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Looking within: self-perceived professional strengths and limitations of

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Article  in  Asia Pacific Journal of Counselling and Psychotherapy · September 2012

DOI: 10.1080/21507686.2012.703957

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Looking within: self-perceived

professional strengths and limitations
of psychotherapists in India
a b c
Poornima Bhola , Shveta Kumaria & David E. Orlinsky
a
Department of Clinical Psychology, National Institute of Mental
Health and Neuro Sciences, Bangalore, 560029, India
b
Department of Social Work, Loyola University, Chicago, IL,
60611, USA
c
Department of Comparative Human Development, University of
Chicago, Chicago, IL, USA

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 Asia Pacific Journal of Counselling and Psychotherapy
2012, 1–14, iFirst Article

Looking within: self-perceived professional strengths and limitations

of psychotherapists in India
Poornima Bholaa* , Shveta Kumariab and David E. Orlinskyc
a
Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences,
Bangalore 560029, India; b Department of Social Work, Loyola University, Chicago, IL 60611, USA;
c
Department of Comparative Human Development, University of Chicago, Chicago, IL, USA
(Received 7 March 2012; final version received 14 June 2012)

Practice as a psychotherapist can be both rewarding and challenging, generating a

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need for therapists to reflect on their professional strengths and vulnerabilities. As part
of a larger international study of psychotherapists, information was gathered from
250 therapists in India using the Development of Psychotherapists Common Core
Questionnaire (DPCCQ). One specific part of the DPCCQ asked for narrative answers
to two questions: ‘What do you feel is your greatest strength as a therapist?’ and ‘What
do you feel is your most problematic limitation as a therapist?’. Using the consen-
sual qualitative research method, qualitative analysis of therapists’ written responses
identified several core themes. Three themes accounted for 82% of responses about
therapists’ perceived strengths: therapeutic relationship skills (32%), therapeutic pro-
fessional expertise (28%), and therapist personal qualities and experiences (22%).
Four themes accounted for therapists’ views of their limitations: inadequate therapeu-
tic competence (22%), professional stress and burnout (20%), inadequate professional
knowledge and experience (19%) and therapist personal qualities and difficult expe-
riences (19%). Themes relevant to the challenges and realities of therapeutic work in
the Indian context also emerged. Implications of these narrative themes of therapist
development are discussed.
Keywords: psychotherapist development; therapist strengths and limitations; Indian
culture

Introduction
The journey of professional development as a psychotherapist can be both rewarding
and challenging. The course of therapy is often unpredictable and at times therapists are
confronted with moments of uncertainty and frustration as well as impediments that are dif-
ficult to control or change. All therapists have their balance of strengths and weaknesses,
their finely honed skills and positive attributes along with their blind spots. Therapy can be
a crucible for self-exploration and reflexivity for therapists as well as for clients. However,
little research has been devoted to therapists’ perceptions of their professional strengths and
vulnerabilities. Historically, psychotherapy research may be biased toward viewing therapy
as a collection of techniques while de-emphasizing the effects attributable to therapists
(Orlinsky & Rønnestad, 2005).

*Corresponding author. Email: [email protected]

ISSN 2150-7686 print/ISSN 2150-7708 online

© 2012 Taylor & Francis
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 2 P. Bhola et al.

