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I became inspired to take on the research outlined in this article because as a trainee I became aware of a pattern of my own non-disclosure during supervision. Recognising that supervision is a career- long commitment that extends past initial training, I was motivated to understand how prevalent non-disclosure is for trainees. The concern was that the behaviours and circumstances which lead to non-disclosure as a trainee could become a sustained pattern of behaviour. This curiosity led to my final year dissertation and consequently, much wailing and self-doubt. The results of that dissertation I present below.
The Importance of Supervision
Whilst the relationship between the supervisor and the supervisee might resemble or parallel the therapeutic relationship, supervision differs as its focus is on developing the skills of the supervisee and protecting the client (Bernard & Goodyear, 2019). O’Farrell (2014) asserts that in developing the skills of the supervisee, supervision ensures the individual is not “operating in a vacuum”, predisposed to repeat inappropriate interventions or remain oblivious to some aspect of the client’s experience (p.134). Supervision should offer the supervisee emotional support and encouragement whilst challenging them to explore their client work from every perspective (O’Farrell, 2014).
In the developed world, different countries have different requirements that need to be satisfied before a trainee can become accredited or licensed to practice as a psychotherapist. The number of clinical practice hours required differs by country. However, consistent across all is that trainees’ clinical practice hours must be supervised. Supervision of trainees is therefore considered an important element of the journey to qualification.
The Trainee
When they start their clinical practice, trainees, because of their lack of experience and skills, are prone to anxiety and can go through a variety of feelings ranging from enthusiasm, elation, self-doubt, fear, despair and shame, which can make them oversensitive to negative feedback (Skovholt & Ronnestad, 2003; Watkins, 2020).
Because trainee therapists can feel isolated and vulnerable, they often question their suitability for the role and consider themselves imposters (Watkins, 2020; Ronnestad & Skovholt, 2013). Watkins (2020) writes that supervision might have its greatest impact early in the career of the therapist.
The Supervisory Relationship
In a review of the literature to identify the ideal supervisor, conducted by Carifio and Hess (1987), trainees described their ideal supervisor as someone more knowledgeable and experienced in therapy and supervision. They wanted a supervisor who demonstrated empathy, respect, congruence and who was supportive and non-critical (Carifio & Hess, 1987). Research suggests that disclosure on the part of the supervisor was found to enrich the relationship (Carifio & Hess, 1987; Ladany et al., 2013) and that if the supervisory relationship was a positive one, then trainee confidence, motivation and therapeutic insight were possible outcomes (Nelson & Friedlander, 2001).
For a good supervisory relationship to be formed, it needs to deliver a safe environment, offer challenge and be based on mutual trust, respect and integrity (Creaner, 2014; Weaks, 2002). Mehr et al. (2020) suggest that in a relationship where there is an inequality of power, the person with less power will frequently be vigilant about what they disclose. Trainees can feel exposed and vulnerable which can lead to them needing to protect themselves, thus making congruence on the part of the trainee critical in the supervisory relationship (Lambers, 2011). It is incumbent on the supervisor to provide that safe space.
Implications of Non-disclosure
There are relatively few historical studies that focus on the impact of non-disclosure by trainees in supervision. However, results from several studies refer to the potential impact of non-disclosure on client care and the possible impact on the trainee’s development.
In a study on trainees’ experience of counter-productive events in supervision, Gray et al. (2001) suggest that a trainee who does not expose their vulnerability in supervision, or who chooses not to disclose, reduces their capacity to develop from supervision. They also suggest that non-disclosure by trainees of mistakes in therapy sessions may impact negatively on the client as the trainee may not learn from their mistakes and may continue making them (Gray et al., 2001).
One way trainees respond to feeling vulnerable in the supervision space is to provide inaccurate information to the supervisor. Yourman and Farber (1996) suggest that the probability of a supervisor appreciating a client’s situation is diminished when a trainee alters the information, which leads to a reduced learning experience for the trainee and negatively impacts the quality of service to the client.
Themes Identified
The results of my research indicate a variety of influences causing trainee therapists’ non-disclosure in supervision. However, non-disclosure within supervision might be an accepted norm. Non-disclosure was admitted to, whether the supervisory relationship was good or problematic.
