Trainee difficulties with therapeutic engagement: a qualitative study of in-session critical incidents

Abstract

Trainee therapists or psychologists starting to practice psychotherapy are met with a number of inherent difficulties in engaging their clients in the treatment process. Using interpersonal process recall and interpretive phenomenological analysis, 18 counselling/clinical psychology trainees were interviewed about core difficulties they faced in engaging their clients in a therapeutic process. Interviews look place after 10 weeks of training and trainees were asked to self-select a single video-taped session for the interview. The analysis uncovered seven main themes: (1) difficulties with ‘personal material’; (2) difficulties with certainty, control, and idealized intentions; (3) frustrations with the client’s presentation; (4) difficulty in becoming the focus of attention; (5) reactions triggered by perceived exclusion; (6) anxieties about difference; and (7) interpersonal strategies to manage intense emotions. Findings are understood to be organized around the trainee’s struggle for self-definition and agency at the expense of empathic relating.

Keywords

Interpersonal process recall novice therapists psychotherapy skills therapeutic alliance trainees

Novice¹ therapists are faced with a number of challenges associated with acquiring clinical skills, engaging in supervision, and treating clients (Gelso & Hayes, 2007; Howard, Inman, & Altman, 2006; Nerdrum & Rønnestad, 2002; Nutt Williams, 2008; Rønnestad & Skovholt, 1992, 2013; Skovholt, 2012; Williams, Hayes, Fauth, Brown, & Lent, 2008). In terms of beginning to treat clients, one of the first challenges trainees face involves generating sufficient rapport with the client so as to engage them in the treatment process and foster a good therapeutic alliance. For the purpose of this article, therapeutic engagement is broadly defined as the ability to respond to the patient in an empathic and collaborative way in order to validate the patient’s experience and develop a good therapeutic alliance (Lemma, Target, & Fonagy, 2011).

The difficulties trainees encounter in engaging the patient and developing a therapeutic alliance have received relatively little attention in the research literature, especially from the trainees’ perspective (Nerdrum & Rønnestad, 2002; Rønnestad & Ladany, 2006). Given that the alliance is a key predictor of a good therapeutic outcome (e.g., Horvath, 2001; Safran & Muran, 2000), understanding the difficulties trainees encounter in this area appears potentially useful.

In the research presented here, interpersonal process recall (IPR; Larsen, Flesaker, & Stege, 2008) was used as a data collection method to facilitate trainees’ reflections on core difficulties they faced in engaging their client. The aim was to understand self-identified difficulties that they encountered in the counselling setting. The emphasis was on capturing ‘real-time’ interactional experiences that brought the inquiry closer to the thoughts, emotions, and processes evident in moments when trainees felt they were failing to engage with their client.

A brief review of the literature indicates that difficulties in engaging the client may be linked to a number of factors. Trainees often have to contend with overwhelming emotions and anxieties when they start counselling clients. The ambiguous nature of the therapeutic process is often a core source of anxiety (Eagle, Haynes, & Long, 2007; Hill, Sullivan, Knox, & Schlosser, 2007; Pica, 1998). More specific trainee anxieties include the fear of failure or incompetence as a helper (Bowman, Roberts, & Giesen, 1978; Eagle et al., 2007; Skovholt & Rønnestad, 2003; Thériault, Gazzola, & Richardson, 2009), anxieties about disappointing their supervisor and client (Skovholt, 2012), fear of rejection (Goodyear et al., 2003), perceived pressure to make correct decisions (Hale and Stoltenberg, 1988; Hill et al., 2007), as well as anxieties about adversely affecting the client, managing silences, and cultural differences (Williams, Judge, Hill, & Hoffman, 1997). Although much of the work in this area focuses on anxiety, trainees struggle with managing a number of other intense emotional states (Skovholt & Rønnestad, 2003). Melton, Nofzinger-Collins, Wynne, and Susman (2005) make the point that trainees experience the therapeutic encounter like an ‘emotional rollercoaster’ as they struggle to contain intense affective states that impact the therapeutic relationship.

