How Did We Learn Best?

A Retrospective Survey of Clinical

Psychology Training in the United Kingdom
Pieter W. Nel, Cinzia Pezzolesi, and Dave J. Stott
University of Hertfordshire

Objectives:

This U.K.-based study aimed to investigate qualified clinical psychologists perceptions of the value and usefulness of the learning activities experienced during their training in clinical
psychology. Design:
Members (N = 357) of the Division of Clinical Psychology of the British
Psychological Society (BPS) completed a self-report questionnaire about their training as clinical psychologists. Results:
The results indicate that most clinical psychologists believe that they learnt
mainly through doing and by observing others clinical practice. They also highlight the importance of
the learning relationship and the value of personal therapy for learning. Conclusions:
The findings
point to the need for more training of trainers, especially clinical supervisors. They also draw attention
to the need for more research to establish which learning activities contribute most / least to trainees
C 2012 Wiley Periodicals, Inc. J. Clin. Psychol. 68:10581073, 2012.
developing competence. 
Keywords: clinical psychology training

Clinical psychology is well established as a mental health profession in the United Kingdom
and members of this profession continue to provide a range of services in a variety of settings,
mainly in the National Health Service (NHS). Over the years the British Psychological Society
(BPS) has played a significant and important role in developing and maintaining appropriate
standards for clinical psychology training programs. For example, for some time now all training
programs have to be accredited by the BPS before they can start operating and, once established,
are subjected to further accreditation visits to ensure that training standards remain in line with
the BPS requirements.
Although much of the monitoring function has recently been taken over by the U.K. Health
Professionals Council (HPC), the BPS continues to play an important role in setting standards for clinical psychology training. For example, in recent years the BPS has adopted a
competency-based model for training clinical psychologists (BPS Committee on Training in
Clinical Psychology, 2007). This model identifies a set of specific competencies that need to
be attained by all trainees to qualify as clinical psychologists. A variety of learning methods
and activities are employed by the various programs to ensure that trainees reach the required
standard of overall competency. Although all training programs in the United Kingdom now
subscribe to competency-based training, this has obviously not always been the case. Given this,
it is fair to say that there have been some changes in the learning methods and activities that
have been employed over the years by the various training programs. However, there is a paucity
of research to determine which methods and activities have been used most (or least) regularly
and, more importantly, which ones are regarded as the most (or least) effective. This article will
report on a retrospective survey of qualified clinical psychologists, who set out to find out which
learning methods and activities they have been subjected to, and to determine their views on
which of these methods and activities have aided their learning the most.
We

thank Prof Graham Turpin for giving permission to use a BPS distribution list to recruit participants,
Professor Ben Fletcher, former Head of the School of Psychology, UH for providing financial support for
the study, and to Professor David Winter and Ms Lizette Nolte for their helpful comments with an early
draft of this paper.
Please address correspondence to: Dr. Pieter W. Nel, Doctorate in Clinical Psychology Programme,
School of Psychology, University of Hertfordshire, Hatfield, AL10 9AB, United Kingdom. E-mail:
p.w.nel@herts.ac.uk.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 68(9), 10581073 (2012)

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).


C 2012 Wiley Periodicals, Inc.
DOI: 10.1002/jclp.21882

How Did We Learn Best?

1059

This research is unique in that it is the first known study of its kind in the United Kingdom to
specifically focus on the views of anyone who has completed their clinical psychology training,
rather than educators who are delivering training. This is an important perspective, because
those who are qualified clinical psychologists are in a unique position to judge what learning
methods and activities during training have actually equipped them to be fit for practice in the
settings that they are, or have been, working in.

