To fail psychotherapy training: Students’ and supervisors’ perspectives on the supervisory relationship

ABSTRACT

Previous research showed that supervision during psychotherapy training sometimes includes negative alliance and harmful events. The aim of this study was to investigate how such events were related to failing psychotherapy training. Interviews were made with informants from two separate samples: psychotherapy students who had failed training (n = 6) and supervisors with experience from failing students (n = 6). The interviews were analyzed separately for the two samples with inductive thematic analysis and then compared. The core category for students (‘Paradoxical response’) indicated that they experienced their supervisors as either demanding too much or nothing at all. The core category for supervisors (‘Balancing contradictory demands’) indicated that they wanted to fail students who did not live up to expectations but were pressured by training institutes to let them pass. Both students and supervisors experienced distress but it seemed that they were not fully aware of each other’s vulnerability. The results suggest that a weak supervisory alliance and harmful events may contribute to student failures, independently of students’ actual suitability for psychotherapy.

Vorherige Forschung zeigte dass Supervision waehren der psychotherapeuten Ausbildung manchmal auch negative Verknuepfungen und schaedende Ereignisse mitbringt. Das Ziel dieser Studie Ausbildung in verbindung sassen. Nachfragen wurden immer mit Teilnehmern gemacht die von zwei verschiedenen Proben kamen: die psychotherapeut Studenten die gescheitert waren (n = 6), die Beauftragen mit Erfahrung von gescheiterten Studenten (n = 6). Die Nachfragen wurden getrennt voneinander analysiert fuer die zwei Stichproben wurde die inductive thematische Analyse benutzt und dann miteinander verglichen. DIe Hauptkategorie der Studenten (‘paradoxische Antworten’) zeigten dass sie die Erfahrungen mit den Beauftragten entweder als anstrengend oder als nicht viel beschrieben wurden. Die Hauptkategorie für die Beauftragten (‘Ausgleich von widersprüchlichen Ansprüchen’) zeigten dass sie die Studenten scheitern ließen die nicht die Erwartungen entsprachen aber die in ein Trainingslager bedrängt wurden um zu bestehen. Beide Studenten und Beauftragte haben Stress erlebt aber es scheint dass Sie nicht vollkommen bewussten von ihren gegenseitigen Vulnerabilität waren. Die Ergebnisse zeigen dass eine schwache aufsichtsführende Verknüpfung hatten und schädliche Erfahrungen hätten ebenfalls zu den scheitern der Studenten geführt, unabhängig von der Angemessenheit für Psychotherapie.

Algunas de las investigaciones anteriores han mostrado que la supervisión durante la formación psicoterapéutica incluye alianza de trabajo negativa y eventos perjudiciales. La meta de este estudio fue investigar cómo tales eventos se relacionaron con el fracaso en la formación psicoterapéutica. Se realizaron entrevistas con informantes separados en dos muestras: estudiantes que habían fracasado en su formación (N=6) y supervisosres con experiencia de estudiantes fracasados. Se analizaron las entrevistas por separado para las dos muestras utilizando Análisis Temático Inductivo y luego se compararon los resultados. La categoría central para los estudiantes (‘’respuesta paradójica’’) indicó que ellos experimentaban a sus supervisores como exigiendo demasiado o muy poco. La categoría central para los supervisores (‘’balanceando exigencias contradictorias’’) indicó que ellos deseaban que fallaran los estudiantes que no satisfacían sus expectativas, pero que estaban bajo presión por parte de los institutos de formación para que permitieran a estos estudiantes aprobar los cursos. Ambos, estudiantes y supervisores experimentaron angustia, pero pareciera que ninguno de ellos hubiera estado consciente de la vulnerabilidad del otro. Los resultados sugieren que una alianza débil en el proceso de supervisión, además de eventos perjudiciales, puede contribuir al fracaso de los estudiantes, independientemente de la adecuación del estudiante para esta profesión o de la formación psicoterapéutica en sí misma.

ABSTRACT

Ricerche precedenti hanno dimostrato che la supervisione durante la formazione in psicoterapia può includere alleanze negative ed eventi dannosi. Lo scopo di questo studio è indagare come tali eventi siano correlati al fallimento della formazione. Sono state condotte interviste su due campioni separati: studenti in formazione alla psicoterapia che avevano sperimentato un fallimento (n = 6) e supervisori con esperienza con studenti in difficoltà (n = 6). Le interviste sono state analizzate separatamente per i due campioni mediante analisi tematica induttiva e successivamente confrontate. La categoria principale per gli studenti (‘Risposta paradossale’) indica che la loro espereinza era con supervisori che chiedevano troppo o niente del tutto. La categoria principale per i supervisori (‘Equilibrio tra richieste contraddittorie’) indicava un desiderio di far fallire gli studenti non all’altezza, ma una contemporanea pressione dagli istituti di formazione per la promozione. Sia gli studenti che i supervisori hanno sperimentato disagio, ma senza essere consapevoli della reciproca vulnerabilità. I risultati suggeriscono che una debole alleanza di supervisione e eventi dannosi possono determinare l’insuccesso degli studenti, indipendentemente dalla loro reale idoneità al lavoro terapeutico.

