Psychotherapy Bulletin

Psychotherapy Bulletin

The Cultural Climate of Clinical Training

Showing Up or Hiding Out

Clinical Impact Statement: This manuscript provides a perspective on the complicated dynamics of supervision relationships in training that include a co-created bind. This bind is described as limiting authenticity in the supervision relationship. Examples of these co-created binds are presented and recommendations to supervisors to enhance trainee openness and self-reflection in supervision are given.

Freud (1913) invented the application of self-reflection to psychotherapy by making himself the subject and the object of the first therapy. He used one of his own dreams as the specimen dream in his breakthrough book, The Interpretation of Dreams, because it was in thinking about this dream that his early ideas came into focus. Ironically, and tellingly, the dream itself was about the loss of status that comes from identifying with patients rather than with doctors (Karson, 2008). Thus, for precisely as long as there has been a clinical profession in the contemporary sense of the phrase, there have been quandaries about the courage needed to apply one’s psychology to oneself and about the status issues involved in wearing the doctor cloak instead of personhood.

Such quandaries also complicate the supervisor-trainee relationship. While there is an expectation that both supervisor and trainee “show up” authentically for supervision and openly engage in self-reflection, they may experience a bind about doing so. We provide examples of ways in which trainees may manifest this bind in supervision, explore how the supervisor and broader training culture co-create this bind, and end with recommendations for enhancing the possibilities of showing-up in supervision.

Therapist Self-Reflection and Personhood

Supervisors highly prize openness and self-reflection in supervisees. Indeed, one of the common measures of a therapist’s clinical competence as well as suitability for advancing in clinical training as a student in training is self-reflective practice (Falander & Shafranske, 2004; Fouad et al., 2009; Ladany & Inman, 2012). Further, life-long learning in advancing clinical skills is thought to hinge on the therapist’s ability to self-reflect (Falander et al., 2004; Orchowski, Evangelista, & Probst, 2010).

The Relational-Competency model of supervision emphasizes that learning and demonstrating self-reflection requires supervisory relationships where trainees authentically engage, presenting their work and themselves openly for consideration, and allowing for useful feedback to be heard and integrated (Mangione & Nadkarni, 2009; Watkins, Budge, & Callahan, 2015). Feedback not only comments on therapeutic technique, it involves discussing and commenting on ways in which trainees co-create relationships with clients (and supervisors) in both facilitative and complicating ways. Showing up for supervision requires that trainees not only show themselves and their work, but that they engage in supervisory relationships where they tolerate considering feedback about both.

The therapist’s personhood is a critical component of positive outcomes in treatment (Blow, Sprenkle, & Davis, 2007; Kissil & Claudio, 2015) and needs examination in supervision (Aponte et al., 2009; Kissil & Claudio, 2015). Desirable therapist characteristics include such traits as positive interpersonal skills, empathy, warmth, and personal fit with theoretical orientation (Ackerman & Hilsenroth, 2003; Castonguay & Beutler, 2006; Lambert & Barley, 2002; Norcross, 2002). Beyond commenting upon the performance of these traits in supervision, supervisors must identify personal vulnerabilities (or “signature themes”) that are life-long (Aponte, 2014; Stone, 2008 in Aponte).

While some supervisors might view personal struggles or vulnerabilities as necessarily requiring resolution in order to practice competently, the inclusion of the therapist’s “self” as a powerful tool in therapy is embraced by others in order to maximize their conscious and productive use (Aponte, 2014). In this inclusive approach, the full person of therapists, and their personal vulnerabilities in particular, are the central tools through which therapists do their work in the context of the client–therapist relationship (Aponte et al., 2009). The courage to authentically show one’s personhood in supervision must be present for training of this nature to occur, and this courage will no doubt be influenced by multiple, interacting contexts that support or hinder it, including the quality of the supervisor-supervisee relationship (Bernard & Goodyear, 2014; Bordin, 1983).