The Development of Clinical Psychology and Its Training in the United Kingdom
With the formation of the U.K. National Health Service (NHS) in 1948, the few clinical psychologists that existed started working for the NHS, mostly in psychiatric hospitals. Since then
the profession of clinical psychology has grown rapidly. For example, the membership of the
Division of Clinical Psychology (DCP) of the BPS has grown from 966 in 1980 to 6,000 at the
time of this study, and to over 8,000 in 2010, with clinical psychologists now contributing a
range of psychological services to a variety of client groups in many different clinical contexts
in the NHS. The last 30 years have also seen a continuous growth in both the number of clinical
psychology training programs in the United Kingdom (currently 30), and the number of clinical
psychologists being trained (for example, up from 189 in 1993 to 623 in 2009). Competition
for places on clinical psychology programs is fierce, with a success rate of about 27% (2,342
applicants for 623 places) in 2009.
In Britain professional training as a clinical psychologist is achieved through a combination
of academic, clinical, and research activities. Although there is some variation between different
training programs, the acquisition of academic, clinical, and research skills typically takes place
through university-based teaching, supervised clinical work in the NHS, and the completion of an
applied research project. In addition to more formal teaching (e.g., didactic lectures), academic
study can also involve experiential learning (e.g., role-plays and interactive workshops), problembased learning (e.g., Keville et al., 2009; Nel et al., 2008; Stedmon, Wood, Curle, & Haslam,
2005), small group discussions (e.g., Brown, Lutte-Elliott, & Vidalaki, 2009), reflective group
work (e.g., Galloway, Webster, Howey, & Robertson, 2003), essay writing, and self-study.
In terms of clinical training, all trainees typically gain supervised experience of working with
adults, children, older people, people with learning disabilities, and one specialist group. On
most programs, trainees are also required to carry out and write up applied research projects,
usually one small-scale project (e.g., a service-related audit) and one major project (in the
form of a doctoral thesis). Although assessment procedures may vary somewhat from program
to program, they usually include a combination of academic course work, oral, and written
examinations, supervisor evaluations of clinical performance on placements, case reports of
clinical work, and a thesis defense. The training is usually full-time, takes place over a 3-year
period, and successful completion culminates in the award of a doctorate degree in clinical
psychology. Once qualified, clinical psychologists are required to register as practitioners with
the Health Professions Council and are also eligible for Chartered status in the BPS.
The competency-based model adopted by the BPS follows the example of a number of other
trainings, such as National Vocational Qualifications (NVQs), nursing, midwifery, medicine, and
public administration. The main driver for adopting an approach of specifying a common set of
capabilities together with an emphasis on measurable behaviors and outcomes (a competencybased model) was to try and raise and maintain the general standards of clinical psychology
training in the United Kingdom. Therefore, all clinical psychology trainees are required to gain
knowledge, skills, and competence in working with a range of clients and problems in a variety of
service contexts. Importantly, they are also required to develop personal and professional competence, that is, an appropriate sense of themselves, effective ways of interacting, and methods
of self-care (Hall & Llewelyn, 2006). Programs provide various types of learning environments
to their trainees in this regard; for example, teaching, individual tutoring, reflective group work,
problem-based learning, and small group discussions. To ensure that the required competencies
are attained, trainees are regularly assessed.

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Journal of Clinical Psychology September 2012

The Need for Evidence-Based Learning in Clinical Psychology

The evidence-based movement started in health care in the early 1990s, and gained popularity in
a number of professions, including that of clinical psychology, throughout the last two decades.
According to this doctrine, clinical psychology practice should be based on sound research
evidence about the effectiveness of each intervention. Not surprisingly, the last 20 years saw a
proliferation of publications on evidence-based practice in the field of clinical psychology (e.g.,
Roth & Fonagy, 2004). Another notable development in this regard was the establishment of the
National Institute for Health and Clinical Excellence (NICE) in the United Kingdom in 1999. It
is the remit of NICE to publish clinical appraisals of whether or not particular treatments should
be considered worthwhile by the NHS. These appraisals are based above all on evaluations of
efficacy and cost-effectiveness.
Although much has been written about the importance of evidence-based practice in the
clinical domain, little attention has so far been paid in the literature to the relative effectiveness of
different teaching methods and learning activities in clinical psychology training. There is much
greater emphasis on evidence-based practice in clinical psychology, but what about evidencebased1 learning? There is clearly a need to develop the evidence base for clinical psychology
training in the United Kingdom.

Rationale and Aims of the Study

As was pointed out above, little is known about the effectiveness of different teaching methods
and learning activities in clinical psychology training in the United Kingdom. Moreover, there
is a lack of research investigating clinical psychologists perceptions about the effectiveness of
their own training. This is an important area of research for several reasons. First, few empirical
studies have addressed the effectiveness of clinical psychology training. Second, much of the
existing training literature is written from the perspective of trainers, that is, what they view
as effective methods for training clinical psychologists. For example, all the contributions in a
recent special issue of Psychology Learning and Teaching (2010, Volume 9, Number 2) on clinical
psychology training in the United Kingdom were written from the perspective of the trainer. So,
there is a need for research to understand more about what takes place in clinical psychology
training and how effective this is from the perspective of those who have undergone training.
The overall aim of this research was therefore to investigate qualified clinical psychologists
perceptions of the value of the teaching approaches and methods used during their own training.
Through this study we hoped to understand the learning experience of becoming a clinical
psychologist better and to contribute to the evidence-base for clinical psychology training in the
United Kingdom. We had three specific goals with respect to understanding the value of different
training methods and learning experiences in clinical psychology training. First, we wanted to
examine which learning activities the participants have experienced. Second, we were interested
to find out which of these activities the participants viewed as most useful in preparing them for
postqualification practice. Third, we wanted to investigate whether participants gender, years
qualified, and theoretical orientation moderated perceptions of learning activities.
We hoped that the results of this study would be useful for those who are involved in the
training of clinical psychologists, including academic staff and clinical placement supervisors.
We also hoped that the results of the survey would ultimately help to improve clinical psychology
training and enhance the training of clinical psychologists that are fit for practice to work in
the NHS and elsewhere.

1 Although

evidence-based is often used rather narrowly to privilege certain reductionist and positivist
methodological perspectives, it is used here in a broader sense that acknowledges the contribution of
multiple research designs to evidence-based practice (see APA Presidential Task Force on Evidence-Based
Practice, 2006).

How Did We Learn Best?

1061

Method
Sample
A total of 1,900 clinical psychologists were randomly selected from all members of the DCP of
the BPS. At the time of the survey in 2007, the DCP had approximately 6,000 members.