Research on therapist qualities and in-session activities, which positively impact the
therapeutic alliance and client outcomes, was reviewed by Ackerman and Hilsenroth
(2003). Positive therapist qualities included being flexible, honest, respectful, trustworthy,
confident, warm, interested and open. Specific positive actions included exploration, reflec-
tion, noting events discussed in past therapy sessions, accurate interpretation, facilitating
expression of affect and attending to patient’s experience.
A set of qualitative studies by Jennings and his colleagues explored the characteristics
shared by ‘master’ therapists. In an interview-based study of 10 peer-nominated therapists
from the United States, Skovholt and Jennings (2004) enquired into their positive personal
qualities, developmental influences and therapeutic skills and practices. Qualitative anal-
ysis suggested that master therapists draw on three areas of expertise: cognitive strengths
(e.g. cognitive complexity), emotional attributes (e.g. emotional receptivity and maturity)
and relational skills (e.g. capacity for empathy). Subsequently, Jennings et al. (2008) iden-
tified similar themes in a qualitative study of nine ‘expert’ therapists in Singapore, and also
highlighted the culture-specific aspects such as multicultural competence and professional
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challenges. Although these studies form an important starting point in exploring therapist
strengths, they focused only on optimal therapist qualities among a small sample of ‘mas-
ter’ or ‘expert’ practitioners. Empirical research on larger, more diverse samples in various
cultural and professional contexts is required to build on the findings of these studies.
Therapists also invariably encounter struggles and difficulties in their therapeutic prac-
tice, but this has been less frequently studied. For example, in a review of research
on therapist qualities and techniques that negatively impact on alliance, Ackerman and
Hilsenroth (2001) found evidence pertaining to personal therapist attributes such as
being rigid, uncertain, critical, distant, tense and distracted. They also identified nega-
tive therapeutic techniques such as overly structuring the therapy, inappropriate therapist
self-disclosure, adamant use of transference interpretation and inappropriate use of
silence.
A few studies have explored therapists’ experiences of difficulties as they conduct treat-
ment. Davis et al. (1987) gathered a series of 125 examples of challenging moments from
seven experienced therapists and developed a taxonomy of therapist difficulties that was
later used as the basis for a set of quantitative scales that form one part of the Development
of Psychotherapists Common Core Questionnaire (DPCCQ; Orlinsky et al. & the SPR
Collaborative Research Network, 1999; Orlinsky & Rønnestad, 2005). Factor analysis
of the DPCCQ scales identified three related dimensions: one focused primarily on the
therapist’s professional role (professional self-doubt), another focused on the therapist
personally (‘negative personal reaction’ to a client) and a third that emphasized difficul-
ties presented by the client’s life situation (frustrating treatment case). Related research
(Schroder & Davis, 2004) reiterated that the origins of therapists’ experienced difficul-
ties could be both personal (paradigmatic) and contextual (situational) and that gaps in
knowledge or experience may also result in transient difficulties.
A series of interview-based studies with small samples of experienced therapists used
grounded theory methodology to explore therapists’ feelings of inadequacy, insecurity and
incompetence (Thériault & Gazzola, 2005, 2006). The common themes they found were
related to a limited repertoire of skills, knowledge or experience; process issues with the
alliance or boundaries and the role of personal issues or conflicts. Thériault and Gazzola
(2008) later integrated these findings into a substantive theory of therapist feelings of
incompetence. Consistently, the most disturbing feelings stemmed from self-doubts and
questions about their own personal qualities and capacities. Of concern was their finding
that novice therapists often lacked supervision spaces to reflect on their difficulties, which
 Asia Pacific Journal of Counselling and Psychotherapy 3

then remained undisclosed instead of being normalized and validated (Thériault, Gazzola,
& Richardson, 2009).
Similar to prior research on therapist strengths, qualitative studies of therapist limi-
tations have also typically involved small samples of 8–10 therapists and have focused
largely on seasoned clinicians rather than including varied levels of experience. As a
notable exception, Joo, Bae, and Orlinsky (2005) analyzed brief narrative reports of pro-
fessional strengths and limitations by 371 South Korean therapists, also (similar to this
study) as part of the Society for Psychotherapy Research Collaborative Research Network
(SPR/CRN). The most frequently reported themes were related to strengths describing
positive relational qualities and skills. By contrast, the majority of responses about pro-
fessional limitations were associated with lack of specific therapeutic skills and training.
Other themes were related to negative personality traits and burnouts. The authors asserted
that the predominance of certain strengths and limitations reflected both the realities of
professional practice and cultural beliefs and values in Korea, and recommended future
research on cultural differences in therapists’ professional experiences.
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Although research has emphasized the need for continuous professional reflection at
all career stages (Skovholt & Rønnestad, 1995), psychotherapists in India typically have
limited occasion for self-reflection and discussion of their experiences with professional
peers or supervisors. They work in a populous, pluralistic society with paucity of manpower
and training resources coupled with large workloads. With one psychotherapist available
per half million population in India, the profession is trying to get a foothold in a context
with stigma about help seeking, reliance on folk healing traditions (Dalal, 2011) and a
wider ‘culture of advice giving’ (Wasan, Neufeld, & Jayaram, 2009).
More than a decade ago, Garfield (1997) spoke of therapists as the neglected variable
in psychotherapy research, and this is still true for therapists in India. As part of the CRN
project, this study responds to this imperative and expands on earlier work by including a
larger sample of therapists across various professional backgrounds and experience levels.
This exploratory work represents a preliminary step to understanding the experiences and
contexts of psychotherapists’ practice in India.