The Cultural Norms of Clinical Training and the Co-created Dynamics of Stigma

While a culture of self-reflective practice may promote openness or “showing up” in supervision, the dynamics of stigmatization may promote impression management or “hiding out.” Stigma is a socially-constructed mark of disgrace or discredit that invalidates the individual’s efforts to play a role (Goffman, 1963). This is a mark that distinguishes someone as different from others, as unsuitable to the role, eliciting negative judgment and bias against those with that “spoiled” identity element. Stigma may be public or self-imposed (Corrigan, 2004), a public endorsement of prejudice against a stigmatized group, versus the individual’s internalization of the public’s devaluing and discriminatory social construction. In a training environment where the press is to be open, but the concern about evaluation is present (perhaps for both student and supervisor), the fear of being discredited may lead to the hiding of personal identities, at least until the cultural norms are learned about what discredits the role of therapist.

Supportive, empathic relational bonds are essential to both therapeutic outcomes and supervisory ones (Angus & Kagan, 2007; Bernard & Goodyear, 2014; Bordin, 1983; Orchowski et al., 2010;). Showing up as a client in therapy involves the challenges of revealing oneself within a co-created therapeutic relationship influenced by intrapersonal, interpersonal, and systemic factors that may facilitate or detract from authenticity (Fox, 2012). With clients, the challenges of showing-up are the very meat of psychotherapy.

Unlike psychotherapy, supervision involves close monitoring and evaluation of trainees, complicating the cultural expectation in supervision that you talk about yourself (Barnett & Molzon, 2014). As an evaluator, the supervisor has significant power over the fate of the trainee to proceed in their training. The expectation to show one’s personhood may inherently promote a sense of needing to show the “right” personhood, a personhood that will be deemed acceptable and even, exceptional by the supervisor. The more that the cultural training environment elucidates specific factors related to acceptable trainee traits, the options for showing aspects of one’s personhood may decrease. Instead of the trainee showing up authentically for supervision, the cultural press may be to perform only culturally-sanctioned traits while hiding others. One example of a fear to reveal personhood might be related to the trainee’s concern about personality styles or qualities revealed in supervision as being deemed unacceptable by the cultural values of the training program. For example, while warmth and empathy are highly esteemed attributes of the therapist (Ackerman & Hilsenroth, 2003; Castonguay & Beutler, 2006), being “real” in supervision may look very different when the student is not in the therapist role. Traits involving anxiety, introversion, self-consciousness or even self-preoccupation in the supervisory relationship may evoke concerns that these traits appear with clients.

Indeed, supervisees may not disclose or may selectively discuss their work to make a positive impression on the supervisor (Ward, Freidlander, Schoen, & Klein, 1985). Further, even in relationally-focused, feminist supervision the overt discussion of the dynamics of power in supervision was found to be a rarity (Mangione et al., 2009), suggesting that power dynamics, and the consequent tendency to engage in impression management, may be present in supervisor-supervisee relationships even though collaboration and authenticity may be stressed by the supervisory approach.

In the following section we offer a few examples that illustrate ways in which the dynamics of co-created stigma may operate to promote supervisee inauthenticity, and some ways in which supervisors might facilitate authentic supervisory relationships.

Co-constructing Stigmatization in the Supervisor-Trainee Relationship

1.Trying to stay off the radar

Supervisory Vignette:

Students in a clinical psychology training program talk with their faculty member supervisor in one of their seminars. Momentarily forgetting her status as one of “them” (the faculty) and not “us” (the students), they lament the approaching evaluation period. “It’s just important to stay off the radar. Once you’re on the faculty’s radar, it’s all over,” the group collectively agreed. Taking the discussion further, the faculty member asks them about what they fear the radar would detect. The sentiment is revealed that once any problems (personal or performance) are identified, the assumption of incompetence follows. Further, “problems” may often be experienced as individual differences where the concern is that differences (behavioral or internal) may not fit into the expected norm of the faculty member who would thereby deem them incompetent (not like her). It is safest to avoid making any impression that might be commented upon.

