Dealing with Insecurity: A Thematic Analysis of Self-reflection in Psychotherapy Training

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However, research on content and quality of self-reflection is scarce and standardized instruments for respective assessments are still missing. The current study qualitatively explores semantics (core contents), modalities (qualitative differences) and foci (direction of reflection-focus) of self-reflection with the aim to operationalize and better understand its key characteristics. Methods 40 self-reflection essays, written by 10 psychology students, were analyzed by employing a combined inductive and deductive thematic analysis. Results In our findings, we differentiate typical modalities , foci and semantics of self-reflection while underlining the connections between these aspects. At the semantic level, the feeling of insecurity emerged as the most prominent impetus for self-reflection. Previous experience, patient-interaction, and external factors like time pressure, were observed to potentially influence insecurity. While assertiveness seemed to be an ineffective strategy in dealing with this feeling, tolerating it could be identified as being helpful in reducing insecurity. Additionally, we find five different modalities of self-reflection as well as inward- and outward-related reflection foci. Conclusions Our findings offer a first operationalization of the self-reflection competency of psychotherapists and constitute a basis for constructing an assessment rating scale. Particularly, reflecting on dealing with insecurity has emerged as a promising key for therapeutic-skill development. qualitative research methods thematic analysis self-reflection psychotherapy training insecurity coping strategies Figures Figure 1 Figure 2 Background In psychotherapy training the ability of being self-reflective is considered to be a key therapeutic competency (e. g., Bennett-Levy et al., 2001 ; Rønnestad et al., 2019 ). Self-reflection is defined as a cyclic process in which psychotherapists first observe and critically reflect their emotions, cognitions, and behaviors to gain self-insight. Consequently, therapists might adapt their own beliefs and approaches regarding situations within therapeutic work based on these newly gained insights (Kimerling et al., 2000 ; Roberts & Stark, 2008 ). Empirical evidence has shown that self-reflection has an important influence on therapy process and outcome. Rønnestad & Skovholt ( 2003 )⁠ conducted an interview-study with 100 counselors/therapists at different experience levels. They show that the ability and willingness to reflect on complex phenomena and processes in therapy play a crucial role in the development of the therapist’s professional self. Continuous self-reflection is seen as a requirement for an optimal learning process for all stages of professional development, whereas a lack of it might lead to stagnant or even deteriorating development (Rønnestad & Skovholt, 2003 , 2005 )⁠. Several reviews summarize empirical findings on the effects of self-reflection for the training and practice of psychotherapists (see e.g., Prasko et al, 2012 ; Laireiter & Willutzki, 2003 ; Knapp et al., 2017 ). The following positive effects of self-reflection were found: gaining of insight, self-awareness, empathy, improvement of technical and interpersonal skills, and the ability to assess one’s own competencies (Laireiter & Willutzki, 2003 ; Knapp et al., 2017 ). The training of self-reflection seems to be especially important for beginner therapists, as it also stimulates the development of critical thinking as well as of ethical decision-making (Prasko et al, 2012 ). Importantly, therapists who are aware of their own part in therapeutic interaction can also evaluate and, if necessary, adapt their behavior or attitude (Knapp et al., 2017 ). Thus, the ability to self-reflect is fundamental for the therapeutic alliance, for professional growth as well as for the development of further therapeutic competencies (Prasko et al. 2012 ). Self-reflection does not only yield professional benefits but also has positive effects on the therapist as a person. Knapp et al. ( 2017 )⁠ point out, that self-reflection is associated with greater self-care and a lesser tendency to overestimate one’s own abilities and thus also protects against burnout symptoms. Nikendei et al. ( 2018 ) could also show in their interview-study that psychotherapists have an explicit desire to reflect on the motives behind their own behaviors. Drawing on the aforementioned research, the American Psychological Association defines reflective practice as a core competency for therapists (American Psychological Association, 2012 ; Levant, 2005 )⁠. Accordingly, self-reflection is specified as one of the basic competencies that should be taught during the training of psychotherapists (Rodolfa et al., 2005 )⁠. Theories on Self-Reflection Although evidence shows that self-reflection competence has a positive effect on therapy process and outcome, there is still no consensus as to what constitutes effective self-reflection for psychotherapists. Research on the characteristics and quality of self-reflection in the field of psychotherapy is still scarce. In contrast, we find several theories conceptualizing self-reflection in the pedagogical field, which will be briefly summarized herein. One of the first conceptualizations was formulated by Schön ( 1987 ), who distinguishes between “reflection-in-action” and “reflection-on-action”. The latter refers to reflection on past situations (with temporal distance), whereas the former means reflecting while being in a certain situation. The author highlights the benefit of the former, which allows a modification of the reflecting person’s actions when appropriate. Yet, Schön’s focus on reflecting-in-action has been criticized for not moving beyond the immediate situation (Gu-Ze’ev et al., 2001 )⁠. Subsequent theories focus on the differentiation between self-reflective levels (we will refer to such levels also as modalities ). Based on an empirical investigation of written self-reflections of student teachers, Hatton & Smith ( 1995 ) describe four distinct levels of reflection. The first level is described as reporting a situation (descriptive writing). According to the authors, this is a basis for it, but it is not self-reflection in itself. The second level consists in explaining/giving reasons, often based on personal judgment or knowledge (descriptive reflection). The two higher levels pertain on the one hand to the assessment of the situation, e.g., by using alternative perspectives (dialogical reflection) and on the other hand to the inclusion of the broader context of the situation (critical reflection). The authors agree with Schön ( 1987 ) that the supreme form of reflection is the ability to use all levels of reflection (descriptive, dialogical and critical) while the situation on which one is reflecting upon, is still taking place. Still, they also recognize the importance of reflection-on-action as a useful starting point for beginner practitioners, who cannot yet reflect “in-action”. Krieg & Kreis ( 2014 ) examined the reflections in teachers’ debriefing after class. They identify six stages of self-reflection: 1. description of the situation (not considered as a reflective process), 2. descriptive reflection (includes an evaluation of the situation or the recognition of a problem), 3. explicative reflection (specifies reasons for behaviors etc.), 4. introspective reflection (pondering of different assumptions and/or relating to one’s own experiences), 5. integrative reflection (reference to scientific theories), 6. transformative reflection (gaining new ideas for future actions) – this last stage of self-reflection can occur during the whole reflection process and ideally leads to new courses of action. The authors find a correlation between higher learning success and the occurrence of higher levels of reflection such as introspective, integrative, and transformative reflection (Krieg & Kreis, 2014 ). Another categorization of levels of self-reflection was developed by Ryan ( 2013 ) based on the analysis of self-reflection texts, written by students at different university faculties. The author describes the following four levels: 1. reporting a situation and responding, e.g., by expressing opinions. This level is crucial for setting a clear focus and it sets a baseline of accuracy for further levels of reflection 2. relating the situation to one’s own experiences and knowledge, 3. reasoning including comprehension of the importance of the situation, 4. reconstructing and reframing knowledge by applying new ideas stemming from the self-reflection process. The levels are conceived as building upon each other. The highest quality of self-reflection is reached at the last level (“reconstructing”). Another model worth mentioning is Jahncke`s (2018) four levels of self-reflection. The model is based on a review of the literature on dimensions and quality levels of self-reflections and results in a coding scale. Jahncke’s four levels are: 1. descriptive presentation (describing the situation), 2. descriptive self-reflection (assessing the situation), 3. reasoning self-reflection (giving reasons for the assessment of the situation), 4. combining self-reflection (creating links between the current situation and scientific theories, previous experience and knowledge). In contrast to the other models the author distinguishes further dimensions: the focus of reflection can be on the reflecting person’s ‘outside’ (external factors, e.g., circumstances) or ‘inside’ (internal factors, e.g., behavior) as well as on the past or the future. The transfer of experience from the past to the future is emphasized as being crucial for learning processes. A good self-reflection includes all the above-mentioned levels of reflection as well as all dimensions. The outlined pedagogical theories distinguish hierarchical levels of self-reflection that differ in their quality and are built up on each other. A high-quality self-reflection is generally identified in higher levels of self-reflection (such as “combining”, “reconstructing” or “integrative reflection”) and most of all in the combined use of the different levels. In contrast, only describing a situation usually does not count as part of the self-reflective process but can serve as a mere building block. All mentioned authors emphasize the need to support and train the ability to self-reflect as higher levels of self-reflections are not part of our natural thinking patterns⁠. Aims of the Study All existing conceptualizations of self-reflection, as well as the coding and rating scales developed for its assessment (see e.g., Jahncke, 2018 ), specifically pertain to the pedagogical field. Their applicability to the clinical context remains unclear. To gain a deeper understanding of the development, qualities, and effects of self-reflection in the psychotherapeutic field, we first need an operationalization of this construct within the clinical context. This is essential for the creation of appropriate assessment instruments, which can facilitate the exploration and evaluation of self-reflective practices in psychotherapy. In pedagogical research, self-reflection has been mainly operationalized in terms of modalities (e.g., describing, reasoning) and foci (e.g., inside, outside), i.e., the “how” of self-reflection. The semantic aspect of self-reflection, i.e., the patterns of meaning entailed in self-reflective narratives (the “what” or content), has been neglected so far. Yet, we allow for the possibility that the very content of self-reflection may additionally play a crucial role in the definition of its nature and quality. Modalities and foci of self-reflection are indeed tightly intertwined and might not be entirely separable from their semantics . In this study, we thus investigate the modalities and foci as well as the central semantics characterizing self-reflections of prospective psychotherapists according to the following research questions: 1. What core semantics characterize the self-reflection narratives of psychology students? 2. What foci of self-reflection (e.g., inside, outside) can be differentiated in the self-reflection narratives of psychology students? 3. Which reflective modalities (e.g., describing, reasoning) can be identified in the self-reflection narratives of psychology students? Since the aim of this study is to gain a first description, systematization and exploratory understanding of self-reflection in the context of psychotherapy training, we focused on the subjective perspectives and individual sense-making of psychology students and chose a qualitative approach. Methods Participants and Data Collection Participants for this study were randomly selected from a cohort of 26 students (7 male, 19 female, age: M = 22,9 years, SD = 5,05) of the Bachelor course in Psychology at the Brandenburg Medical School. There were no exclusion criteria. During the 3rd, 4th and 5th Semesters, students take part in clinical internships (one day per week), which take place in three different psychiatric clinics. After each internship students have to hand in 3 self-reflection essays (2–4 pages) focusing on different therapeutic tasks they have been involved in during the internships. The self-reflection essays are structured by five guideline questions (see appendix). Each of the 26 students thus submitted a maximum of 9 essays over the 3 semesters. Due to some structural changes in the curricular requirements some students handed in less than 9 essays. The data pool for this study thus consisted of a total of 188 self-reflection essays, written by 26 students over a period of three semesters. For the purpose of this study a sample of 40 texts from a subset of 10 of the 26 students (3 male, 7 female, age: M =: 22,4 years, SD = 3,01) was randomly selected. Randomly picking this subsample from the whole three-semester data pool ensures to represent possible variations in each students’ self-reflection over time. The data were collected after winter semester 2020/21, after summer semester 2021 as well as after winter semester 2021/22. On average, the self-reflection essays included 1.261 words, ranging from 606 to 3.008 words. Data Analysis To investigate the semantics central to the students‘ narratives, when reflecting upon their clinical experiences as well as to find out about how they reflect in terms of which foci and modalities they apply, a thematic analysis (Braun & Clarke, 2006 )⁠ was conducted. Thematic analysis (TA) is a method developed for identifying themes and analyzing repeated patterns within textual data. A constructivist epistemology underpinned and shaped the use of the TA in this study (Lyons & Coyle, 2007 ). The authors understand meaning and experience as a social construct, which is constructed and reproduced through a constant interaction between what is already known and ongoing influences within its agents (Lyons & Coyle, 2007 ). Due to the lack of previous research on the semantic aspect of self-reflection, we explored the first research question ( semantics ) with an inductive approach. We here adopted the typical semantic focus of TA. For the second and third research questions we drew on the pedagogical literature and front-loaded the categories of foci and modalities to the analysis thus adopting an explorative-deductive approach (Casula et al., 2021 ). These two categories were thus additionally considered during TA coding⁠. The TA was implemented using the qualitative analysis software MAX QDA (VERBI Software, 2021 )⁠. EK conducted a TA of the whole data set, following the six analytic steps of TA (Braun & Clarke, 2006 : 1. getting familiar with the data, 2. generating initial codes, 3. searching for themes, 4. reviewing themes, 5. defining and naming themes & 6. producing a report). As a starting point, all texts were read to get familiar with the content. During this primary reading phase, first thoughts and ideas arising while reading the texts have been written down. Then, initial codes were generated for the whole data set. Both descriptive and interpretative codes were used (Lyons & Coyle, 2007 ). In a third step, codes were clustered into themes and sub themes. The generated themes were then checked with respect to their fitting with the respective data and were revised accordingly. Finally, the themes were refined by considering the broader context of the whole data set, to ensure that they are representative for the data. This process included rereading the texts as well as comparing the results with the researchers’ initial codes. The resulting themes were sorted