Procedure
An anonymous survey was used to optimize representative sampling, honest reporting, and generalizability. The DCP was contacted and it agreed to distribute the survey and an accompanying
cover letter via mail among its members. Upon request it randomly identified 1,900 potential
participants from all members of the Division residing in the United Kingdom who at the time
provided, or had provided in the past, psychological services in the NHS as a professional activity. To maximize participation, we also specified in the cover letter that accompanied the survey
a website where participants could complete the survey online.

Survey Design
The survey was developed by the first author, an experienced clinical psychology trainer at a
doctorate in clinical psychology program in the United Kingdom. The survey was pretested with
a number of the team members at the same training institution to ascertain question clarity.
As a result a number of items were reworded and the face validity ensured. The final version
of the survey contained three main sections.2 The first section related to learning methods or
activities typically found in academic, clinical, research, personal and professional development,
and general aspects of clinical psychology training in the United Kingdom. Each of these five
subsections included a list of methods and activities, and asked respondents to indicate whether
or not they have experienced each method or activity during their training. If they answered in
the affirmative, then they were asked to rate the importance of the learning method or activity
for their future practice on a 5-point Likert scale, ranging from 1 (no importance) and 5 (very
important).
The second section contained two questions which were ranked from one to three: (a) In
your view, which three learning methods or activities mentioned above best prepared you for
postqualification practice? Why? and (b) In your view, which three learning methods or
activities mentioned above least prepared you for postqualification practice? Why?; and two
open-ended questions: Is there any learning method or activity not mentioned above that you
found useful in your own training? and Any other comments? The third and final section
collected demographic data such as age, gender, number of years qualified, whether or not they
were trained in the United Kingdom, whether or not they were currently or previously employed
by the NHS, whether or not they were currently or previously employed by a clinical psychology
program, and their theoretical orientation.

Data Analysis
The data were analyzed in two stages. The first stage comprised a frequency analysis of responses
to each question. To begin with, we determined how many respondents reported that they have
experienced each of the activities. Next, we looked at the scores on the 5-point scale (1 to 5) and
found that these were typically negatively skewed: a median of four or greater was achieved in
responses to 32 of the 37 questions, with 16 of those recording a median of five. As such, it was
noted that many of differences according to covariates were most evident in the proportion of
scores of either four or five at the upper tail of the distributions. Scores of one and two were
combined to avoid problems of very low cell values in cross-tabulations. In subsequent tables
scores of four have been labeled as important and scores of five as very important. Responses

2 The

complete survey is available upon request from the first author.

1062

Journal of Clinical Psychology September 2012

according to gender and years qualified were compared across the four revised categories of
importance; statistical significance was assessed using appropriate two-tailed tests (Chi-square
test for trends for gender and Kendalls tau b for years qualified using four groups: <3, 39,
1019, and 20+ years). Differences according to four categories of theoretical orientation (i.e.,
excluding other) were examined using the proportion of very important responses; Fishers
exact test was used to assess statistical significance. All the analyses were undertaken using SPSS
version 16.
In the second stage, a thematic analysis (Braun & Clarke, 2006) was conducted to identify
emergent themes from the two open-ended questions (see above). This analysis was conducted
prior to finalizing the quantitative analysis to reduce potential biases in interpretation because of
the knowledge of the quantitative results. Responses from respondents who answered at least one
of the two questions were utilized. Both authors analyzed data independently. Initially, all the
responses were read and re-read to identify potential issues of interest and patterns of meaning.
Next, initial codes were generated based on the issues and patterns identified in the first step.
This was followed by a sorting of the different codes into potential themes and subthemes, and
collating all of the relevant data extracts with the coded themes. Following this, the themes and
subthemes were reviewed and refined to produce a thematic map of the data. The final stage was
to make sure that the themes and subthemes were clearly defined and appropriately named. A
final set of themes and subthemes was agreed through a discussion between the two authors.

Results
Participant Characteristics
Responses were received from 357 of the 1900 clinical psychologists invited to participate (response rate 19%). Among respondents who stated their gender (n = 349) 71% were women.
The average age of respondents was 41 years (standard deviation [SD] 12) and the median years
postqualification was nine. The distribution of the sample according to years qualified was:
02 years 21.5%; 39 years 28.3%; 1019 years 23.3%; 20+ years 25.5%. The overall profile of
participants is in line with that of the applied psychology workforce in the NHS and Prison
and Probationary Service (Department of Health, 2005). The vast majority (97%) was current
or past employees of the NHS, of whom 24% were currently or had in the past been involved
in clinical psychology training. With respect to theoretical orientation, 47.3% of participants
described themselves as integrative, 33.6% as cognitive-behavioral, 6.2% as systemic, 5.6% as
psychodynamic, and 5.9% as other. An earlier survey of the clinical psychology profession in
the United Kingdom and the United States reported that 36% identified their orientation as
cognitive-behavioral, 32% eclectic, 21% psychodynamic, and 6% systemic (Norcross, Brust, &
Dryden, 1992). A summary of the characteristics of the participants in the present study is
presented in Table 1.
Tables 2 to 5 summarise the results for four subsets of learning activities: academic, clinical, research, and professional and personal development. The proportion of respondents who
reported experience of a particular activity is stated along with the proportion of those respondents who considered the activity to be important or very important. Variations according
to the three covariates gender, years qualified, and theoretical orientation are indicated using
the proportion that rated the experience very important. This proportion is stated for both
genders, for <3 and 20+ years qualified. Given the small sample numbers in the systemic and
psychodynamic subgroups, the proportion very important is restricted in Tables 2 to 5 to the
cognitive behavioural and integrative subgroups. Where difference/association according to a
covariate reached significance (p = <0.05), the relevant cells have been highlighted in bold using
underlined italics.