This pattern is self-perpetuating for both faculty and students. In clinical training programs, as elsewhere, people are cautious about revealing their backstage thoughts, histories, or personal or relational differences for fear of becoming stigmatized (Karson, 2008). Those who can keep up a facade that simulates the norm do so, while others may be found out (or fear being found out) as deviating in some way. The price of deviation is high when the fear is related to stigmatization. For students facing evaluation by their supervisors, they fear that negative evaluation may leave them in the “out” group, defenseless and at risk for not obtaining their

The approach to commenting on trainees’ personal psychology as it affects performance may contribute to the tendency for trainees to be motivated to stay off the radar and engage in impression management. These supervisory methods of giving feedback may likewise reinforce the status differential in a way that creates concern or, even, fear of evaluation. For example, although supervisors have thoughts along the way about the personal psychology and work of their trainees, they may save such feedback for an evaluation meeting in the future, rather than making comments along the way. Indeed, supervisors have been found to have difficulty discussing negative as opposed to positive impressions of supervisees’ work in supervision (Hoffman, Hill, Holmes, & Freitas, 2005). Having useful, evaluative thoughts about the performance and personal psychology of the trainee, but not revealing them, adds to the experience of the supervisor as maintaining a below-board, hidden style of relating where her authentic self is kept out of the relationship. Supervisor authenticity, of course, includes the supervisor’s personal psychology, and this is revealed in the moment-to-moment connection with the trainee. Keeping one’s reactions out of the supervisory interaction decreases connection and maintains one’s status as an evaluator with secrets and power, and supervisors sharing reactions and reflections have been found to promote supervisee engagement, disclosure and self-reflection (Orchowski et al., 2010). A culture in which evaluative comments are kept under wraps until a formal evaluation is one in which the trainee wonders what the content will be, potentially strengthening the tendency to hide

2. Having negative reactions to clinical sessions and/or the supervisory relationship

Supervisory Vignette:

Feeling overwhelmed and angry about the hours of work in his training program, Matt sat down with his supervisor who was fidgeting with his pen, something that Matt found to be very annoying. In a frustrated tone of voice, Matt told him how much coming to supervision weekly made his schedule intolerable and wondered if they could meet bi-monthly instead. “I’m not really enjoying seeing the clients you supervise. I think you’d agree it’s not very interesting; nothing happens so we don’t have much to talk about.” Although the supervisor may have felt like decreasing meetings with Matt, he didn’t. Concerned about Matt’s irritability and general instability, he brought the situation up to colleagues in the faculty meeting for consultation, and then met with Matt to discuss his behavior in their last meeting. Feeling called on the carpet, Matt said angrily, “I was just being real, but obviously faculty can’t handle

The concern about the identification of a personal vulnerability, and consequent stigmatization, may come up in discussing personal reactions to clients or supervision sessions even though this is a clearly stated goal of supervision. The press to be “real” in supervision is complicated and, at times, confusing for all concerned. Further complicating the picture is a goal of supervision, to examine the co-constructed relationship between therapist and patient partly by looking at the supervisees’ experience of the client and themselves in their relationship. This stands true for the co-constructed supervisory relationships as well but may be complicated for trainees who are evaluated as well as for supervisors operating in an evaluative collegial context. Not only have supervisors needed to have experience risking professional stigmatization in their collegial context (by showing their personal self), they need to participate in a supervisory relationship in ways that permit students to explore personal reactions and behaviors that fall within and without professional “norms,” for that is the nonjudgmental intimacy that they attempt to co-construct with their clients. The academic climate may encourage and promote faculty “showing-up,” or, alternatively, advance a clear cultural norm for “acceptable” behavior. A student’s anxiety is heightened when she is taught to discuss personal reactions in supervision while sensing the supervisor’s/faculty’s ambivalence about taking off the doctor’s

In the vignette above, the supervisor might take off his cloak and add, “I’ve thought about my contribution to the atmosphere between us, including my confusion about how stuck the therapy with your client seems to be. Perhaps my pen-clicking is a sign or illustration that there is also something difficult between us. Let’s look at the case and our interaction and see what we can make out of it.” But such a statement, like the mutual examination of co-constructed problems in therapy, requires a supervisor willing to acknowledge having a psychology and willing to relinquish the posture of superiority.