Analysis of the eight studies identified in the final selection indicated two main themes, each with a number of sub-themes as identified in Figure 1 below.
Theme 1: The Consequence of Hierarchy
Sub-Theme 1.1: The Power Differential
From the studies reviewed, evidence of the power differential manifested itself in several ways.
Theoretical Orientation
One of the interesting findings to emerge was that supervisors exerted their power by rejecting any discussion on alternative interventions or theoretical orientations other than their own. Several of the studies showed that the trainees saw this as an exercise of power on the part of the supervisor (Singh- Pillay & Cartwright, 2019; Reichelt et al., 2009; Hess et al., 2008).
Based on the information supplied by the authors of the research, it is unclear if the supervisors held qualifications in supervision. Fifty per cent of the studies made no mention of the supervisor’s qualifications or experience (Singh-Pillay & Cartwright, 2019; Cook et al., 2018; Meydan, 2020; Hess et al., 2008). Of the remaining 50%, only one study, (Sweeney & Creaner, 2014), reported that the supervisors involved were qualified in the role.
Regardless of the supervisor’s inexperience or lack of training in supervision, trainees were left with a feeling that discussion or dialogue was not allowed. This ultimately resulted in non-disclosure.
Safety
An unexpected finding was that trainees reported feeling unsafe because of how their supervisor used their power in the supervision session. What is concerning is how trainees chose to address the situation. They presented inaccurate accounts of their sessions, with one trainee reporting “kind of just making stuff up at this point” (Cook et al., 2019, p.214), or withheld information on perceived clinical mistakes because they were afraid of the negative reaction they might receive if they disclosed (Sweeney & Creaner, 2014, p.217). It is not surprising that some trainees first experience of supervision could be anxiety-inducing. What is surprising is that this seemed to lead to a level of distrust in the supervisor (Sweeney & Creaner, 2014). A criticism could be that there is no evidence provided to determine if the expressions of distrust are particular to the supervisor or if it is a learned general distrust of authority as suggested by one trainee: “It is difficult to confront authorities, as suggested particularly in a hierarchical relationship” (Reichelt et al., 2009, p13).
Countertransference
Regarding countertransference, three of the studies (Cook et al., 2018; Hess et al., 2008; Singh-Pillay & Cartwright, 2019) identified two influences resulting in non-disclosure. One influence was the trainees’ lack of awareness that countertransference was occurring. An example of this is an incident where the trainee was so afraid of their client that they chose to present “the least problematic case” (Singh- Pillay & Cartwright, 2019, p.86) in supervision. It was not unexpected to discover this lack of awareness of countertransference, considering how much information trainees are trying to assimilate when they first commence clinical practice. What was unexpected was when some trainees tried to bring issues of countertransference to supervision they “were dismissed by the supervisor” (Hess et al., 2008, p.407).
Sub-Theme 1.2 – An Unsatisfactory Relationship and the Person of the Supervisor
In reference to the supervisory relationship, several of the findings were predictable. Trainees reported feeling unequal, insecure and inferior because of their trainee status (Cook et al., 2018, p.122) and because of a belief that as trainees, they do not know enough. What was not predicted was that trainees also believed that their opinions were not valued as their supervisors gave the impression they were “disinterested in the perspectives of the students” (Reichelt et al., 2009, p.13).
One criticism that could be levelled at supervisors from a number of the studies was that there was a distinct lack of evidence that Rogers’ core conditions of empathy, congruence and unconditional positive regard (Rogers, 2004), were present in some supervision sessions. Trainees reported supervisors who lacked empathy, who scolded them and who made them fearful (Meydan, 2020; Cook et al., 2018; Reichelt et al., 2009).
Sub-Theme 1.3 - Career Impact
The studies show that concern reported by the trainees for the potential impact on their careers was expressed in three interrelated arguments: evaluation, professionalism and self-respect.
