention over several years was the timing and nature of teaching on basic pluralistic concepts, and how a pluralistic perspective aligned with other therapy approaches introduced within the programme, such as psychodynamic, person-centred and CBT. An example of readjustment of the programme in the light of shifts in the external professional landscape was the increasing attention given to the use of routine outcome measures as feedback tools. At the start of the period covered by the case study, there was relatively limited research and practice literature on this topic, and it was covered in the programme as an aspect of collaborative working. Over time, judicious use of feedback tools became a more central focus of the programme (e.g. activities around the personal meaning of giving and receiving feedback; assessment of competence in use of feedback measures)

Discussion

This study used a realist methodological approach to examine how a postgraduate training programme equipped counsellors to work in non-medicalised community settings. Operating within a specific organisational and societal context, the course afforded trainees multiple learning mechanisms in which they could participate in order to make progress on a pathway to becoming competent and resourceful counsellors. Consistent with the aims of the study, the following discussion primarily focuses on the two context-mechanism-outcome configurations that were most directly relevant to the contextual domain of non-medicalised practice: building on pre-existing skills, knowledge and awareness, and acquiring a collaborative model of practice appropriate to the demands of working as a counsellor in a community setting.

The programme built on the considerable interpersonal skills, relational competencies, self-awareness and life experience possessed by trainees at the point of entry to the course, conceptualised as a contextual dimension of readiness to learn. Entry to the programme was conditional on a capacity to demonstrate readiness to learn. The training curriculum aimed to help students to formulate and practice therapy-relevant versions of skills and awareness that they already possessed. This aspect of the programme can be compared with findings from studies of medicalised clinical psychology training that have examined the significance of participant readiness in terms of pre-existing interpersonal skills. Anderson et al. (2016) found that trainee facilitative interpersonal skills at the point of entering clinical psychology training predicted clinical outcomes when they began to work with clients more than a year later, and Schöttke et al. (2017) reported that this effect persisted over a five-year period. In addition to highlighting the importance of trainee readiness to learn, there are important points of contrast between these studies and the present investigation. Trainees in the Anderson et al. (2016) and Schöttke et al. (2017) studies were significantly younger (average age 20–30) than those in the present study. The facilitative interpersonal skills assessment measures used by Anderson et al. (2016) and Schöttke et al. (2017) were designed to evaluate how candidates responded to emotional pressure and provocation. It is unlikely that their students would have much previous experience in handling such scenarios. By contrast, the majority of students in the present study had worked in occupations such as nursing, reaching, social work and criminal justice, in which stressful interpersonal interactions were a common occurrence. While confirming the importance of facilitative interpersonal skills, the findings of the present study suggest that the nature and operation of such skills in training may be contingent on a broader understanding of trainee readiness.

It could be valuable for further research to document the procedures and criteria through which readiness is assessed at point of entry to therapist training programmes, and whether transparency about such criteria might enable participants to make more effective use of training, for instance, in respect of self-assessment of personal preparedness. .

Other studies of therapist training have identified further ways in which pre-existing practical knowledge and experience of trainees have influenced the process of learning therapeutic skills. In a longtitudinal study of training in psychodynamic psychotherapy, Carlsson (2012) reported significant tensions between trainers and students around the perceived unwillingness of trainers to acknowledge or take account of pre-formed trainee clinical skills. Two studies of training in motivational interviewing reported that trainees with different professional backgrounds and experience responded in different ways to different programme elements (Carpenter et al., 2012; Martino et al., 2011). Experienced therapists report that the relevance for practice of prior personal knowledge and experience was not addressed in training, but instead was something they needed to work out for themselves (Bernhardt et al., 2019). In contrast, the training course in the present study involved learning mechanisms that were specifically focused on acknowledging the relevance of pre-existing knowledge and providing opportunities for adapting that knowledge to a new professional role.

