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Nordic Psychology
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rnpy20
The development of facilitative interpersonal skills
during 5-year psychology training programs: a
cross-sectional study
O. Salim, E. Davidsson, J Carlsson & J. Norberg
To cite this article: O. Salim, E. Davidsson, J Carlsson & J. Norberg (2022): The development of
facilitative interpersonal skills during 5-year psychology training programs: a cross-sectional study,
Nordic Psychology, DOI: 10.1080/19012276.2022.2144937
To link to this article: https://doi.org/10.1080/19012276.2022.2144937
Published online: 16 Nov 2022.
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The development of facilitative interpersonal
skills during 5-year psychology training
programs: a cross-sectional study
O. SALIM, E. DAVIDSSON, J CARLSSON & J. NORBERG
Correspondence address: O. Salim, €
Orebro University, €
Orebro, Sweden. E-mail: osame93@gmail.com
Abstract
Research has consistently found that therapists differ in psychotherapy outcomes.
Interpersonal skills, as measured with the Facilitative interpersonal skills (FIS) task, have
been found to be one of few therapist characteristics that reliably predicts outcome. To
extend current knowledge of the development of interpersonal skills, this study investigates
the association between FIS and progression on a 5-year psychologist program, while also
accounting for potentially confounding or moderating variables. Utilizing a cross-sectional
design, sixty-five students from psychology programs in Sweden were assessed with the FIS
performance task and completed self-reports on several variables, including demographics,
indicators of clinical experience and psychological variables (deliberate practice, natural
helping, motivation for clinical work and test anxiety). Using hierarchical linear regression
and moderated regression analysis the results showed that student’s semester on the
program was a significant predictor of FIS above and beyond the effect of other variables.
Also, higher motivation for clinical work and higher test anxiety emerged as significant
positive predictors of FIS scores. Deliberate practice did not moderate the relationship. The
findings provide preliminary support for an association between FIS and further progression
on the psychology program in Sweden. Implications for practice, theory and future
investigations are discussed.
Keywords: facilitative interpersonal skills, deliberate practice, formal education, therapist training
Factors such as professional self-doubt (Nissen-Lie et al., 2017), trait mindfulness (Pereira
et al., 2017) and engagement in deliberate practice (Chow et al., 2015; Goldberg, Babins-
Wagner et al., 2016) seems to predict difference in effectiveness between therapists.
However, one factor has more consistently than others been shown to predict therapeutic
effectiveness, namely the interpersonal skills of the therapist. Indeed, interpersonal skills
seems to be alluded to in most investigations of therapeutic effectiveness as an important
factor (Wampold et al., 2017) even when reviewing studies across time (Costanzo &
Philpott, 1986) and in different settings (Karver et al., 2006). The interpersonal skills of the
therapist have been proven to affect therapeutic alliance formation, symptom reduction
€
Orebro University, €
Orebro, Sweden
© 2022 The Editors of Nordic Psychology
Nordic Psychology, 2022
https://doi.org/10.1080/19012276.2022.2144937 ARTICLE
and overall success in therapeutic outcomes (Norcross, 2019). Despite these successes,
attaining a fully valid measurement of interpersonal skills has been difficult. Self-report
measures of interpersonal skills suffer from issues of social desirability and other biases
(Loewenstein & Lerner, 2003) and in session assessment leaves a lot of variability open to
the specific client and their impact upon the therapist (Anderson, Crowley et al., 2016).
Therefore, performance-based measures have lately been growing in popularity, with this
design using a standardized fictive patient or clinical case that trainees are required to
respond to. This method has been shown to predict differential effectiveness among thera-
pists several years ahead of the measurement point (Anderson, McClintock et al., 2016;
Sch€
ottke et al., 2017).
The most common method of assessing therapist interpersonal skills via performance-
based measures is with the use of The Facilitative interpersonal skills task (FIS) (Anderson
et al., 2009) which involves answering simulations of challenging clinical situations captured
on video, an example of which might be a client expressing doubts about the therapist
competence or showing anger about a previous session. The participants respond as if they
were the therapist and their responses are recorded and rated (Anderson, Finkelstein et al.,
2020). The FIS task consists of assessing for eight key relational capacities (verbal fluency,
emotional expression, persuasiveness, hope/positive expectations, warmth/acceptance/
understanding, empathy, alliance bond capacity and alliance rupture-repair responsiveness),
all of which are derived from clinical observation, theory, and meta-analytic process-out-
come research (Anderson et al., 2009; Anderson & Strupp, 2015; Norcross, 2019).