Des recherches précédentes ont montré que la supervision au cours d’une formation en psychothérapie incluait parfois une alliance négative et des évènements nocifs. L’objectif de cette étude était d’investiguer en quoi de tels événements étaient liés à l’échec de la formation en psychothérapie. Des entretiens ont été conduits avec des participants provenant de deux échantillons distincts: des étudiants en psychothérapie qui avaient échoué (n = 6) et des superviseurs ayant déjà recalé des étudiants (n = 6). Les entretiens des deux échantillons ont été analysés séparément en utilisant l’analyse thématique inductive puis comparés. La catégorie centrale chez les étudiants (« une réponse paradoxale ») indiquait qu’ils avaient trouvé leurs superviseurs soit trop exigeants soit au contraire pas assez exigeants. La catégorie centrale chez les superviseurs (« trouver un équilibre entre des demandes contradictoires ») indiquait qu’ils souhaitaient sanctionner les étudiants qui ne se montraient pas au niveau mais étaient sous la pression des instituts de formation pour les laisser réussir. Etudiants et superviseurs expriment leur désarroi mais il semble qu’ils ne soient pas conscients de la vulnérabilité les uns des autres. Les résultats suggèrent qu’une alliance faible de la relation de supervision couplée à des évènements dommageables peut contribuer à l’échec des étudiants, indépendamment de l’aptitude réelle de l’étudiant pour la psychothérapie.

ΠΕΡΊΛΗΨΗ

Προηγούμενες έρευνες έχουν δείξει ότι η εποπτεία κατά τη διάρκεια της εκπαίδευσης στην ψυχοθεραπεία κάποιες φορές περιλαμβάνει αρνητική σχέση και τραυματικά γεγονότα. Ο στόχος της παρούσας έρευνας ήταν να εξετάσει πώς αυτά τα γεγονότα σχετίζονται με την αποτυχία στην εκπαίδευση στην ψυχοθεραπεία. Οι συνεντεύξεις πραγματοποιήθηκαν με άτομα από δύο διαφορετικά δείγματα: φοιτητές ψυχοθεραπείας που είχαν αποτύχει στην εκπαίδευση (n = 6) και επόπτες που είχαν εμπειρία με φοιτητές που είχαν αποτύχει (n = 6). Οι συνεντεύξεις αναλύθηκαν ξεχωριστά για τα δύο δείγματα με επαγωγική θεματική ανάλυση και στη συνέχεια συγκρίθηκαν. Η κύρια κατηγορία για τους φοιτητές («παράδοξη αντίδραση») έδειξε ότι βίωσαν τους επόπτες τους σαν αυτοί να απαιτούσαν πάρα πολλά ή σαν να μην απαιτούσαν τίποτα. Η βασική κατηγορία για τους επόπτες («ισορροπώντας αντιφατικές απαιτήσεις») έδειξε ότι αυτοί επιθυμούσαν να «κόψουν» φοιτητές που δεν ανταποκρίθηκαν στις προσδοκίες, αλλά δέχτηκαν πίεση από τα εκπαιδευτικά ινστιτούτα να τους επιτρέψουν να περάσουν. Τόσο οι φοιτητές, όσο και οι επόπτες βίωσαν δυσφορία, αλλά φάνηκε ότι δεν ήταν πλήρως ενήμεροι για την ευαλωτότητα της άλλης πλευράς. Τα αποτελέσματα προτείνουν ότι μια αδύναμη εποπτική σχέση και τα τραυματικά γεγονότα μπορεί να συμβάλουν στις αποτυχίες των φοιτητών ανεξάρτητα από την πραγματική καταλληλότητα των φοιτητών για ψυχοθεραπεία.

KEYWORDS:

• Psychotherapy training
• supervision
• alliance
• harmful events
• professional development

HAUPTWOERTER:

• Psychotherapeutisches Training
• Supervision
• Verknuepfung
• schaedliche Geschehen
• professionelle Weiterbildung

PALABRAS CLAVE:

• formación psicoterapéutica
• supervisión
• alianza
• eventos perjudiciales
• eventos perjudiciales
• desarrollo profesional.