3. Experiencing stigmatization while presenting authentically

Supervisory Vignette:

“I just wanted to wring his neck,” said the student about a father engaging in emotionally abusive behavior with his 7-year-old son. “It reminded me of the rage I felt at my own father whose temper was scary and dangerous.” The student began to cry, feeling so sad and scared for the boy she was treating, and for herself. Taken aback by the personal, family content to do with her wanting to “wring the neck” of this parent, the supervisor was concerned about this student’s mental health status. The supervisor wasn’t sure how to respond. Sensing her supervisor’s anxiety, the student quickly wiped her eyes and became more composed, thinking she had just been totally

In the confusion about wearing or not wearing a cloak, both supervisor and student are left to interpret the interaction. The student felt ashamed and potentially stigmatized by her sudden revelation of her personal history and its place in her treatment of this family, and the supervisor questioned whether the revelation suggested emotional problems on the part of the student, or insightful

Rather than seeing the training opportunities available when students sense familiarity and pain associated with a client’s behavior or background, supervisors may experience anxiety not knowing enough to be able to deem the pain as pathological or resilient or merely informative. Clearly, students sense this balance beam of stigmatization and pathology versus acceptance and/or perceived resilience when supervisor anxiety is expressed, and they worry about on which evaluative side they will land. Rather than walk the beam, impression management may be far more appealing.

In this example, the supervisor might have turned the moment into a lesson on how to tell the difference between what might be called a neurotic pattern, in which the individual uses an outdated map that interferes with her functioning, and what might be called a characterological pattern, in which the individual uses the only map she knows. A key element of the discrimination might be the student’s awareness or lack of it that her client’s father might or might not be like her own father in important ways, with the supervisor in the position to help the student with the natural tendency to react to new people (clients) with old expectations.

4. Experiencing life-stresses and emotions as a barrier to competence

Supervisory Vignette:

Amy slinked into supervision having just signed divorce papers. Feeling a failure in her marital relationship, she had no clue how she could present the couple’s work she was doing in supervision, let alone do it. On top of that, she needed to look for part-time work to help support herself through graduate school and was worried that she would be viewed by faculty as having a lack of focus and commitment to her school work. She would need to change her supervision time to accommodate a new job. Describing these circumstances, she became even more disillusioned about herself when her faculty supervisor said, “This must be a lot to handle. Perhaps you should consider taking a break from school right now to get things on track? Do you think this might be negatively affecting your ability to focus in sessions?”

Stressful life events and/or personal vulnerabilities in the throes of clinical training may be difficult to reveal, particularly if emotional energy for training is drained. Students in training may perceive themselves as failing if they “succumb” to the stresses of life events, and if these events are so emotionally challenging that their work is affected. The idea that one’s personal psychological health, or lack thereof, may be subject to examination and stigmatization may inhibit discussing these factors in supervision. While some life stresses may be ones that can be compartmentalized so that work with others continues unaffected, others may not be. This is a lesson particularly important to learn in graduate training, since the avoidance of compromised practice depends upon making solid judgments about one’s psychological capacity to work with others (Schoener, 2013).