Exposure to Learning Activities and Their Perceived Importance

Table 2 summarizes frequency and rating of the academic learning activities. Didactic lectures,
academic essays, experiential teaching sessions, role-plays, and small group discussions were the

How Did We Learn Best?

1063

Table 1

Participant Characteristics (Overall n = 357)

Age (mean, SD)
Gender (women n, %)
Orientation (n, %)
Integrative
Cognitive-behavioral
Systemic
Psychodynamic
Othersa
NHS employed (n, %)
Clinical Psychology Trainer (n, %)

41 (12)
252 (71.0)
169 (47.3)
120 (33.6)
22 (6.2)
20 (5.6)
21 (5.9)
346 (96.9)
87 (24.4)

Note. SD = standard deviation; NHS =National Health Service.

a Others include Attachment Theory, CAT, Neuropsychology, Narrative Therapy, Social Constructionist,
Humanistic, Gestalt, PCP, Community Psychology, Solution Focused Therapy and EMDR.

Table 2
Exposure to Academic Learning Activities and Their Perceived Importance
% Very important

Academic learning activity

Didactic lectures
Experiential teaching sessions
Class seminars
Role-plays
Videos of clinical work
Academic essays
Problem-based learning (PBL)
Reflective accounts
Small group discussion
Written exams
Oral exams

% Important
Or very

Exposed

important

99
90
85
90
79
92
34
55
90
70
61

78
88
74
75
87
61
64
75
73
46
48

All

Years
qualified

Gender

Theoretical
orientation

exposed Female Male <3 20+ CBT Integrative

41
56
36
44
53
22
30
43
36
19
19

42
57
39
46
59
19
27
46
41
17
17

39
52
30
39
35
28
36
35
24
23
23

37
59
34
42
59
14
27
47
37
8
13

57
52
44
53
52
30
60
40
44
31
20

50
50
40
39
48
32
32
32
36
30
24

36
58
34
48
50
15
33
47
37
12
12

Note. CBT = cognitive-behavioral therapy.

activities most frequently experienced by participants. Experiential teaching sessions and watching videos of clinical work were both frequently experienced and perceived as important/very
important in preparation for postqualification practice. Women rated small group discussions
and videos of clinical work significantly higher than men. There was a significant association
between years of qualification and the value placed on written exams, didactic lectures, and
academic essays; this is evident from the higher values for those who were qualified 20+ years
compared with those who were qualified for less than 3 years. There were significant differences
according to theoretical orientation with respect to academic essays and written exams: Those
from cognitive behavioral background rated them higher than the integrative subgroup.
Table 3 summarizes the frequency and rating of the clinical learning activities. Direct clinical
case work, observing another clinician, clinical activity (case) reports, case reviews with a supervisor, and multidisciplinary team working were experienced by over 90% of participants. All of
these activities were also rated as important/very important by over 80% of participants, with
direct clinical casework and observing another clinician working being rated as important/very
important by 100% and 97% of respondents, respectively. Logging of placement activities was
frequently experienced by the participants, but not rated very highly. Women rated keeping

1064

Journal of Clinical Psychology September 2012

Table 3
Exposure to Clinical Learning Activities and Their Perceived Importance
% Very important

% Important
Or very

Academic learning activity

Exposed

important

Direct clinical case work

Live clinical supervision
Case reviews with a
supervisor
Observing another clinician
working
Clinical activity (case)
report
Logging of placement
activities
Keeping process notes
Clinical activity (case)
presentation
Clinical supervisor reports
Multi-disciplinary team
working

99
73
93

100
93
85

97
80
77

96
82
79

97
74
72

99
86
87

96
72
65

97
74
77

96
85
79

97

97

79

79

78

85

74

73

81

96

84

43

44

38

43

51

40

40

86

32

13

13

13

10

13

10

15

73
85

72
76

36
32

38
33

27
28

37
28

26
43

26
33

39
29

81
93

70
85

33
57

35
60

30
48

38
68

34
55

33
56

32
56

All

Years
qualified

Gender

Theoretical
orientation

exposed Female Male <3 20+ CBT Integrative

Note. CBT = cognitive-behavioral therapy.