Methods
Participants
Purposive sampling was used to contact mental health professionals through membership
lists of professional societies, professional electronic mail groups, professional confer-
ences and workshops, academic departments at national mental health training centres,
informal professional networks and community agencies that engage in counselling and
psychotherapy practice. This mixed model of sampling and data collection was also
followed in the larger international study of psychotherapist development (Orlinsky &
Rønnestad, 2005). A total of 412 individuals were contacted through electronic mail or
in person. Of these, 11 did not meet the inclusion criteria. Participation in the study was
voluntary, anonymous and without remuneration. Confidentiality was ensured by providing
two stamped envelopes for separate return of the questionnaire and a signed informed con-
sent letter. Email reminders were sent after a month requesting participants to return the
completed questionnaire. Of the 401 questionnaires sent, 250 completed questionnaires
were returned by professional psychotherapists and counsellors (62% return rate). The
study sample included male and female individuals who had completed professional men-
tal health training, had at least 1 year experience in psychotherapy or counselling of clients
in India and were currently engaged in therapeutic practice in India. All participants had
the ability to read and write in English.
 4 P. Bhola et al.

Instrument
This study was conducted using narrative data collected with a part of the Development
of Psychotherapists Core Questionnaire-India (DPCCQ-I; Bhola, Kumaria, & Orlinsky,
2008), a culturally modified version of the original self-administered survey instrument
reported by Orlinsky et al. & the SPR Collaborative Research Network (1999). The orig-
inal 392-item DPCCQ has been used over the past two decades to gather information
from more than 11,000 therapists in more than 30 countries (Orlinsky, pers. comm.). The
DPCCQ-I examines diverse aspects of therapists’ personal and professional characteris-
tics and contains 370 items presented in English, most with structured response formats,
and also some open-ended questions requesting narrative responses. Modifications were
made with respect to terms and phrases, overall content and length based on applicability
in India, and a new section of 23 items was added to focus on cultural aspects of psy-
chotherapeutic practice. To assure cultural fidelity, a separate pilot study of 10 therapists of
differing levels of experience in India was conducted by administering the DPCCQ-I and
interviewing subjects individually to assess their understanding of key terms and questions.
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This study focuses on therapists’ written responses to two open-ended questions: ‘What do
you feel is your greatest strength as a psychotherapist?’ and ‘What do you feel is your most
problematic limitation as a psychotherapist?’

Data analysis
The consensual qualitative research (CQR) method (Hill, Thompson, & Williams, 1997;
Hill et al., 2005) was used to code the transcripts of written responses to the two open-ended
questions. The inductive method has been widely used to provide an in-depth understand-
ing of individual experiences. CQR analyses were conducted by the first two authors who
are trained clinical psychologists with substantial academic teaching, clinical and research
experience and who familiarized themselves with the CQR methodology by extensive
reading of published research using the method.
The first step in data coding involved the development of broad topic areas as domains
or themes by reviewing subjects’ written responses to the questions. The team members
worked independently to formulate the themes and met subsequently to discuss them and
reach a consensus. The next step involved the construction of core ideas by listing sum-
mary statements capturing the main ideas that formed each domain. In the cross-analysis
stage, commonalities of core ideas across all the written responses were identified to form
categories. Any discrepancies at each stage in defining themes, core ideas, categories
and coding of written responses were resolved by discussions and consensus among the
members of the primary research team. Two other independent auditors with Master’s
degrees in psychology independently reviewed the process and provided feedback about
overlaps or discrepancies at different stages. Some themes were expanded and some
were condensed during this process. Occurrence rates of final categories and themes are
reported.

Results
Of the 250 therapists who provided usable DPCCQ-I returns, 215 (86%) responded to the
open-ended question on strengths. Socio-demographic and professional characteristics of
these 215 therapists are reported in Table 1. The mean age of the therapists was 42.5 years
(SD = 11) and the number of years of psychotherapy practice ranged from 2 to 41 years
(M = 14, SD = 10). The Indian therapists represented various career levels and had a larger
representation of more experienced therapists. About two-thirds (66%) of the therapists
 Asia Pacific Journal of Counselling and Psychotherapy 5

Table 1. Demographic and professional characteristics of psychotherapists (N = 215).