Difficulties in engaging the client may also be influenced by the trainee’s ability to negotiate boundaries between professional and personal roles (Hill et al., 2007). While this is an inevitable part of the trainee’s developmental journey (Skovholt, 2012; Stoltenberg, 1981), difficulties in assimilating the role of the therapist can lead to trainees feeling like ‘imposters’ (Thériault et al., 2009) in the therapeutic relationship. Challenges in negotiating their new role often manifest in difficulties such as knowing when to speak or remain silent in the session, managing personal boundaries, knowing how to effectively end the session, and managing fees (Skovholt, 2012).

Trainee difficulties in the counselling relationship have often been linked to novice therapists’ concerns about self-efficacy and performance (Orlinsky & Rønnestad, 2003; Skovholt, 2012; Stoltenberg, 1981; Tang et al., 2004). Inevitable lack of experience renders trainees fragile, hypersensitive, reactive, prone to idealistic expectations, and pre-occupied with self-efficacy. Acute sensitivities of this kind can be understood as emerging from a ‘fragile and incomplete practitioner self’ (Skovholt & Rønnestad, 2003, p. 50). They can also be linked to findings that indicate that novice therapists who often have doubts about their effectiveness (Orlinsky & Rønnestad, 2003) are often self-critical about their interventions (Hill et al., 2007) and engage in a great deal of negative ‘self-talk’. All the above factors make trainees more prone to narcissistic injury in the therapeutic relationship (Halewood & Tribe, 2003; Mollon, 1989).

One final area of difficulty that may affect the novice’s ability to engage with their client involves an under-developed level of awareness about self-other distinctions in the therapeutic process (Skovholt, 2012). The identification and regulation of emotion during the therapeutic process are dependent on trainees developing adequate self-awareness, empathy, and the capacity to collaborate with the client. Difficulties in this area manifest in problems managing boundaries (Hill & Knox, 2009), a lack of awareness of relational conflict and ruptures in the therapeutic alliance (Safran, Muran, Samstag, & Stevens, 2001), and difficulties in noticing and making use of emotional states in treatment (Melton et al., 2005).

The above observations have emerged from observer accounts, as well as journal and interview research. Most of the research, however, stops short of yielding rich, phenomenological, in-session accounts of the processes involved in such difficulties. How trainees make sense of these challenges as they occur in the interpersonal process is also less understood. Although some research has focused on critical incidents (turning points and points of learning) to isolate particular moments in the counselling experience (e.g., Furr & Carroll, 2003; Howard et al., 2006), very little research has attempted to understand critical incidents (like difficulties) in context and as they occur in the interpersonal exchange. For this reason, there still exists a relatively superficial understanding of how trainee difficulties emerge in their dynamic interpersonal context. The research presented here uses a data collection method that attempts to capture trainee difficulties in real-time interaction and analyses them using a phenomenological method. Such an approach may help us better understand trainee difficulties related to specific interpersonal events such as attending to the client’s needs, negotiating their own needs in the counselling exchange, understanding their awareness of the ‘relational impact’ of their actions, the strategies they adopt to manage emotions during the session, and so forth.

Method

Participants

A convenience sample was drawn from Clinical and Counselling Psychology students undergoing their first year of training at the University of KwaZulu-Natal, South Africa. In South Africa, Clinical and Counselling Psychology students are required to complete a coursework Master’s degree in Psychology (12–18 months) followed by an internship (12 months). During the Clinical and Counselling Psychology Master’s programme, students are required to conduct psychotherapy consultations under supervision.

The sample comprised 14 female and 4 male trainees. Of the participants, nine were African, three Indian, and six White.² The average age of the trainees was 28 years, and ages ranged between 22 and 42 years. A total of 12 trainees were registered for a Clinical Psychology Master’s degree, while the remainder were registered for a Counselling Psychology Master’s degree.

All trainees had undergone an intensive 6-week psychotherapy skills training programme and were under supervision. At the time of the interviews, students had completed 10 weeks of their Clinical and Counselling Master’s programme and had been consulting with clients for a period of 4 weeks.