PAROLE CHIAVE:

• training di psicoterapia
• supervisione
• alleanza
• eventi dannosi
• sviluppo professionale

MOTS-CLÉS:

• formation en psychothérapie
• supervision
• alliance
• évènements dommageables
• développement professionnel

ΛΈΞΕΙΣ-ΚΛΕΙΔΙΆ:

• εκπαίδευση στην ψυχοθεραπεία
• εποπτεία
• συμμαχία
• τραυματικά γεγονότα
• επαγγελματική ανάπτυξη

Introduction

Supervision of clinical work is a key element of psychotherapy training. Indeed, psychotherapists regardless of theoretical orientation and nationality state that clinical supervision has been one of the most significant factors in their professional development, (Orlinsky, Rønnestad & the Collaborative Research Network of the Society for Psychotherapy Research, 2005). During training, clinical supervision plays an important part in providing students with the competence needed to develop their professional identity (e.g. Bernard & Goodyear, 2014).

Bernard and Goodyear (2014) argued that supervision occurs between two or more individuals who share the same or similar occupations. During training, the supervisor is a colleague with more experience than the student. Their relationship may be hierarchical, especially when considering that the supervisor functions as a gatekeeper to the profession. This gatekeeping function can be seen as a way to protect clients from inadequate or harmful treatment. In this, the supervisor is expected to evaluate students’ efforts and professional development (Bernard & Goodyear, 2014). Supervision during training is thus a complex process in which the supervisor not only needs to focus on students’ learning of techniques and skills but also on securing treatment of current and future clients (Ögren & Sundin, 2009; Rønnestad & Skovholt, 2012). Supervision can be a challenging process for students as they continually are evaluated and assessed during training on both therapeutic skills and suitability as therapists (Bernard & Goodyear, 2014) with the possibility of being failed.

The supervisory alliance

Ellis (2010) argued that effective supervision is not primarily about using the correct theories or techniques but about the relationship between supervisor and supervisee. A strong supervisory alliance has been shown to have a number of positive effects on students, such as lower levels of stress, lower risk of burn-out syndrome, higher satisfaction with therapeutic work, better self-confidence, higher satisfaction with supervision (Watkins, 2015), higher degree of self-disclosure (Ladany, Hill, Corbett, & Nutt, 1996) and lower level of anxiety (Mehr, Ladany, & Caskie, 2015). In contrast, a weak supervisory alliance in supervision can affect students negatively in various ways (Ladany, Ellis, & Friedlander, 1999; Watkins, 2015). For example, a weak supervisory alliance is associated with more frequent negative experiences, more conflicts and a higher degree of avoidance (Watkins, 2015). Students who experience an inadequate working alliance are generally less satisfied with their supervision (Ladany et al., 1999), and they may also be less willing to share sensitive information with their supervisor. Ladany et al. (1996) argued that this is problematic because the client may not receive adequate help when students are not willing to ask supervisors for help with problems. This is not only risky for the client welfare but also for supervisors as they are responsible for students’ clinical work.

Supervisors’ actions and characteristics may affect the supervisory alliance. For example, supervisors’ unethical behaviors tend to have negative effects on students’ alliance ratings (Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999). On the other hand, supervisors’ self-disclosure affects alliance ratings positively (Ladany & Lehrman-Waterman, 1999). Supervisors’ social skills can also affect the supervisory alliance (Bambling & King, 2014), social expressiveness and social control. Several authors (e.g. Carlsson, 2012; Carlsson, Norberg, Sandell, & Schubert, 2011; Rønnestad & Skovholt, 2012) have pointed out the importance of negotiating the supervisory alliance in regular ‘time-outs’ in the supervision to meta-communicate on the supervisory alliance.

Harmful supervision

Studies have showed that supervision can be perceived as harmful by students (Carlsson et al., 2011; Gray, Ladany, Walker, & Ancis, 2001; Nelson & Friedlander, 2001; Ramos-Sánchez et al., 2002; Strømme, 2012). Recent research indicates that about 35% of all supervised students have experienced harmful supervision (Ellis et al., 2014). In a study by Carlsson et al. (2011), former students, now licensed psychotherapists, were interviewed on their professional development during psychotherapy training; all, even when not explicitly asked, reported negative experiences from supervision during training, often that to an extent which seemed to have inhibited their learning.

Harmful events seem to be related to the supervisory relationship and a negative supervisory alliance (Ramos-Sánchez et al., 2002). Students may experience problems in the interaction with the supervisor after such events, and most students believe that the supervisor was not aware that the student had perceived it as harmful (Gray et al., 2001). Students can be reluctant to criticize supervisors in order to avoid conflicts with them (Jacobsen & Tanggaard, 2009).

The aim of this study was thus to explore the supervision in the process of failing psychotherapy training from both the perspective of students and supervisors.

