Psychotherapy Bulletin

Psychotherapy Bulletin

Discrepancies Between Beginning Psychotherapists’ Clinical Self-Perceptions and Their Presentation to Supervisors and Teachers

There are several sources of this conflict or dilemma. As they learn to do the work of what Freud (1937) termed an “impossible profession” (p. 401), beginning therapists are typically beset with multiple stressors, including a greater awareness of their own personal issues; the myriad of difficulties and frustrations inherent to treatment per se; the confusion that may be attendant to learning diverse treatment options and forming a professional identity; the scrutiny and evaluation of multiple teachers and supervisors; and the awareness of disjunctions between their preferred personal style (e.g., informality; friendliness) and the assumptions of a more professional demeanor (Eckler-Hart, 1987; Farber, 1983, 2006; Gold, 2005; Hill, Sullivan, Knox, & Schlosser, 2007; Skovholt & Rønnestad, 2003).

Their responsibilities and expectations—both internally and externally imposed—are considerable, and despite their typically outstanding scholarly achievements, many trainees feel distressed by the demands and challenges of clinical and supervisory work. While such experiences are normative, disclosure of these feelings, or of seemingly non-prescribed clinical interventions, may nevertheless be problematic given trainees’ understandable wish for approval from supervisors, complementary fears of being judged as “less than” or wanting in some respect, and eventual need for highly complimentary letters of recommendation for externships, internships, and/or jobs (Bernard & Goodyear, 2014; Hahn, 2001; Skovholt & Rønnestad, 2003; Wallace & Alonso, 1994).

Moreover, as Farber (2006) has noted, fears of failing oneself and/or one’s supervisor may be particularly acute because clinical work is so inextricably tied to the therapist’s sense of self: “The work of the psychotherapist . . . draws so palpably upon an individual’s skills as a caring, well-related human being. Thus, acknowledgement that one is struggling with the work all too often feels tantamount to admitting that one is struggling to be the human being one wants to be and should be” (p. 182).

In fact, studies have shown that trainee anxiety and fear of unfavorable supervisor evaluations are significantly related to greater nondisclosure and more frequent manipulation of presented clinical material during supervision (e.g., Mehr, Ladany, & Caskie, 2010). Studies have also shown that supervisee nondisclosure may be nearly universal. In one study (Ladany, Hill, Corbett, & Nutt, 1996), over 97% of a sample consisting primarily of doctoral students in counseling and clinical psychology reported withholding at least some information from their supervisors. In another study (Yourman & Farber, 1996), 47% of clinical supervisees acknowledged telling their supervisor—at moderate to high levels of frequency—“what he or she wanted to hear” (p. 571).

Research has determined that trainees are most likely to conceal negative reactions to their supervisors and clinical mistakes (Ladany et al., 1996; Mehr et al., 2010; Yourman & Farber, 1996). Although valuable in its own right, this line of research has neither examined the specific types of emotions or behaviors that trainees find difficult to acknowledge nor the extent of the discrepancies between what trainees experience while doing clinical work (e.g., feelings of anxiety or sexual attraction) and their reports of these experiences to supervisors—the dual focal points of the current study.

Method

Participants

The sample consisted of 133 students in psychotherapy training programs.  Most were female (84.2%), Caucasian (74%), and between the ages of 25-34 (70.5%).  These students were divided among PhD (39.7%), PsyD (30.8%), and license-eligible MA programs (28.8%).  They were well distributed regarding the theoretical orientation that “informs their work” on a 7–point scale (1 = not at all; 4 = somewhat; 7 = to a great extent); their responses indicated that their work is at least moderately informed by psychodynamic (M = 5.02; SD = 1.65), humanistic/existential (M = 4.52; SD = 1.78), and cognitive-behavioral therapy (CBT) (M = 4.29; SD = 2.42) perspectives.  On average, these beginning therapists were currently seeing 5.4 clients, and to date had seen 12 clients (M = 12.18). Among this sample, 96 (72.2%) had at some point been in their own psychotherapy.  There were no significant differences between men and women in terms of perceived adherence to each of the three theoretical orientations assessed in this study, nor in regard to age or ethnicity.

Instrument and procedure. The “Experiences of Beginning Therapists Survey” (BTRS; Farber, Geller, Coren, Hazanov, & Lyman, 2013) consists of several sections; for the purposes of this report, the relevant section requested participants to compare, on a 1-7 Likert-type scale, the extent to which they believe they are less, about the same, or more (1 = far less; 4 = about the same; 7 = far more) “compassionate, “disclosing,” “warm,” etc. (over a total of 32 items) in their actual clinical work than they disclose to their supervisors.

Participants were recruited through networking, primarily by sending announcements to Directors of Clinical Training throughout the country. Participants completed the survey online (via Survey Monkey).