according to the research questions capturing the semantics , foci and modalities of self-reflection. To ensure trustworthiness (Lincoln et al., 1985 )⁠, the research team applied the following steps: First, to ensure credibility the six TA steps (Braun & Clarke, 2006 ) were followed closely and recursively implemented. Moreover, the authors utilized investigator triangulation (EK analyzed all, while a research fellow analyzed 5 essays) and consensus discussions (EK, LG, research fellow). Additionally, to ensure replicability, an audit trail reporting in detail all activities, decisions, research steps and provisional results was used to save and document all phases of the research project. The presentation of our research is based on the APA standards for reporting qualitative research (see Levitt et al., 2018 ). Reflexivity We are aware of several personal influencing factors regarding the data analysis. The fact that EK works as a CBT therapist shaped her perspective and expectations on what aspects of self-reflection could be important. Particularly, she became attentive to the aspects of self-awareness (thoughts, emotions, body sensations, behavior) that are typically addressed during CBT therapy. Including a research fellow (with a psychoanalytic background) and LG (trained systemic psychotherapist) in the analysis brought in more perspectives, and at the same time consolidated EK’s initial impressions. Moreover, at the beginning of the data analysis EK still worked in one of the cooperating clinics, organized students’ internships and supervised students. Her dual role of researcher und students’ tutor made it difficult for her to take an external observer’s perspective on the data. Moreover, due to her previous research experience with quantitative research methods, EK found the shift from a positivist to a constructivist perspective (which has a direct impact on the way data are coded) especially challenging. To reflect on and handle these issues EK utilized a regular exchange with the research team. Ethical Remarks All participants received information about the study and gave their informed consent. The data were treated anonymously and confidentially. Published data contain no quotes that could disclose the identity of any student. The study was conducted according to the national and international ethical guidelines, and it was approved by the BMS ethics committee (Brandenburg Medical School: no. E-01-20230211). Results The resulting themes were systematized according to the research questions into the three dimensions of foci , modalities , and semantics . In what follows, we describe all themes and sub themes generated in the analysis (Fig. 1). Semantic Themes of Self-reflection We begin with the presentation of the semantic themes, i.e., themes pertaining to core meaningful contents in the students‘ narratives. We carve out four central semantic themes that characterize students’ self-reflections: (1) Moving between insecurity and security as a source of self-reflection (2) Demonstrating competence and giving opinions as a strategy of assertiveness, (3) The need for meaningfulness and comprehensibility as a source of self-reflection, (4) Curiosity and fascination as a motivating force for self-reflection. In what follows, we present the four themes in more detail, by grounding them on textual quotes. Moving between Insecurity and Security as a Source of Self-reflection At the beginning I was nervous and insecure. In the course of the conversation, I regained the feeling of security, which I would not have expected. (Stud. 6) The main focus of this theme is on the shift from feeling insecure to feeling secure and on the influencing factors regarding this transformative process. Indeed, we observe that the main topic of self-reflection are insecurities evoked in clinical situations. Semantically speaking, insecurity thus seems to initiate the self-reflection process. Students described insecurity as being so challenging that their self-reflections were mostly concerned with how to handle or to get rid of this feeling. Coping strategies such as relying on theory, preparing in advance or trying to steer the situation were experienced as not being helpful in dealing with insecurity. On the contrary, enduring challenging situations and tolerating insecurity was experienced as adjuvant (for examples on hindering and helpful strategies, see quotes in sub themes below). This first theme thus emphasizes the constructive potential of insecurity (and of accepting it) as a source of self-reflective processes and thus – even if counterintuitively – as an important building block for one’s own self-confidence. In the analysis we could also carve out factors that influenced the feeling of insecurity. These factors were clustered in three sub themes: (1a) Previous experience as a diachronic influencing factor, (1b) Interpersonal interaction as a synchronic influencing factor, (1c) Framework as a contextual influencing factor. These three influencing factors differ in the way they are temporally experienced (previous, immediate, or enduring aspects). Yet, the aspect of newness was a character shared by all three influencing factors and semantically related to the feeling of insecurity. In what follows we describe the sub themes in more detail. Previous Experience as a Diachronic Influencing Factor. Across self-reflection essays we found that students’ feelings of (in)security changed according to their previous clinical experience: Lack of clinical experience yielded feelings of insecurity, whereas previous clinical experience supported a feeling of security. Interestingly, theoretical knowledge learned during lectures, in a “secure surrounding” (Stud. 5), was not experienced as having a substantial impact on students’ feeling of insecurity when dealing with challenging clinical situations. A tendency to prepare in advance or to rely on already learned knowledge when feeling insecure emerged from the narratives. However, this was not experienced as helpful in dealing with insecurity: I tried to consider all the details we have learned: body posture, paraphrasing, relationship building. But I realized quickly that this is hard for me as a 3rd semester student without much practical experience. Experience, that will occur over time (…) so that hopefully one day all these concerns will become second nature to me. (Stud. 6) On the other hand, students mentioned previous clinical experience and practical training to be beneficial in difficult clinical situations: The cranky comments of the patient made me feel insecure but because I have observed the reactions of therapists and doctors in similar situations, I was able to react self-confidently to his comments (…). That helped me a lot during the testing. (Stud. 3) In this example, Stud. 3 regards themselves as being capable of reacting self-confidently due to their previous life experiences. This was confirmed by other students’ narratives: more clinical experience gave them a feeling of “calmness” (Stud. 3), “confidence” (Stud. 6) and “security” (Stud. 8). Interestingly, helpful experience was not limited to a student’s own gained clinical experience. Additionally, observing similar challenges undergone by colleagues was also perceived as being beneficial. In the semantic analysis of text extracts, in which students reflected on their lack of clinical experience, we observe that it was essentially the aspect of unfamiliarity/newness of the situation that yielded insecure feelings. Yet, at the same time, students experienced tolerating, instead of avoiding, insecurity as helpful and as leading to more confidence in future clinical situations. Students even described feelings of pride and satisfaction after trying to face situations in which they felt insecure. Thus, not only clinical training in a narrow sense but also the enduring of previous challenging clinical experiences constitute this sub theme, which we call a diachronic influencing factor on (in)security. For instance, in the following quote, Stud. 6 considers rising to the challenge of tolerating feelings of insecurity as an opportunity: This task would have been easier with a different patient. But then I would not have been able to gain the experience, to feel frustrated and to reflect on this fact, to have self-doubts regarding my competencies. I would not have been able to see the task as a chance to grow. (Stud. 6) Interpersonal Interaction as a Synchronic Influencing Factor. Interpersonal interaction is presented here as a further central influencing factor on (in)security that permeates students’ narratives. Students reported that the suddenness or newness coming with the situational moment evokes challenging insecure feelings. Such insecurity is related to the experience that, in the here-and-now unfolding of an interaction, immediate reactions are required. This was thus clustered as a s ynchronic influencing factor. As in the sub theme above, here students also attempted to prepare in advance and to rely on previous knowledge as strategies to face insecurity. Yet, what was experienced as helpful was rather to rely on and trust in one’s own intuition as well as to engage in the interaction and adjust to it instead of trying to steer it. In the following quote a student carefully describes their emotional fluctuations in the here and now of an interaction with a patient and how they let themselves be influenced by the patient’s calmness. Before the conversation (…) my body and my mind were relaxed (…). When the patient arrived and we entered the room together, I found I was getting nervous, and my heart raced a bit. However, this feeling changed quickly because the patient had a very calming nature, which was a bit infectious and served to calm me down quickly. (Stud. 8) Even if it is not always the case that calmness and security are directly conveyed by patients, across these reflections we observe that engaging in the here-and-now dynamic of an interaction and – again – tolerating the insecurity related to the process, helped students to feel more grounded and self-confident. Framework as a Contextual Influencing Factor. Finally, the contextual framework that the students have to deal with appears to be another important factor affecting the feeling of (in)security. Here, with contextual factors we refer to external circumstances such as hospital routines or structures, time pressure, the specific role of being an intern in the psychiatric hospital, or a (lacking) support by supervisors. According to the students’ reflections, these contextual and structural aspects can both be helpful and supporting, or disconcerting. Students consistently described time pressure as a hindering factor. The characteristic of this experience was that under time pressure it was not possible for students to prepare in advance and reliably predict or control a situation. Also here, what seems challenging is specifically the confrontation with the newness and suddenness of a situation: The therapist (…) only asked two minutes before the beginning of the testing if I could conduct the testing, so I was taken by surprise. I had no time in advance to read about the test or examine it thoroughly. At the beginning of the testing, I was very insecure (...) But the further we got into the testing, the more relaxed I became. (Stud. 3) Throughout the essays, the experience of a lack of support by colleagues and of difficult team dynamics formed another challenging contextual aspect associated with feelings of insecurity. Contrarily, the support of other clinicians appeared to help students handle insecurity. This could be the experience of being “taken by the hand” (Stud. 8) in a challenging moment or having the opportunity to exchange views with a clinician while still being in the afterglow of a demanding situation. Students described their insecurity as arising from the desire to do things right and to appear competent in their new field of work. Thus, insecurity seemed to be fed by expectations in the work environment (which were internalized by students). In the following quote, a student describes the inner conflict between wanting to meet these expectations and at the same time accepting the fact that as an intern, one does not yet have the ability to fulfill them: The desire of an intern to appear like a professional is now paradoxical to me. At the same time, I barely know human beings who would like to willfully appear incompetent. Of course, it is important to reflect on oneself (...) but the capacity I have for the other person (the patient) would then suffer from that. (Stud. 1) Demonstrating Competence and Giving Opinions as a Strategy of Assertiveness. In this theme, we present a pattern of meaning that was generated across students’ self-reflections: the expression of confidence, giving opinions, and highlighting one’s own competence. In contrast to the previous theme, which included the experience of pride and confidence when facing insecurity in challenging situations (see theme 1a), the semantic core of this theme is rather assertiveness. Here, assertiveness is differentiated from confidence as it was semantically related to a “desire… to appear like a professional”, as student 1 mentions it in the quote above, i.e., to show competence rather than feel confident and competent. Thus, in the narratives, assertiveness was related to feelings of insecurity, also yielded by the expectations from others (see also Subtheme 1c). Next to semantic codes explicitly referring to the experience of being assertive, the classification of this theme was also supported by several latent codes, which captured the implicit semantic connotation of the narrative. We further differentiate two sub themes regarding the ways in which students asserted themselves in the narratives: (2a) demonstrating competence and (2b) giving opinions. We observe throughout these narratives that when demonstrating competence and giving opinions, the students’ focus moved away from themselves (i.e., from self-reflection) and shifted to a (factual) description of good practice (as exemplified in all quotes below). Consequently, assertiveness seemed to reduce the self-reflective character of the narratives. Demonstrating Competence In their self-reflection narratives, students attempted to demonstrate their competence and knowledge, e.g., by reporting about methods learned at university, which they might assume is expected from them. This is also coherent with the felt pressure to fulfill others’ expectations as shown in subtheme 1c. In the following quote a student reflects on the first time they had contact with a suicidal patient by describing the typical screening questions they asked I then asked him if he only dreams about suicide or if he also experiences suicidal thoughts during daytime (...). Subsequently, I asked how he would commit suicide (...) and if he already had a date in mind for when he wants to do it. Finally, I asked him if he had talked about his thoughts with others, if he had made any preparations or if he had written a goodbye letter. (Stud. 5) This quote represents a way of demonstrating that they know how to act in the right way for this situation, more than reflecting upon their own experience in that moment. Giving Opinions Within their reflections, students confidently shared their opinions and assessments on the relevant circumstances. Also here, in their given opinions we observe a shift of focus to the external reality instead of engaging in the reflection of oneself. Similar to demonstrating their competence, by giving opinions they assert themselves and appear more self-confident and secure. When giving their opinions, students engaged in considerations such as, what they think raises the quality of psychiatric treatment, which interventions they find helpful, or what kind of behavior is most professional in their view. While doing so they generally took the stance of someone who knows what is right or wrong Regarding the concrete situation, I have the opinion that the group had a good opportunity to learn. Even though it may sound harsh, I do not think that patients should leave the hospital expecting that their environment will react with concern towards them. (Stud. 1) As an extreme form of giving opinions, some students also devalued others, possibly to demonstrate their competence: I realized in part, that I would have used different questions than the therapist and had engaged in deeper questioning (...). Moreover, I found it difficult when the therapist would interrupt the patient. In my opinion, when a patient with an eating disorder talks about eating, all information should be recorded. (Stud. 6) The Need for