Method

Study context

Psychotherapy training in Sweden consists of two parts: one basic, 2-year part-time, and one advanced, 3-year part-time. Supervision, which could be group or individual, is included as a mandatory part in both the basic and advanced training. The basic training is included in the Swedish psychologist program and training for psychiatrists. To be admitted to advanced training, in addition to completion of the basic psychotherapy course, you need a bachelor’s university degree or higher, at least 125 sessions of personal psychotherapy and at least 2 years of documented clinical work under supervision. Graduating from the advanced course leads to licensing by the National Board of Health and Welfare and one is free to work independently as a psychotherapist.

Formal training in supervision is required to serve as a supervisor in psychotherapy training. To undertake this training, a minimum of 2 years of clinical experience is needed after completion of advanced psychotherapy training. Training in supervision is a 2-year part-time effort and includes lectures, seminars and supervised supervision of psychotherapy.

Procedure

The study used two samples: one sample with former psychotherapy students who had failed and another sample with supervisors who had experience of failing students.

To recruit students who had failed psychotherapy training, all 12 existing Swedish training institutes that hosted advanced level psychotherapy training were contacted. Invitations to participate in the study were also posted in relevant Facebook groups, e-mailed to all employees of a psychiatric division within the Stockholm County Council and through personal connections. Altogether, these efforts resulted in contact information to six former students who had experience of failing psychotherapy training. These former students were contacted by e-mail with information about the study and an invitation to participate. All of them agreed to participate in the study.

To recruit supervisors with experience of failing psychotherapy students, all 12 existing Swedish training institutes that hosted advanced level psychotherapy training were contacted again. The supervisors were asked to participate in the study if they had experience of failing students. This effort resulted in contact information to six supervisors with experience of failing students. These six supervisors were also contacted by e-mail with information about the study and an invitation to participate. All of them agreed to participate in the study.

The study was conducted as MA and ML’s master’s thesis at the psychology program at Örebro University, Sweden. The work was supervised by JN and JC. Both were licensed psychologists. JC is in addition licensed psychotherapist and supervisor. All authors jointly contributed to the study’s aim, research questions and design. Interviews were made by JN, MA and ML. The analyses were made by MA and ML, and supervised by JN and JC. Writing of the manuscript was a joint effort.

Informants

Student informants had the following basic academic training: nurse (n = 1), bachelor of social work (n = 3), psychologist (n = 1) and physician (n = 1). They described their psychotherapeutic training as psychodynamic (n = 4), CBT (n = 1) and integrative (n = 1). Their training experiences were from 1998 to 2015. They were between 34 and 64 years old (M = 54 years, SD = 11.0) at the time of the interview (please note that this corresponds to the mean age of psychotherapy students in Sweden). Five were female and one was male.

The supervisor informants had the following basic academic training: bachelor of social work degree (n = 3), psychologist (n = 2) and other (n = 1). They were all licensed psychotherapists and had training in supervision. They described their psychotherapeutic orientation as psychodynamic (n = 2), CBT (n = 2) and integrative (n = 2). They had worked as supervisors 7–15 years (M = 10.7 years, SD = 3.4). They were between 52 and 66 years old (M = 60 years, SD = 4.9) at the time of the interview. Three were women and three were male.

The interviews

Semi-structured interviews were conducted over the phone (because of geographical distance). Interviews lasted 30–60 min. The same interview guide was used for all informants but was adapted to fit the two different informant groups: interviews with students focused on the relation to the supervisor, while interviews with the supervisors focused on the relation to the student.

The interviews aimed at capturing the informants’ experiences of the supervisory relationship. All interviews started with the same introducing question (for students: ‘You did not finish your training. Could you tell me about what happened?’; for supervisors ‘You failed a student that you supervised in psychotherapy training. Could you tell me about what happened?’), followed by relevant supplementary questions relating to three main areas that were thought to make up the supervisory relationship: ‘collaboration’, ‘climate’ and ‘passed/failed’. The areas ‘collaboration’ and ‘climate’ were taken from to Bordin’s theory of the supervisory alliance (agreement on task and goal, and bond) (Bordin, 1983). The area pass/fail was included since this was a common experience for all the informants.

Analysis

Inductive thematic analysis (Langemar, 2008) was applied to the two samples separately (Figure 1). The interviews were first transcribed verbatim and then read through several times to provide an overview.

Figure 1. Overview of the analysis process for both of the groups.

Next, sections of the interviews relevant for the research question (‘meaning units’) were marked and given names (‘codes’). For example, the section ‘As I understood the situation, you had to reflect in the way that person perceived was the right way’ was considered a meaning unit and given the code Must reflect in the right way.

All codes were then grouped into preliminary categories based on content similarity. For example, the codes Talking in the student group, I know others that have left with the tails between the legs, Very many had a hard time in the training and Many were crying after the supervision as the category Other students describes the same thing. These preliminary categories were then compared to the transcribed interviews to make sure that they accurately reflected the informants’ meaning. If not, changes were made until it corresponded to the material. When this process was completed and the categories had become homogenous, they were provided new names that adequately reflected their content.