The results of the present study underscore the significance of findings of earlier studies that have drawn attention to the influence on training of trainee pre-formed therapy skills and attitudes. Taken as a whole, available evidence suggests that there are contrasting ways that training programmes take account of this factor. Further research is needed that explores how this issue is handled by trainees and trainers in different programmes, how this process translates into competency outcomes, and how it is shaped by contextual influences. For example, in more medicalised practice settings where participants are receiving training in a manualised therapy protocol, pre-existing attitudes and practice may be a hindrance to the development of target competencies.

A notable feature of how the Abertay training programme equipped participants to work in community settings was the correspondence between the flexible, collaborative model of therapy on which the course was based, and the requirements of community agencies. A key theme within this aspect of the programme was the development of resourcefulness: trainees described themselves as building up a toolkit or repertoire of ideas, skills and activities that could be offered to clients, along with a capacity to facilitate the client’s activation of their own personal and cultural resources. The services within which course graduates were employed needed to be able to respond to clients with complex needs who did not fit into psychiatric diagnostic categories and were receiving interventions or care from other sources at the same time as seeing a counsellor (Strong, 2017). Building on their pre-existing life experience, the course enabled participants to engage actively with client preferences around what would be helpful, in ways that took advantage of whatever resources were to hand. Students were encouraged to think about the course as a stage in a process of lifelong learning in which they could expect to need to learn new skills and ideas on a regular basis, and continue to seek training in ways of combining therapy methods to meet the needs and preferences of new groups of client. Programme outcomes demonstrated that graduates actively used research knowledge and practical ingenuity to develop solutions to problems at individual and organisational levels, and enthusiastically engaged in further training to acquire new skills. These findings contrast with evidence from other studies that have observed that it can be troubling for therapists to add new techniques and skills to their practice (Cook et al., 2009; Jefford, 2013; Stewart et al.). Two main sources of difficulty have been identified. First, practitioners identify practical barriers such as time pressures and costs. A second commonly-reported source of difficulty is the absence of a framework for understanding how one therapy approach can be assimilated into another approach that the trainee has already mastered (Byrne et al., 2018; Mackay et al., 2001; Sotskova & Dossett, ; Trub & Levy, 2017). The findings of the present study suggest that training that is organised around a conceptual meta-model or map that is introduced to students from the outset (Ziv-Beiman, 2014) may contribute towards a capacity for open-ness to learning at later stages in a professional career.

In addition to learning mechanisms that were specifically responsive to the non-medicalised community-based context within which the programme was situated, the programme theory that was constructed also incorporated further configurations: engaging with personally challenging learning tasks; confidence in the credibility of the programme; participation in an immersive learning environment; engaging in focused reflection; readjustment of programme elements in response to participant learning needs. These processes operated as ways of intensifying the extent to which trainees were able to work therapeutically with clients. For example, building on pre-existing skills was more effective if the trainee was able to engage with personally challenging learning tasks and make use of focused reflection.

Important aspects of these additional configurations represent aspects of training that do not appear to have been widely explored in the therapy training literature. The idea that the effectiveness of training is enhanced when trainers work together as a team to adjust the curriculum in response to student feedback and changes in the external professional environment, is widely understood by counsellor educators. However, we were not able to find published research on this topic. Similarly, there is a limited evidence base around the implications of immersive learning for counsellor training (Prosek & Michel, 2016; Robinson, 2018).

The present study has implications for debates around the design and delivery of training in integrative therapy (Aafjes-van Doorn et al., 2018; Norcross & Finnerty, 2019). Due to the need to learn about different therapy approaches, integrative training may present challenges for both students (Ivey & Deans, 2019; Lowndes & Hanley, 2010; Scott & Hanley, 2012) and teaching staff (Kostínková & Roubal, 2018). In the training course analysed in the present study, procedures for teaching a pluralistic integrative model had evolved over several years, in response to participant feedback that reflected concerns similar to those recorded in other studies (Ivey & Deans, 2019; Lowndes & Hanley, 2010; Scott & Hanley, 2012). This suggests that the development of effective training in integrative therapy may require an iterative process that is responsive to student experience. In addition, the model of practice provided in the training programme studied in the present investigation, emphasised the skills required to engage in an active process of integrating, rather than on delivering a pre-defined integrative model.