It is understandable that trainees were aware that their supervisor’s evaluation of them would go towards their grades. What is difficult to understand is that trainees thought that by disclosing fully to their supervisor, it would result in a negative evaluation. A possible explanation might tie back to the feelings of being unsafe expressed by the trainees and discussed earlier. Gilbert & Evans (2000) argued that if the supervisory relationship is not a safe one, then the trainee could experience the evaluative quality of the relationship as critical or fault-finding. This could be the case for the trainees across the studies reviewed.
It emerged from a number of the studies (Cook et al., 2018; Cook et al., 2019; Meydan, 2020; Lonn & Juhnke, 2017; Singh-Pillay & Cartwright, 2019), that many of the trainees were concerned that they would appear unprofessional or affect their future careers by their disclosures. Moreover, they “did not want to … burn a professional relationship” (Cook et al., 2018, p.123). It is surprising that trainees are mindful about potential impacts on their careers as therapists. Perhaps this is to be expected if a lack of trust in their supervisor extends to the supervisor’s potential influence on their relationships in the therapy community post-graduation.
It could be suggested from the results that non-disclosure is a means by which trainees maintain their self-respect and project a professional persona. Trainees stated they did not want to appear weak, inarticulate, or incompetent (Cook et al., 2018; Cook et al., 2019; Meydan, 2020; Lonn & Juhnke, 2017; Singh-Pillay & Cartwright, 2019). They appeared to use non-disclosure as a means to safeguard the supervisor’s perception of them, and exude an air of competency, with one research participant stating “I don’t want her to think that I’m just like winging it every week or that I have no idea what I’m doing” (Cook et al., 2019, p.213). Where trainees believed that they were viewed positively by their supervisor they used non-disclosure as a means to protect that positive view (Hess et al., 2008, p.404).
Theme 2: The Unconscious at Play
Sub-Theme 2.1 – Mirroring
There was evidence in the findings that indicate trainees were mirroring a variety of supervisor behaviours witnessed by them. Where the supervisor was deemed to be holding back, the trainee mirrored this by also withholding (Singh-Pillay & Cartwright, 2019). In cases where the supervisor was thought to be disinterested, the trainee likewise adopted disinterest, for example stating “my supervisor seemed oblivious to my pulling back and I became less disclosing.” (Hess et al., 2008, p.405). One trainee mirrored the person of the supervisor because they wanted to be like them, as they saw them as “a really cool person” (Cook et al., 2019, p.210) and so scaled back on their disclosures.
The trainees mirrored the supervisor’s non-disclosure in a number of instances: “If your supervisor is not competent about the issues you are raising and cannot really tell you ‘this isn’t in my line’, and ends up mumbling around it, it’s what you are taking out (as a professional) and it does reflect on your work because you will do exactly as taught” (Singh-Pillay & Cartwright, 2019, p.88).
If we are to consider Bandura’s (Bandura and Walters, 1977) Social Learning Theory, that we learn new behaviour through a process of observation and imitation, mirroring in supervision is to be expected and might be an area of consideration for supervisors during the session.
Sub-Theme 2.2 – Projection
Freud (1968) explains projection as being a defence mechanism a person uses to assign their unwanted characteristics onto someone else.
It is surprising and fascinating that evidence of projection was found in the majority of the studies reviewed. It appeared that trainees, fearing being hurt or “overwhelmed” (Cook et al., 2018, p.121), projected these feelings onto their supervisors, for example reporting “I didn’t want to hurt my supervisor’s feelings” (Hess et al., 2008, p.404). In some instances, their reason for non-disclosure was because they thought the supervisor would not be able to handle it, stating for example, “I don’t trust that the supervisor will manage it” (Reichelt et al., 2009, p.13).
Further instances of projection involved trainees not understanding what the supervisor required of them: “I don’t know if I’m not giving her what she wants” (Cook et al., 2019, p.214) or censoring themselves when they were “taken aback” (Cook et al., 2019, p.210) by the supervisor’s style.
It would be interesting to understand the degree of self-reflection the trainees in these instances practised or whether they brought these issues to personal therapy. Discussion with their personal therapist could highlight the possibility of projection which could be explored further. It would also be interesting to know to what degree supervisors were able to recognise the projection and use it, as suggested by Hawkins and Shohet (2012) in their seven-eyed model of supervision, to tease out whether it was something that was happening in the supervisory or the client relationship.