Procedure

Trainees were contacted via email requesting their participation in the study. In the email, they were given information about the research subject and asked to attend a 90-min interview in the psychology clinic. Those who wished to participate in the study were asked to (1) select one video-taped session from their caseload that demonstrated some of the difficulties they had encountered in engaging their client in the therapeutic process, (2) review the tape prior to the interview and self-identify ‘difficult moments in engaging or relating to their client’, and (3) record a time reference for each critical incident or ‘difficult moment’ so that they could be easily accessed during the interview.

Interview data were collected over a 3-year period,³ with three different cohorts of Clinical and Counselling Master’s Psychology students included in the study. All interviews were transcribed in preparation for data analysis. During transcription, notes were added to aid in the identification of the actual video-taped event being described.

Qualitative interview guide

A semi-structured interview was used following the IPR (Larsen et al., 2008) method. IPR interviewing uses video-assisted recall to access conscious, yet unspoken, experiences implicit in the interactive process. The interview focused on discussing the ‘difficult moments’ trainees identified⁴ and was guided by the following questions: (1) How did the difficulty in engaging the patient unfold? (the process of the difficulty); (2) What feelings and thoughts did you experience? (their inner experience); and (3) What was happening to you when your client said/did that? (the relational context). On reviewing the recorded material with the interviewer, the trainee was permitted to stop or rewind the recording at any time to reflect on the material. The real-time focus on actual events (using IPR) aimed to minimize overly abstract and rationalized accounts of their experience (Larsen et al., 2008).

Ethical considerations

The study was approved by the Research Ethics Committee of the School of Applied Social Science, University of KwaZulu-Natal. All references to trainees and clients were kept anonymous. All clients in the video recordings had signed an informed consent form stating that video material would be used in clinical supervision, training, and research. Trainees were permitted to end the research process at any time. Counselling and debriefing were made available to make provision for trainees who might have become overly distressed during the interview. No trainees requested this service.

Data analysis

Interpretive phenomenological analysis (IPA; Smith, 2007) was used to analyse the interviews in order to explore how participants made sense of their experiences. IPA involves a detailed examination of the participant’s ‘lifeworld’ (Smith, 2007) while recognizing that the investigator’s observations are an inevitable part of the research process.

After undergoing a period of immersion in the interview transcripts, open-coding was used to isolate themes emerging from the interview data. Care was taken to ensure that each theme was comprehensively represented in the transcripts. In keeping with IPA, the final seven themes were selected on the basis of their ability to illuminate salient aspects of trainees’ experience of difficulties in engaging patients (Smith, Flowers, & Larkin, 2009).

Morrow’s (2005) qualitative research guidelines were followed to ensure credibility and trustworthiness of the data. To this end, trustworthiness was maintained through (1) careful transcription of data, (2) adequate immersion in the data, (3) adopting a reflexive attitude in discussions about the data and the authors’ apparent biases, and (4) discussing and adjusting thematic categories after a process of consensual validation. In keeping with IPA analysis, however, no claim is made for a definitive analysis of the subject matter (Morrow, 2005; Smith et al., 2009). Rather, the themes examined here should be seen as part of a body of experiences that appear useful in understanding trainee development in the context of trainee difficulties in building a therapeutic alliance.

During the research, both authors were involved in the training programme from which the research participants were drawn.⁵ While this has been viewed negatively in the past (due to bias and undue influence), advantages, in terms of achieving greater immersion in the research field, are now acknowledged and accepted (Morrow, 2005). Given limited space, the presentation of themes has been limited to key exemplar quotes that highlight core experiences and interpersonal events across the sample.

Results

Theme 1: difficulty with ‘personal material’

So where do I draw the line between just being myself and just being the therapist, you know what I mean? (Trainee 2)

A number of the difficult episodes were associated with attempts to negotiate a self-imposed distinction between what might be called the ‘personal self’ and the ‘trainee self’. Trainee 5, for instance, expressed a sense that she was concerned that her own ‘personal stuff’ would get in the way of listening to her client ‘objectively’. She discusses the matter in the context of trying to engage with a client who had just undergone a divorce:

So here I am listening to her loneliness . . . about the divorce . . . but I don’t know what to do with my personal stuff. I know I actively tried to push those thoughts away but they come back . . . I feel like I get in the way . . .