Meaningfulness and Comprehensibility as a Source of Self-reflection. Students expressed a need for meaningfulness and comprehensibility, mainly regarding the behavior of patients or clinical staff as well as in the general structures within the psychiatric hospital environment. In their accounts, students reflected upon various aspects that would cause them to question the given situations. Here they would try to find “solutions” (Stud. 1) and to “understand the patients and their concerns” (Stud. 1). The self-reflection process was thus often initiated by a need to try to understand what was yet incomprehensible: His thoughts would not deal with suicide itself but only with the wish to not be there anymore, because he then would not have to handle the feelings of guilt. It is beyond my imagination how big the feelings of guilt must be, to have thoughts like that. (Stud. 5) In this example the student acknowledges not being able to fully comprehend the patient. In the students’ narratives we observe that a lack of comprehension led to and maintained reflective processes: “The patient stayed in my mind for a very long time (...) I still don’t understand the reason for her call” (Stud. 1). Yet, the feeling of not being able to let go of an “unresolved/incomprehensible” situation could also result in rumination: “Due to the unresolved situation and the desire to find a label for the patient, I forgot (...) the task I wanted to accomplish” (Stud. 1). Thus, when the feeling of incomprehensibility becomes too much or too persistent, it might have a hindering effect on the capacity to deal with the situation, resulting in losing focus. Yet at the same time, students reflected upon the need to accept (instead of avoid) the uncertainty related to the feeling of not-knowing: Again, I feel puzzled. I think I am not the only one with the idea of studying psychology because I hoped that through this (applied) science I would find answers to various questions. Instead, even more questions are raised (...) instead of answering questions the essence is probably to develop an acceptance for the uncertainty. (Stud. 1) Although looking for quick answers appeared to be an automatic impulse of many students, they also reflected upon the costs of it: ”The wish to name things, to demystify them and finally get the feeling to have understood the ‘big picture’ seems to be threatening my stance of curiosity regarding the patients“ (Stud. 1). While the feelings of incomprehensibility can challenge students and make them lose focus, giving quick answers might come with losing one’s curiosity for human beings Curiosity and Fascination as a Motivating Force for Self-reflection. Curiosity and fascination are captured as core semantic aspects of this last theme. We define those, based on the narrative accounts, as being particularly relevant with regard to motivating the engagement in self-reflecting processes. These aspects especially occur in situations that are novel to students and often create feelings of insecurity. Thus, we observe a co-occurrence of fascination, curiosity, and insecurity The situation was difficult for me, because on the one hand (…) I found it fascinating that he seemed to be so convinced by his stories, as if they were reality. On the other hand, I was concerned about validating his thoughts, so that he’d lose reality out of sight even more. That is why I felt very insecure. (Stud. 5) As deducted from the quote above, on the one hand students were fascinated by or curious about the patients they have met, their syndromes or their interactions. On the other hand, students showed fascination for observing how (“competent”, Stud. 6; “professional”, Stud. 1; “serene”, Stud. 3) clinicians handled certain situations: While the patient had been visited during the ward round, I felt a tense curiosity about how the conversation might proceed (...). I was especially curious about the interaction between clinician and patient (…). I have experienced how one (…) handles a difficult patient. (Stud. 6) Curiosity and fascination might have the potential to act as a motivating force for self-reflection. As the quote above underlines, the way clinicians handle potentially unsettling situations seems to be particularly fascinating for students. This also relates to theme 1a, in which we could show how students’ insecurity was reduced by experiencing and witnessing the competence of more experienced therapists. Observing the clinical work of psychotherapists thus seems to both foster self-confidence and motivation. Foci of Self-reflection Due to their more self-explanatory nature, we will give a concise summary of themes regarding foci and modalities of self-reflection in the following. The first relevant distinction regarding self-reflection foci is between inside and outside foci . It is remarkable to observe that some of the students focused their reflection more on the outside world while others turned their attention back toward themselves. When reflecting on the outside, students mainly tended to focus on patients and staff, along with the circumstances in the psychiatric ward. Students also looked at the interaction between their focus on the outside and their focus on the inner life, mostly in observing how the outside world influenced what was evoked inside of them. For example, they observed how the patients’ behavior evoked certain behavioral reactions or how it affected their emotions: “In comparison to the last times I’d seen him, he appeared to be a different person. That frightened me a little bit” (Stud. 5). Focusing on the inside and the observation of how the outside influences the inside appeared to foster self-reflection. In contrast, we notice that exclusively focusing on the outside, as in the following example, seemed to prevent the self-reflective process: Two other patients encouraged her that it would probably be best if she left her mother-in-law in a nursing home. This discussion helped the patient as she also said that she feels relieved not to be the only one with this problem. (Stud. 7) Based on the narrative accounts, the inner focus can be further differentiated by focusing on traits or states . When focusing on their inner world, students would concentrate on their states rather than on their traits, meaning that they concern themselves with exploring their behavior, emotions, bodily feelings, and thoughts in the situation, rather than with their personality and how it influences their experience. The frequency of the use of those different inward related foci differs widely. Yet, the analysis generally shows that students focus mostly on their behavior, followed by their emotions. Few students focus on their thoughts and only a couple of them focus on their bodily feelings. Modalities of Self-reflection In the narrative accounts we construct five different types of modalities students use to reflect on situations during their internships: a. describing , b. assessing , c. reasoning , d. connecting , e. concluding . Students do not exclusively use one modality but combine them throughout their written self-reflections. Examples of the different kinds of modalities are shown in Table 1. T A B L E 1. Examples of modalities. describing : neutral description of the observed or experienced situation At the beginning of the testing, I introduced myself again and informed about my professional secrecy, described the procedure, and told the patient that he could ask if questions arise. (Stud. 3) assessing : evaluation of situations, oneself, staff members, patients I would evaluate the whole conversation as professional as well as experienced. (Stud. 1) reasoning : explaining reactions, feelings, etc. of oneself and others Moreover, the patient appeared helpless. Combined with the sympathy, it provoked a strong need to help her. The helplessness resulted from her very small and tiny figure, that she appeared so fragile and much younger. (Stud. 6) connecting : drawing connections to former experiences, knowledge, etc. In fact, I already knew about the topic, because we talked about it during a practical seminar, but it was very interesting to see how patients with psychosomatic symptoms reacted to the euthyme therapy. Therefore, it was a very informative lesson for me. (Stud. 8) concluding : drawing conclusions out of the experiences made during the situation that was reflected on Anger and frustration are for me an indicator that I have to develop strategies to handle such and other professional challenges. My current coping strategies in this regard, like reading, are still not sufficient. (Stud. 1) Bold Italic: type of modality, bold: description of modality, normal font: textual quotes Interestingly, the occurrence of the modalities differs. The most recurrent modality is describing (e.g., what they do). Secondly, students use the modalities assessing (e.g., evaluating behaviors) and reasoning (e.g., why they would feel a certain way). Several students also occasionally use the modality concluding: for example, in summing up what learning experience they drew out of the described situation. Less common was the modality connecting (putting their experiences into context, e.g., regarding previous experiences). Furthermore, we also observe an interesting overlap between modalities and semantics . Students would especially use assessing for assertiveness or for devaluing others. Both, as we discussed when looking into the semantics , could be viewed as possibilities to cope with insecurities. Discussion The present qualitative study examines written self-reflections of a cohort of psychology students, aiming to describe and systematize relevant foci , modalities and semantic aspects of the self-reflection process. Dealing with insecurity has been carved out as a core and overarching semantic theme and as the central process that fuels or thwarts self-reflection. Nearly all self-reflections in the students’ narratives express shifts on a movement between security and insecurity or can be related to this theme. The scientific relevance of our results is mainly related to two main findings: Firstly, insecurity - in its different facets - has been shown to be relevant for the initiation of self-reflection. Secondly, such an initiation of self-reflection seems to depend on the way prospective therapists cope with their insecurities. Figure 2 summarizes our findings. Our finding that insecurity can initiate an act of self-reflection and can therefore be supportive for further professional development supports the results of previous studies (Atkins & Murphy, 1993 ; Niemi, 1997 ; Taubner & Evers, 2021 ; Thériault et al., 2009 ; Thériault & Gazzola, 2005 ). Two semantic themes concerning the need for meaningfulness and comprehensibility as well as the feeling of curiosity and fascination specifically capture ways in which insecurity (e.g., the feeling of not yet knowing) can fuel self-reflection. According to Antonovsky ( 1997 ), meaningfulness and comprehensibility are two necessary aspects for experiencing a sense of coherence (SOC), which is described as a resilient mindset that enables individuals to confidently navigate life’s challenges, promoting well-being and effective stress management. He describes meaningfulness and comprehensibility respectively as 1. when requirements are to be understood as challenges worth committing to 2. when events of one's inner and outer environment are predictable and explainable. When applying Antonovsky’s concept to our results, one could hypothesize that experiencing meaningfulness might give one a reason to better tolerate insecurity (2. challenge worth committing to). On the other hand, looking for comprehensibility might be an attempt to reduce insecurity by being more capable and in control (1. events are predictable and controllable). This would therefore support the finding that striving for meaningfulness and comprehensibility might help tolerate uncertainty and thus in turn foster self-reflection. We find that feelings of curiosity and fascination can additionally serve as a motivating factor for engaging in self-reflection. Expectedly, we recognize that the states of curiosity and fascination , the need for meaningfulness and comprehensibility as well as insecurity seem usually to arise in new situations and are often experienced concurrently. As Antonovsky ( 1997 ) argues, it is a typical human reaction to seek a sense of security or increased knowledge. Yet according to our results, as soon as these situations appear to be less challenging or new, they lose their potential to raise curiosity and fascination as a motivating force and in that also the potential for self-reflection seems to stagnate. This conclusion is supported by previous research, where especially new and challenging experiences were shown to prompt self-reflective processes (Niemi 1997 ; Pompeo & Levitt, 2014 )⁠. Our findings also indicate that some students experience insecure feelings as overwhelming and thus hope to eventually get rid of their insecurities. This is not surprising, as previous studies have shown that psychotherapists in training experience their first therapy sessions as challenging and distressing (Rønnestad & Skovholt, 2003 ; Taubner et al., 2010 ; Thériault & Gazzola, 2010 ). As a way of coping, we find in the analyzed accounts that students tend to compensate for their insecurities by preparing for their tasks and relying on previous knowledge. Thériault & Gazzola ( 2010 )⁠ describe this kind of impression of lacking knowledge or experience as the “empty toolbox syndrome”. Accordingly, therapists might believe they will feel more competent once they know more. Schön ( 1983 )⁠ argues that relying primarily on knowledge serves as an effective strategy for those who experience uncertainty as threatening or a sign of weakness. Yet, the author also states that it is exactly this reliance on knowledge that keeps the person away from being attentive to the moment. As our findings suggest, meticulous preparation or theoretical knowledge do not automatically reduce insecurity. It is instead prior experience that seems to have an impact on how secure students feel. The effect of experience on (in)security is supported by the research of Rønnestad & Skovholt ( 2003 ), who demonstrate that insecurity occurs less as therapists become more experienced. A second adverse coping strategy central to our results is assertiveness : Students present their competencies and give opinions, evaluate themselves or devalue others which leads to a shift in the focus of a reflection away from one’s own (insecure) feelings towards the outside world. We conceive of this as a way to avoid insecurity, which, interestingly enough, is also narratively related to reduced self-reflection. Thériault & Gazzola (2009) show in their interview study, that therapists apply several adverse coping strategies to compensate their feelings of insecurity, such as giving advice or sticking to theory. Similarly, as a way of mastering challenging therapeutic situations, Rønnestad & Skovholt ( 2003 )⁠ describe the concept of ‘premature closure’: By using strategies like sticking to theoretical approaches or only focusing on a certain group of patients, therapists might try to avoid being emotionally overwhelmed by reducing the complexity of the situation (Rønnestad & Skovholt, 2003 ; Skovholt & Rønnestad, 1995 ). Akin to our findings, premature closure can interrupt the self-reflection process by yielding a shift from reflection to evaluation (Skovholt et al., 2016 ; Rønnestad & Skovholt, 2003 ). We thus hypothesize that assertiveness could be a way of premature closure and that students resort to assertiveness to deal with (or avoid) overwhelming feelings. Nevertheless, from our findings we can conclude that insecurity is not per se deleterious. Depending on the coping strategies students adopt, insecurity could even be helpful. The current study illustrates that it is exactly the experience of accepting insecurity that seems to be the most helpful in reducing it. As previous studies could show, tolerating insecurity can also serve as a base for using constructive coping strategies (e.g., Quinlan et al., 2021 ; Nissen-Lie et al., 2017 ). In a similar manner, Galbusera et al. ( 2024 ) could stress out the positive impact of tolerating insecurity for the therapeutic process. Their study implies that avoiding uncertainty (e.g., through piling up theoretical knowledge), results in a more distant relationship, whereas tolerating it leads to more closeness between therapist and patient. Yet, our results also draw attention to potential negative effects of insecurity on self-reflection. We observe that insecurity can sometimes end up in