Categories were then grouped into subthemes based on content similarity. For example, the categories Practical problems for the informants, Personal circumstances and Did not get enough information were grouped and the resulting subtheme was named Aggravating circumstances.

These subthemes were then grouped into main themes based on content similarity. For example, the subthemes High demands, Authorities, Difficulties to question and Disrespect formed the main theme Demanding.

Finally, a core category was created that summarized the main themes. The results from the two samples were compared to each other and a composite model was created that showed how the students’ and supervisors’ experiences could relate to each other (see Figure 2).

Figure 2. Composite model: Students’ and supervisors’ experiences in relation to each other.

To test if the student model was saturated, a deductive analysis was performed with one additional interview with a student informant that had failed the clinical course at the psychology program. Deductive thematic analysis is done in the same way as inductive analysis except that the themes in a deductive analysis are formulated beforehand (Langemar, 2008). No new categories were needed to account for this additional interview.

When the analysis was completed, the informants were invited to participate in a member check by e-mail. The informants responded that the result represented their experiences, and the models were therefore not changed.

The authors’ preconceptions

All the authors had personal experiences from supervision that had been more or less fruitful. The authors expected both student and supervisor informants to report negative views about their counterparts and also about open conflicts.

Ethical considerations

The study got ethical approval from the Psychology Program Ethics Group at Örebro University, and was conducted in compliance with principles of research ethics of the Swedish Research Council (Vetenskapsrådet, 2002). The informants were initially informed via e-mail about the purpose of the study and about their right to discontinue their participation whenever they wanted to. This information was also repeated at the time of interviewing. Participants were guaranteed confidentiality and that their interviews would be de-identified.

Results

In the following, the results from the analyses of the two groups are presented separately: First, the analysis of failed students, and then the analysis of supervisors with experience of failing students. This is followed by a composite model for both students and supervisors (Figure 2).

The process for the students

The analysis showed that the students’ experiences could be summarized in the core category Paradoxical response. The core category consisted of three main themes.

Main theme 1: Demanding. The students experienced that they were subjected to an excess of examining and criticizing. Students could receive criticism that they experienced as irrelevant and intrusive. They sometimes felt personally attacked and criticized for things that were not related to their training. They described that the climate during supervision sessions was instable and that supervisor’s behavior often was difficult to anticipate. One informant described that ‘The whole atmosphere, there was a scrutinizing and criticizing of everything and also of things that I didn’t think had any relevance of helping the patient, it could be about formulations and that they would be accurate.’ Students had high demands on themselves, but also experienced that their supervisors had high demands on them. The students also seemed to be inclined to blame themselves when they failed. One informant expressed this: ‘Yes, I felt completely wrong, unsuccessful and that it was something wrong with me, that I did not live up, that I did not live up to the demands.’ They experienced that supervisors as authoritarian and rigid, and that supervisors’ opinions were impossible to criticize or question. Students did not always agree with supervisors regarding the theories discussed, but they felt that there was no room for different opinions. The protests they could express were often interpreted as defensive by the supervisors. The students wanted to fit in and when they failed to do this they felt ashamed.

Main theme 2: Insufficient presence. The analysis showed that students experienced supervisors as restrained in giving both positive and negative criticism and feedback. One informant stated: ‘It’s a learning situation, a dependent relationship; I come there as a student and I think that the teacher should encourage my curiosity and the abilities within me and not sit like an empty paper and only hum.’ They experienced that without adequate feedback they did not know how they were expected to perform neither in supervision nor with the clients. There was a lack of feedback and that the supervisor often seemed to keep criticism of the students to themselves. Many students experienced that they still don’t know the reasons to them failing their training. The students also described that supervisors sometimes lacked commitment to supervision. Students could find support from other sources, both not only from people outside of training, like their personal therapist, but also from people within the training institute and from clients who gave them positive feedback on their work. However, this support did not seem to be sufficient to balance all of their negative experiences.

Main theme 3: Dissatisfaction. The students had high expectations on their training, which they described as prestigious. One informant stated: ‘But I was of course very happy when I was admitted. So this was a big thing in my, it was a goal in my life to become a licensed psychotherapist.’ They also described that the training differed much from their previous experiences. The students felt that some thing lacked in supervision, for example, that the supervisor lacked pedagogical skills or that they did not get support that they felt they needed. In previous supervision experiences, they had felt more free and less afraid or inhibited. The analysis showed that they experienced problems with motivation and that it declined the longer they stayed in training. The students experienced that they, at times, felt offended in supervision and that they instead of growing became more afraid and insecure. The supervision made them feel bad, both psychologically and physically, and that they suffered from fear, anxiety and stomach aches. They also experienced that both self-confidence and self-esteem suffered. The supervision led them to become more inhibited and insecure, and that these feelings lingered, in some cases even after training was over.