N %

Career cohort
1 to <3.5 years 23 11.4
3.5 to <7 years 36 17.9
7 to <12 years 46 22.9
12 to <20 years 41 20.4
More than 20 years 55 27.4
Profession
Psychology 126 58.6
Psychiatry 50 23.3
Counselling 17 7.9
Social work 14 6.5
‘Psychotherapist’ 5 2.3
Nursing 1 0.5
Other 43 23.2
Academic qualification
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PhD 72 33.8
MPhil 50 23.5
MD 48 22.5
MA/MSc 35 16.3
BA 5 2.3
Treatment modality
Individual 189 98.9
Couple 175 91.2
Family 167 90.0
Group 142 75.5
Other 41 23.2
>1 Modality 185 94.9
Salient theoretical orientationa
Cognitive 139 64.7
Supportive 131 60.9
Behavioural 119 55.4
Interpersonal 91 42.3
Family/systemic 76 35.4
Humanistic 64 29.8
Other 39 18.6
Analytic/dynamic 36 16.7
Gender
Female 142 66.0
Male 73 34.0
Marital status
Single 39 18.8
Living with partner 1 0.5
Married 155 74.9
Separated/divorced 8 3.9
Widowed 4 1.9

M SD

Age (years) 42.5 11.9

Practice duration (years) 14.0 10.0
Current caseload 28.7 27.0

Note: N’s vary slightly due to occasional missing data.

a An orientation was considered salient if it was marked 4 or 5 on a 0–5 scale of influences on
therapeutic practice.
 6 P. Bhola et al.

were female and the majority of them were married (74.9%); only 0.5% of the sample was
in a live-in relationship, perhaps reflecting Indian social mores.
About three-fifths (59%) identified themselves professionally as psychologists, and
another 23% as psychiatrists, with smaller numbers of counsellors (8%) or social work-
ers (6.5%), and a few (2.3%) who referred to themselves as ‘psychotherapists’ without
identifying with any other professional background. In terms of academic qualifications,
79.8% of the therapists held the PhD, MD or MPhil degree, which is recognized among the
highest professional qualifications in the field.
The therapists and counsellors worked in diverse settings across 61 towns or cities in
21 Indian states or union territories. There were large variations in the caseloads, with the
SD being close to the mean. Half of the therapists were treating more than the median of
19 clients. The predominant treatment modality was individual therapy (98.9% of the sam-
ple), while the practice of couple and family therapy was also common. Strikingly, almost
95% of the therapists practice in more than one modality of therapy. The limited manpower
resources in India may not allow for a focus or specialization in one modality while treating
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clients. The types of theoretical orientations most commonly rated as salient were cognitive
(64.7%) and supportive (60.9%). This was followed by the behavioural (55.4%), inter-
personal (42.3%), family/systemic (35.4%), humanistic (29.8%) and analytic/dynamic
(16.7%) orientations.

Therapeutic strengths
The data analysis yielded five themes related to therapeutic strengths: positive per-
sonal attributes, beliefs or developmental experiences, professional knowledge, training
and growth, therapeutic expertise, therapeutic relationship skills and professional role
commitment.
Table 2 shows the frequencies of responses to each theme related to therapeutic
strengths in this sample. The triad of relationship skill, professional expertise and personal

Table 2. Themes of therapeutic strengths reported by Indian therapists.

Theme Categories %

Relationship skills Empathy, warmth, genuineness 32

Strong therapeutic alliance
Therapeutic expertise Case conceptualization, problem evaluation and 28
planning
Listening, communication and linguistic skills
Self-awareness, cultural competence
Skills with specific therapy orientations or client groups
Professional ethics (e.g. confidentiality, privacy,
boundaries)
Positive personal qualities Personal attributes (e.g. humour, determination and 24
and experiences perseverance)
Personal beliefs and values
Positive family or other personal experiences and
practices (past and present)
Professional knowledge, Training, knowledge, supervision 8
experience and growth Experiences with clients
Openness to new learning
Professional role Commitment to therapist role 8
commitment Belief in value of psychotherapy
 Asia Pacific Journal of Counselling and Psychotherapy 7