Results

Descriptive data

The basic research question posed was, “Which emotions and behaviors common to beginning therapists are most likely to be over- or under-reported to supervisors?” To answer this question, we looked at participants’ self-reports (i.e., mean scores) on 32 distinct therapy-related feelings and behaviors. As Table 1 indicates, the most discrepant items were “anxious,” “uncertain,” “overwhelmed,” “humorous,” “protective,”  “compassionate,” “advice-giving,” “confused,” “encouraging,” “self-assured,” “friendly,” and “chatty”; in each case (except “self-assured”), trainees’ experiences of these feelings or behaviors were greater than they reported to their supervisors. Notably, though, none of these scores exceeded 5.0 on a 7.0 scale (where 4 = about the same, and 7 = far more). Several items had mean scores at or around 4.0 — including, for example, awareness of one’s own and the client’s erotic feelings, and one’s availability outside of sessions—suggesting a near exact correspondence between trainees’ reported felt experiences and their reports to supervisors. While a Principal Components Analysis of the survey items (followed by regressions of these factors on selected demographic variables) would have been instructive, the small sample size precluded this.

Hierarchical regression analyses: Effects of demographics on factor scores

Five hierarchical regressions were computed to determine which demographic variables, including age, gender, ethnicity, current year in psychology program, type of graduate program, and current status of personal therapy, predicted scores on each of the five “most discrepant” items.  Only the top two most discrepant items, anxious and uncertain, yielded significant overall R-squared values (.15 and .16, respectively).  Two variables—gender and ethnicity—were significant predictors of the anxious item; three variables—age, ethnicity, and current status of personal therapy—significantly predicted the uncertain item.  Younger age, male gender, non-minority status, and being in therapy were predictive of higher scores (i.e., greater discrepancies) on these items.   

Discussion

Although this sample of beginning therapists did indicate discrepancies on several items between their self-experiences of clinical work and their reports of these experiences to supervisors, these discrepancies tended to be minimal to moderate. Thus, despite decades of research suggesting that psychotherapy trainees inevitably experience a great deal of stress and anxiety, and that nondisclosure to supervisors is normative, the results of this study indicate, somewhat surprisingly, that beginning therapists are generally honest in their reporting of their clinical experiences. This may be due, in large part, to supervisors’ ability to provide a sufficient “holding environment” (Winnicott, 1960) for trainees’ distress.

We also believe that training programs, increasingly aware of and attentive to the results of psychotherapy research, have increased their attention to relational factors and the critical importance of developing a strong therapeutic relationship across multiple theoretical perspectives. The current zeitgeist—one that typically encourages therapists to be genuine, empathic, and open—has likely created an atmosphere in which clinical trainees feel more authorized than trainees of previous generations to disclose their in-session relational experiences with supervisors—and that supervisors, compared to previous generations, are more receptive to hearing and processing such experiences. To explicitly acknowledge that one is self-disclosing or spiritual—self-attributions which would almost certainly have led to significant under-reporting to supervisors a generation ago—is now seen as acceptable, representing a significant shift in the therapeutic and supervisory landscape.

Nevertheless, this sample of beginning therapists did, to a certain extent, mask some of their distressed feelings. The three most under-reported items—experiences of anxiety, uncertainty, and feeling overwhelmed—reflect a complex tension inherent to beginning therapists’ development. Even as trainees feel mostly unconstrained to disclose many of their relationally-oriented clinical experiences with their supervisors, they still struggle somewhat to report doubts about their ability to do the work well. Despite trainees’ awareness that clinical work is inevitably difficult, and despite their (presumed) awareness that supervisors recognize this fact, it may still feel shameful to fully acknowledge these difficulties. Clearly, though, while it may be adaptive for supervisees to conceal distress at times (e.g., defending against supervisor criticism protects supervisee self-esteem), “half truths” in the context of supervision may ultimately hinder beginning therapists’ professional development by limiting opportunities to process and understand how their in-session experiences affect their therapeutic work and professional sense of self.

It is notable, too, that beginning therapists were hesitant to fully acknowledge the degree to which their sense of humor is part of their work.  We speculate that this reflects trainees’ fears that their supervisors and teachers might judge this aspect of their clinical work as unprofessional. Thus, while some aspects of relationality are deemed eminently disclosable, humor, and to a somewhat lesser extent compassion, advice-giving, encouragement, friendliness, and chattiness, are apparently viewed more cautiously in terms of their clinical appropriateness. These qualities, we imagine, feel a bit too close to the margins of “soft,” and somewhat too far from whatever stance or technical interventions (e.g., interpretations; refutations of self-deprecating patient self-statements) trainees have been taught. Our sense is that most beginning therapists feel authorized to act relationally with their clients and report doing so to their supervisors, but also that most trainees want to feel more technically competent, not just reliant upon their usually well-honed and considerable interpersonal skills. Thus, they may somewhat downplay those aspects of themselves that are self-judged as too far in the realm of friendship or informality.