Core category student model: Paradoxical response. Students who failed psychotherapy training experienced paradoxical responses from their supervisors. Students described that supervisors sometimes were very demanding and that this made them blame themselves for not living up to these demands, resulting in feelings of shame and being broken-down. However, at other times, supervisors were not present enough and the students did not get the feedback or commitment they expected and needed. The insufficient supervisor presence made them feel both confused and rejected. The students described feeling dissatisfaction with training, and that it did not meet their own high expectations. They were disappointed and their motivation declined because of this. They suffered from strong feelings of discomfort caused by the critical climate which created both fear and insecurity in them. The students also described that they felt that they received support from other people both outside the training institute and from within. But it seemed that this support was not sufficient.

The process for the supervisors

The analysis showed that the supervisors’ experiences could be summarized in the core category Balancing contradictory demands. The core category consisted of three main themes.

Main theme 1: The students’ inability. The supervisors described some students as unsuitable for the profession and that these never should have been admitted to training. Some of students did not live up to expectations. These students were also described as having a lack of interest and as passive in supervision and difficulties with reflecting on their own responsibility. Supervisors described that it was hard to confront students regarding shortcomings as the students often did not have the ability to reflect on their own responsibility and instead responded with excuses. Supervisors also experienced that the students’ motivation was low. One informant expressed: ‘She did not even try, there was no will and not even any attempts, no actions, she did not manage to do it, but she did not want to either.’ The supervisors felt that there were a number of reasons behind this. They mentioned, for example, that many students felt forced to attend the training, as their employer was paying for it.

Main theme 2: The organization’s caretaking. The supervisors felt it was important to be transparent regarding assessment criteria and communication when students did not pass. Some supervisors said that they had a clearly designed routine to follow when they suspected that a student would not meet their standards. The analysis showed that supervisors experienced that it was easier to fail a student if they had something concrete to go on, for example, if the student did not participate in supervision or that they did not submit notes from sessions. It was more difficult to fail students when they lacked skills, not showed empathy or were unable to build an alliance with the client. Sometimes the supervisor would let a colleague make an additional assessment and this was easier if the therapy sessions had also been video recorded. Supervisors said that they were eager to help students to make it through training since they understood the consequences of failing and that this sometimes led to that the supervisors did not confront the student at once when problems arose. The supervisors were willing to support the students to make it easier for them to complete their training. The supervisors offered to put more effort into supervision and were willing to bend the rules to support and help the students. One supervisor stated: ‘My task as a supervisor is to support, so I did. I tried to sort what she could take to self-therapy. And I tried to support her during several weeks. That’s a long time’. The supervisors reported feeling supported by colleagues and employees when failing a student. They held that the employers often respected their assessments. One supervisor reflected on the support like this: ‘The management, they always support me. I have never experienced that they tell me to pass students for statistics or for the economy when I do not agree. I think that they are glad that we nowadays fail students.’ They stated that they were certain of their assessment of the student and that they had done their best to supervise the student.

Main theme 3: The supervisor’s vulnerability. The supervisors sometimes experienced little or no support from the organization when failing a student. They described that the employer not always respected their judgment of a student that did not meet the criterion for the training. They pondered the reasons for this and mentioned that there could be an economic incentive to pass unsuitable students. Some students were allowed to change supervisors and continue their training, despite having difficulties meeting the standards of the training institute. This sent the wrong signals according to the supervisors. One supervisor described the lack of support from the employer: ‘I did not expect her to leave the training, that’s not up to me, it is up to the organization, but that they did not respect that I had failed her, that is the important point.’ Supervisors also described a number of negative consequences from failing a student. The employer could for example discontinue collaboration with them. One supervisor described: ‘Yes I have burned my bridges there that is clear. I will never be employed there again and I will not get any more supervision assignments from there.’ Some described an anxiety and fear for what the student would tell other colleagues and future employers about them. Others described that the failure led to them being required to do more practical work outside ordinary working hours. Analysis also showed supervisors experiencing frustration in the situation and feelings of failure. They also described feeling stressful and lonely when failing a student and that the students’ reactions could be difficult to handle. The supervisors experienced it as a big responsibility to judge whether the students met the criteria for the training or not, and that the approaching failure of a student created a feeling of vulnerability in them. They also described some colleagues as lenient by being more prone to pass students, even when the interviewed supervisors judged the students as unsuitable.