Development and training of FIS
It is still unclear as to when and how these facilitative interpersonal skills develop in each
individual. The research team (Anderson et al., 2018) that developed the FIS task argues
that “Interpersonal skills are the learned emotional and interpersonal patterns of behavior
that allow some people to be more effective at navigating through difficult and complex
interpersonal situations”(Anderson et al., 2018, p. 2). However, not much research has been
focused on empirically validating this assumption. A view which does not preclude the
above statement, but frames it differently is the hypothesis that FIS represent innate abil-
ities or talent (Anderson et al., 1999; Hatcher, 2015; Heinonen & Nissen-Lie, 2020). Studies
on the development and training of FIS have been scarce, but two recent studies found dif-
fering results. One cross-sectional study found a significant effect of time spent in formal
university education on higher FIS scores (Wolfer et al., 2021). Another, longitudinal, study
found no significant improvements in FIS scores 5-years after initial assessment of FIS
scores, although participants who had continued mental health education on average
scored higher than those who did not continue after undergraduate studies (Hill et al.,
2020). However, both studies only included two distinct groups of participants, namely
undergraduate students and graduated trainees. This design prevents seeing any linear
effects of development throughout the training period.
Additionally, both studies had smaller sample sizes and did not assess fully for potential
covariates and moderating factors. When examining the relation between education and
skill acquirement, relevant covariates such as supervision and amount of personal therapy
may be controlled for since they represent what is traditionally thought of as important
2 O. Salim et al.
Nordic Psychology 2022, Vol. 0(0), 1–17 © 2022 The Editors of Nordic Psychology
ingredients in therapeutic skill development (Rousmaniere et al., 2017). Also, previous aca-
demic achievements are known to be highly predictive of future achievement (Casillas
et al., 2012) and it is plausible that one’s therapeutic skills acquired during university educa-
tion is connected to overall academic success. Additional predictors such as test anxiety are
hypothesized to relate to the FIS task due to the task being a high anxiety inducing situ-
ation (Anderson, Finkelstein et al., 2020) which specifically targets therapists’ability to per-
form under pressure. Therefore, it is prudent to assess to what degree performance is
influenced by students’tendency for anxiety in performance demanding situations
(Steggles & de Jong, 2018). Also, motivation for clinical work has been touted in previous
research as a straightforward but potent predictor of success in therapeutic training (Stahl
and Hill, 2008). Controlling for these factors improves chances of accurately estimating any
possible effects of continuing education on interpersonal skill level.
There have also been two studies examining the effects of brief training on FIS scores
(Anderson, Perlman et al., 2020; Perlman et al., 2020). Both studies found significant effects
for the dimensions targeted by the training. However, Perlman et al. (2020) reported finding
only nonsignificant small effects for results on the whole scale. Both studies also used delib-
erate practice principles to inform and guide their training towards improving specific FIS
dimensions. Deliberate practice has been used in other studies to improve skills closely
linked to those assessed in the FIS task, such as responsivity to resistance which is akin to
alliance-rupture responsiveness (Westra et al., 2021) and accurate empathy (Larsson &
Werth
en, 2020). When reviewing research regarding the impact of education on client out-
come e.g. Erekson et al., (2017), a rather heterogenous picture appears between trainees. A
minority of trainees seem to improve while most do not. One possibility can thus be that
students own engagement in deliberate practice moderates their development as it seems
to do among professional therapists (Chow, 2015). Overall, one could say that little is known
about the FIS task convergent validity (Anderson et al., 2018) therein highlighting the need
for exploratory studies looking at a multitude of variables in different settings.
Aim
The inhabitance of therapeutic and interpersonal skills seems from prior research to be a
key factor in achieving favorable outcomes with clients (Norcross, 2019). Since a large pro-
portion of graduates from the psychologist program will presumably go on to work clinic-
ally, ensuring that students have achieved a measurable acquisition of therapist skills would
seem a reasonable goal of the psychologist program in Sweden (H€
ogskolef€
orordning,
HSF, 1993).
Yet, it is hitherto unclear if psychology students acquire increased interpersonal and thera-
peutic skills from attending a structured university education. The purpose of the present
study was to better understand the relation between structured, university education and
the development of facilitative interpersonal skills (FIS). Two hypotheses were formulated:
Firstly, we expected that progression along the 5-year psychologist program would be
associated with higher ratings on the FIS task. Moreover, this relationship was expected to
exist above and beyond any effects of the controlled variables including demographics
(age, gender, grades), indicators of clinical experience (personal therapy, number of clients
The development of facilitative interpersonal skills during 5-year psychology training programs: a cross-
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3
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seen, hours in supervision) and psychological variables (test anxiety, motivation of working
as a therapist, natural helping ability, engagement in deliberate practice).