Surprisingly few predictor variables significantly affected scores on those items with highest discrepancies. That younger trainees hide feelings of uncertainty from supervisors more than their older counterparts is easily understood and perhaps even expectable; we imagine their need to appear certain of themselves would be especially pronounced if they are part of a cohort that is significantly older. Notably, ethnicity was the only demographic factor to significantly predict the top two most discrepant items. That Caucasian beginning therapists report concealing more anxiety and uncertainty than non-Caucasian trainees is a somewhat puzzling finding about which we can only speculate. Perhaps as programs become more diverse, Caucasian students experience an unarticulated, mostly out-of-awareness pressure to look relatively unshakeable; perhaps minority trainees are simply more comfortable expressing their self-experiences; perhaps these differences are due to the demographics at clinics located in urban communities wherein Caucasian students working with minority clients struggle to acknowledge their difficulties in working with people whose backgrounds are different from their own.

The sole use of self-report measurement has inherent limitations. Some beginning therapists are likely to be reluctant to acknowledge, even on an anonymous survey, the extent to which they have concealed some of their experiences to supervisors. In addition, since participants in this study were asked to report on how they represent their experiences of self in therapy to supervisors “in general,” it is possible that some responses were influenced by a single, salient supervisory experience or by a recent and/or specific supervisory exchange. Furthermore, this study did not investigate the extent to which supervisor factors—for example, the quality of the supervisory alliance or supervisors’ willingness to disclose personal information—affect beginning therapists’ willingness to accurately disclose their self-experiences.  Follow-up research, either involving a larger sample or employing qualitative analyses, would likely provide more detailed information on the processes involved in trainees’ decisions to withhold, distort, or accurately disclose their clinical experiences.

The results of this study suggest that in training settings, particularly in clinical supervision, supervisors and teachers should normalize and validate the distress that beginning therapists inevitably experience.  If supervisors and teachers invite beginning therapists to acknowledge and express the full extent to which they feel anxious or uncertain or overwhelmed in session, and if they (individuals in charge of training) facilitate such discussions by sharing anecdotes from their own training and practice, trainees are likely to feel more comfortable disclosing the true nature of their own experiences. Such authentic exchanges are likely to facilitate a particularly trusting supervisory space, one in which it becomes more fully possible to discuss emotionally charged interactions between patient and therapist (and supervisor and supervisee). In turn, this safer and more mutually disclosing space may provide trainees with greater opportunities to develop therapeutic interventions and skills that help them feel more competent and confident (e.g., less distressed) during clinical sessions and supervision.

We would suggest, too, that participants in supervisor-trainee dyads sensing tension surrounding the disclosure of trainee feelings would benefit from finding the courage to address it. A trainee would likely feel proud, if somewhat apprehensive, of being able to say to a supervisor: “I’d like to talk about how overwhelming this work is for me, but I’m also a bit fearful of how you will see me if I do.” A supervisor would do well to say, “It strikes me that you disclose a great deal to me about some of your feelings and behaviors—and I appreciate your honesty in doing so—but I also have a sense that you may be leaving some of the really hard pieces out of our work together, pieces that we all experience.”

Since shame and anxiety are inevitable aspects of clinical training, the finding that beginning therapists hide some of their clinical behaviors and emotions when reporting to supervisors is not surprising. What is greatly encouraging, though, is the extent to which this tends to occur minimally, a testament apparently to the honesty of beginning clinicians and the safety and trust provided by clinical supervisors.

Table 1. Psychotherapy Trainees’ Self-Experiences Compared to their Reports to Supervisors: Means and Standard Deviations (N = 133).

  Mean SD Min. Max.
Anxious 4.68 .95 2 7
Uncertain 4.53 .87 3 7
Overwhelmed 4.50 .91 2 7
Humorous 4.47 .73 2 6
Protective 4.46 .80 3 7
Compassionate 4.36 .70 3 7
Advice-giving 4.33 .81 1 7
Confused 4.33 .96 1 7
Encouraging 4.32 .70 3 7
Self-assured 3.68 .85 2 7
Friendly 4.31 .53 4 6
Chatty 4.31 .77 2 6
Empathic 4.30 .74 3 7
Warm 4.29 .63 3 7
Frightened 4.29 .79 1 7
Confrontational 3.73 .78 1 7
Stuck 4.27 .85 0 7
Self-disclosing 4.26 .82 1 6
Boundary-extending 4.25 .74 1 7
Bored 4.22 .70 2 6
Interpretive 4.21 .70 1 6
Praising 4.21 .65 2 6
Impatient 4.20 .72 2 7
Irritated 4.19 .73 2 7
Frustrated 4.18 .77 2 7
Talkative 4.18 .63 2 6
Defensive 4.12 .58 2 6
Aware of my own erotic feelings 4.10 .71 2 6
Spiritual 3.95 .55 1 6
Aware of my client’s erotic feelings 3.98 .70 1 6
Available outside sessions 4.01 .60 2 6
Quiet 4.00 .50 2 6

 

Note

Scores based on a scale where respondents indicate the extent to which they believe they experience less, about the same, or more (1 = far less; 4 = about the same; 7 = far more) of this feeling or behavior in their clinical work than they disclose to their supervisors. Thus, scores higher than “4” indicate that the respondent typically feels more of this experience than reported.

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Cite This Article

Farber, B. A., & Coren, S., (2015). Discrepancies between beginning psychotherapists’ clinical self-perceptions and their presentation to supervisors and teachers. Psychotherapy Bulletin, 50(2), 24-29.

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