The findings of the present study support some general conclusions about the nature and direction of travel of counsellor and psychotherapist training. A key conclusion is that, to improve training outcomes it may be useful to pay more attention to contextual factors. The present study has highlighted the implications for training of the differences between medicalised and non-medicalised settings for the provision of therapy. It seems likely that all forms of training share certain common features. For example, any therapist needs to be able to listen, and adhere to ethical standards. However, there may be distinctive training ‘leverage points’ (Warren & Park, 2018) associated with different contexts. In the programme studied in the present article, crucial leverage points included flexible ways of responding to clients, building on prior professional knowledge, working collaboratively, and using feedback tools. Each of these areas was highly relevant for the social context and practice sector within which students were most likely to be employed. In terms of future research, it may be useful to identify points of leverage that are salient within different programmes. For example, a key point of leverage within programmes that train clinical psychologists to work within state-run healthcare systems might be demonstration of competence in an empirically-validated therapy protocol, or diagnostic ability. Racism awareness training may represent an essential point of leverage within programmes serving multicultural populations.

It would be valuable for further research to map the institutional landscape of psychotherapeutic practice in more detail, in respect of the medicalised vs. non-medicalised distinction. Strong (2017; Strong et al., 2018) developed this distinction as a means of making sense of tensions within counselling psychology training and practice in Canada. By contrast, the present study described a domain of community-based non-medicalised training and practice that existent largely separate from NHS-based training and services, where such tensions were not highly salient.

A further general conclusion arising from this study is its overall conclusions are consistent with the position articulated by Johnson et al. (2014)concerning ways in which a communitarian training culture, in which trainees learn to work together with colleagues, promotes lifelong competence and resourcefulness that is sensitive to social and technological change.

It is essential to acknowledge important limitations of the present study. Data were collected and analysed by researchers who were also teachers on the programme. It would be valuable for future studies to be carried out by independent researchers. The primary aim of a realist methodological approach is to develop programme theory, formulated in terms of context-mechanism-outcome configurations or cause-effect sequences. An inevitable consequence of adopting such a methodological stance is that it allows little space to highlight fine-grained accounts of the lived experience of programme participants. It would be valuable if future research could explore specific configurations using interview data and analysis of individual cases, to enable more richly-described accounts of training trajectories and outcomes to be generated. The population of students attending the course was highly culturally homogeneous, with the result that the findings of the study were not able to address important issues around cultural aspects training such as broaching skills or addressing white privilege. Information on the effectiveness of trainees in relation to client outcomes, or measures of therapist facilitative interpersonal skills, would have enabled a more differentiated analysis of programme outcomes. Data on student experience of clinical supervision and personal therapy would have enabled analysis of important learning processes occurring concurrently with training. A multiple case design, in which similar data were collected in comparison programmes would allow additional learning mechanisms to be identified and for the cross-context transferability of configurations to be better understood. The general aim of realist evaluation is to identify ‘what works’. As a consequence – as in many other realist studies – there is a lack of attention to difficulties, failures and participant disappointment. While we have reported on some of these factors, such as groups of trainees who found it harder to engage with the programme, it would be important for future studies to do more to incorporate such perspectives. It is hoped that the present study can be regarded as an exploratory investigation that will encourage other researchers to pursue all of these important lines of inquiry.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

No funding was received for the work reported in this paper.

Notes on contributors

Julia McLeod

Julia McLeod is Lecturer in Counselling in the School of Applied Sciences, Abertay University, Scotland. She has extensive experience as a psychotherapist and counselling trainer, and has published in the areas of pluralistic practice, counselling for long-term health conditions, and counsellor training and development.