Secondly, we expected the relationship between semester and FIS scores to be moderated
by engagement in deliberate practice.
Method
The setting
The psychologist program in Sweden is a five-year program currently available in eleven
universities around the country. The final aim is a Master of Psychology degree which after
a year of paid internship allows you to apply for a licensing to practice from the National
Board of Health and Welfare. Generally, the first two years in the psychologist training con-
sists of learning theory in various fields of psychology as well as basic communicative skills.
The latter three years focus more directly on application of psychology in individuals,
groups, and organizations. There are also practicum courses as well as supervised treatment
of clients at the end of the programs. The programs all share similar mandated course con-
tent and learning objectives mandated by National Board of Health and Welfare. It should
be noted that at some, but not all, universities going to personal therapy is a mandatory
part of the curriculum.
Participants
Recruitment was made via several channels. Social media was prominently used where a
brief statement about the study accompanied by a flyer was posted on local campus
Facebook groups which were open to psychology program students only. Potential partici-
pants were also contacted by visiting classes and by sending emails using the universities’
digital platforms for students. The total eligible participants (active students in the program)
were roughly estimated to be around five thousand at the time of recruitment, out of
which an unknown subset was presumably reached by the recruitment information.
The sample was a convenience sample of interested students and included sixty-five clin-
ical psychology students from nine different universities (two universities not being repre-
sented in the study due to a lack of volunteers) Participant demographics are summarized
in Table 1.
Procedure
All participants who showed interest in the study were asked to visit a website made espe-
cially for this study, where they read extensive information regarding the study and its
requirements. Those who wished to continue then independently booked a time for online
administration of the FIS task using the website and were thereafter given a link to an
online survey (see below) to fill out prior to completing the FIS task, they were also asked
to sign informed consent forms stating that they were active students in the psychology
program and met the other inclusion criteria. On the booked timeslot, participants joined
an online meeting with the experimenter and were given standardized verbal instructions
on how to complete the FIS task. The participants were then left alone to complete the
task by remotely controlling a FIS website (https://www.fisresearch.com) where the stimulus
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clips were presented in a set order. The participants were only given one attempt to
respond to each stimulus clip and were asked to do so without delay. The experimenter
(one of the two authors) turned their video, microphone, and sound off so that the
Table 1. Demographic characteristics of the sample (N ¼65).
Variable MSDRange
Age 27.97 6.08 20–52
Grades (HSP) 1.61 1.00 1.5–1.9
Grades (HSG) 21.52 0.78 18.8–22.5
Personal therapy
a
36.37 32.28 0–100
Number of clients seen
b
6.40 14.61 0–100
Group supervision
a
5.29 7.53 0–35
n%
Gender
Female 40 61.5
Male 24 36.9
Other 1 1.5
Semester
1 8 12.3
2 3 4.6
3 5 7.7
4 7 10.8
5 6 9.2
6 3 4.6
7 8 12.3
8 8 12.3
9 6 9.2
10 11 16.9
University
€
Orebro 37 56.9
G€
oteborg 9 13.8
Lund 6 9.2
Uppsala 4 6.2
Stockholm 3 4.6
Karolinska Institutet 2 3.1
Link€
oping 2 3.1
Mittuniversitetet 1 1.5
Umeå 1 1.5
a
Personal therapy and Group supervision were measured in hours accomplished.
b
Number of clients seen was measured in number of contacts (including both therapy and other helping activities such as support line volunteering)
regardless of number of sessions.
The development of facilitative interpersonal skills during 5-year psychology training programs: a cross-
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participants were left alone with the task. During the task, the participants’verbal responses
were recorded by the experimenters and saved with an anonymous code on an external
storage device. After completing the task, the participants were thanked and asked if they
had any questions about the study or their task. They were given contact information to
the experimenters and chief investigators if further need for discussion around their experi-
ence arose. During the online meeting, each participant was also asked if they would like to
receive feedback on their FIS task performance. Almost all participants answered affirma-
tively (97% of total sample) and for those participants, a document containing their relative
strengths and relative weaknesses among the assessed skills was sent to them after the
completion of all data collection.
Measures
Two of the five measures included in the online survey (Demographics and Motivation for
clinical work) were constructed by the authors and the remaining three (Deliberate practice,
Test anxiety and Natural helping measure) were translated from the original English version
to Swedish using a procedure proposed in the back-translation model by Brislin (1970).
Specifically, one of the authors translated the items to Swedish, the other author translated
it back to English. After this, the correspondence of the two English versions was checked,
resulting in some minor changes in the final Swedish version.