Faculty, however, may succumb to the same stigmatizing notions as the general public and stigmatize trainees who experience negative life events and, even, some mental health symptoms (Corrigan, 2004), fueling a tendency for trainees to fail to mention these in supervision. Highly stigmatizing life events and consequent emotional symptoms such as depression may lead to self-stigma and a sense of shame and blame. Events like these are especially stigmatizing in clinical training. Goffman (1963) says that a stigma is information that discredits an individual’s performance of a role, usually the role of a normal or fully authorized group member. Clinicians are supposed by some to be experts on relationships and families, and an event such as a divorce can discredit that expertise. Further, life circumstances assumed to be stressful, such as going to graduate school at the same time as raising a family, tend to raise questions about the student’s ability to manage therapeutic relationships competently. The thought here is, perhaps, that when life is taxing there’s not enough left to invest in therapeutic relationships or psychotherapy training.

The tendency for faculty to become braced when hearing of life events, rather than embracing these life circumstances as a normal part of development and grist for the training mill, may co-create the conditions that the best course is to hide that one has a personal life at all. These issues may also be present for faculty, who may feel they need to disguise problems in their personal lives from colleagues for fear of being discredited. Amy’s supervisor might have discussed with her strategies for managing her sense of failure and her distractibility before raising questions about whether these were manageable at all and, even, disclosed times when she herself had experienced life-stresses being difficult and getting in the way.

5. Having an expectation of premature competence

Supervisory Vignette:

Audrey called her supervisor after a confusing session to say that she wanted to see the client again before meeting for supervision. She indicated feeling confused about a presentation of highly discrepant information from the client including such facts as place of birth and marital status. Audrey said that she wanted to get the “real story” on the client before presenting her in supervision and that more time with the client would be helpful.

Another common presentation of hiding out in supervision involves the real or perceived idea that clinical competence is expected by oneself and/or others (faculty) from the get-go. Most graduate students have experienced significant academic success prior to their graduate training, showing a high degree of competence to perform academically. The competition in graduate admissions may also lead to an overabundance of graduate student applicants who have high self-expectations that involve immediate performance excellence in graduate school. While many of the same skills may be applied to their academic coursework and confirm these performance expectations, the skills required for clinical work are unlike listening to lectures, writing academic papers, or taking tests. Many trainees have been praised all their lives for even modest attempts in various fields, leading to participation medals and graduation ceremonies from kindergarten. Many trainees have not been exposed to the rewards and frustrations of delayed reinforcement where learning new skills is involved. Having self-expectations of excellence may stigmatize taking a long time to learn a difficult skill, which may in turn lead to a variety of ways of hiding out in supervision. This may take the form of the trainee acting overconfidently, counterdependently, and avoidantly with respect to supervisory relationships. In this way, internal distress related to not knowing is masked by a presentation of already knowing and not needing supervision. Ironically, this can lead trainees to avoid supervisors they think might make them feel ignorant. Similarly, supervisors who may feel uncomfortable revealing their own mistakes or lack of knowledge may fuel the co-creation of supervision avoidance.

Additionally, many graduate training programs institute a competency examination wherein trainees display their “competence.” While the timing of this is specific to the training program, it may be given as early as the end of the second year. The very name of this examination suggests something that is truly unattainable so early in one’s training but implies the attainment of competency to practice psychotherapy, something that most seasoned therapists would indicate takes many years (Barnett, 2009).

6. When there may be something to hide

Supervisory Vignette:

Anna presents two seemingly conflicting scenarios when explaining her failure to call her child client’s parent back to answer a question. A few weeks earlier, she had reported a confusing explanation of the lack of completed paperwork in her client’s file. This time, the student explains to the supervisor her thoughts about the clinical benefits to the parent of keeping the boundaries of their contacts to their already scheduled parent meeting. When the supervisor inquires about her thinking on this, the student senses the supervisor’s disapproval. She becomes concerned about the quality of her explanation and expresses concern that this parent is disengaging from treatment and will only talk with her on the phone. Because of her performance anxiety and sense of mistrust, the student struggles to come up with the “right” answer that will satisfy the supervisor who, she hopes, will ultimately retreat from exploring what was probably a mistake. Whether this hiding-out is related to trainee psychopathology or a cultural environment that stokes a sense of dangerousness to show-up is difficult to tease out.