Table 4
Exposure to Research Learning Activities and Their Perceived Importance
% Very important

%
Academic learning activity
Research teaching lectures
Class exercises
Small scale service related project
Major research project
Thesis supervision
Thesis defense
Disseminating research results
Preparing a journal-ready paper

% Important
Or very

All

Gender

Years
qualified

Theoretical
orientation

Exposed important exposed Female Male <3 20+ CBT Integrative

96
55
80
97
95
92
63
40

72
60
73
87
77
44
66
74

33
23
31
57
53
19
33
40

34
23
31
54
55
20
32
37

33
23
32
66
47
14
35
47

35
22
33
62
59
21
33
48

41
40
46
56
44
18
37
50

35
16
35
59
51
20
35
41

29
25
31
55
52
17
31
39

Note. CBT = cognitive-behavioral therapy.

process notes significantly higher than men. The values placed on reviews with a supervisor,
live clinical supervision, and observing another clinician work were significantly associated
with years qualified, with higher values evident among those qualified for less than 3 years
compared with those qualified for 20+ years. Significant differences according to theoretical
orientation were evident, with the integrative subgroup rating the keeping process notes higher
than those with a cognitive behavioral orientation.
Table 4 summarizes frequency and rating of the research learning activities. Major research
projects (i.e., thesis), lectures, thesis supervision, and thesis defense were the most frequently
experienced activities by the participants. Major research projects (thesis) were also rated as

How Did We Learn Best?

1065

Table 5
Exposure to PPD Learning Activities and Their Perceived Importance
% Very important

%
Academic learning activity
Individual tutorials
Reflective group work
Personal therapy
Peer support
Annual appraisal report
External workshop/conferences
Self-study
Comments on mark sheet

% Important
Or very

All

Gender

Years
qualified

Theoretical
orientation

Exposed important exposed Female Male <3 20+ CBT Integrative

57
60
26
83
45
75
95
78

58
58
88
84
46
83
95
64

32
32
58
57
18
37
68
26

32
31
57
61
19
40
68
28

35
33
65
51
18
25
71
17

34
29
46
64
15
44
78
26

46
41
68
55
27
42
75
28

33
19
41
57
21
34
67
19

33
36
64
59
16
38
68
30

Note. CBT = cognitive-behavioral therapy.

important/very important by the participants, while thesis defense was considered less important. Preparing a journal-ready paper was experienced by only 40% of respondents, but was
positively rated as important/very important by 74% of them. The association between years of
qualification and the value placed on thesis supervision was significant with higher importance
accorded by those who were qualified for less than three years compared with those who had
been qualified for 20+ years.
Table 5 summarizes frequency and rating of the professional and personal development
(PPD) learning activities. Self-study and peer support were the most frequently experienced
activities and both were highly rated by the participants. Personal therapy was experienced by
few participants but nevertheless rated as highly important. Annual appraisal reports were less
frequently experienced and generally not highly rated. However, the importance given to annual
appraisal reports did vary significantly according to years qualified with the higher values noted
for those qualified 20+ years. Significant differences according to theoretical orientation were
evident in responses to personal therapy and reflective group work; those with an integrative
orientation rated these activities higher than those with a cognitive behavioral orientation.
Among the psychodynamic subgroup, 9 out of the 10 respondents who had experienced personal
therapy rated it as very important.

Most and Least Useful Activities for Postqualification Practice

A majority of respondents answered both of the two ranking questions. However, because of
inconsistencies in the way this was done, the answers were not subjected to formal statistical
analysis. Table 6 shows the five activities that best or least prepared the study participants for
postqualification practice.

Thematic Analysis
Five main themes and a number of subthemes emerged from the thematic analysis of the data.
These are summarized in Table 7 below.
The above themes and subthemes are presented below in narrative form. Extracts from the
participants responses to the open-ended questions of the survey will be used to illustrate the
themes and subthemes3 .
3 Each

extract will include a participant number (for example P53) to demonstrate that extracts from a
variety of participants were used throughout this section as supportive evidence.

1066

Journal of Clinical Psychology September 2012

Table 6
Activities That Most and Least Prepared Participants for Postqualification Practice
Activity

Most useful (n, %)

1. Direct clinical case work

2. Case reviews with supervisor (supervision)
3. Observing another clinician
4. Didactic lectures
5. Live supervision

241 (68)
126 (35)
93 (26)
90 (25)
64 (18)
Least useful (n, %)
127 (36)
109 (31)
71 (20)
64 (18)
46 (13)

1. Examsa
2. Logging of placement activities
3. Thesis defense
4. Academic essays
5. Didactic lectures
a Written

and oral exams were collapsed here into the single category of exams.

Table 7
Themes and Subthemes of a Thematic Content Analysis
Themes
Learning best by doing and observing

Quality matters
Just jumping through hoops
The importance of learning relationships
The value of personal therapy

Subthemes
Active learning is best
Doing for real prepares for NHS
Value of observation for learning
Learning from clients
Quality of training varies significantly
Quality of clinical and academic staff crucial
Paper exercises and ticking boxes
Memory exercises do not facilitate learning
Importance of relationships for learning to occur
Learning relationships can add or relieve stress
The importance of personal therapy for learning
Personal therapy lacking in training

Learning Best by Doing and Observing

A very strong theme to emerge from the qualitative data was how highly the respondents valued
learning by doing. This referred mostly to their direct work with clients on clinical placements,
but also to experiential exercises (such as role-plays and problem-based learning) as part of their
academic teaching.
I learnt best from doing . . . . (P53)
The most useful aspects of learning for the job were clinical activitybums on
seats! No substitute for face-to-face contact with clients. (P131)
It is easier to learn when it is connected to an actual case. Without direct client
contact, problem-based learning is the next best thing. (P77)
I found that experiential teaching sessions were the best means of learning new information in a meaningful, interesting and interactive way that supported reflection.
Role-plays provided an opportunity to practice . . . . (P133)

How Did We Learn Best?