Core category supervisor model: Balancing contradictory demands. The analysis showed supervisors with experience of failing students in psychotherapy training could be described as balancing contradictory demands. They experienced some students to be unsuitable to become psychotherapists, and perceived the students lack of motivation and activity as a problem. It was important to be transparent when failing students, and that this meant that there were clear procedures to use when students did not fulfill the criteria of the training institute. Supervisors would like to help students with extra time when facing a failure. When not receiving support from the organization, they experienced being vulnerable. The supervisors argued that there could be an economic incentive for passing unsuitable students, and they described negative consequences from failing students, like the organization discontinuing the collaboration and having their competence being questioned when unsuitable students were allowed to change supervisors and continue the training. Supervisors also sometimes experienced receiving support from their employers, colleagues and other students when failing a student. The combination of the students’ lack of skill, the level of caretaking from the organization and the feeling of vulnerability led supervisors to experiencing that they were balancing contradictory demands.

The process for the students and supervisors

After the analysis was made, similarities appeared between the two models, as illustrated by Figure 2. Please note that because the interviewed supervisors and students were not from the same supervisory dyads, they did not describe each other. Rather they represent two sides of the same general process. It seems that supervisors experience of the students’ inability corresponds to what students experienced as supervisors being demanding. Further, what supervisors described as the organization’s caretaking may correspond to what students described as insufficient presence. Both groups described a negative experience associated with the supervision process. For the supervisors, the negative feelings were about the supervisor’s vulnerability, and for the students, the negative feelings were their own dissatisfaction.

Discussion

Students experienced their supervisors as either demanding too much or nothing at all. This resulted in students perceiving supervisors as unpredictable, and it caused them distress. Supervisors on the other hand described that they wanted to fail students who did not live up to expectations, but that they were pressured by the training institutes to let them pass. This resulted in a lot of stress also to the supervisors. However, it seemed that supervisors and students were not fully aware of each other’s vulnerability.

Students and supervisors in distress

Supervisors felt that students did not live up to expectations. However, this may have been a consequence of the stress that students experienced. Indeed, learning new skills, theories and strategies could result in considerable confusion and anxiety (Stoltenberg & McNeill, 2010). High levels of anxiety were reported by students in a qualitative study of Rønnestad and Skovholt (2012). Orlinsky and Rønnestad (2005) demonstrated that beginners (with less than 5 years in practice) were consistently more likely than other cohorts to find therapeutic work a distressing practice (high stress and low healing involvement).

Adding to this, previous work also related student stress to supervisor’s gatekeeping function (Rønnestad & Skovholt, 2012). Bernard and Goodyear (2014) argued that there is a hierarchical relationship between students and supervisors. Previous studies also showed that supervisors increase their control when students do not perform as expected (Rønnestad & Skovholt, 2012). This is unfortunate, since social support is an important part of effective supervision (Orlinsky & Rønnestad, 2005).

The unpredictable behavior of supervisors that students experienced could result from the difficult situation that supervisors found themselves in when they wanted to fail a student. Being responsible for failing a student was stressful to the supervisors and they wanted to make sure no mistakes were made. However, the training institutes sometimes did not agree with the supervisors’ decisions, possibly because training institutes had economic interests in letting students pass. Supervision is challenging in that supervisors must balance a number of contradictory demands (Norberg, Axelsson, Barkman, Hamrin, & Carlsson, 2016; Veilleux, Sandeen, & Levensky, 2014). The contradictory demands that stemmed from on the one hand supervisors’ own standards and on the other hand the organizations’ needs may be yet another such conflict. It is possible that the stress that this conflict provoked in supervisors also made it hard for them to balance the other demands (such as balancing feedback with support), thus leading to the unpredictable behavior that students perceived.

For this reason, it seems crucial that training institutes provide support to supervisors who get involved in the process of failing a student. Failing a student is in itself a stressful event to supervisors, as indicated by both the present study and previous research (Hoffman, Hill, Holmes, & Freitas, 2005; Norberg et al., 2016). To be thwarted by the training institute seems to add to this. Unfortunately, there is a lack of research about how supervisors experience support from employers, and more knowledge is needed about the organizational motivations involved in the process of passing or failing students.

Students and supervisors misunderstood each other

Supervisors and students seemed to be unaware of each other’s vulnerability and also made different attributions about what transpired in the relationship. Supervisors focused on students’ shortcomings whereas students felt supervisors were too demanding. Further, both groups attributed passivity to each other (but agency to themselves?), and whereas supervisors’ questioned students’ inherent motivation, students attributed their failing motivation to the bad supervisory relationship. Students tended to perceive supervisors as difficult to engage with, and the support that supervisors provided was virtually unnoticed by the students.