When hidden clinical practices and/or professional behaviors reflect a level of deviance from the training program’s cultural norms, they may reflect unethical or pathological behavior on the part of the student. They also may reflect personal vulnerabilities (such as a history of trauma and/or difficulties in psychological functioning) that, for concerns of stigmatization, have been left unexplored in supervision as to their relevance to the trainee’s work with a particular client (Kern, 2014). Untangling the dynamics of personal psychopathology and/or personal vulnerabilities from the cultural dynamics of the training environment is a formidable task. Specifically, are trainee difficulties in clinical performance hidden for personal pathological reasons, or are they hidden because of a fear of shame, humiliation, and/or punishment fueled by real and perceived environmental circumstances?

Anna’s supervisor might use the moment as a lesson in the difficulties in obtaining useful information across a power differential. The supervisor can make explicit what can be learned about clients’ caution in revealing themselves to therapists by examining Anna’s concern about what will become of any information she reveals. If good therapists wonder with their clients what they might do to make showing-up in therapy more likely, good supervisors do the same with supervisees.

Promoting Authentic Engagement in Clinical Training

1. Articulating the mutual goal of showing-up

Showing-up in supervision is largely dependent on the sense of safety and security in the trainee-supervisor relationship, although there is often much confusion about what the supervisee is supposed to be safe from (many trainees think it’s criticism!). Expecting a trainee to immediately show her personhood would be unrealistic given the complicated cultural factors involved in the trainee-supervisor relationship. Indeed, Goffman (1963) teaches us that new roles are more easily discredited than those with which the performer and audience have a history. Just as is true in psychotherapy relationships, a trainee-supervisor bond takes time to develop. This bond requires an initial articulation of the goals of supervision, with one goal being an examination of the trainee’s personhood as this interacts with her work with clients. Without this expressed and agreed-upon goal being commented upon, showing up and revealing one’s clinical work may be experienced as a sign of failure and embarrassment rather than one constant and important intention of supervision. Beginning supervision by asking the trainee what would need to happen in supervision for it to be a place where looking forward to sharing their work, especially their mistakes, would be a welcomed experience positions this supervision goal as an essential and primary task.

2. Explicitly acknowledging the bind

While articulating showing-up as a mutual goal seems rather straightforward, it is not. Similar to developing initial treatment goals with clients, the stated goals may come with unspoken and unknown psychological barriers that make tackling them together challenging. In the case of trainee-supervisor relationships, recognizing the barriers to showing-up, and agreeing to notice when these barriers are present, helps make authenticity in supervision a goal rather than an initial starting point. It also parallels how some goals in psychotherapy are obtained, i.e., through noticing the personal and/or therapist-client variables that make them challenging to simply do. In that way, the agreed upon task in supervision is to assist the trainee to learn self-reflection, where showing one’s personhood in supervision is one identified process of developing self-reflective practice. Acknowledging this as a goal to work on in the process of the trainee-supervisor relationship rather than as a foregone conclusion, allows for an empathic and expectable look at times when this is difficult, rather than fueling impression management strategies to simply perform self-reflection.

Another advantage to acknowledging the bind involves the lessons to be learned about communicating across a power differential. Therapists have a particular power over clients—the power to define what’s going on (Karson, 2008)—that parallels the supervisor’s power to evaluate the trainee. Examination of the bind in supervision can teach trainees how to examine the power differential in therapy.

3. Modeling authenticity

Supervisors can help by ensuring that hiding their own all-too-human psychologies does not become part of the role of clinical expert. Commenting upon one’s personal psychology, or inviting others to, may seem status-reducing to supervisors functioning in a culture of training that also monitors their performance as supervisors. Similar to the impact of monitoring and evaluating trainee competence, trainee ratings of supervisor competence impact decisions of job security, promotion, and/or tenure. If showing one’s personhood is seen as separate from competent supervision, this leaves open the prospect of stigmatization and the supervisor’s trust that authenticity is valued is hampered.