Strengths and Limitations
This systematic literature review has shown that multiple influences are contributing to non- disclosure amongst trainees within supervision. The body of research indicates that these influences cross multiple themes. The research studies in the final yield range from the year 2008 to 2020. They span different continents, ethnicities, age groups and data collection methodologies and reveal that non-disclosure persists as an issue in supervision today.
Supervision is an important part of the therapy triad. Because the supervisor is not present in the therapy room, they are reliant on the relevant information being disclosed by the trainee. Without this information, the supervisor is at a disadvantage, which means that the client’s welfare and the development of the trainee might be in jeopardy. It is therefore vital that non-disclosure by the trainee is reduced to a minimum.
The eight studies (noted by an asterisk in the reference section), were chosen because of their focus on non-disclosure by trainees and therefore give us a one-sided view. As the trainee is only one half of the supervisory relationship, it would be key to include the voice of the supervisor. Supervisors could have different perspectives on the influences on non-disclosure which may alter the themes. Future research should be conducted to determine the degree to which supervisors are aware of non- disclosure within the session and also what they believe would help in minimising it.
As the client is the third part of the supervisory triad, future research should be conducted to understand the impact of non-disclosure on the client and their growth. If we have clarity on the possible impact on the client, it could help us to mitigate that impact.
Conclusion
Supervision is a critical component of a trainee’s development and throughout their career as a therapist.
The findings of the review highlighted the prevalence of non-disclosure in supervision. The power differential, the supervisory relationship and perceived negative consequences all influenced what trainees chose to disclose. Non-disclosure was used as a form of self-protection and as a way for some trainees to reclaim their power within the session.
The exercise of power and inflexibility by the supervisor to move outside their theoretical orientation made trainees feel unsafe, fearing a negative reaction. Issues with the supervisory relationship were also a contributing influence on the trainees who felt subordinate and unequal. Concerns over the potential impact on their future careers were evident across all eight studies, including being viewed as unprofessional or incompetent by the supervisor.
The unconscious also played a part in influencing trainees’ non-disclosure, with trainees modelling the behaviour of the supervisor, mirroring the supervisor’s non-disclosure, or projecting their feelings of fear and overwhelm onto the supervisor.
Supervision is an essential element in the development of the therapist (O’Farrell, 2014; Watkins, 2020; Casement 2014; Ladany & Bradley, 2010; Yourman & Farber, 1996; Bernard & Goodyear 2019; Sköld et al., 2018); therefore the implications of non-disclosure on the welfare of the client and the development of the trainee deserve the full attention of supervisors and training institutions. The duty of care they have to trainees and their clients mandates this. Supervisors, as previous trainees, are well placed to understand the anxieties of their trainees and address these in sessions.
The following recommendations, if implemented, could address the influences on non-disclosure, improve the learning experience of the trainee and possibly form a persistent pattern of disclosure for the future. These recommendations include: understanding trainee non-disclosure from the supervisor’s perspective; understanding the impact on client growth because of non-disclosure in supervision; ensuring supervisors are formally trained and accredited in supervision; matching the theoretical orientation of the supervisor to that of the trainee; inclusion of supervision induction in training courses, covering the purpose, process and benefits of supervision; supervisors holding regular ‘health checks’ with their trainees to identify the trainee’s anxieties and allow bi-directional feedback; supervisors sharing their own experience regarding perceived mistakes to encourage disclosure.
Notwithstanding its limitations, this is an important study due to the importance of supervision in the therapy triad. The study gives us insight into what drives trainees to limit their disclosure. If the recommendations were adopted, it could empower supervisors and training institutions to address the influences recorded here to reduce non-disclosure to a more acceptable minimum.
Lorraine Dowdall earned her MSc in Counselling and Psychotherapy in 2021 from the University of Northampton, studying with the Dublin Counselling and Therapy Centre. She is currently working towards accreditation and can be contacted at lorrainedowdall@live.com
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IAHIP 2024 - INSIDE OUT 102 - Spring 2024