rumination, which can lead the attention away from the interaction with the patient. In this context, previous research shows that therapists who are not able to manage insecurity might experience negative personal effects such as burn out (Hannigan et al., 2004 )⁠ or quitting the profession (Thériault & Gazzola, 2006 )⁠. Finding the right balance between overwhelming insecure feelings and stagnation due to a potentially false sense of security thus appears to be very relevant for a constructive self-reflective process. In our analysis, we can observe a complex interplay between the semantic aspects and other dimensions of self-reflection ( modalities and foci ). For example, the semantic of assertiveness is related to the modality of assessing. As such, a potential attempt to avoid insecurity is also related to a shift in the focus to the ‘outside’. Our differentiation between outside and inside foci matches the dimensions developed by Jahncke ( 2018 ). With the inside-outside dimension, the author differentiates between one's own behavior (inside) and exterior circumstances regarding the learning environment (outside), stressing the importance of both for self-reflection. In our analysis, we observe that if a focus on the outside steers the attention away from oneself it potentially diminishes the ability to self-reflect (i.e., possibly also affecting the modality ). Empirical evidence indicates that focusing on the outside is more common in inexperienced therapists and fades over time (Rønnestad & Skovholt, 2003 )⁠. Interestingly, although we do not quantitatively assess the occurrence of different foci , a stronger (inside-)focus on emotions and behavior, and a neglect of bodily sensations, characterized the students’ narratives. Mojta et al. ( 2014 )⁠ highlight that the reflection on internal experiences including physiological reactions might be helpful for the development of self-awareness⁠. In conclusion, we assume that for psychotherapists, bodily sensations might be conceived as an important experiential aspect to be reflected upon (see Kanfer & Saslow, 1965 ). Moreover, we find it remarkable that students usually do not focus on their traits (e.g., personality, behavioral patterns). Unfortunately, there is relatively little research on the question of if and how therapists’ traits influence the therapy outcome (Gries et al., 2020 )⁠. More empirical evidence is needed to examine the relation between these foci (states-traits) and the quality of self-reflection as well as the therapy outcome. Finally, in our findings we can differentiate five modalities of self-reflection: describing, assessing, reasoning, connecting, concluding. While these results represent similar self-reflection categories as discussed in the pedagogical field by Hatton & Smith ( 1995 ), Jahncke ( 2018 ), Krieg & Kreis ( 2014 ) and Ryan ( 2013 ), one important insight, emerging from our analysis, is that different modalities seem to relate to semantic aspects, which are specific to the psychotherapeutic field. Limitations and Future Directions When interpreting the study’s results, one should consider several limitations. First, it is important to note that the analyzed self-reflection essays were part of students‘ educational performance and were marked by supervisors. Moreover, students might have felt that they had to appear competent to fulfill expectations from the clinical staff. Both aspects could lead to social desirability and make students focus more on self-assertion than on self-reflection. Second, using a qualitative-explorative design, our study should be conceived as a pilot exploration, which can serve as a basis for quantitative studies on larger samples. Only such studies could potentially show how frequently the foci , modalities and semantic aspects derived within this work, are in fact apparent in self-reflections of prospective psychotherapists. Based on our results, we cannot yet define what constitutes good self-reflection. Experimental studies are needed to support our interpretations concerning the usefulness of different self-reflection and coping styles in therapy training. Further investigations could focus on explicitly inquiring about the perspective of the reflecting individuals and their fostering professionals thereby complementing our findings on what supports and hinders the self-reflection process. Moreover, future research should investigate the question of what modalities contribute to the quality of self-reflection (over time), with the aim of developing a tool able to measure competency to self-reflect by means of connecting the captured modalities to therapeutic abilities and therapy outcome. Finally future research could focus on the way training for psychotherapists should be designed, to support the development of self-reflection competence. Conclusions To our knowledge, the present study is the first to analyze self-reflection essays in the psychotherapeutic field, particularly covering the students’ progress over the full course of their practice semesters. Our study presents important findings regarding insecurity and related feelings as sources of self-reflection as well as coping strategies in dealing with insecurity. Moreover, the findings of this study offer a basis for a first operationalization of self-reflection-competency in the training of psychotherapy and constitute a basis for the construction of a rating scale for assessing it. Abbreviations BMS Brandenburg Medical School CBT Cognitive Behavioral Therapy SOC Sense of coherence TA Thematic Analysis Declarations Ethics approval and consent to participate: The study was conducted according to the national and international ethical guidelines, and it was approved by the BMS ethics committee (Brandenburg Medical School: no. E-01-20230211). Consent for publication: not applicable Availability of data and materials : The datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : The research project was not supported by any specific grant from funding agencies in the public, commercial, or non-profit sectors. Author’s contributions: E K : Investigation; conceptualization; methodology; validation; writing; formal analysis; project administration; data curation; software; visualization. CN : Investigation, conceptualization; project administration. LG: Supervision, conceptualization, methodology; writing and paper revision, formal analysis. JL : Supervision; conceptualization; paper revision Acknowledgements : The authors would like to thank Maren Schlimm for her support in analyzing the data. Moreover, we would like to thank Nathan Hudson and Till Martini for their valuable feedback on the manuscript. Authors’ information: EK is a researcher at Brandenburg Medical School and responsible for the training of prospective psychotherapists at MAPP Institut, Germany. Her research focuses on psychotherapeutic skill development and its support in training. As a CBT-trained psychotherapist with a private practice in Berlin, she works with individuals as well as couples, applying schema-therapeutic and emotion-focused approaches. CN is employed as a Research Assistant and Associate Lecturer at Brandenburg Medical School where she teaches and supervises students during training. Her doctorate studies are focused on the subject of “Teaching and measuring basic psychotherapeutic skills during studies”. Additionally, she works as CBT-psychotherapist and supervisor. LG is a professor of clinical psychology and systemic therapy at Brandenburg Medical School. Her research focuses on therapeutic processes, psychosis treatment, and the impact of the therapeutic stance on recovery. She is actively involved in the teaching and supervision of psychology students at Brandenburg Medical School and works as a systemic psychotherapist at the psychiatric clinic in Rüdersdorf. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6990651","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484998614,"identity":"f0d25d87-09f6-4a37-affa-8d0f7ea53f9c","order_by":0,"name":"Esther Knichel","email":"data:image/png;base64,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","orcid":"","institution":"Medizinische Hochschule Brandenburg Theodor Fontane","correspondingAuthor":true,"prefix":"","firstName":"Esther","middleName":"","lastName":"Knichel","suffix":""},{"id":484998615,"identity":"a4737393-56f9-42aa-95c8-1eb94a5592c2","order_by":1,"name":"Carolyn Nelles","email":"","orcid":"","institution":"Medizinische Hochschule Brandenburg Theodor Fontane","correspondingAuthor":false,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"Nelles","suffix":""},{"id":484998616,"identity":"9c0589a6-d358-4cf0-aca1-9ef24692fb87","order_by":2,"name":"Laura Galbusera","email":"","orcid":"","institution":"Medizinische Hochschule Brandenburg Theodor Fontane","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Galbusera","suffix":""},{"id":484998617,"identity":"95a9a625-f707-47ac-9dcd-e47249286dfb","order_by":3,"name":"Johannes Lindenmeyer","email":"","orcid":"","institution":"Medizinische Hochschule Brandenburg Theodor Fontane","correspondingAuthor":false,"prefix":"","firstName":"Johannes","middleName":"","lastName":"Lindenmeyer","suffix":""}],"badges":[],"createdAt":"2025-06-27 10:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6990651/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6990651/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-025-03694-w","type":"published","date":"2025-12-01T15:57:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86777233,"identity":"1707cc0a-6476-46d3-a57f-c92ab3e949a0","added_by":"auto","created_at":"2025-07-15 12:49:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":182328,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIdentified themes and sub themes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6990651/v1/74108f9c14287350ab41b4a8.png"},{"id":86778575,"identity":"93d70e6b-9ae5-4e2c-bfe9-951ba2b3a16d","added_by":"auto","created_at":"2025-07-15 12:57:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":118938,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHeuristic model of the core findings\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6990651/v1/175d78294375a25e667ab937.png"},{"id":97724064,"identity":"12c6f2e6-0ed6-4cdf-915f-ed6af67074c2","added_by":"auto","created_at":"2025-12-08 16:11:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1245805,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6990651/v1/a7c9f89c-0551-4282-977c-4af0472ca29d.pdf"},{"id":86777234,"identity":"b1bb22b2-65ca-4d41-9f59-b3b695555966","added_by":"auto","created_at":"2025-07-15 12:49:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15521,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6990651/v1/7ef4bad1c29b449188cb48ff.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dealing with Insecurity: A Thematic Analysis of Self-reflection in Psychotherapy Training","fulltext":[{"header":"Background","content":"\u003cp\u003eIn psychotherapy training the ability of being self-reflective is considered to be a key therapeutic competency (e. g., Bennett-Levy et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; R\u0026oslash;nnestad et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Self-reflection is defined as a cyclic process in which psychotherapists first observe and critically reflect their emotions, cognitions, and behaviors to gain self-insight. Consequently, therapists might adapt their own beliefs and approaches regarding situations within therapeutic work based on these newly gained insights (Kimerling et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Roberts \u0026amp; Stark, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Empirical evidence has shown that self-reflection has an important influence on therapy process and outcome. R\u0026oslash;nnestad \u0026amp; Skovholt (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e)⁠ conducted an interview-study with 100 counselors/therapists at different experience levels. They show that the ability and willingness to reflect on complex phenomena and processes in therapy play a crucial role in the development of the therapist\u0026rsquo;s professional self. Continuous self-reflection is seen as a requirement for an optimal learning process for all stages of professional development, whereas a lack of it might lead to stagnant or even deteriorating development (R\u0026oslash;nnestad \u0026amp; Skovholt, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2005\u003c/span\u003e)⁠. Several reviews summarize empirical findings on the effects of self-reflection for the training and practice of psychotherapists (see e.g., Prasko et al, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Laireiter \u0026amp; Willutzki, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Knapp et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The following positive effects of self-reflection were found: gaining of insight, self-awareness, empathy, improvement of technical and interpersonal skills, and the ability to assess one\u0026rsquo;s own competencies (Laireiter \u0026amp; Willutzki, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Knapp et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The training of self-reflection seems to be especially important for beginner therapists, as it also stimulates the development of critical thinking as well as of ethical decision-making (Prasko et al, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Importantly, therapists who are aware of their own part in therapeutic interaction can also evaluate and, if necessary, adapt their behavior or attitude (Knapp et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Thus, the ability to self-reflect is fundamental for the therapeutic alliance, for professional growth as well as for the development of further therapeutic competencies (Prasko et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Self-reflection does not only yield professional benefits but also has positive effects on the therapist as a person. Knapp et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)⁠ point out, that self-reflection is associated with greater self-care and a lesser tendency to overestimate one\u0026rsquo;s own abilities and thus also protects against burnout symptoms. Nikendei et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) could also show in their interview-study that psychotherapists have an explicit desire to reflect on the motives behind their own behaviors. Drawing on the aforementioned research, the American Psychological Association defines reflective practice as a core competency for therapists (American Psychological Association, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Levant, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2005\u003c/span\u003e)⁠. Accordingly, self-reflection is specified as one of the basic competencies that should be taught during the training of psychotherapists (Rodolfa et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2005\u003c/span\u003e)⁠.\u003c/p\u003e\n\u003ch3\u003eTheories on Self-Reflection\u003c/h3\u003e\n\u003cp\u003eAlthough evidence shows that self-reflection competence has a positive effect on therapy process and outcome, there is still no consensus as to what constitutes effective self-reflection for psychotherapists. Research on the characteristics and quality of self-reflection in the field of psychotherapy is still scarce.\u003c/p\u003e\u003cp\u003eIn contrast, we find several theories conceptualizing self-reflection in the pedagogical field, which will be briefly summarized herein. One of the first conceptualizations was formulated by Sch\u0026ouml;n (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1987\u003c/span\u003e), who distinguishes between \u0026ldquo;reflection-in-action\u0026rdquo; and \u0026ldquo;reflection-on-action\u0026rdquo;. The latter refers to reflection on past situations (with temporal distance), whereas the former means reflecting while being in a certain situation. The author highlights the benefit of the former, which allows a modification of the reflecting person\u0026rsquo;s actions when appropriate. Yet, Sch\u0026ouml;n\u0026rsquo;s focus on reflecting-in-action has been criticized for not moving beyond the immediate situation (Gu-Ze\u0026rsquo;ev et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2001\u003c/span\u003e)⁠.