In a system that sometimes divides between the roles of commentator and commented-upon, it becomes a status move to comment on others and a reduction of status to be commented upon (Johnstone, 1981). This feature of interpersonal comments is probably rooted in childhood, where parents and other adults comment on children, but it really takes hold in clinical training, where the professionals do the commenting and the clients get commented upon. Trainees do both, commenting on their clients and on other people’s clients, and getting commented upon by faculty. The whole enterprise makes it stigmatizing to get commented upon, and what gets commented upon is typically any deviation from the assigned role, and any sign of having a psychology.

To counter this tendency, faculty can good-naturedly accept the fact that their own psychologies are continually on display, and only the tact of their colleagues and students keeps others from pointing out the displays. Faculty can even take this a step further and treat unwanted behaviors by students as commentaries on the psychology of the faculty. The very public nature of group supervision, for example, where the supervisor’s all too human psychology is displayed may be received well by some trainees, but not by others. Reception of the supervisor’s personhood, and the modeling of this as part of supervision and psychotherapy, is likely increased the more that the supervisor comments on her personhood, rather than leaving this up to trainees to do so. Taking ownership of one’s psychology maintains the role of expert and being the first to comment on oneself models the very behavior supervisors are trying to teach.

4. Acknowledging the role of stigma in the cultural climate

Departments and agencies vary considerably with regard to the valuing of personhood in clinical work, clinical training, and in collegial work relationships, and this sets the tone for supervisors to include or exclude these as variables in their work with trainees. While a primary disciplinary goal is inclusiveness, faculty are subject to the same stigmatizing dynamics as are present in the larger sociocultural environment. Power and privilege may be maintained through the creation of “in” and “out” groups that place value on particular types of clinical expertise, such as theoretical orientation or whether or not one subscribes to “evidence-based” or evidence-informed notions. The more circumscribed and narrow the view of acceptable theoretical orientations in practice, the greater the likelihood that personhood variables are excluded as important in training and practice with an emphasis on the procedures of the psychotherapeutic approach as the emphasis of training. We recommend that faculties periodically revisit the question of what they want the role of supervisor to entail. These value statements, which are always humanist in our experience, can quell concerns about stigma associated with being all-too-human.

5. Acknowledging factors related to anxiety about corrective feedback in supervision

Although the advice of “comment on the behavior as bad but not the child as bad” may be aptly adopted by parents as a means of preserving their child’s self-esteem, in supervision the very discussion of personhood and its influence on the trainee’s therapeutic skills and behaviors makes these factors inseparable at times (O’Donovan & Dyck, 2005). Such personhood factors as emotional vulnerabilities and functioning, personality, and interpersonal skills may influence trainee effectiveness with a need to focus on these in supervision.

That supervisors may be overly concerned about providing critical feedback, consequently avoiding it altogether, may be key to limiting trainee learning (Green, 2011). Another complicating factor includes the frequency with which trainees’ self-evaluations do not match the evaluations of others who are more advanced. Trainees with less skill, for example, were found to have a higher degree of confidence in their therapeutic abilities than those with more skill (Overholser, 2010). Further, there may be a general tendency for trainees to overestimate their counseling skills (Urbani et al., 2002). Not only could supervisor feedback assist in providing information about specific clinical skills development, it may also assist trainees in more accurate self-reflection about the level of their abilities.

Supervision is one of the few relationships where “already knowing” is stigmatized and communicating “not knowing” gains prestige in the eyes of the supervisor. An open discussion and supervisory agreement that the performance of self-reflection in supervision includes engaging with corrective supervisory feedback about oneself and one’s performance is required for effective supervision. Viewing “not knowing” as a valued trainee role in supervision may decrease anxiety about revealing vulnerability or lack of skill and make way for increased learning. Open discussion of this role may increase trainee openness to learning and allay the anxiety that both trainee and supervisor may experience about grappling with corrective feedback. Corrective feedback no longer is defined as problematic, aggressive, and/or hurtful in the relationship but as expected and valuable. Of course, this view of corrective feedback can help trainees provide their clients with observations about what they see without feeling as if they are thereby humiliating or harming their clients.