qualities and experiences emerged as the most frequently identified themes. Based on their
written responses, the predominant professional strength that therapists possess is the abil-
ity to forge a strong therapeutic relationship (32% of the responses). Second, 28% of the
responses concerned their therapeutic expertise. Personal attributes, beliefs and develop-
mental experiences formed 22% of the responses. Professional knowledge, training and
growth (8%) and a sense of professional role commitment (8%) were reported as strengths
by a smaller number of therapists.
Close to one-third of the responses focused on the ability to build and sustain a thera-
peutic bond. For example, ‘Nothing my client says or does, decreases my trust in him; my
empathy and acceptance of him’. Another therapist described, ‘My ability to empathize
with clients, accept them and give them the courage to disclose their deepest secrets. This
makes them reflect in the sessions without being guarded and defensive’.
Almost as many therapists (28%) elaborated on various aspects of professional
expertise, including case conceptualization, problem evaluation and planning; listening,
communication and linguistic skills; self-awareness; cultural competence, skills with spe-
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cific therapy orientations or client groups, and professional ethics, including issues of
confidentiality, privacy and relationship boundaries.
Finally, about one-fourth (24%) of the therapists reflected on their personal attributes
which functioned as professional strengths. These included descriptors such as ‘humour’,
‘patience’, ‘flexibility’, ‘resilient nature’, ‘a little authoritative’ and ‘perseverance’. Some
responses focused on the anchoring provided by spiritual beliefs and practices. The positive
and enduring impact of family members and developmental experiences was mentioned in
a few responses. For instance, ‘My father as a role model for his endless/tireless service to
anyone who seeks help’.
The strengths imbued by a fulfilling and balanced personal life or relationships were
also mentioned. This is exemplified in the words of one therapist:
The first and foremost is the balance in life, because I think that in this role, with comprehen-
sive, real difficult cases, I don’t think I could sustain my passion if I didn’t have a balanced
personal life. Because I think this job - and it has, a couple of years ago – can take over, and
so I’ve learned that even with passion, without balance, I will burn out.
Some therapists referred to life experiences without elaborating further on their positive or
negative valence.
A smaller number (8%) of responses mentioned the positive impact of training and
supervision, learning from experiences with clients and an attitude of openness to profes-
sional growth. For instance, ‘My readiness to learn – both professionally as a counsellor by
means of further training and supervision, as well as personally by continuing counselling
to further my growth’.
Similarly, 8% of therapists’ responses focused on the strong commitment to their ther-
apeutic identity and profession as an important strength. ‘It’s challenging – it’s using that
creative process. Oh, I think the most difficult things in life are also immensely rewarding.
Commitment to the profession is my most greatest inner strength’.

Therapeutic limitations
Table 3 presents four major and three minor themes that therapists regarded as their
most problematic limitations. The major themes were inadequate therapeutic competence
(22%), professional stress and burnout (20%), inadequate professional knowledge and
experience (19%) and personal qualities and difficult experiences (19%). Less frequently
 8 P. Bhola et al.

Table 3. Themes of therapeutic limitations reported by Indian therapists.

Theme Categories %

Inadequate therapeutic Inadequate case formulation, goal setting, planning 22

competence Difficulties in control of therapy agenda or client
behaviours
Degree of limit-setting and directiveness
Lack of skill in specific therapy modalities,
orientations or client groups
Professional stress and burnout Time pressure, client overload 20
Poor work–life balance
Physical or emotional exhaustion
Low motivation
Doubts about professional competence
Inadequate professional Inadequate professional education, training, 19
knowledge and experience supervision or experience
Personal qualities and difficult Personal attributes (e.g. therapist age, rigidity and 18
experiences anxiety)
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Personal beliefs
Negative personal or family experiences or current
relationships
Socio-cultural factors Poor client involvement/belief in therapy 11
Reliance on traditional healing systems
Cultural/linguistic diversity, poverty
Limited professional resources
Difficulties in maintenance of Session logistics (e.g. time and money) 9
therapeutic frames Emotional involvement with clients
Inadequate therapeutic Poor therapeutic alliance 2
relationship skills Lack of empathy and judgemental attitude
Transference and counter-transference

mentioned were socio-cultural factors (11%), difficulties in maintaining the therapeutic