1067

The respondents frequently observed that doing things for real prepared them best to face
the challenges of working in the NHS postqualification. Those teaching methods and learning
experiences that best reflected real life were valued the most.
I felt that most learning occurred during placements as practical examples in real
life facilitated learning more rapidly. (P142)
[These methods] helped prepare me for the realities of applying psychological theory,
and working in the NHS. (P266)
These experiences were invaluable preparation for the realities of clinical practice.
(P270)
Another strong theme to emerge from the data was that the respondents highly valued opportunities to observe others (such as their supervisors) doing clinical work. Many respondents
also highlighted the value of being observed by a supervisor and getting constructive feedback
on their performance.
Watching another clinician provided an invaluable learning opportunity that could
not be gained elsewhere . . . . This alongside having a go yourself was very useful . . . .
(p99)
Best way I learn is by watching someone else do it. Live supervision gives you
feedback about what you really do in sessions, not what you think you do . . . . (P101)
The clinical supervision for the live cases I was working with in placement was
invaluable, and I learnt more from that than anything else. It gave me ideas of
therapeutic skills/styles, formulation, and perhaps most uniquely showed me invivo what types of clinician I could be, had the potential to be, and wanted to be.
(P222)
I remain shocked that I was only ever observed undertaking clinical work on
two occasions in my training, and was never required to produce video or audio
recordings of sessions to demonstrate acquisitioning clinical competencies. (P161)
We could be better at learning through more emphasis on being observed, observing
others and receiving feedback at all stages of training. There is a potential for this
to be tokenistic rather than rigorous and inherent in our training, as it is for many
other professionals. (P350)
Finally, a number of participants noted how they have not only learnt from observing their
supervisors, but also from clients themselves.
I have learnt most from my clients and have always asked if they are prepared to
talk to my trainees informally to discuss their experiences . . . . (P253)

Quality Matters
The respondents indicated that it was not only the type of learning that mattered, but also the
quality of those who provided it. Good quality supervisors and teachers facilitated learning;
however, poor quality supervisors and teachers inhibited learning.

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Journal of Clinical Psychology September 2012

Ones placement supervisor is crucial to learning whilst training. I was fortunate to

have had excellent supervisors but from colleagues I know that this is not always
the case. (P69)
Supervision if carried out properly is where you can learn most, but it can be very
hit and miss . . . . (P106)
Some supervisors were useless, others great. (P146)
Modes of teachings usefulness largely dependent on quality provided by supervisors
and academic staff. (P305)
Some teaching on my course was superb, other sessions led by psychologists in the
field was unprepared and did not add to my learning at all. (P128)

Just Jumping Through Hoops

The respondents frequently identified certain learning methods as not useful. These included
activities that were seen as memory exercises (e.g., exams), as not related to clinical practice (e.g.,
research and thesis defence), as artificial (e.g., poorly facilitated role-plays), and as paper or tickbox exercises (e.g., keeping a log of clinical activities). These activities were seen as hoops that
needed to be jumped through just for the sake of the course team, rather than as opportunities
for learning.
Essays, case studies and thesis were academic requirements which represented
jumping through hoops not relevant. (P143)
Essays, thesis and viva [thesis defence] just felt like hoops to jump through, rather
than anything that left me with any useful, lasting clinical skills or knowledge.
(P161)
These were tasks / hoops to jump through purely for the course. (P259)

The Importance of Learning Relationships

This theme highlights the importance that respondents placed on their relationships with trainers,
especially their clinical supervisors and course team members. A good relationship was identified
as important for learning to occur and for trainees to develop into confident and independent
clinical psychologists. Moreover, given the often stressful nature of training, a good learning
relationship (e.g., with a clinical supervisor or course team member) was recognized as an
important mediator against course stress. Equally, a poor learning relationship was identified as
an important factor in increasing course stress.
Informal supervision from supervisors was by far the most stimulating, supportive, real and humannothing could beat hours and hours of discussion with
someone you trust, respect and whose experience can never be equaled by all the
textbooks I couldve read. Supervisors are fantasticI have extremely powerful
memories of most of them. I remember their words of wisdom, anecdotes, humor and humanitylearning with love really nurtured me professionally and
personally. Supervisors are the unsung heroes in the whole training process. (P322)
Relationships with course team members and their attitudes towards trainees are
very importantthey can both add to or relieve stresses of clinical training. (P273)

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The Value of Personal Therapy

A significant number of respondents highlighted the value of personal therapy in becoming
a good clinical psychologist. However, most, if not all commented on the fact that personal
therapy was not a part of their training and regretted that this was the case. It was suggested that
clinical psychology training is lacking compared with other types of training where personal
therapy is an integral part of training.
Since qualifying, Ive had personal therapy and wish my course had promoted or
encouraged this during training. (P92)
I feel personal therapy has enabled me to function more empathically and effectively.
I regret not having undertaken this much earlier in my career. I feel it should be a
mandatory part of clinical training. (P218)
Personal therapy is still mainly not a core part of training, yet how can we know
about therapy without going through it ourselves. (P260)