Previous research showed that students tend not to voice their concerns to their supervisors (Gray et al., 2001; Jacobsen & Tanggaard, 2009; Ladany et al., 1996). For that reason, supervisors may be unaware of students’ distress and needs (Strømme, 2012). Supervisors can have difficulties with registering students’ discomfort (Bambling & King, 2014) and fail to realize what students’ perceive as harmful events (Gray et al., 2001). Supervisors then have to be guided by their own ideas about progress in supervision. Studies show that students’ learning needs depend on their skill level (Jacobsen & Tanggaard, 2009; Rønnestad & Skovholt, 2012). It is possible that supervisors and students did not share the same view of the students’ developmental level and that the supervisors gave insufficient support, believing students were on a more advanced level. Some supervisors used a clinical approach to handle students possibly leading to further misunderstandings (Bernard & Goodyear, 2014; Norberg et al., 2016). Indeed, research suggests that feedback is more effective when focused on specific aspects of students’ efforts (Hoffman et al., 2005).

Weak supervisory alliance and harmful events

The experiences from supervising the informants narrated could be conceptualized in terms of a weak supervisory alliance (Bordin, 1983), alliance ruptures that were never repaired or even harmful events (Ellis et al., 2014). Indeed, several of the factors mentioned by the informants were identified that it could be associated with weak supervisory alliance. For example, the blank and passive behavior that students attributed to supervisors indicates that they lacked social expressivity (Bambling & King, 2014). Student informants also described supervisors’ behaviors as unethical and sometimes even offensive, something that previous research found also had negative effects on the supervisory alliance (Ladany & Lehrman-Waterman, 1999).

There is a growing literature on supervision that stresses transparency and mutual agreement between supervisor and student about task and goals, possibly also in the form of a written contract (Rønnestad & Skovholt, 2012). This should include both parties’ expectations. This literature also stresses skills in delivering feedback and a reflective climate in supervision. By using such means, the supervisory alliance may be strengthened, alliance ruptures healed and harmful events possibly avoided. Also, the use of meta-communication, that is discussion about the supervisory relationship in order to overcome difficulties, has been recommended (Safran & Muran, 2000).

All student informants reported a weak supervisory alliance and harmful events, which suggests that it may have contributed to student failures. However, weak supervisory alliance and harmful events in supervision are common (e.g. Ellis et al., 2014), and may indeed be more common than student failure. Indeed, for this study, we only managed to find a few students who had failed.

Why then do not a weak supervisory alliance and harmful events always lead to failure? It is possible that it is a matter of degree. Previous studies found that supervisors used positive and negative feedback in a flexible manner (Norberg et al., 2016), but student informants in this study reported that they experienced that their supervisors were single-handedly negative. Support from supervisors may buffer negative effects. The students in this study did not get the support they needed.

Carlsson et al. (2011) described that students can experience a lack of self-confidence during training due to negative experiences with supervisors, but after graduation they usually experience a sense of freedom and self-confidence. However, for students who fail to graduate, negative experiences in supervision can have more global and longer lasting consequences (Ramos-Sánchez et al., 2002). Indeed, the students in this study were stuck with low self-confidence remained long after they had quit training.

Limitations and directions for future research

This study has a number of limitations and the results should be interpreted with caution. First, the results suggest that a weak supervisory alliance and harmful events can contribute to student failures, independently of students’ actual suitability. However, students’ suitability was never independently determined in this study. Future research should use objective assessments of students, for example by including expert ratings based on recordings of therapy sessions or standardized tests. Second, the two included samples were small. Even if great effort were put into recruiting informants, not many responded, and institutions did not keep good records of those who dropped out of training. The small number of informants may be a result of shame associated with failing psychotherapy training or of failing students. It may also indicate that failing psychotherapy training is indeed uncommon. Third, another limitation is that the two samples did not correspond to supervisor–supervisee dyads, and for that reason, they did not provide perspectives on the same events. Rather they provide general supervisor and supervisee perspectives on the process of failing supervision. It is possible that the results had been different if analyses were made on dyads. This may be a task for future research to explore. Last, the interviews were made long after the actual events took place. To avoid memory bias, data should be collected closer in time to the events. However, this would involve a longitudinal design, and considering the apparent rarity of failure, such a data collection may have to be very lengthy.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Mattias Larsson Sköld

Mattias Larsson Sköld is a licensed psychologist and has a bachelor's degree in technology. The author’s interests are in psychotherapy training and technological applications in psychology.

Magdalena Aluan

Magdalena Aluan is a licensed psychologist and works in child and adolescent psychiatry.  The author’s interest is in psychotherapy training.

Joakim Norberg

Joakim Norberg, PhD, is a licensed psychologist and also an assistant professor in neuropsychology. The author’s interests are in psychotherapy research and psychotherapy training.

Jan Carlsson

Jan Carlsson, PhD, is a licensed psychologist, licensed psychotherapist, and supervisor; also an assistant professor in clinical psychology. The author’s interests are in psychotherapy research and psychotherapy training.