Other trainees tried to deal with perceived ‘personal interference’ by trying to actively shut off from its influence. Trainee 3, for instance, expressed this in terms of trying to ‘forget about me’:

We are now training . . . I feel like I have to forget all that other stuff, what I know, and start again . . . I feel like I am trying to do that here (in the session) . . . I must reflect with the patient, not think about me . . . empathize and forget about me.

The ‘other stuff’ that Trainee 3 refers to here is associated with her own sense of person. She expresses a wish or intention to separate ‘the personal’ from her ‘trainee self’. This is linked with her ideas about ‘training’ (‘we are training now’) representing something divorced from her own personal resources or identity. The remark, ‘empathize and forget about me’, seems to poignantly express what most trainees felt about the difficulties they experienced in conceptualizing their own thoughts, feelings, or sense of self, as an integrated part of the therapeutic relationship.

A number of trainees linked this perception to a sense of feeling ‘interpersonally rigid’ (Trainee 14) when trying to engage with the client. On negotiating ‘personal’ and ‘trainee’ attributes, there was also often a sense of shame and embarrassment related to trainees ‘being too much themselves’ (Trainee 5) in the session:

I switched back to, you know, a more personal lay role of: ‘Oh, my gosh, I can’t believe that really happened to you’. So yes, I don’t think I contained her very well . . . So embarrassing . . .

The separation of ‘personal’ and ‘trainee’ attributes appears to be articulated further in trainees’ experiences of distancing themselves from the client and a sense of depersonalization in the process. For instance, Trainee 3 touches on this experience in describing a difficulty in ‘connecting’ that is related to her sense of ‘not feeling myself’:

I feel far away from the process here. Like I am not feeling myself . . . I’m just doing techniques, trying to interpret . . . Like I’m on the outside looking in but not really part of the process.

It is difficult to say whether this is an active rejection of the ‘personal self’ or a function of depersonalization due to anxiety. However, ‘just doing techniques’ is an experience associated with ‘not feeling myself’, indicating a split between the personal and the professional.

Difficulties in managing ‘personal’ attributes were also apparent when trainees reported distancing themselves from the client when interaction became ‘too personal’ (Trainee 5) or when they noticed an over-identification with the client’s situation. In these situations, trainees would get into difficulty because they thought they ‘knew what the client wanted and wanted to give it to them’ (Trainee, 18).

Theme 2: difficulties with certainty, control, and idealized intentions

Trainees expressed a great need for certainty in engaging the client. This was often linked to anxiety about ‘doing the right thing’ (Trainee 15) that had an almost compulsive quality and was expressed alongside a need to be ‘all-knowing’ about the encounter. As Trainee 2 illustrates, this appears linked to self-efficacy:

Although I’m not saying it here [while looking at the DVD], I feel like I’m pushing the patient to say ‘you’re doing it right’. I need that sureness to feel good about myself.

The need for certainty was often linked to the need to have ‘a label’ or diagnosis for a client. In many instances, ‘certainty’ was also associated with idealized views of the therapeutic process to counter anxiety about losing control or performing ineffectively. This is expressed in Trainee 10’s view of how therapy works:

I’m doing terrible therapy here because the patient is not changing the way he should . . . I wonder if I’m good enough, in fact I think I’m shit at it . . .

As demonstrated above, idealized views were often linked to a ‘devaluing attitude’ towards their own therapeutic attempts, leading to a sense of hopelessness in the interaction.

Many trainees commented on how they felt put out by ‘unexpected moves and questions’ (Trainee 18) that interrupted their sense of control in the session. In a number of cases, this led to intense frustration, anger, and sometimes a sense of feeling violated by the client.