frame (9%) and inadequate therapeutic relationship skills (2%).
Concerns about therapeutic competence included felt difficulties with case formulation
and treatment planning. Therapists frequently mentioned being too directive with clients
or alternatively finding it difficult to set limits. For example, one therapist wrote:
My most problematic limitation is the pressure within me to solve a problem, to become
directive and provide a solution. To accept pain and anguish, as it is, and give it a place, due
in the whole of life, that is tough.
Therapists also reported feelings limited in their work with certain client groups, such as
personality disorders, children or adolescents and substance dependence, or with certain
therapy modalities or orientations. One of the therapists described difficulties in terms of
‘issues like death, disabilities, future concerns – issues that are ambiguous’.
Some therapists expressed doubts about themselves in their professional role or felt
inadequately motivated to continue in the profession. For example, ‘Fear that I may not
be good enough for a client to sustain work’. Comments about time pressures, excessive
workload, monotony and fatigue were echoed in many narratives. The difficulty of bal-
ancing professional and personal selves is illustrated by the quote, ‘I have a high need for
achievement and this causes me to be unable to “switch off” after work. This is destroying
my personal life. I have no personal life’.
 Asia Pacific Journal of Counselling and Psychotherapy 9

One-fifth (19%) of the responses highlighted concerns about inadequate professional

education, training, supervision or experience. One of the therapists elaborated: ‘No facili-
ties in the Institute for structured supervisory process. Due to the high case load, emphasis
was always on self-learning. Though there were several discussions, the supervisor would
not sit in the session. No one way mirror’. This was also evident in the following quote,
‘Training! India lacks good trainers and courses that are offered part-time. Other col-
leagues and places of work have too many constraints and pre-agendas!’. Another therapist
reported, ‘At times I feel that techniques are outdated and am at a loss as to what I can do
instead’.
A similar number of responses highlighted varied personal attributes perceived as pro-
fessional limitations. For example, these included: ‘At times cluster C traits of mine,
including perfectionism, being too open-minded or too patient and negative, hostile,
aggressive tendencies’. One of the therapists explained:
Not being assertive, being anxious, self-doubt. I may wait too long before I push for important
changes; I lack confidence and need to check with a ‘higher authority’ before I move ahead
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with major decisions which can prolong the pace of therapy – a lot of time is spent weighing
whether I made the right decision or not.

One of the therapists shared some difficult personal experiences:

I often have found my own parents and sibling are emotionally not in touch with their own
selves and myself – and I’ve gone through abuse experiences as well – these sometimes
limit me. If I am dealing with an abusive parent – sometimes my own fears and experiences
resurface. Though I am working towards resolving these experiences by working with myself.

Some therapists experienced difficulties in maintaining therapeutic frames pertaining to

session arrangements. For example, ‘(1) Time management – sessions get extended,
(2) Inability to charge fee for extended sessions, (3) Do a lot of free service but am unable
to collect higher fee from those who can afford it’.
Other responses suggested concerns about therapeutic boundaries and emotional
involvement with clients. One therapist expressed:
I begin to feel “friendly” with some long-term clients – especially female clients; i.e. I like
them as a person. I tend to talk longer on the phone should they call in between appointments
or extend the session by some minutes.

Some responses also mentioned constraints due to poverty, illiteracy and working in a mul-
tilingual and multicultural societal context. Many referred to the limited understanding and
acceptance of therapy among clients in India and their reliance on other methods of tradi-
tional healing or medical treatment. One therapist referred to the effort needed ‘to wean
clients off from the influence of “Gurus and charlatans” or family giving negative inputs’.
Another therapist remarked on the difficulty in ‘convincing my patient that he has to find
time to have psychotherapy, instead of dropping in for a few minutes and taking a prescrip-
tion’. Focusing on the limited professional resources, one of the therapists emphasized: ‘In
dealing with a crisis situation with a suicidal client. Not having emergency 911 services in
the country or organizations for more intensive therapy’.