Online survey
Demographics and clinical experience
Participants were asked about age, gender, what university they were enrolled to, current
semester in the program and grades that led to admission into the program. The question-
naire also included different indicators of current clinical experience (hours in personal ther-
apy, number of clients seen in helping sessions (including both therapy and other helping
activities such as support line volunteering)), and hours receiving group supervision in clin-
ical work.
Motivation for clinical work
Participants motivation for clinical work was measured with two items created for this study
which were rated on a 7-point Likert scale ranging from 1 (“not at all correct”)to7(“very
much correct”). The items consisted of the two following statements: “After I graduate, I
plan to work mainly with psychological treatment”and “I am strongly motivated to work
with psychological treatment in the future”. The internal consistency of the items was a¼
.79, and the items were positively correlated at r(65) ¼.66, p<.001. Thus, for the purpose
of this study the mean of the two items was used as the estimate of participants’motiv-
ation for clinical work.
Deliberate practice measure (Moulaert et al., 2004)
A 16-item questionnaire measuring students’use of deliberate practice in skills acquisition
was used (Moulaert et al., 2004). The questionnaire was originally developed to measure
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medical students’use of deliberate practice in clinical skills training. The 16 items corres-
pond to four separate factors that was found in the original study: planning (e.g. “Iam
good at planning my time”), study style (e.g. “I pay extra attention to subjects I do not
understand”), motivation (e.g. “I work hard on my study”), and self-reflection (e.g. “I know
my strong and weak points with regard to studying”). Each item is rated on a 5-point Likert
scale ranging from 1 (“never”)to5(“always”). Internal consistency of this measure was
acceptable (a¼.72).
Natural helping measure (NHM; Stahl & Hill, 2008)
This measure assesses the participants’self-reported experiences of, and inclinations to,
helping. The NHM includes 5 items (e.g. “I often find myself helping others with their prob-
lems”) using a 7-point Likert scale ranging from 1 (“never”)to7(“always”). The final score is
the average of all items, with high scores reflecting higher natural helping ability. Test-retest
reliability over a 2- to 4-week period has been found to be acceptable (.67) and internal
consistency was high (a¼.81; Stahl and Hill, 2008).
Single item measure of test anxiety (SIMTX: Dominguez-Lara, 2018)
The SIMTX measures the level of tension experienced by participants during exams, asking
(“during exams, I feel a great deal of tension”). Responses are recorded on a 4-point Likert
scale, ranging from 1 (“almost never”)to4(“almost always”). The single item scale has been
found to correlate with a 10-item measure of test anxiety, Test anxiety inventory (TAI) (r¼
.70, p<.001), indicating good convergent validity (Dominguez-Lara, 2018).
Facilitative interpersonal skills task (FIS: Anderson et al., 2009)
The FIS is an observer-rated performance task measuring the interpersonal skills exhibited
in helping and therapeutic situations. In the performance task, participants are presented
with a standard set of eight video clips. Each video clip has been selected to simulate actual
psychotherapy sessions and displays clients who presents with different types of challeng-
ing interpersonal situations for the therapist. After each clip, the participants are asked to
respond to the clients as if they were the actual therapist. The verbal responses are
recorded and saved for later evaluation. In the present study, the FIS task was adminis-
tered online.
The responses are then coded by trained raters following the FIS coding manual on eight
items, each skill is rated on a 5-point Likert scale ranging from 1 (deficits in skills)to5(opti-
mal performance). The rating manual has multiple anchor points to aid raters in coding
each skill. Raters are advised to use the rating of “3”as a baseline and to increase or
decrease the rating based on evidence of the presence or lack of skills in the responses.
The total FIS score is the average of all eight items. In the present study, internal consist-
ency of the eight items was high (a¼.92).
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Rating
A team of three raters served as coders of the FIS task in the present study. The coding
team included the two first authors (advanced psychology students at master’s level) and
one clinical psychologist who was otherwise unrelated to the project. The two first authors
had previous experience of rating another observer-rated measure (Measure of Expressed
Empathy: MEE, Watson & Prosser, 2002) together. All raters read and learned the FIS rating
manual, which has been used in previous FIS studies (Anderson et al., 2009; Anderson,
Crowley et al., 2016; Anderson, McClintock et al., 2016; Anderson, Perlman et al., 2020; Hill
et al., 2016,2020; Perlman et al., 2020), and practiced rating using pre-recorded sample
responses, with an overall training time of approximately fifty hours. During training, all
coders rated sample responses independently and met regularly in a group to discuss the
ratings that were most discrepant among the raters. This procedure was repeated until
good inter-rater reliability was achieved. Inter-rater reliability was assessed using intraclass
correlation coefficients (ICC; Shrout & Fleiss, 1979). ICC estimates and their 95% confidence
intervals were calculated using a single-rater, absolute agreement, 2-way mixed-effects
model. The ICC for the last set of training responses coded by the raters was .75, with a
95% confidence interval ranging from .41 to .94 (F(7, 14) ¼10.49, p<.001), indicating a
good reliability according to Koo and Li (2016).