Discussion
The current study examined qualified clinical psychologists perceptions of which learning activities that they have encountered during their training prepared them best for postqualification
practice. The characteristics of the participants are not unusual in that they are largely what
one would have expected from this particular professional group. Perhaps of some interest is
the finding that the largest single percentage of respondents (47.3%) indicated that they draw on
more than one therapeutic orientation to inform their postqualification practice. In our view,
a somewhat higher than expected portion of the sample (24%) indicated that they are, or have
been employed as trainers on programs. It might be that those involved in training were more
interested in completing the questionnaire, or that people included themselves not only when
they have been employed in substantial posts, but also when they taught on programs or supervised trainees on their clinical placements (a relatively common occurrence amongst clinical
psychologists practicing in the NHS).
An important, but perhaps not surprising, finding of the study is how consistently respondents
emphasized the importance of learning through doing. This was evident in both the quantitative
and qualitative data and across all four areas that were investigated: academic, clinical, research,
and personal and professional development. In particular, the respondents highlighted the
value of learning through direct clinical practice, through participating in experiential and
problem-based learning, and through doing research and writing it up for publication. This
was in contrast with the value that respondents placed on more traditional learning activities
such as exams and didactic teaching that are based more on empiricist or rationalist teaching
philosophies. Interestingly, the results seem to indicate that those who have been qualified for
more than 20 years rated traditional teaching methods more highly than their counterparts who
have qualified more recently. Nevertheless, the high value placed on learning through doing is
broadly in line with research done in the 1950s by the National Training Laboratories (NTL)
for Applied Behavioral Science on the relative effectiveness of different teaching methods.
The findings of this research are commonly known as the learning pyramid and suggest the
following in terms of average retention rates of information following teaching or activities by
the method indicated: lectures (5%), reading (10%), audio-visual (20%), demonstration (30%),
discussion group (50%), practice by doing (75%), and teaching others / immediate use (90%);
Dale, 1954.
Experiential learning theory (Kolb, 1984) draws on the work of John Dewey, Kurt Lewin,
and Jean Piaget to emphasize the important role that experience plays in the learning process.
According to Kolb (1984), experiential learning emphasizes the process of learning rather than
any specific behavioural outcomes that can be measured. From this perspective, learning occurs
optimally when, among other things, the learner is actively involved in the experience, the

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Journal of Clinical Psychology September 2012

experience is interactive, the learner is involved on affective, behavioural, and cognitive levels,
and some contact with the real world (or at least a real-world-like contact) occurs. The learning
activities that respondents in this study found most useful in preparing them for postqualification
practice certainly fit this bill. In our view, anyone who has ever worked with a client, participated
in a role-play, completed a PBL presentation, done simulation training, or analyzed research data
has first-hand knowledge of this. This survey provides evidence that substantial components of
current clinical psychology training programs enable trainees to learn from experience. However,
with the introduction of a competency-based model there is the potential for this learning to be
situated again in a more rationalist and idealist model of learning that focuses on the outcome
rather than process of learning. In such a model trainees, rather than learning from their own
experience to develop their own judgment, are instructed to acquire universal and permanent
truths by reason only.
The results also highlight the importance of observational learning in clinical psychology
training. Most participants rated opportunities to observe another clinician as important or
very important, with those more recently qualified rating it significantly higher than those
qualified for more than 20 years. Social learning theory, concerned with observational learning,
is primarily based on the work of Albert Bandura (1977). In essence this theory posits that people
acquire new behavior by watching someone else perform that behavior. The person performing
the behavior is known as the model, and the learner is known as the observer. The extent to
which the learner will learn from observing a model depends on a number of factors, including
the extent to which they identify with the model, find some of their characteristics attractive,
and whether or not they are viewed as an authority figure. The potential implications for clinical
psychology training are quite interesting.
From a social learning point of view, it would not only be important to make sure that
trainees have ample opportunity throughout their training to observe other clinicians in action
(for example, to observe their supervisor doing clinical work with a client), but also to make sure
that clinical supervisors are models that can inspire their trainees to acquire new behaviors. One
of the difficulties here is that programs often have to make do with a limited number of clinical
placement supervisors, and that choice of good enough supervisors can be restricted. This perhaps highlights the need for the continued professional development of placement supervisors.
Although most training programs provide some training for their clinical supervisors, the results
here suggest a need to take this issue more seriously and to require placement supervisors to
undergo more systematic and ongoing training in the supervision of clinical psychology trainees.
Whereas other talking therapy professions, most notably systemic family therapy, have formal
supervision training programs (up to doctoral level), clinical psychology seems to be lagging
behind in this area of developing trainer competence.
Another interesting finding was the importance that participants seem to place on the quality
of relationships (with tutors, supervisors, and peers) for learning to occur. Although the interpersonal nature of clinical supervision (Hess, 1980; Loganbill, Hardy, & Delworth, 1982) and the
importance of the supervisory relationship (e.g., Beinart, 2004; Higgins & Nel, 2009) have been
acknowledged in the literature; the respondents in this study seem to highlight the importance
of relationship in not only clinical supervision but also other aspects of learning. In our view,
the concept of a learning relationship4 is similar to that of a therapeutic relationship. In
clinical practice, the powerful association between outcome and the therapeutic relationship has
been well documented (e.g., Norcross, 2002).
Moreover, as much as the quality of the therapeutic relationship has been shown to be crucial
for ensuring clinical outcomes (e.g., Norcross, 2002), the findings here seem to suggest that
relational aspects of learning may play a similarly important role in the achievement of learning
outcomes. This has potentially important implications for clinical psychology training. If training

4 This

idea of a learning relationship links well with Vygotskys (1978) notion of learning as a type of social
collaboration. From Vygotskys (1978) social constructivist perspective trainees do not learn in isolation.
Rather, their learning occurs in a social setting, involving the trainee (learner) and at least one other person
(e.g. a trainer or supervisor) or source of information.