6. Allaying trainee anxiety about the need to know

The supervision relationship is a unique teaching relationship where the roles of “knowing” or “not knowing” are determined not only by the relative levels of professional experience and development of the participants, but by the need to develop skill at approaching co-created therapeutic relationships with clients. While learning and supervised practice in the field of psychology enter into increasing levels of competence to perform the therapist role, the skills needed to develop therapeutic relationships require comfort with ambiguity and “not knowing.” Such a stance allows therapists to remain open to coming to unique understandings of clients and therapeutic relationships.

“Knowing” is often a more familiar trainee stance than “not knowing.” This stance may have been shaped by such experiences as participation in education systems and/or family dynamics where producing the “right” answer may be the task. In such environments, competence is associated with getting the right answer and receiving positive reinforcement for this. The cultural climate of evaluation in psychotherapy training may similarly complicate the task of presenting in supervision in a questioning, self-examining way when trainees connect competency with “knowing.”

Helping trainees see “not knowing” and curiosity as a prestigious stance in supervision is required in order to both profit from supervision from someone more expert and learn how to understand and form therapeutic relationships with clients. Further, when acknowledgement of one’s developmental level of training is clear in supervision, the position of learning and “not knowing” becomes more comfortable. Explicating this developmental process in supervision may further the trainee’s capacity to show up in a curious fashion that promotes self-esteem rather than detracts from it. We like to introduce ourselves to trainees as a “42nd-year student” or a “40th-year student,” signifying our ongoing effort to get a little better at clinical work this year than we were last year.

7. Understanding oneself with compassion

The supervision relationship offers an opportunity to untangle the stigmatizing dynamics that lead to hiding out by emphasizing a need to practice self-care and self-compassion (Kern, 2014). The acknowledgement in supervision that self-reflection and awareness of the need to grapple with personal vulnerabilities are a part of professional identity that can empathically inform work with clients may reduce stigma, specifically the stigma that may be exacerbated by a sense that mental health professionals should be unaffected by personal vulnerabilities. Instead, an acknowledgement of these all too human personal factors as they enter into therapeutic work and supervision frees up trainees to show themselves in supervision and practice self-reflection.

Many of the difficulties that bring people to psychotherapy have to do not with what the person sees when they look at themselves but with the way they look at themselves. Much of the work of psychotherapy involves providing clients with a new, more welcoming way of looking at themselves. The training program’s culture and the supervisor’s stance can further the goal of looking at people with compassion and curiosity.


Although the valuing of professional traits of openness, self-reflection, and authenticity in supervision is clearly a part of training in psychology, articulating and addressing the cultural factors that may contribute to trainee reluctance to “show up” in supervision are necessary to address practicing these values in a training environment. The bind created by the complexities of the supervisor-trainee relationship, if not addressed overtly, may lead to trainees hiding-out in such a way that one of the major goals of training, i.e., self-reflective practice, is left unmet. Addressing these relational binds earnestly and mutually in the supervisory relationship is key to promoting authentic engagement in clinical training.

Judith Fox, Ph. D. is a clinical and child-clinical psychologist who has practiced for over 35 years. She is a professor in the Graduate School of Professional Psychology (University of Denver) where she teaches and supervises masters and doctoral students. She directs the International Disaster Psychology Program and has expertise and interests in the field of trauma, development and attachment theory and mental health stigma.

Cite This Article

Fox, J. & Karson, M. (2018). The cultural climate of clinical training: Showing up or hiding out. Psychotherapy Bulletin, 53(4), 78-91.


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