Theme 3: frustrations with the client’s presentation

I just want to shake the person and say, ‘wake the f . . . k up!’ (Trainee 1)

Some trainees described difficulties with allowing the client’s communications to unfold as part of the therapeutic process. They expressed frustration when the client’s response was not in keeping with how they wanted, or imagined, the therapeutic process to unfold. Often this led to the trainee objectifying, blaming, or pathologising clients as ‘difficult’ (Trainee 10) or ‘personality disordered’ (Trainee 1).

Most frustrations were related to the client not articulating or expressing emotions in ways that were in keeping with the trainee’s wishes or goals as Trainee 8 illustrates:

Watching it now . . . I experience difficulty because he’s not saying what I expected . . . not feeling what I expected . . . So now I’m feeling lost and withdrawn because he put me off . . .

As suggested above, frequently, frustration was followed by blame and then a withdrawal or distancing from the client. There was some evidence that this process was linked to a need to externalize feelings of insecurity and associated frustrations, as illustrated by Trainee 15:

This is difficult for me, I felt uncomfortable. There he goes again playing out his pathology. I can’t reach him and I’m irritated. I feel like he should go to church or something . . .

This statement captures well the dynamics of frustration and blame, followed by a process of externalization. The process of externalizing feelings appeared evident in a number of cases where trainees noticed that they tended to displace ‘self-insecurity’ (Trainee 14) onto their clients. Trainee 11 insightfully described this process as follows:

Watching it now on the DVD . . . I can see how vulnerable and insecure I am. I don’t know what to do! I know that I started focusing on his insecurities about here [referring to a moment on the DVD]. Then I actually asked him: ‘are you feeling insecure with me!’ I can’t believe I said that! This is my issue, not his!

Theme 4: difficulty in becoming the focus of attention

A number of trainees described feeling ‘drained’ or overwhelmed by their clients. Interestingly, this was often linked to ‘feeling like the centre of attention in the session’ (Trainee 10). The sense of feeling ‘drained’ was also associated with experiencing the client as intrusive, leading to a sense of losing their sense of self during the difficult moment in the session. As Trainee 17 put it,

I’m not feeling myself here, I know I’m getting drained and tired because he keeps on focusing on me and my thoughts and sort of coming into my space . . .

In many critical incidents, trainees responded to intrusion by (1) deflecting attention, (2) disengaging from the therapeutic process, or (3) resorting to a more structured or ‘practical approach’. The latter is illustrated by Trainee 6 below:

Things were getting too close. He was asking me questions I couldn’t answer. So here I suggest that we do a relaxation exercise! It was completely unrelated to what he was asking . . .

A number of trainees noted their avoidance of acknowledging or dealing with transference issues. This was mainly associated with the idea that it made the relationship feel ‘too personal and unpredictable’ (Trainee 2).

Theme 5: reactions triggered by perceived exclusion

As suggested in other themes, a number of trainees experienced difficulties related to feeling excluded or rejected in the therapeutic encounter. This appeared to be associated with a need for some kind of recognition or acknowledgement from the client. As Trainee 4 put it, after recognizing the reason for her frustration,

I need her to tell me I am doing a good job! This seems to stop me listening to her properly.

Trainees also made mention of moments when they felt ‘passed over’ (Trainee 2) by the client, often leading to doubts about their effectiveness, feelings of frustration, and attempts to distance themselves from the interaction:

It’s just frustrating, because I feel like I can get what she is saying, and I feel like she doesn’t even listen when I let her know that I have got it . . . and then it’s like, ‘Well, what am I doing here?’ You know, I am not being heard. (Trainee 4)

In the above example, Trainee 4 continued to question whether she should keep trying to connect and noticed how she became ‘very matter of fact and unempathic’.

Theme 6: anxiety about differences (culture, race, religion, and age)

Trainees voiced concern about being able to help clients from different cultures. Their greatest concern involved a sense of feeling inadequate about being different, as well as finding it difficult to raise the issue as they feared it would affect therapy negatively:

Here (on the DVD), I’m worried that he’s not listening and I’m worried I can’t help him because he’s from a different culture . . . I feel bad, useless . . . but I’m also worried because I can’t raise it with him . . . It will make it worse! (Trainee 17)

Yes, I’m worried that if I mention our difference in race, he will think I am a racist . . . it will create a distance . . . (Trainee 13)

Similar concerns with other differences, such as religious and age differences, also emerged as significant experiences in the analysis.