When training was completed, and all participants had completed the FIS task, most par-
ticipants’FIS responses (n¼59, 90.8%) were divided between the raters, so that each
response was coded by one rater. A subset of the participants’FIS responses (n¼6, 9.2%)
were selected for a reliability check, to ensure that calibration was maintained throughout
the rating process. All three coders provided FIS ratings for these participants’FIS responses,
with an ICC of .77, 95% confidence interval ranging from .66 to .86 (F(46, 92) ¼11.16, p>
.001). These results suggest that the good inter-rater reliability that was obtained during
training remained during actual rating. The final FIS estimates for analysis in the study was
based on mean rating of all three raters for the participants included in the reliability check.
For the rest of the participants, final FIS estimates were based on the rating of a sin-
gle coder.
Power analysis
There has been a lack of similar investigations in a Swedish sample therefore making the
effect size used for power analysis hard to estimate. Wolfer et al. (2021) showed a large
effect size (d ¼1.17, n ¼36) while Hill et al. (2020) showed a small nonsignificant effect size
(d ¼0.27, n ¼33). However, these were both published after this study’s conception, thus
making it impossible to inform the investigators decisions on effect/sample size. After
recruitment, the complete sample size was N ¼65. This allowed for the detection of large
effects which exceeds (f 2 >.34) to be found. The achieved power when running a post-
hoc power analysis was high, showing a 97% chance of detecting effects in the sample, this
was due to a large effect size (f 2 ¼.54) found by the model.
Ethical considerations
This research project was approved by the Swedish Ethical Review Authority (dnr 2020-
00609). All participants were informed about the study in writing and given opportunity to
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ask questions prior to signing informed consent forms. Furthermore, participants were
informed that they could end their participation at any moment without giving a reason.
Data was treated with confidentiality and was used exclusively for the research project.
Data diagnostics
Data transformation
Deliberate practice measure. This measure was previously shown to load onto four dif-
ferent factors (Moulaert et al., 2004): planning, study style, motivation, and self-reflection
(see Table 2 for means and standard deviations). In the current study, there were no signifi-
cant correlations between these subscales and FIS scores. However, high correlation
between the subscales were found. Therefore, only the full-scale estimate was included in
the main analysis.
Grades. There are two main grade systems in Sweden which allows for admission into
courses and programs at universities in Sweden, high school grades (HSG) and
“h€
ogskoleprovet”(HSP), a national test of skills considered to be important for higher edu-
cation. Ranges for these grades are 0 22.5 for HSG and 0 2.0 for HSP. The participants
were asked what grading system they were admitted through and asked to report their
grade on that measure. The participants were evenly distributed between high school
grades (N ¼32) and “h€
ogskoleprovet”(N ¼32), with one data point missing. The data was
examined in relation to outliers by identifying standardized residuals (z-scores) larger than
þ- 3 (Field, 2013). One outlier was identified among high school grades, and the rating was
considered so low that it was unlikely to be the actual grade that led to admission to the
program. The outlier was therefore deleted and recorded as missing data. After this, new z-
scores was calculated for both variables. The two variables containing z-scores were then
transformed into one single variable, resulting in one variable with standardized estimates
of participants grades.
Table 2. Descriptive statistics for study variables (n ¼65).
Variable MSDRange
FIS
a
3.16 .39 2.41–4.17
Test anxiety
b
2.28 .80 1.00–4.00
Motivation
c
5.17 1.29 1.50–7.00
Natural Helper Measure
d
5.26 .92 3.00–6.60
Deliberate Practice (DP)
full-scale
3.49 .53 2.06–4.63
DP Planning 3.34 .80 1.17–5.00
DP Study Style 3.58 .64 1.67–5.00
DP Motivation 3.40 .86 1.50–5.00
DP Self Reflection 3.49 .62 2.67–5.00
a
Facilitative Interpersonal skills task.
b
Single Item Measure of Test Anxiety (SIMTX).
c
Motivation for clinical work.
d
Natural Helper measure (NHM).
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Parametric assumptions
All data was examined in relation to outliers by identifying standardized residuals (z-scores)
larger than ± 3 (Field, 2013). Outliers were detected in two variables, namely age and num-
ber of clients. However, these outliers were retained for reasons listed below. The outlier in
age (age ¼52) was kept since the results of the main analyses were not substantially differ-
ent when comparing results with and without this outlier. Also, an outlier in number of cli-
ents met (clients met ¼100) was retained since the aim was to assess the effect of
experience, including experience prior to the program, so large variations were expected. If
outliers were excluded on this item, this purpose would have been lost. Normality tests,
using Shapiro-Wilks’test, indicated that FIS scores were normally distributed, while remain-
ing variables were not.