Discussion
Extensive research on psychotherapy has identified empathic attunement between therapist
and client as a most important pan-theoretical factor contributing to outcome (Norcross,
2011), as has the therapist’s ability to use this to create a place of sanctuary for the
 10 P. Bhola et al.

client (Jennings & Skovholt, 1999). Consonant with this research, relational skills were the
most commonly reported strengths in this group of psychotherapists from India. A simi-
lar pattern emerged in self-reports of professional strengths and limitations among Korean
therapists (Joo et al., 2005) and of limitations among Norwegian therapists (Helland, 2006).
Therapists also experienced a sense of competence in using skills and techniques
from their repertoire in order to plan and structure the therapeutic process. However,
modality-specific skills and techniques were rarely mentioned, perhaps reflecting the recog-
nition of the role played by integrative approaches and non-specific factors in real-world
psychotherapy (Norcross, Karpiak, & Lister, 2005).
The personal qualities of the therapist invariably impact therapeutic work along with
competence in therapeutic skills and approaches (Ackerman & Hilsenroth, 2003). With
the current focus on acquisition of skills and techniques and the manualization of ther-
apies, the potential influence of the therapist’s personal characteristics and experiences
is often neglected. Jensen (2007) contested the assumption that it is primarily the ther-
apy (i.e. specific techniques and procedures) that works to benefit patients rather than the
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therapist and illustrated the influence of personal and private characteristics of therapists
on their clinical practice. Personal attributes and lives of therapists may have both direct
and indirect positive impacts on clinical work. Increasing awareness and sensitivity to the
reciprocal interactions of personal and professional factors is important for building upon
these assets to influence professional growth. An increasing integration of professional and
personal selves has been noted as therapists move from the novice stage and become more
experienced practitioners (Rønnestad & Skovholt, 2001).
The relational framework, therapeutic techniques and the person of the therapist were
collectively viewed as the most important strengths among therapists in this sample of
Indian psychotherapists, attesting to the universality of these factors across national, geo-
graphical and cultural boundaries. The results speak to the importance for therapists of
awareness and reflection on strengths and the ways in which they influence their work.
Given the challenging nature of therapeutic work, there are also inevitable encoun-
ters with frustrations and difficulties in doing therapy, which the participants in this study
reflected on as well. Those findings suggest that psychotherapists in India experience
uncertainties regarding limitations of their therapeutic skills and inadequacies in train-
ing and professional education. Some also appear vulnerable to burnout resulting from
the intense demands of the contexts in which they work. Disclosures of personal issues
and attributes that were impediments in fulfilling the helping role evoked the concepts of
counter-transference and therapist as a ‘wounded healer’. Our results in this respect closely
mirror those described by Thériault and Gazzola (2005) in their qualitative analysis of ther-
apists’ feelings of inadequacy and incompetence. These encompassed doubts concerning
skills and training, followed by low professional confidence and decreased faith in the pro-
cess of therapy as well as personally sensitive issues and vulnerabilities. One limitation
of this study is that it does not allow for the estimation of the intensity and impact of
self-perceived difficulties.
Collectively, the results underline the value of dissonance, complexity and reflective
processes in the professional growth and development of therapists. In a field where the
‘self’ is used as an instrument (Orlinsky & Howard, 1975; Aponte & Winter, 2000), per-
sonal experiential work and the cultivation of a reflective stance (Schön, 1983) may be
vital. Successes, strengths and ‘aha’ moments of understanding; mistakes, difficulties and
limitations, and ‘yawns’ or moments of boredom (Dallos & Stedmon, 2009) all can pro-
vide fertile ground for reflective practice and growth. There is concern though that this
has been a blind spot (Bennett-Levy, 2003), and concerted effort is needed to promote
 Asia Pacific Journal of Counselling and Psychotherapy 11