\u003c/p\u003e\u003cp\u003eSubsequent theories focus on the differentiation between self-reflective levels (we will refer to such levels also as \u003cem\u003emodalities\u003c/em\u003e). Based on an empirical investigation of written self-reflections of student teachers, Hatton \u0026amp; Smith (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) describe four distinct levels of reflection. The first level is described as reporting a situation (descriptive writing). According to the authors, this is a basis for it, but it is not self-reflection in itself. The second level consists in explaining/giving reasons, often based on personal judgment or knowledge (descriptive reflection). The two higher levels pertain on the one hand to the assessment of the situation, e.g., by using alternative perspectives (dialogical reflection) and on the other hand to the inclusion of the broader context of the situation (critical reflection). The authors agree with Sch\u0026ouml;n (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1987\u003c/span\u003e) that the supreme form of reflection is the ability to use all levels of reflection (descriptive, dialogical and critical) while the situation on which one is reflecting upon, is still taking place. Still, they also recognize the importance of reflection-on-action as a useful starting point for beginner practitioners, who cannot yet reflect \u0026ldquo;in-action\u0026rdquo;. Krieg \u0026amp; Kreis (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) examined the reflections in teachers\u0026rsquo; debriefing after class. They identify six stages of self-reflection: 1. description of the situation (not considered as a reflective process), 2. descriptive reflection (includes an evaluation of the situation or the recognition of a problem), 3. explicative reflection (specifies reasons for behaviors etc.), 4. introspective reflection (pondering of different assumptions and/or relating to one\u0026rsquo;s own experiences), 5. integrative reflection (reference to scientific theories), 6. transformative reflection (gaining new ideas for future actions) \u0026ndash; this last stage of self-reflection can occur during the whole reflection process and ideally leads to new courses of action. The authors find a correlation between higher learning success and the occurrence of higher levels of reflection such as introspective, integrative, and transformative reflection (Krieg \u0026amp; Kreis, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Another categorization of levels of self-reflection was developed by Ryan (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) based on the analysis of self-reflection texts, written by students at different university faculties. The author describes the following four levels: 1. reporting a situation and responding, e.g., by expressing opinions. This level is crucial for setting a clear focus and it sets a baseline of accuracy for further levels of reflection 2. relating the situation to one\u0026rsquo;s own experiences and knowledge, 3. reasoning including comprehension of the importance of the situation, 4. reconstructing and reframing knowledge by applying new ideas stemming from the self-reflection process. The levels are conceived as building upon each other. The highest quality of self-reflection is reached at the last level (\u0026ldquo;reconstructing\u0026rdquo;). Another model worth mentioning is Jahncke`s (2018) four levels of self-reflection. The model is based on a review of the literature on dimensions and quality levels of self-reflections and results in a coding scale. Jahncke\u0026rsquo;s four levels are: 1. descriptive presentation (describing the situation), 2. descriptive self-reflection (assessing the situation), 3. reasoning self-reflection (giving reasons for the assessment of the situation), 4. combining self-reflection (creating links between the current situation and scientific theories, previous experience and knowledge). In contrast to the other models the author distinguishes further dimensions: the \u003cem\u003efocus\u003c/em\u003e of reflection can be on the reflecting person\u0026rsquo;s \u0026lsquo;outside\u0026rsquo; (external factors, e.g., circumstances) or \u0026lsquo;inside\u0026rsquo; (internal factors, e.g., behavior) as well as on the past or the future. The transfer of experience from the past to the future is emphasized as being crucial for learning processes. A good self-reflection includes all the above-mentioned levels of reflection as well as all dimensions.\u003c/p\u003e\u003cp\u003eThe outlined pedagogical theories distinguish hierarchical levels of self-reflection that differ in their quality and are built up on each other. A high-quality self-reflection is generally identified in higher levels of self-reflection (such as \u0026ldquo;combining\u0026rdquo;, \u0026ldquo;reconstructing\u0026rdquo; or \u0026ldquo;integrative reflection\u0026rdquo;) and most of all in the combined use of the different levels. In contrast, \u003cem\u003eonly\u003c/em\u003e describing a situation usually does not count as part of the self-reflective process but can serve as a mere building block. All mentioned authors emphasize the need to support and train the ability to self-reflect as higher levels of self-reflections are not part of our natural thinking patterns⁠.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eAims of the Study\u003c/h2\u003e\u003cp\u003eAll existing conceptualizations of self-reflection, as well as the coding and rating scales developed for its assessment (see e.g., Jahncke, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), specifically pertain to the pedagogical field. Their applicability to the clinical context remains unclear.\u003c/p\u003e\u003cp\u003eTo gain a deeper understanding of the development, qualities, and effects of self-reflection in the psychotherapeutic field, we first need an operationalization of this construct within the clinical context. This is essential for the creation of appropriate assessment instruments, which can facilitate the exploration and evaluation of self-reflective practices in psychotherapy.\u003c/p\u003e\u003cp\u003eIn pedagogical research, self-reflection has been mainly operationalized in terms of modalities (e.g., describing, reasoning) and foci (e.g., inside, outside), i.e., the \u0026ldquo;how\u0026rdquo; of self-reflection. The \u003cem\u003esemantic\u003c/em\u003e aspect of self-reflection, i.e., the patterns of meaning entailed in self-reflective narratives (the \u0026ldquo;what\u0026rdquo; or content), has been neglected so far. Yet, we allow for the possibility that the very content of self-reflection may additionally play a crucial role in the definition of its nature and quality. \u003cem\u003eModalities\u003c/em\u003e and \u003cem\u003efoci\u003c/em\u003e of self-reflection are indeed tightly intertwined and might not be entirely separable from their \u003cem\u003esemantics\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eIn this study, we thus investigate the \u003cem\u003emodalities\u003c/em\u003e and \u003cem\u003efoci\u003c/em\u003e as well as the central \u003cem\u003esemantics\u003c/em\u003e characterizing self-reflections of prospective psychotherapists according to the following research questions:\u003c/p\u003e\u003cp\u003e1. What core \u003cem\u003esemantics\u003c/em\u003e characterize the self-reflection narratives of psychology students? 2. What \u003cem\u003efoci\u003c/em\u003e of self-reflection (e.g., inside, outside) can be differentiated in the self-reflection narratives of psychology students? 3. Which reflective \u003cem\u003emodalities\u003c/em\u003e (e.g., describing, reasoning) can be identified in the self-reflection narratives of psychology students?\u003c/p\u003e\u003cp\u003eSince the aim of this study is to gain a first description, systematization and exploratory understanding of self-reflection in the context of psychotherapy training, we focused on the subjective perspectives and individual sense-making of psychology students and chose a qualitative approach.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eParticipants and Data Collection\u003c/h2\u003e\u003cp\u003eParticipants for this study were randomly selected from a cohort of 26 students (7 male, 19 female, age: M\u0026thinsp;=\u0026thinsp;22,9 years, SD\u0026thinsp;=\u0026thinsp;5,05) of the Bachelor course in Psychology at the Brandenburg Medical School. There were no exclusion criteria.\u003c/p\u003e\u003cp\u003eDuring the 3rd, 4th and 5th Semesters, students take part in clinical internships (one day per week), which take place in three different psychiatric clinics. After each internship students have to hand in 3 self-reflection essays (2\u0026ndash;4 pages) focusing on different therapeutic tasks they have been involved in during the internships. The self-reflection essays are structured by five guideline questions (see appendix). Each of the 26 students thus submitted a maximum of 9 essays over the 3 semesters. Due to some structural changes in the curricular requirements some students handed in less than 9 essays. The data pool for this study thus consisted of a total of 188 self-reflection essays, written by 26 students over a period of three semesters.\u003c/p\u003e\u003cp\u003eFor the purpose of this study a sample of 40 texts from a subset of 10 of the 26 students (3 male, 7 female, age: M =: 22,4 years, SD\u0026thinsp;=\u0026thinsp;3,01) was randomly selected. Randomly picking this subsample from the whole three-semester data pool ensures to represent possible variations in each students\u0026rsquo; self-reflection over time. The data were collected after winter semester 2020/21, after summer semester 2021 as well as after winter semester 2021/22. On average, the self-reflection essays included 1.261 words, ranging from 606 to 3.008 words.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eTo investigate the \u003cem\u003esemantics\u003c/em\u003e central to the students\u0026lsquo; narratives, when reflecting upon their clinical experiences as well as to find out about how they reflect in terms of which \u003cem\u003efoci\u003c/em\u003e and \u003cem\u003emodalities\u003c/em\u003e they apply, a thematic analysis (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e)⁠ was conducted. Thematic analysis (TA) is a method developed for identifying themes and analyzing repeated patterns within textual data. A constructivist epistemology underpinned and shaped the use of the TA in this study (Lyons \u0026amp; Coyle, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). The authors understand meaning and experience as a social construct, which is constructed and reproduced through a constant interaction between what is already known and ongoing influences within its agents (Lyons \u0026amp; Coyle, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDue to the lack of previous research on the semantic aspect of self-reflection, we explored the first research question (\u003cem\u003esemantics\u003c/em\u003e) with an inductive approach. We here adopted the typical semantic focus of TA. For the second and third research questions we drew on the pedagogical literature and front-loaded the categories of \u003cem\u003efoci\u003c/em\u003e and \u003cem\u003emodalities\u003c/em\u003e to the analysis thus adopting an explorative-deductive approach (Casula et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These two categories were thus additionally considered during TA coding⁠. The TA was implemented using the qualitative analysis software MAX QDA (VERBI Software, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)⁠.\u003c/p\u003e\u003cp\u003eEK conducted a TA of the whole data set, following the six analytic steps of TA (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e: 1. getting familiar with the data, 2. generating initial codes, 3. searching for themes, 4. reviewing themes, 5. defining and naming themes \u0026amp; 6. producing a report). As a starting point, all texts were read to get familiar with the content. During this primary reading phase, first thoughts and ideas arising while reading the texts have been written down. Then, initial codes were generated for the whole data set. Both descriptive and interpretative codes were used (Lyons \u0026amp; Coyle, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). In a third step, codes were clustered into themes and sub themes. The generated themes were then checked with respect to their fitting with the respective data and were revised accordingly. Finally, the themes were refined by considering the broader context of the whole data set, to ensure that they are representative for the data. This process included rereading the texts as well as comparing the results with the researchers\u0026rsquo; initial codes. The resulting themes were sorted according to the research questions capturing the \u003cem\u003esemantics\u003c/em\u003e, \u003cem\u003efoci\u003c/em\u003e and \u003cem\u003emodalities\u003c/em\u003e of self-reflection. To ensure trustworthiness (Lincoln et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1985\u003c/span\u003e)⁠, the research team applied the following steps: First, to ensure credibility the six TA steps (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) were followed closely and recursively implemented. Moreover, the authors utilized investigator triangulation (EK analyzed all, while a research fellow analyzed 5 essays) and consensus discussions (EK, LG, research fellow). Additionally, to ensure replicability, an audit trail reporting in detail all activities, decisions, research steps and provisional results was used to save and document all phases of the research project. The presentation of our research is based on the APA standards for reporting qualitative research (see Levitt et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eWe are aware of several personal influencing factors regarding the data analysis. The fact that EK works as a CBT therapist shaped her perspective and expectations on what aspects of self-reflection could be important. Particularly, she became attentive to the aspects of self-awareness (thoughts, emotions, body sensations, behavior) that are typically addressed during CBT therapy. Including a research fellow (with a psychoanalytic background) and LG (trained systemic psychotherapist) in the analysis brought in more perspectives, and at the same time consolidated EK\u0026rsquo;s initial impressions. Moreover, at the beginning of the data analysis EK still worked in one of the cooperating clinics, organized students\u0026rsquo; internships and supervised students. Her dual role of researcher und students\u0026rsquo; tutor made it difficult for her to take an external observer\u0026rsquo;s perspective on the data. Moreover, due to her previous research experience with quantitative research methods, EK found the shift from a positivist to a constructivist perspective (which has a direct impact on the way data are coded) especially challenging. To reflect on and handle these issues EK utilized a regular exchange with the research team.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthical Remarks\u003c/h2\u003e\u003cp\u003e All participants received information about the study and gave their informed consent. The data were treated anonymously and confidentially. Published data contain no quotes that could disclose the identity of any student. The study was conducted according to the national and international ethical guidelines, and it was approved by the BMS ethics committee (Brandenburg Medical School: no. E-01-20230211).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe resulting themes were systematized according to the research questions into the three dimensions of \u003cem\u003efoci\u003c/em\u003e, \u003cem\u003emodalities\u003c/em\u003e, and \u003cem\u003esemantics\u003c/em\u003e. In what follows, we describe all themes and sub themes generated in the analysis (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003ch3\u003eSemantic Themes of Self-reflection\u003c/h3\u003e\n\u003cp\u003eWe begin with the presentation of the \u003cem\u003esemantic\u003c/em\u003e themes, i.e., themes pertaining to core meaningful contents in the students\u0026lsquo; narratives. We carve out four central \u003cem\u003esemantic\u003c/em\u003e themes that characterize students\u0026rsquo; self-reflections: (1) Moving between insecurity and security as a source of self-reflection (2) Demonstrating competence and giving opinions as a strategy of assertiveness, (3) The need for meaningfulness and comprehensibility as a source of self-reflection, (4) Curiosity and fascination as a motivating force for self-reflection. In what follows, we present the four themes in more detail, by grounding them on textual quotes.