Analytic strategy
A four-stage hierarchical linear regression (HLR) was conducted with the aim of assessing
the unique effect of semester while accounting for additional control variables and other
moderating factors. In the first block, demographic variables (age, gender, and grades) were
added as control variables. In the second block, indicators of experience (personal therapy,
clients seen and group supervision) were added as further potential control variables since
previous research has mostly shown them to be unrelated to FIS scores but not as conclu-
sively as simply demographic variables (Anderson et al., 2018; Bennett-Levy, 2019). In the
third block, psychological variables (test anxiety, motivation for clinical work, natural help-
ing, and deliberate practice) were added as variables that could have a potential direct
effect on FIS scores. In the fourth and final block, semester was added as the main inde-
pendent variable. Missing data was excluded listwise, excluding one participant who had
reported gender to be “other”and two participants that had no scores for grades. Thus,
with three participants excluded, the analysis was conducted on a final sample (N¼62).
To examine whether engagement in deliberate practice moderated the relationship
between semester and FIS, a moderation analysis was conducted using the PROCESS macro
for SPSS by Andrew Hayes. Semester was added as the independent variable, FIS as the
dependent variable and deliberate practice as the moderator variable. The remaining varia-
bles (age, gender, grades, personal therapy, number of clients seen, group supervision, test
anxiety, motivation, and natural helper) were added as control variables.
Results
Descriptive statistics for study variables are presented in Table 2.
The relationship between FIS and semester
A four-stage hierarchical linear regression (HLR) was conducted with FIS scores as the
dependent variables (see Table 3). The results of the first block in the HLR suggested that
the demographic variables (age, gender, and grades) did not significantly explain variance
in FIS, F(3, 58) ¼.43, p>.05.
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Table 3. Hierarchical linear regression for facilitative interpersonal skills.
Variable BSEBbR
2
DR
2
Step 1 .02 .02
Gender
a
.04 .10 .06
Age .01 .01 .10
Grades .03 .05 .08
Step 2 .07 .04
Gender
a
.06 .11 .08
Age .01 .01 .10
Grades .03 .05 .07
Personal Therapy .00 .00 .08
Number of patients .00 .00 .06
Group supervision .00 .00 .18
Step 3 .23 .16
Gender
a
.06 .11 .08
Age .00 .01 .07
Grades .00 .05 .01
Personal Therapy .00 .00 .15
Number of patients .00 .00 .02
Group supervision .00 .00 .17
Test Anxiety .18 .07 .38
Motivation .11 .05 .36
Natural Helper Measure .04 .06 .10
Deliberate practice .07 .12 .10
Step 4 .35.12
Gender
a
.12 .10 .16
Age .00 .01 .05
Grades .03 .05 .07
Test Anxiety .15 .07 .31
Motivation .12 .04 .39
Natural Helper Measure .00 .06 .01
Deliberate practice .01 .11 .02
Personal Therapy .00 .00 .23
Number of patients .00 .00 .03
Group supervision .00 .00 .20
Semester .07 .02 .59
p<.05, p<.01.
a
0¼female 1 ¼male.
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The addition of experience-related variables (hours in personal therapy, number of clients
and hours receiving group supervision) in the second block did not significantly explain any
additional variance in FIS, F
change
(3, 55) ¼.84, p>.05.
Introduced in the third block, psychological variables explained 16.3% of the variance in
FIS scores, when accounting for the variables in the first two blocks, F
change
(4, 51) ¼2.67, p
<.05. While natural helping ability and deliberate practice did not emerge as significant
predictors of FIS, higher levels of test anxiety b¼.38, t(50) ¼2.47, p<.05, and higher
motivation for working clinically b¼.36, t(50) ¼2.39, p<.05 predicted higher FIS scores.
Adding semester in the fourth and final block explained an additional 12.4% of the vari-
ance in FIS scores, F
change
(1, 50) ¼9.53, p<.005. Specifically, further progression on the
program predicted higher FIS scores b¼.59, t(50) ¼3.09, p<.005. Thus, after controlling
for demographics, psychological variables and clinical experience, semester remained a sig-
nificant predictor of FIS.
With all independent variables included in stage four of the HRL, the overall model signifi-
cantly predicted FIS scores, F(11, 50) ¼2.46, p<.05, accounting for approximately 35% of
the variance, R
2
¼.351.