Theme 7: interpersonal strategies to manage intense emotions

A number of interpersonal strategies emerged in the IPR analysis related to managing intense emotional states. These included interrupting the client with an overzealous need to use ‘techniques’:

I was getting lost here and was anxious . . . So I interrupted him and started talking to him about using breathing exercises to help his anxiety. (Trainee 2)

Other trainees attempted to keep the patient talking as a means of distraction:

I felt like I was hot, you know, with anxiety, so I just wanted to make sure that we were both talking. (Trainee 7)

A sense of giving difficult emotional experiences back to the client in an unmodified form also appeared to be a prominent experience. For instance, Trainee 9 had this to say after listening to a client’s struggle with cancer:

I became so overwhelmed by it all. It’s sort of like just throwing it back at her, like, ‘This is yours, you had this trouble and I don’t know what to do with it’ . . . I’m blocking myself off from this experience . . . it is too hard for me.

Trainees also used overcompensation as an interpersonal strategy. Here, trainees attempted to make up for perceived ‘failures’ by extending sessions and scheduling additional sessions. Trainee 11 illustrates this after feeling ineffective in a session:

I actually extended it by five minutes because I felt bad . . . I just didn’t know, I could not say, ‘Okay, the session has ended. Goodbye’. Because I felt like I had not done anything and I had been judgemental . . . I felt like I had failed.

Discussion

The ‘fragile trainee self’ in action

In the context of the trainee’s developmental journey, many of the difficulties that emerged from the interviews can be linked to challenges faced when adjusting to the ‘therapist role’. In Skovholt and Rønnestad’s (2003) terms, such difficulties can be readily associated with managing a ‘fragile and incomplete practitioner self’ (p. 50). The difficulties encountered were also in keeping with general findings mentioned earlier about training anxieties, difficulties with self-efficacy, self-worth, self-focused attention, and performance (e.g., Eagle et al., 2007; Melton et al., 2005; Skovholt, 2012; Stoltenberg, 2005). In addition, the research project’s focus on experiential interpersonal events appeared to shed further light on how such factors are linked to trainee perceptions, how they manifest in interaction, and how they are managed by trainees as part of an interpersonal process. Put another way, the findings presented here appear to usefully illuminate the ‘fragile and incomplete practitioner self’ in action, exposing how moments of difficulty linked to interpersonal scenarios are closely associated with heightened ‘self-focus’, the need for acknowledgement, difficulties in assimilating the ‘therapist’ role, narcissistic vulnerability, and concerns with self-efficacy. Some of the findings also suggest that concomitant strategies that attempt to reduce fragility in the interpersonal encounter also form part of the difficulty in maintaining therapeutic contact with the client.

One of the major findings of this piece of research related to struggles trainees had with integrating their ‘personal identity’, or one’s sense of person, with their new-found ‘therapist identity’. This is clearly illustrated in difficult experiences (particularly in Themes 1, 3, and 5) where trainees were acutely aware of their sense of self in the therapeutic relationship but felt it needed to be side-lined or ignored in order to empathize with the patient. Importantly, the use of one’s ‘personal’ sense of self was often rejected and seen as shameful. This was supported by findings indicating an elevated degree of sensitivity to feeling rejected by the patient and withdrawal from the process once their sense of agency appeared to waver.

Given the inevitable fragility associated with training to be a therapist, it may be useful to conceptualize the themes isolated in this article as organized around the trainee’s need for self-definition and agency within the therapeutic process while, at the same time, trying to attend to the needs of the client. Negotiating this kind of self-other tension in the relationship is present in all forms of therapeutic relating. But as Safran and Muran (2000) have illustrated, when this tension cannot be managed, ruptures in relating start to occur. During the research interviews, trainees were able to reflect on how excessive self-focus had the effect of compromising their ability to empathize and attend to the client’s needs. Perhaps the most illustrative example of this dynamic was evident when trainees pointed out that their difficulties in engaging emerged from a desperate need for affirmation from their clients. Here, the need for self-definition trumps attention paid to building the therapeutic alliance and a focus on the client. Other difficulties isolated by trainees point to a similar dynamic, such as the need for excessive certainty and control, as well as sensitivity to rejection and being the centre of attention. All of these dynamic undercurrents help explain some of the reasons why empathic relating becomes difficult and exposes some of the challenges trainees face in balancing the need for self-definition and agency, on one hand, and the needs of the client and the therapeutic alliance, on the other.