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMoving between Insecurity and Security as a Source of Self-reflection\u003c/h2\u003e\u003cp\u003eAt the beginning I was nervous and insecure. In the course of the conversation, I regained the feeling of security, which I would not have expected. (Stud. 6)\u003c/p\u003e\u003cp\u003eThe main focus of this theme is on the shift from feeling insecure to feeling secure and on the influencing factors regarding this transformative process. Indeed, we observe that the main topic of self-reflection are insecurities evoked in clinical situations. Semantically speaking, insecurity thus seems to initiate the self-reflection process.\u003c/p\u003e\u003cp\u003eStudents described insecurity as being so challenging that their self-reflections were mostly concerned with how to handle or to get rid of this feeling. Coping strategies such as relying on theory, preparing in advance or trying to steer the situation were experienced as not being helpful in dealing with insecurity. On the contrary, enduring challenging situations and tolerating insecurity was experienced as adjuvant (for examples on hindering and helpful strategies, see quotes in sub themes below). This first theme thus emphasizes the constructive potential of insecurity (and of accepting it) as a source of self-reflective processes and thus \u0026ndash; even if counterintuitively \u0026ndash; as an important building block for one\u0026rsquo;s own self-confidence.\u003c/p\u003e\u003cp\u003eIn the analysis we could also carve out factors that influenced the feeling of insecurity. These factors were clustered in three sub themes: (1a) Previous experience as a diachronic influencing factor, (1b) Interpersonal interaction as a synchronic influencing factor, (1c) Framework as a contextual influencing factor. These three influencing factors differ in the way they are temporally experienced (previous, immediate, or enduring aspects). Yet, the aspect of newness was a character shared by all three influencing factors and semantically related to the feeling of insecurity. In what follows we describe the sub themes in more detail.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrevious Experience as a Diachronic Influencing Factor.\u003c/em\u003e Across self-reflection essays we found that students\u0026rsquo; feelings of (in)security changed according to their previous clinical experience: Lack of clinical experience yielded feelings of insecurity, whereas previous clinical experience supported a feeling of security. Interestingly, theoretical knowledge learned during lectures, in a \u0026ldquo;secure surrounding\u0026rdquo; (Stud. 5), was not experienced as having a substantial impact on students\u0026rsquo; feeling of insecurity when dealing with challenging clinical situations. A tendency to prepare in advance or to rely on already learned knowledge when feeling insecure emerged from the narratives. However, this was not experienced as helpful in dealing with insecurity:\u003c/p\u003e\u003cp\u003eI tried to consider all the details we have learned: body posture, paraphrasing, relationship building. But I realized quickly that this is hard for me as a 3rd semester student without much practical experience. Experience, that will occur over time (\u0026hellip;) so that hopefully one day all these concerns will become second nature to me. (Stud. 6)\u003c/p\u003e\u003cp\u003eOn the other hand, students mentioned previous clinical experience and practical training to be beneficial in difficult clinical situations:\u003c/p\u003e\u003cp\u003eThe cranky comments of the patient made me feel insecure but because I have observed the reactions of therapists and doctors in similar situations, I was able to react self-confidently to his comments (\u0026hellip;). That helped me a lot during the testing. (Stud. 3)\u003c/p\u003e\u003cp\u003eIn this example, Stud. 3 regards themselves as being capable of reacting self-confidently due to their previous life experiences. This was confirmed by other students\u0026rsquo; narratives: more clinical experience gave them a feeling of \u0026ldquo;calmness\u0026rdquo; (Stud. 3), \u0026ldquo;confidence\u0026rdquo; (Stud. 6) and \u0026ldquo;security\u0026rdquo; (Stud. 8). Interestingly, helpful experience was not limited to a student\u0026rsquo;s own gained clinical experience. Additionally, observing similar challenges undergone by colleagues was also perceived as being beneficial.\u003c/p\u003e\u003cp\u003eIn the semantic analysis of text extracts, in which students reflected on their lack of clinical experience, we observe that it was essentially the aspect of unfamiliarity/newness of the situation that yielded insecure feelings. Yet, at the same time, students experienced tolerating, instead of avoiding, insecurity as helpful and as leading to more confidence in future clinical situations. Students even described feelings of pride and satisfaction after trying to face situations in which they felt insecure. Thus, not only clinical training in a narrow sense but also the enduring of previous challenging clinical experiences constitute this sub theme, which we call a \u003cem\u003ediachronic\u003c/em\u003e influencing factor on (in)security. For instance, in the following quote, Stud. 6 considers rising to the challenge of tolerating feelings of insecurity as an opportunity:\u003c/p\u003e\u003cp\u003eThis task would have been easier with a different patient. But then I would not have been able to gain the experience, to feel frustrated and to reflect on this fact, to have self-doubts regarding my competencies. I would not have been able to see the task as a chance to grow. (Stud. 6)\u003c/p\u003e\u003cp\u003e\u003cem\u003eInterpersonal Interaction as a Synchronic Influencing Factor.\u003c/em\u003e Interpersonal interaction is presented here as a further central influencing factor on (in)security that permeates students\u0026rsquo; narratives. Students reported that the suddenness or newness coming with the situational moment evokes challenging insecure feelings. Such insecurity is related to the experience that, in the here-and-now unfolding of an interaction, immediate reactions are required. This was thus clustered as a s\u003cem\u003eynchronic\u003c/em\u003e influencing factor. As in the sub theme above, here students also attempted to prepare in advance and to rely on previous knowledge as strategies to face insecurity. Yet, what was experienced as helpful was rather to rely on and trust in one\u0026rsquo;s own intuition as well as to engage in the interaction and adjust to it instead of trying to steer it. In the following quote a student carefully describes their emotional fluctuations in the here and now of an interaction with a patient and how they let themselves be influenced by the patient\u0026rsquo;s calmness.\u003c/p\u003e\u003cp\u003eBefore the conversation (\u0026hellip;) my body and my mind were relaxed (\u0026hellip;). When the patient arrived and we entered the room together, I found I was getting nervous, and my heart raced a bit. However, this feeling changed quickly because the patient had a very calming nature, which was a bit infectious and served to calm me down quickly. (Stud. 8)\u003c/p\u003e\u003cp\u003eEven if it is not always the case that calmness and security are directly conveyed by patients, across these reflections we observe that engaging in the here-and-now dynamic of an interaction and \u0026ndash; again \u0026ndash; tolerating the insecurity related to the process, helped students to feel more grounded and self-confident.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFramework as a Contextual Influencing Factor.\u003c/em\u003e Finally, the contextual framework that the students have to deal with appears to be another important factor affecting the feeling of (in)security. Here, with \u003cem\u003econtextual\u003c/em\u003e factors we refer to external circumstances such as hospital routines or structures, time pressure, the specific role of being an intern in the psychiatric hospital, or a (lacking) support by supervisors. According to the students\u0026rsquo; reflections, these contextual and structural aspects can both be helpful and supporting, or disconcerting. Students consistently described time pressure as a hindering factor. The characteristic of this experience was that under time pressure it was not possible for students to prepare in advance and reliably predict or control a situation. Also here, what seems challenging is specifically the confrontation with the newness and suddenness of a situation:\u003c/p\u003e\u003cp\u003eThe therapist (\u0026hellip;) only asked two minutes before the beginning of the testing if I could conduct the testing, so I was taken by surprise. I had no time in advance to read about the test or examine it thoroughly. At the beginning of the testing, I was very insecure (...) But the further we got into the testing, the more relaxed I became. (Stud. 3)\u003c/p\u003e\u003cp\u003eThroughout the essays, the experience of a lack of support by colleagues and of difficult team dynamics formed another challenging contextual aspect associated with feelings of insecurity. Contrarily, the support of other clinicians appeared to help students handle insecurity. This could be the experience of being \u0026ldquo;taken by the hand\u0026rdquo; (Stud. 8) in a challenging moment or having the opportunity to exchange views with a clinician while still being in the afterglow of a demanding situation. Students described their insecurity as arising from the desire to do things right and to appear competent in their new field of work. Thus, insecurity seemed to be fed by expectations in the work environment (which were internalized by students). In the following quote, a student describes the inner conflict between wanting to meet these expectations and at the same time accepting the fact that as an intern, one does not yet have the ability to fulfill them:\u003c/p\u003e\u003cp\u003eThe desire of an intern to appear like a professional is now paradoxical to me. At the same time, I barely know human beings who would like to willfully appear incompetent. Of course, it is important to reflect on oneself (...) but the capacity I have for the other person (the patient) would then suffer from that. (Stud. 1)\u003c/p\u003e\u003cp\u003e\u003cem\u003eDemonstrating Competence and Giving Opinions as a Strategy of Assertiveness.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn this theme, we present a pattern of meaning that was generated across students\u0026rsquo; self-reflections: the expression of confidence, giving opinions, and highlighting one\u0026rsquo;s own competence. In contrast to the previous theme, which included the experience of pride and confidence when facing insecurity in challenging situations (see theme 1a), the semantic core of this theme is rather assertiveness.\u003c/p\u003e\u003cp\u003eHere, assertiveness is differentiated from confidence as it was semantically related to a \u0026ldquo;desire\u0026hellip; to appear like a professional\u0026rdquo;, as student 1 mentions it in the quote above, i.e., to show competence rather than feel confident and competent. Thus, in the narratives, assertiveness was related to feelings of insecurity, also yielded by the expectations from others (see also Subtheme 1c). Next to semantic codes explicitly referring to the experience of being assertive, the classification of this theme was also supported by several latent codes, which captured the implicit semantic connotation of the narrative. We further differentiate two sub themes regarding the ways in which students asserted themselves in the narratives: (2a) demonstrating competence and (2b) giving opinions. We observe throughout these narratives that when demonstrating competence and giving opinions, the students\u0026rsquo; focus moved away from themselves (i.e., from self-reflection) and shifted to a (factual) description of good practice (as exemplified in all quotes below). Consequently, assertiveness seemed to reduce the self-reflective character of the narratives.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDemonstrating Competence\u003c/strong\u003e\u003cp\u003eIn their self-reflection narratives, students attempted to demonstrate their competence and knowledge, e.g., by reporting about methods learned at university, which they might assume is expected from them. This is also coherent with the felt pressure to fulfill others\u0026rsquo; expectations as shown in subtheme 1c. In the following quote a student reflects on the first time they had contact with a suicidal patient by describing the typical screening questions they asked\u003c/p\u003e\u003c/p\u003e\u003cp\u003eI then asked him if he only dreams about suicide or if he also experiences suicidal thoughts during daytime (...). Subsequently, I asked how he would commit suicide (...) and if he already had a date in mind for when he wants to do it. Finally, I asked him if he had talked about his thoughts with others, if he had made any preparations or if he had written a goodbye letter. (Stud. 5)\u003c/p\u003e\u003cp\u003eThis quote represents a way of demonstrating that they know how to act in the right way for this situation, more than reflecting upon their own experience in that moment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eGiving Opinions\u003c/strong\u003e\u003cp\u003eWithin their reflections, students confidently shared their opinions and assessments on the relevant circumstances. Also here, in their given opinions we observe a shift of focus to the external reality instead of engaging in the reflection of oneself. Similar to demonstrating their competence, by giving opinions they assert themselves and appear more self-confident and secure. When giving their opinions, students engaged in considerations such as, what they think raises the quality of psychiatric treatment, which interventions they find helpful, or what kind of behavior is most professional in their view. While doing so they generally took the stance of someone who knows what is right or wrong\u003c/p\u003e\u003c/p\u003e\u003cp\u003eRegarding the concrete situation, I have the opinion that the group had a good opportunity to learn. Even though it may sound harsh, I do not think that patients should leave the hospital expecting that their environment will react with concern towards them. (Stud. 1)\u003c/p\u003e\u003cp\u003eAs an extreme form of giving opinions, some students also devalued others, possibly to demonstrate their competence:\u003c/p\u003e\u003cp\u003eI realized in part, that I would have used different questions than the therapist and had engaged in deeper questioning (...). Moreover, I found it difficult when the therapist would interrupt the patient. In my opinion, when a patient with an eating disorder talks about eating, all information should be recorded. (Stud. 6)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe Need for Meaningfulness and Comprehensibility as a Source of Self-reflection.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eStudents expressed a need for meaningfulness and comprehensibility, mainly regarding the behavior of patients or clinical staff as well as in the general structures within the psychiatric hospital environment. In their accounts, students reflected upon various aspects that would cause them to question the given situations. Here they would try to find \u0026ldquo;solutions\u0026rdquo; (Stud. 1) and to \u0026ldquo;understand the patients and their concerns\u0026rdquo; (Stud. 1). The self-reflection process was thus often initiated by a need to try to understand what was yet incomprehensible:\u003c/p\u003e\u003cp\u003eHis thoughts would not deal with suicide itself but only with the wish to not be there anymore, because he then would not have to handle the feelings of guilt. It is beyond my imagination how big the feelings of guilt must be, to have thoughts like that. (Stud. 5)\u003c/p\u003e\u003cp\u003eIn this example the student acknowledges not being able to fully comprehend the patient. In the students\u0026rsquo; narratives we observe that a lack of comprehension led to and maintained reflective processes: \u0026ldquo;The patient stayed in my mind for a very long time (...) I still don\u0026rsquo;t understand the reason for her call\u0026rdquo; (Stud. 1). Yet, the feeling of not being able to let go of an \u0026ldquo;unresolved/incomprehensible\u0026rdquo; situation could also result in rumination: \u0026ldquo;Due to the unresolved situation and the desire to find a label for the patient, I forgot (...) the task I wanted to accomplish\u0026rdquo; (Stud. 1). Thus, when the feeling of incomprehensibility becomes too much or too persistent, it might have a hindering effect on the capacity to deal with the situation, resulting in losing focus.