reflective practice as a core clinical competency during training. The process of continuous
critical self-evaluation about professional vulnerabilities and assets can be encouraged by
systematic reflection about impact on others and reflection on self (Lavender, 2003).
These findings have several implications. At any stage of their professional journey,
some therapists are likely to confront internal struggles and questions and voice them pri-
vately to trusted colleagues or to supportive supervisors. Sharing results of studies such as
this might help normalize these experiences for all therapists, and perhaps particularly for
trainees and less-experienced practitioners. Self-care strategies and supportive supervision
and peer frameworks for addressing vulnerability to burnout or ‘compassion fatigue’ are
essential for helping professionals (Farber, 1990; Baruch, 2004; Norcross & Guy, 2007).
Unfortunately, for the participants in our study, the usual advocated avenues for profes-
sional development like peer supervision or consultation and personal therapy are scarce
in India.
The socio-cultural and professional realities in the populous Indian context are reflected
in the limitations reported by therapists. Inadequate manpower, high work load, limited
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training or professional resources and low priority given to therapy are ongoing realities
(Rao & Mehrotra, 1998), with the primary sources of self-reported stress among clinical
psychologists in India being work overload, organizational structure and lack of resources.
Other reported barriers included ignorance about psychotherapy and associated stigma
in the population, poverty, low literacy rates and a multi-religious and multilingual cul-
ture with 22 official languages. Additionally, therapists need to navigate through different
socio-cultural nuances of help seeking and how to use culturally sensitive knowledge in
the initiation and preparation phases of therapy with Indian clients. Dominant Western
models often do not match client expectations of therapy processes and the construction
of the therapy relationship, and cultural adaptations and systematic indigenization must
be developed. Modern psychotherapies need to interface with folk healing traditions that
are embedded in the social tradition, channel the authority of the healer, involve commu-
nity participation and define accepted ways of emotional expression (Kakar, 2003; Dalal,
2011). Ongoing efforts are required with media and professional participation to reduce
stigma and create public awareness and acceptance of the therapy in India.
The range of candid responses in this study suggests that these practitioners are
open to answering questions about themselves and do not subscribe to the image of
an ‘invincible therapist’, although our results may disproportionately represent respon-
dents concerned with issues related to professional development and who value empirical
research. Nevertheless, efforts were made in this study to include a diverse participant pool
across professions, geographical locations and experience levels, and the 62% return rate
for questionnaires was more than reasonable for survey research.
Although this study has a relatively large sample, it has not been randomly drawn
and naturally cannot be considered representative of all therapists and counsellors prac-
tice in India. The issue of ‘external validity’ or generalizability of findings from the CRN
studies has been discussed elsewhere (Orlinsky & Rønnestad, 2005), focusing on the fact
that the population of ‘psychotherapists’ spans multiple professions and is a ‘fuzzy cat-
egory’ with poorly defined boundaries, making meaningful random sampling virtually
impossible. In place of generalizability in the usual sense of inference from sample to
population, Orlinsky and Rønnestad (2005) suggested a strategy of testing the generality
of findings through replication across diverse samples, such as therapists in India, South
Korea, Norway and elsewhere.
This study is an initial step in illuminating the importance of self-awareness, expres-
sion and exploration of professional strengths and vulnerabilities for the development
 12 P. Bhola et al.

of therapists in India, but findings distilled from these personal narratives may resonate
with experiences of professionals who practise in different parts of the world. With large
caseloads and inadequate numbers of trained personnel, professional training tends to
emphasize theoretical knowledge and learning of therapeutic techniques. While the cre-
ation of space and time for self-reflection may not be seen as a priority, the results of
our study underscore their importance in training curricula and supervision frameworks.
Similar concerns were also mirrored by practitioners from Korea, where training resources
were seen as inadequate (Joo et al., 2005). The development of an ‘internal supervisor’
(Casement, 1985) becomes perhaps even more crucial in the context of countries like
these with limited opportunities for external supervision. Dissemination of these findings
may be helpful in stimulating workshops and special interest groups within professional
organizations and societies in those countries. Looking toward the future, expansion of
opportunities for training, supervision and continuing professional education needs to be a
focus for India and other countries where the therapeutic profession is growing and being
shaped.
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Future analyses could examine differences in self-perceived strengths and limitations

among early career and more experienced therapists, therapists of different professions
(e.g. psychologists vs. psychiatrists), therapists in different work settings (e.g. private prac-
tice vs. inpatient or outpatient institutions) and therapists in different life situations (e.g.
single vs. married with children). The planned series focusing on psychotherapists in India
will include additional quantitative analyses about therapist experiences of difficulties and
coping, therapy goals and other aspects of professional development.
The exploration of stress levels and the coping and self-care approaches among practic-
ing psychotherapists and counsellors could be a potential avenue for future research. The
use of interviews to explore both therapist experiences and public perceptions and accep-
tance of therapy or counselling (Yu, Fu, Zhao, & Davey, 2010) would yield a more complex
and detailed understanding and directions on which to build future work. The inclusion of
therapists’ voices in contemporary research can contribute to answering questions attuned
to the realities of the psychotherapeutic profession.

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