Deliberate practice as a moderator
FIS was added as the dependent variable, semester as the independent variable, and delib-
erate practice as the moderator variable, with the variables from step 1–3 from the hierarch-
ical regression model added as control variables. The interaction between semester and
deliberate practice was not found to be statistically significant, b¼.03, 95% CI [-.09, .02],
t(49) ¼1.15, p¼.25, suggesting that deliberate practice did not moderate the relation-
ship between semester and FIS.
Discussion
The aim of this study was to examine if progression in a 5-year psychologist program pre-
dicted higher scores of interpersonal skills, as measured by the facilitative interpersonal
skills (FIS) task. The results of the hierarchical linear regression showed that semester signifi-
cantly predicted higher FIS scores above and beyond the effects of variables such as demo-
graphics, experience, natural helping ability, engagement in deliberate practice, test anxiety,
and motivation for clinical work.
This is in line with the results of Wolfer et al. (2021) that found group differences between
students and psychologist trainees. However, the results are inconsistent with the findings
of Hill et al. (2020) that showed no significant effect of continued mental health education
on FIS scores.
A possible explanation for the discrepancy between these studies is the differing method-
ology. Hill et al. (2020) followed up the same participants five years after an undergraduate
course while Wolfer et al. (2021) and the present study used a cross-sectional design com-
paring students in the earlier years with later students/trainees. The longitudinal design of
Hill et al. (2020) has one major advantage since it removes the plausible rival hypothesis of
finding differences only due to the mechanism of self-selection (i.e. only students with
higher interpersonal skills remain in the psychologist program while students with lower
12 O. Salim et al.
Nordic Psychology 2022, Vol. 0(0), 1–17 © 2022 The Editors of Nordic Psychology
skills drop out). The self-selection hypothesis is a possibility and future studies should take
extra care to examine this question utilizing a longitudinal design.
Another possibility for why this study found an effect of training when Hill et al. (2020)
did not is that since participants signed up voluntarily, and only a minority of the total
psychology students in Sweden participated, perhaps subjective apprehension of one’s own
interpersonal skills played a part in choosing to participate. For example, perhaps students
in the earlier stages of the program, who had little to none experience of therapeutic work,
was interested in participating regardless of their apprehension of their own interpersonal
skills, while students in the later stages of the program only wanted to participate if they
believed they had good interpersonal skills. Such an effect could have contributed to effect
sizes bigger than those that exist in the actual population.
Contrary to our expectations, engagement in deliberate practice did not moderate the
relationship between FIS scores and semester. Additionally, there was no indication that
engagement in deliberate practice correlated directly with FIS scores at all.
This is surprising since previous studies have shown that both hat brief training on FIS
skills informed by DP principles (Anderson, Perlman et al., 2020; Perlman et al., 2020)as
well as DP training programs for interpersonal skills such as empathy is effective (Larsson &
Werth
en, 2020). One possibility is that DP only improves skills after one has acquired a
baseline level of therapeutic skills. This would imply that more engagement in deliberate
practice for earlier program students does not lead to increased skills since they are already
acquiring basic clinical skills through education, but that later stages, and especially post-
graduation, psychologists would need to apply DP principles to continue improvement. This
fits with research showing stagnant effects of experience on improved outcomes (Goldberg,
Rousmaniere et al., 2016).
Methodological considerations
One main limitation of the study is the cross-sectional design. With data only collected at
one time point, the design does not allow for inferences to be made about changes in
interpersonal skills over time. While the results of the study points to an association
between semester on the program and facilitative interpersonal skills, there are several
potential confounders that cannot be ruled out due to the study design. One main such
possible confounder is drop-out from the program, as discussed above. A longitudinal
design would have been better suited to account for such a confounding effect. Also, the
sample size of the present study could be deemed small considering the number of predic-
tors included in the hierarchical linear regression. A sample size of approximately 120 would
have been needed to detect a medium effect size with 11 predictors in the model (Field,
2013). However, because of the large effect size of the current regression model, the
acquired power was high, with a 97% chance of detecting such an effect size. Additionally,
since the FIS task was developed with an American population originally there may be
questions regarding its applicability in a different cultural context. However, the FIS task has
now been translated into several languages (Anderson et al., 2018) and versions have so far
produced good validity and psychometric properties (Van Thiel et al., 2021). Also, the FIS
mean and standard deviation in the sample of the current study (M ¼3.16, SD ¼.39) was
similar to that found by Perlman (2020) when he computed a composite FIS mean from
The development of facilitative interpersonal skills during 5-year psychology training programs: a cross-
sectional study
13
Nordic Psychology 2022, Vol. 0(0), 1–17 © 2022 The Editors of Nordic Psychology
five independent studies (M ¼3.06, SD ¼.48). This indicates that the current sample per-
formed comparably to other samples. The universities represented in our sample was
unevenly distributed, with a majority of the participants attending €
Orebro University. This
could represent a potential limitation in generalizability across all universities. However, the
Swedish psychology program is regulated in terms on length, content, and course goals
(H€
ogskolef€
orordning, HSF, 1993). Many of the programs follow a similar progression of
semesters with clinical courses usually being dominant in the end. The uneven distribution
might therefore only represent a negligible heterogeneity in participants.