\u003c/p\u003e\u003cp\u003eYet at the same time, students reflected upon the need to accept (instead of avoid) the uncertainty related to the feeling of not-knowing:\u003c/p\u003e\u003cp\u003eAgain, I feel puzzled. I think I am not the only one with the idea of studying psychology because I hoped that through this (applied) science I would find answers to various questions. Instead, even more questions are raised (...) instead of answering questions the essence is probably to develop an acceptance for the uncertainty. (Stud. 1)\u003c/p\u003e\u003cp\u003eAlthough looking for quick answers appeared to be an automatic impulse of many students, they also reflected upon the costs of it: \u0026rdquo;The wish to name things, to demystify them and finally get the feeling to have understood the \u0026lsquo;big picture\u0026rsquo; seems to be threatening my stance of curiosity regarding the patients\u0026ldquo; (Stud. 1).\u003c/p\u003e\u003cp\u003eWhile the feelings of incomprehensibility can challenge students and make them lose focus, giving quick answers might come with losing one\u0026rsquo;s curiosity for human beings\u003c/p\u003e\u003cp\u003e\u003cem\u003eCuriosity and Fascination as a Motivating Force for Self-reflection.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCuriosity and fascination are captured as core semantic aspects of this last theme. We define those, based on the narrative accounts, as being particularly relevant with regard to \u003cem\u003emotivating\u003c/em\u003e the engagement in self-reflecting processes. These aspects especially occur in situations that are novel to students and often create feelings of insecurity. Thus, we observe a co-occurrence of fascination, curiosity, and insecurity\u003c/p\u003e\u003cp\u003eThe situation was difficult for me, because on the one hand (\u0026hellip;) I found it fascinating that he seemed to be so convinced by his stories, as if they were reality. On the other hand, I was concerned about validating his thoughts, so that he\u0026rsquo;d lose reality out of sight even more. That is why I felt very insecure. (Stud. 5)\u003c/p\u003e\u003cp\u003eAs deducted from the quote above, on the one hand students were fascinated by or curious about the patients they have met, their syndromes or their interactions. On the other hand, students showed fascination for observing how (\u0026ldquo;competent\u0026rdquo;, Stud. 6; \u0026ldquo;professional\u0026rdquo;, Stud. 1; \u0026ldquo;serene\u0026rdquo;, Stud. 3) clinicians handled certain situations:\u003c/p\u003e\u003cp\u003eWhile the patient had been visited during the ward round, I felt a tense curiosity about how the conversation might proceed (...). I was especially curious about the interaction between clinician and patient (\u0026hellip;). I have experienced how one (\u0026hellip;) handles a difficult patient. (Stud. 6)\u003c/p\u003e\u003cp\u003eCuriosity and fascination might have the potential to act as a motivating force for self-reflection. As the quote above underlines, the way clinicians handle potentially unsettling situations seems to be particularly fascinating for students. This also relates to theme 1a, in which we could show how students\u0026rsquo; insecurity was reduced by experiencing and witnessing the competence of more experienced therapists. Observing the clinical work of psychotherapists thus seems to both foster self-confidence and motivation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFoci of Self-reflection\u003c/h2\u003e\u003cp\u003eDue to their more self-explanatory nature, we will give a concise summary of themes regarding \u003cem\u003efoci\u003c/em\u003e and \u003cem\u003emodalities\u003c/em\u003e of self-reflection in the following. The first relevant distinction regarding self-reflection \u003cem\u003efoci\u003c/em\u003e is between \u003cem\u003einside\u003c/em\u003e and \u003cem\u003eoutside foci\u003c/em\u003e. It is remarkable to observe that some of the students focused their reflection more on the outside world while others turned their attention back toward themselves. When reflecting on the outside, students mainly tended to focus on patients and staff, along with the circumstances in the psychiatric ward. Students also looked at the interaction between their focus on the outside and their focus on the inner life, mostly in observing how the outside world influenced what was evoked inside of them. For example, they observed how the patients\u0026rsquo; behavior evoked certain behavioral reactions or how it affected their emotions: \u0026ldquo;In comparison to the last times I\u0026rsquo;d seen him, he appeared to be a different person. That frightened me a little bit\u0026rdquo; (Stud. 5). Focusing on the inside and the observation of how the outside influences the inside appeared to foster self-reflection. In contrast, we notice that exclusively focusing on the outside, as in the following example, seemed to prevent the self-reflective process:\u003c/p\u003e\u003cp\u003eTwo other patients encouraged her that it would probably be best if she left her mother-in-law in a nursing home. This discussion helped the patient as she also said that she feels relieved not to be the only one with this problem. (Stud. 7)\u003c/p\u003e\u003cp\u003eBased on the narrative accounts, the inner focus can be further differentiated by focusing on \u003cem\u003etraits\u003c/em\u003e or \u003cem\u003estates\u003c/em\u003e. When focusing on their inner world, students would concentrate on their states rather than on their traits, meaning that they concern themselves with exploring their behavior, emotions, bodily feelings, and thoughts in the situation, rather than with their personality and how it influences their experience. The frequency of the use of those different inward related \u003cem\u003efoci\u003c/em\u003e differs widely. Yet, the analysis generally shows that students focus mostly on their behavior, followed by their emotions. Few students focus on their thoughts and only a couple of them focus on their bodily feelings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eModalities of Self-reflection\u003c/h2\u003e\u003cp\u003eIn the narrative accounts we construct five different types of \u003cem\u003emodalities\u003c/em\u003e students use to reflect on situations during their internships: a. \u003cem\u003edescribing\u003c/em\u003e, b. \u003cem\u003eassessing\u003c/em\u003e, c. \u003cem\u003ereasoning\u003c/em\u003e, d. \u003cem\u003econnecting\u003c/em\u003e, e. \u003cem\u003econcluding\u003c/em\u003e. Students do not exclusively use one \u003cem\u003emodality\u003c/em\u003e but combine them throughout their written self-reflections. Examples of the different kinds of \u003cem\u003emodalities\u003c/em\u003e are shown in Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003e\u003cb\u003eT A B L E 1. Examples of modalities.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003edescribing\u003c/em\u003e: neutral description of the observed or experienced situation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt the beginning of the testing, I introduced myself again and informed about my professional secrecy, described the procedure, and told the patient that he could ask if questions arise. (Stud. 3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eassessing\u003c/b\u003e: \u003cb\u003eevaluation of situations, oneself, staff members, patients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI would evaluate the whole conversation as professional as well as experienced. (Stud. 1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ereasoning\u003c/b\u003e: \u003cb\u003eexplaining reactions, feelings, etc. of oneself and others\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMoreover, the patient appeared helpless. Combined with the sympathy, it provoked a strong need to help her. The helplessness resulted from her very small and tiny figure, that she appeared so fragile and much younger. (Stud. 6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003econnecting\u003c/b\u003e: \u003cb\u003edrawing connections to former experiences, knowledge, etc.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn fact, I already knew about the topic, because we talked about it during a practical seminar, but it was very interesting to see how patients with psychosomatic symptoms reacted to the euthyme therapy. Therefore, it was a very informative lesson for me. (Stud. 8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003econcluding\u003c/b\u003e: \u003cb\u003edrawing conclusions out of the experiences made during the situation that was reflected on\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnger and frustration are for me an indicator that I have to develop strategies to handle such and other professional challenges. My current coping strategies in this regard, like reading, are still not sufficient. (Stud. 1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"1\"\u003eBold Italic: type of modality, bold: description of modality, normal font: textual quotes\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eInterestingly, the occurrence of the \u003cem\u003emodalities\u003c/em\u003e differs. The most recurrent \u003cem\u003emodality\u003c/em\u003e is describing (e.g., what they do). Secondly, students use the \u003cem\u003emodalities\u003c/em\u003e assessing (e.g., evaluating behaviors) and reasoning (e.g., why they would feel a certain way). Several students also occasionally use the \u003cem\u003emodality\u003c/em\u003e concluding: for example, in summing up what learning experience they drew out of the described situation. Less common was the \u003cem\u003emodality\u003c/em\u003e connecting (putting their experiences into context, e.g., regarding previous experiences).\u003c/p\u003e\u003cp\u003eFurthermore, we also observe an interesting overlap between \u003cem\u003emodalities\u003c/em\u003e and \u003cem\u003esemantics\u003c/em\u003e. Students would especially use \u003cem\u003eassessing\u003c/em\u003e for assertiveness or for devaluing others. Both, as we discussed when looking into the \u003cem\u003esemantics\u003c/em\u003e, could be viewed as possibilities to cope with insecurities.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present qualitative study examines written self-reflections of a cohort of psychology students, aiming to describe and systematize relevant \u003cem\u003efoci\u003c/em\u003e, \u003cem\u003emodalities\u003c/em\u003e and \u003cem\u003esemantic\u003c/em\u003e aspects of the self-reflection process.\u003c/p\u003e\u003cp\u003eDealing with insecurity has been carved out as a core and overarching semantic theme and as the central process that fuels or thwarts self-reflection. Nearly all self-reflections in the students\u0026rsquo; narratives express shifts on a movement between security and insecurity or can be related to this theme. The scientific relevance of our results is mainly related to two main findings: Firstly, insecurity - in its different facets - has been shown to be relevant for the initiation of self-reflection. Secondly, such an initiation of self-reflection seems to depend on the way prospective therapists cope with their insecurities. Figure\u0026nbsp;2 summarizes our findings.\u003c/p\u003e\u003cp\u003eOur finding that insecurity can initiate an act of self-reflection and can therefore be supportive for further professional development supports the results of previous studies (Atkins \u0026amp; Murphy, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1993\u003c/span\u003e; Niemi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Taubner \u0026amp; Evers, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Th\u0026eacute;riault et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Th\u0026eacute;riault \u0026amp; Gazzola, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Two semantic themes concerning the need for \u003cem\u003emeaningfulness and comprehensibility\u003c/em\u003e as well as the \u003cem\u003efeeling of curiosity and fascination\u003c/em\u003e specifically capture ways in which insecurity (e.g., the feeling of not yet knowing) can fuel self-reflection. According to Antonovsky (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1997\u003c/span\u003e), meaningfulness and comprehensibility are two necessary aspects for experiencing a sense of coherence (SOC), which is described as a resilient mindset that enables individuals to confidently navigate life\u0026rsquo;s challenges, promoting well-being and effective stress management. He describes meaningfulness and comprehensibility respectively as 1. when requirements are to be understood as challenges worth committing to 2. when events of one's inner and outer environment are predictable and explainable. When applying Antonovsky\u0026rsquo;s concept to our results, one could hypothesize that experiencing \u003cem\u003emeaningfulness\u003c/em\u003e might give one a reason to better tolerate insecurity (2. challenge worth committing to). On the other hand, looking for \u003cem\u003ecomprehensibility\u003c/em\u003e might be an attempt to reduce insecurity by being more capable and in control (1. events are predictable and controllable). This would therefore support the finding that striving for meaningfulness and comprehensibility might help tolerate uncertainty and thus in turn foster self-reflection.\u003c/p\u003e\u003cp\u003eWe find that feelings of \u003cem\u003ecuriosity and fascination\u003c/em\u003e can additionally serve as a motivating factor for engaging in self-reflection. Expectedly, we recognize that the states of \u003cem\u003ecuriosity and fascination\u003c/em\u003e, the need for meaningfulness and comprehensibility as well as insecurity seem usually to arise in new situations and are often experienced concurrently. As Antonovsky (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) argues, it is a typical human reaction to seek a sense of security or increased knowledge. Yet according to our results, as soon as these situations appear to be less challenging or new, they lose their potential to raise curiosity and fascination as a motivating force and in that also the potential for self-reflection seems to stagnate. This conclusion is supported by previous research, where especially new and challenging experiences were shown to prompt self-reflective processes (Niemi \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Pompeo \u0026amp; Levitt, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)⁠.\u003c/p\u003e\u003cp\u003eOur findings also indicate that some students experience insecure feelings as overwhelming and thus hope to eventually get rid of their insecurities. This is not surprising, as previous studies have shown that psychotherapists in training experience their first therapy sessions as challenging and distressing (R\u0026oslash;nnestad \u0026amp; Skovholt, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Taubner et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Th\u0026eacute;riault \u0026amp; Gazzola, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). As a way of coping, we find in the analyzed accounts that students tend to compensate for their insecurities by preparing for their tasks and relying on previous knowledge. Th\u0026eacute;riault \u0026amp; Gazzola (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)⁠ describe this kind of impression of lacking knowledge or experience as the \u0026ldquo;empty toolbox syndrome\u0026rdquo;. Accordingly, therapists might believe they will feel more competent once they know more. Sch\u0026ouml;n (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1983\u003c/span\u003e)⁠ argues that relying primarily on knowledge serves as an effective strategy for those who experience uncertainty as threatening or a sign of weakness. Yet, the author also states that it is exactly this reliance on knowledge that keeps the person away from being attentive to the moment. As our findings suggest, meticulous preparation or theoretical knowledge do not automatically reduce insecurity. It is instead prior experience that seems to have an impact on how secure students feel. The effect of experience on (in)security is supported by the research of R\u0026oslash;nnestad \u0026amp; Skovholt (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), who demonstrate that insecurity occurs less as therapists become more experienced.