The kinds of difficulties that emerged in the research can also be linked to what Skovholt and Rønnestad (2003) refer to as the ‘self-other’ differentiation process that occurs as part of professional development. Here, being able to develop the ability to reflect on one’s inner experience acts as a crucial means of separating one’s self (and needs) from the client’s concerns and needs. Difficulty with this process was most vividly illustrated by the specific kinds of anxieties expressed about cultural and racial differences between trainee and client. As all the themes demonstrate, in different ways, one of the central challenges trainees faced involved a struggle to separate their own needs and concerns from those of the client. An interesting unanticipated feature of the research process involved observing the growth of this reflective process during the IPR interviews. Here, a focus on their own difficulties often led to experiences of clarity about the differentiation between trainee and client needs.

The above findings further highlight the importance of raising awareness about the relational qualities of the ‘fragile practitioner self’ in training and supervision. This includes acknowledging and understanding the novice’s need for self-definition and agency in an effort to convert excessive self-focus into self-awareness. Furthermore, raising awareness about the need for affirmation, sensitivities to rejection, withdrawal from the client, deflection of feelings, may serve to build greater understanding, openness, and reflexivity in the learning process. Such awareness may also help to build greater tolerance for both trainee and client difficulties (Nutt Williams, 2008; Williams et al., 2008) and potentially attenuates unrealistic expectations of the healing process (Goodyear et al., 2003; Hill et al., 2007; Skovholt, 2012). The difficulties trainees appear to have in integrating their ‘personal selves’ with their ‘therapist identity’ also seem to be a useful point to draw on in supervision and training.

The research raises questions about how to adequately deal with the novice therapist’s need for affirmation and self-definition. The clinical supervisor’s role in supporting the trainees’ need to feel effective and agentive in the session, as well as raising awareness and normalizing such needs, appears important here. Through adequate support and awareness of such dynamics, it may be possible to take the ‘heat’ out of an excessive need for affirmation from the client, as well as the overzealous need to feel agentive during sessions.

From a trainer’s perspective, our findings highlight how trainees tend to shame or devalue their own personal attributes in an attempt to appropriate a ‘perfect’ or idealized professional role. Although this appears to be an inevitable and necessary aspect of the learning process (Skovholt, 2012), generating awareness about how such issues may play out in the therapeutic process may help normalize and attenuate such idealized views. This is especially the case given that such difficulties are often unwittingly reinforced in some training environments where trainers are portrayed as experts (Furr & Carroll, 2003; Nelson & Neufeldt, 1998; Tang et al., 2004).

Conclusion

There is now a fairly large literature base that explores the challenges trainees face in learning therapeutic skills and working with clients. This study attempted to focus specifically on difficulties in engaging clients. Instead of relying on abstract observations about trainee experiences, the researchers endeavoured to (1) explore how these difficulties actually manifest in therapeutic interaction and (2) collect trainee observations about such experiences.

Findings indicate that difficulties in engaging the client are closely linked to the trainee’s own quest for self-definition that can, at times, impact their ability to empathize or engage with their client. Although not claiming to be exhaustive, the core themes isolated here appear to highlight common interpersonal processes linked to problems that trainees face in building the therapeutic alliance. The fact that trainees chose the sessions that they wanted to view, as part of the research, may have had some influence on the kind of themes that emerged and could be viewed as a limitation. In this regard, it would be useful in future research to consider a more extensive review of trainees’ clinical work or adopt a more intensive analysis of single cases across a number of sessions using the IPR method.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

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