This study also has several strengths. Firstly, the current sample size is greater than that
of previous studies examining the relationship between formal education and FIS. (Hill
et al., 2020; Wolfer et al., 2021) Hence, the current study builds on these findings, showing
an association between FIS and formal education in a larger sample. Secondly, this is the
first study investigating this question using participants from all stages of a university pro-
gram which enabled the results to show a linear improvement of skills throughout the pro-
gram. Lastly, for the first time to our knowledge, the variables of test anxiety and
motivation for clinical work were examined in relation to facilitative interpersonal skills, our
findings that these variables are positive predictors for better FIS scores leads to implica-
tions on the theoretical construct of FIS. Test anxiety is usually thought to impact negatively
upon performance, yet the present study found a positive correlation between amount of
test anxiety the subjects reported usually experiencing and their results on the FIS task
meaning that the participants did better with higher levels of anxiety. Perhaps the thera-
pists who can consciously experience anxiety yet can choose to regulate their emotions are
better able to handle challenging interpersonal situations. This research question is cur-
rently being investigated (Steggles & de Jong, 2018). Also, motivation is an interesting fac-
tor since it can interact with FIS scores in many ways, any future studies on FIS and training
should include assessment of motivation at different timepoints to investigate in which dir-
ection the association flows.
Implications
The main implication of our findings is further support for the notion that facilitative inter-
personal skills can be improved, either through formal education or brief training. Of course,
the question remains whether the effects of education observed in this study is due to
drop-out from the program by less interpersonally skilled students or some active mechan-
ism in training. Following this, a theoretical argument that FIS represents trait-like dimen-
sions that are more innate and resistant to change (Anderson et al., 1999; Hatcher, 2015;
Heinonen & Nissen-Lie, 2020) can be looked upon more questioningly if taking our findings
together with the studies demonstrating increases in FIS from brief training (Anderson,
Perlman et al., 2020; Perlman et al., 2020). However, future research should examine
whether gains made by training is long-lasting and if they indeed lead to improved clinical
outcomes as differences in one’s baseline FIS seems to do, preferably utilizing a longitudinal
design as mentioned previously.
In terms of practice, FIS has been reasoned to have applicability in areas such as selection,
assessment, and training of therapists (Anderson, Finkelstein et al., 2020) and our results fur-
ther indicate that the FIS task can be useful for such needs in a university setting. It seems
14 O. Salim et al.
Nordic Psychology 2022, Vol. 0(0), 1–17 © 2022 The Editors of Nordic Psychology
reasonable that the psychologist program already selects for interpersonal skills, only in an
indirect fashion. Students naturally compare themselves with their peers and if they feel
inadequate in their skill level, they will most likely take action, meaning efforts to try to
improve or change courses in their careers. Of course, some students are likely unaware of
their relative skill level and would need outside feedback to change and enact new behav-
iors. Whether or not university programs should directly select for interpersonal skills is a
multilayered question, with ethical, practical, and scientific considerations. Leaving aside
ethical and practical considerations, research should first confirm whether, and how much,
training can impact one’s relative interpersonal skills. It could be that it is possible to last-
ingly change one’s rank order level of interpersonal skills through structured training and if
so, selecting for high entry-level skills might unnecessarily restrict the number of candidates
who would otherwise be able to perform admirably as therapists after training.
FIS can also be used as an assessment tool to ascertain whether students have acquired a
reasonable level of skills before embarking on practicum training or meeting with actual cli-
ents. Research has shown that 5 to 10% of clients deteriorate in treatment (Lambert, 2013)
and that especially ineffective therapists accounts for a disproportionate amount of deterio-
rations (Okiishi et al., 2003). In our own sample, we observed some students in later stages
scoring well below average suggesting that the program has been unable to train or
improve all students skill level. Ensuring that clients are met by competent and professional
therapists that have the ability to empathize, instill hope and understand basic interper-
sonal messages sent is an ethical imperative of our profession. Therefore, the FIS task has a
given role in the assessment of therapist trainees.
Disclosure statement
No potential conflict of interest was reported by the authors.
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