\u003c/p\u003e\u003cp\u003eA second adverse coping strategy central to our results is \u003cem\u003eassertiveness\u003c/em\u003e: Students present their competencies and give opinions, evaluate themselves or devalue others which leads to a shift in the focus of a reflection away from one\u0026rsquo;s own (insecure) feelings towards the outside world. We conceive of this as a way to avoid insecurity, which, interestingly enough, is also narratively related to reduced self-reflection. Th\u0026eacute;riault \u0026amp; Gazzola (2009) show in their interview study, that therapists apply several adverse coping strategies to compensate their feelings of insecurity, such as giving advice or sticking to theory. Similarly, as a way of mastering challenging therapeutic situations, R\u0026oslash;nnestad \u0026amp; Skovholt (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e)⁠ describe the concept of \u0026lsquo;premature closure\u0026rsquo;: By using strategies like sticking to theoretical approaches or only focusing on a certain group of patients, therapists might try to avoid being emotionally overwhelmed by reducing the complexity of the situation (R\u0026oslash;nnestad \u0026amp; Skovholt, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Skovholt \u0026amp; R\u0026oslash;nnestad, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Akin to our findings, premature closure can interrupt the self-reflection process by yielding a shift from reflection to evaluation (Skovholt et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; R\u0026oslash;nnestad \u0026amp; Skovholt, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). We thus hypothesize that assertiveness could be a way of premature closure and that students resort to assertiveness to deal with (or avoid) overwhelming feelings.\u003c/p\u003e\u003cp\u003eNevertheless, from our findings we can conclude that insecurity is not per se deleterious. Depending on the coping strategies students adopt, insecurity could even be helpful. The current study illustrates that it is exactly the experience of accepting insecurity that seems to be the most helpful in reducing it. As previous studies could show, tolerating insecurity can also serve as a base for using constructive coping strategies (e.g., Quinlan et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nissen-Lie et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In a similar manner, Galbusera et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) could stress out the positive impact of tolerating insecurity for the therapeutic process. Their study implies that avoiding uncertainty (e.g., through piling up theoretical knowledge), results in a more distant relationship, whereas tolerating it leads to more closeness between therapist and patient.\u003c/p\u003e\u003cp\u003eYet, our results also draw attention to potential negative effects of insecurity on self-reflection. We observe that insecurity can sometimes end up in rumination, which can lead the attention away from the interaction with the patient. In this context, previous research shows that therapists who are not able to manage insecurity might experience negative personal effects such as burn out (Hannigan et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2004\u003c/span\u003e)⁠ or quitting the profession (Th\u0026eacute;riault \u0026amp; Gazzola, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2006\u003c/span\u003e)⁠. Finding the right balance between overwhelming insecure feelings and stagnation due to a potentially false sense of security thus appears to be very relevant for a constructive self-reflective process.\u003c/p\u003e\u003cp\u003eIn our analysis, we can observe a complex interplay between the \u003cem\u003esemantic\u003c/em\u003e aspects and other dimensions of self-reflection (\u003cem\u003emodalities\u003c/em\u003e and \u003cem\u003efoci\u003c/em\u003e). For example, the \u003cem\u003esemantic\u003c/em\u003e of assertiveness is related to the \u003cem\u003emodality\u003c/em\u003e of assessing. As such, a potential attempt to avoid insecurity is also related to a shift in the focus to the \u0026lsquo;outside\u0026rsquo;. Our differentiation between outside and inside \u003cem\u003efoci\u003c/em\u003e matches the dimensions developed by Jahncke (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). With the inside-outside dimension, the author differentiates between one's own behavior (inside) and exterior circumstances regarding the learning environment (outside), stressing the importance of both for self-reflection. In our analysis, we observe that if a focus on the outside steers the attention away from oneself it potentially diminishes the ability to self-reflect (i.e., possibly also affecting the \u003cem\u003emodality\u003c/em\u003e). Empirical evidence indicates that focusing on the outside is more common in inexperienced therapists and fades over time (R\u0026oslash;nnestad \u0026amp; Skovholt, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2003\u003c/span\u003e)⁠. Interestingly, although we do not quantitatively assess the occurrence of different \u003cem\u003efoci\u003c/em\u003e, a stronger (inside-)focus on emotions and behavior, and a neglect of bodily sensations, characterized the students\u0026rsquo; narratives. Mojta et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)⁠ highlight that the reflection on internal experiences including physiological reactions might be helpful for the development of self-awareness⁠. In conclusion, we assume that for psychotherapists, bodily sensations might be conceived as an important experiential aspect to be reflected upon (see Kanfer \u0026amp; Saslow, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1965\u003c/span\u003e). Moreover, we find it remarkable that students usually do not focus on their traits (e.g., personality, behavioral patterns). Unfortunately, there is relatively little research on the question of if and how therapists\u0026rsquo; traits influence the therapy outcome (Gries et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)⁠. More empirical evidence is needed to examine the relation between these \u003cem\u003efoci\u003c/em\u003e (states-traits) and the quality of self-reflection as well as the therapy outcome.\u003c/p\u003e\u003cp\u003eFinally, in our findings we can differentiate five \u003cem\u003emodalities\u003c/em\u003e of self-reflection: describing, assessing, reasoning, connecting, concluding. While these results represent similar self-reflection categories as discussed in the pedagogical field by Hatton \u0026amp; Smith (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), Jahncke (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), Krieg \u0026amp; Kreis (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and Ryan (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), one important insight, emerging from our analysis, is that different \u003cem\u003emodalities\u003c/em\u003e seem to relate to \u003cem\u003esemantic\u003c/em\u003e aspects, which are specific to the psychotherapeutic field.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e\u003cp\u003eWhen interpreting the study\u0026rsquo;s results, one should consider several limitations. First, it is important to note that the analyzed self-reflection essays were part of students\u0026lsquo; educational performance and were marked by supervisors. Moreover, students might have felt that they had to appear competent to fulfill expectations from the clinical staff. Both aspects could lead to social desirability and make students focus more on self-assertion than on self-reflection. Second, using a qualitative-explorative design, our study should be conceived as a pilot exploration, which can serve as a basis for quantitative studies on larger samples. Only such studies could potentially show how frequently the \u003cem\u003efoci\u003c/em\u003e, \u003cem\u003emodalities\u003c/em\u003e and \u003cem\u003esemantic\u003c/em\u003e aspects derived within this work, are in fact apparent in self-reflections of prospective psychotherapists. Based on our results, we cannot yet define what constitutes good self-reflection. Experimental studies are needed to support our interpretations concerning the usefulness of different self-reflection and coping styles in therapy training. Further investigations could focus on explicitly inquiring about the perspective of the reflecting individuals and their fostering professionals thereby complementing our findings on what supports and hinders the self-reflection process. Moreover, future research should investigate the question of what \u003cem\u003emodalities\u003c/em\u003e contribute to the quality of self-reflection (over time), with the aim of developing a tool able to measure competency to self-reflect by means of connecting the captured \u003cem\u003emodalities\u003c/em\u003e to therapeutic abilities and therapy outcome. Finally future research could focus on the way training for psychotherapists should be designed, to support the development of self-reflection competence.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo our knowledge, the present study is the first to analyze self-reflection essays in the psychotherapeutic field, particularly covering the students\u0026rsquo; progress over the full course of their practice semesters. Our study presents important findings regarding insecurity and related feelings as sources of self-reflection as well as coping strategies in dealing with insecurity. Moreover, the findings of this study offer a basis for a first operationalization of self-reflection-competency in the training of psychotherapy and constitute a basis for the construction of a rating scale for assessing it.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eBMS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBrandenburg Medical School\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCBT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCognitive Behavioral Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSOC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSense of coherence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThematic Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was conducted according to the national and international ethical guidelines, and it was approved by the BMS ethics committee (Brandenburg Medical School: no. E-01-20230211).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The research project was not supported by any specific grant from funding agencies in the public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003cstrong\u003eK\u003c/strong\u003e: Investigation; conceptualization; methodology; validation; writing; formal analysis; project administration; data curation; software; visualization. \u003cstrong\u003eCN\u003c/strong\u003e: Investigation, conceptualization; project administration. \u003cstrong\u003eLG:\u003c/strong\u003e Supervision, conceptualization, methodology; writing and paper revision, formal analysis. \u003cstrong\u003eJL\u003c/strong\u003e:\u0026nbsp;Supervision; conceptualization; paper revision\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: The authors would like to thank Maren Schlimm for her support in analyzing the data. Moreover, we would like to thank Nathan Hudson and Till Martini for their valuable feedback on the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information: EK\u0026nbsp;\u003c/strong\u003eis a researcher at Brandenburg Medical School and responsible for the training of prospective psychotherapists at MAPP Institut, Germany.\u0026nbsp;Her\u0026nbsp;research focuses on psychotherapeutic skill\u0026nbsp;development and its support in training. As a CBT-trained psychotherapist with a private practice in Berlin, she works with\u0026nbsp;individuals as well as couples, applying schema-therapeutic and emotion-focused approaches.\u003cstrong\u003e\u0026nbsp;CN\u003c/strong\u003e is employed as a Research Assistant and Associate Lecturer at Brandenburg Medical School where she teaches and supervises students during training. Her doctorate studies are focused on the subject of \u0026ldquo;Teaching and measuring basic psychotherapeutic skills during studies\u0026rdquo;. Additionally, she works as CBT-psychotherapist and supervisor.\u003cstrong\u003e\u0026nbsp;LG\u003c/strong\u003e is a professor of clinical psychology and systemic therapy at Brandenburg Medical School. Her research focuses on therapeutic processes, psychosis treatment, and the impact of the therapeutic stance on recovery. She is actively involved in the teaching and supervision of psychology students at Brandenburg Medical School and works as a systemic psychotherapist at the psychiatric clinic in R\u0026uuml;dersdorf.\u003cstrong\u003e\u0026nbsp;JL\u003c/strong\u003e is Professor for Clinical Psychology and Rehabilitation at the Brandenburg Medical School. One of his focusses is the teaching therapeutic skills. He also works as supervisor in BCT.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAntonovsky, A. 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Berlin, Germany: VERBI Software. Available from maxqda.com. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"qualitative research methods, thematic analysis, self-reflection, psychotherapy training, insecurity, coping strategies","lastPublishedDoi":"10.21203/rs.3.rs-6990651/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6990651/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSelf-reflection constitutes a core-competency of psychotherapists. However, research on content and quality of self-reflection is scarce and standardized instruments for respective assessments are still missing. The current study qualitatively explores \u003cem\u003esemantics\u003c/em\u003e (core contents), \u003cem\u003emodalities\u003c/em\u003e (qualitative differences) and \u003cem\u003efoci\u003c/em\u003e (direction of reflection-focus) of self-reflection with the aim to operationalize and better understand its key characteristics.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e40 self-reflection essays, written by 10 psychology students, were analyzed by employing a combined inductive and deductive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIn our findings, we differentiate typical \u003cem\u003emodalities\u003c/em\u003e, \u003cem\u003efoci\u003c/em\u003e and \u003cem\u003esemantics\u003c/em\u003e of self-reflection while underlining the connections between these aspects. At the semantic level, the feeling of insecurity emerged as the most prominent impetus for self-reflection. Previous experience, patient-interaction, and external factors like time pressure, were observed to potentially influence insecurity. While assertiveness seemed to be an ineffective strategy in dealing with this feeling, tolerating it could be identified as being helpful in reducing insecurity. Additionally, we find five different modalities of self-reflection as well as inward- and outward-related reflection foci.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eOur findings offer a first operationalization of the self-reflection competency of psychotherapists and constitute a basis for constructing an assessment rating scale. Particularly, reflecting on dealing with insecurity has emerged as a promising key for therapeutic-skill development.\u003c/p\u003e","manuscriptTitle":"Dealing with Insecurity: A Thematic Analysis of Self-reflection in Psychotherapy Training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 12:48:58","doi":"10.21203/rs.3.rs-6990651/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-05T07:56:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T09:10:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235698827706356950102500948296464587223","date":"2025-08-16T16:33:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8950025488074895597764846894070253750","date":"2025-08-15T10:12:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-13T09:28:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122260046960742108135328250993686428240","date":"2025-07-14T08:38:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213390391304052259783810343646290648408","date":"2025-07-11T11:44:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-11T08:12:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-03T08:27:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-29T23:39:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-29T23:38:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-06-27T10:17:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53ec5a2c-9e20-4b7a-92de-2f44bcd9c17d","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:06:33+00:00","versionOfRecord":{"articleIdentity":"rs-6990651","link":"https://doi.org/10.1186/s40359-025-03694-w","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2025-12-01 15:57:56","publishedOnDateReadable":"December 1st, 2025"},"versionCreatedAt":"2025-07-15 12:48:58","video":"","vorDoi":"10.1186/s40359-025-03694-w","vorDoiUrl":"https://doi.org/10.1186/s40359-025-03694-w","workflowStages":[]},"version":"v1","identity":"rs-6990651","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6990651","identity":"rs-6990651","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}