How Did We Learn Best?

1071

is seen as an interpersonal relationship between a trainer and a trainee, the compatibility of the
trainer and the trainee becomes particularly important. Also, from this perspective, the trainers
interpersonal expertise becomes as important as, if not more important than, his or her subject
knowledge. Interpersonal expertise for trainers would include things such as the ability to form
learning relationships with trainees from diverse backgrounds, to respond with empathy to
the trainees explicit and implicit experiences and concerns, to develop learning outcomes in
collaboration with the trainee, to be responsive to the trainees feedback, to pay attention to
the acknowledged and unacknowledged meanings, beliefs and emotions of trainees, to locate
problems in the learning relationship rather than the individual trainee, and to be able to
challenge trainees in a supportive way that fosters exploration, openness, and change.
Therefore, in the same way as the interpersonal skills of trainees are judged in selection for
clinical psychology training, we suggest that this should be an integral part of the selection
criteria for appointing trainers (including clinical supervisors) who are to work with trainees.
Moreover, based on these findings, one could also argue that it is not only the trainee who needs
training to be interpersonally competent with their clients, but also that trainers might need
further training to develop their interpersonal competence with their trainees.
An interesting finding of this study is the high value that those participants who had undergone
personal therapy (either during or after their training) place on it to help them be or become more
competent practitioners. This finding is in line with studies that have found that psychotherapists
who have had personal therapy generally report positive outcomes (e.g., Grimmer & Tribe, 2001;
Orlinsky & Ronnestad, 2005; Orlinsky, Norcross, Ronnestad, & Wiseman, 2005). However,
although personal therapy is often compulsory for psychotherapists and psychoanalysts in
training, there is no such requirement for clinical psychologists who train in the United Kingdom.
A study by Gilmer and Marckus (2003) found that only four out of a sample of 17 British
clinical psychology training programs subsidized or funded personal therapy for their trainees.
This finding, together with the apparent lack of interest to conduct research in this area, seems
to indicate the profession places a lower value on the issue of personal therapy than other
psychotherapy professions (Timms, 2007).
The results of the present study suggest that this lower value might be due, at least in part, to
the fact that those with a cognitive-behavioral orientation rate personal therapy not as important
as those from other theoretical orientations. In this study 70% of participants with a cognitivebehavioral orientation rated personal therapy as important or very important, compared with
100% for those with a psychodynamic orientation, 98% for those with an integrative orientation,
and 90% for those with a systemic orientation. Be that as it may, given the high value placed
on personal therapy by those participants who have experienced it, we concur with Timms
(2007) that the profession should consider more seriously whether personal therapy should be a
prerequisite for membership of our professional body.
There are some limitations to the present study. First, the questionnaire survey provided
only one method of measurement, that is, a self-report. As such the findings represent the
perceptions of the participants, rather than observable evidence or facts. It would be important
to conduct further studies that include alternative approaches to assess and measure the actual
efficacy of different learning activities in clinical psychology training. Moreover, it also needs
to be acknowledged that some of the respondents negative perceptions about participating in
activities such as exams, research and essay writing during their training (labeled as jumping
through hoops) may be because clinical psychologists still see their role primarily as therapists;
thus, negating the importance of using all their competencies in postqualification practice.
Although the questionnaire was developed by one expert only, it was piloted before it was used
in the survey. Given that the participants in this study were asked to recall training experiences,
there is a reliance on retrospective memory (in some cases over 20 years). What participants recall
may not only be inaccurate or partial, but also may have changed over time. A few participants
commented on these matters in their completed surveys.
Another issue to acknowledge is the subjective nature of self-reports. Although these give
an insight into peoples perceptions, one must also acknowledge that the views expressed may
be significantly influenced by their own subjective beliefs about training and their own unique
training experiences. To minimize this potential bias, a representative random sample of the

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Journal of Clinical Psychology September 2012

clinical psychology population was used. To get a more in-depth understanding of peoples
lived experiences of participating in different learning activities during clinical training, it is
recommended that future studies employ methods such as semistructured interviews to collect
data that can be analyzed qualitatively.
Another potential limitation is that participants might differ from clinical psychologists, in
general, in that they chose to respond because they view training issues as important. This was
perhaps evident in the relatively high percentage of respondents who indicated that they are, or
have been, involved in clinical psychology training. Finally, it is worth drawing attention to the
fact that clinical psychology training is constantly evolving, and that current training might be
very different from training, say, 20 years ago.

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