Training and Education in Professional Psychology

Clinical Supervisors’ Experiences With and Barriers to Supporting Trainees

Who Have Experienced Identity Based Harassment
Lynette Adams, Georgina Gross, Jennifer M. Doran, and Meaghan Stacy
Online First Publication, July 1, 2021. http://dx.doi.org/10.1037/tep0000384

CITATION
Adams, L., Gross, G., Doran, J. M., & Stacy, M. (2021, July 1). Clinical Supervisors’ Experiences With and Barriers to
Supporting Trainees Who Have Experienced Identity Based Harassment. Training and Education in Professional
Psychology. Advance online publication. http://dx.doi.org/10.1037/tep0000384
 Training and Education in Professional Psychology
© 2021 American Psychological Association
ISSN: 1931-3918 https://doi.org/10.1037/tep0000384

Clinical Supervisors’ Experiences With and Barriers to Supporting Trainees

Who Have Experienced Identity Based Harassment
Lynette Adams1, 2, Georgina Gross1, 2, 3, Jennifer M. Doran1, 2, and Meaghan Stacy2
1
VA Connecticut Healthcare System, West Haven, Connecticut, United States
2
Department of Psychiatry, Yale University School of Medicine
3
VA Northeast Program Evaluation Center, Veterans Health Administration, West Haven, Connecticut, United States

The healthcare literature suggests that a majority of trainees experience some form of harassment based on
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

an aspect of identity (Cencirulo et al., 2020; Fnais et al., 2014). However, there is very little research on the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

experiences of clinical supervisors who support trainees who experience harassment, and the existing
literature tends to focus on sexual or gender-based harassment (deMayo, 2000; Hartl et al., 2007). The
following study aimed to fill this gap by collecting information from clinical supervisors (N = 28) within a
psychology training program located within a VA Medical Healthcare System in the Northeast. Most
supervisors reported harassment of trainees is a problem at their facility (82.1%), had directly witnessed
harassment of trainees (64.3%), and had experienced harassment themselves (82.1%). Most (89.3%)
reported discussing harassment with a trainee on at least one occasion. On average, supervisors reported
being very likely to initiate such a discussion. Six themes emerged regarding barriers that supervisors
identified to discussing harassment with trainees: (1) Lack of Knowledge or Skill, (2) Trainee Factors, (3)
Limitations of Supervision, (4), Negative Feelings, (5) Relational Issues, and (6) Negative Outcomes. We
discuss recommendations for both supervisors and training committees that directly address these barriers.

Public Significance Statement

This study provides information on experiences of clinical supervisors in supporting psychology
trainees who have experienced harassment based on identity, including qualitative analysis of barriers
experienced by supervisors in discussing harassment with trainees. Recommendations are provided to
supervisors and training programs that can address these barriers.

Keywords: training, harassment, harassment of trainees, supervision

Healthcare trainees are often exposed to various forms of harass-
ment. For the purpose of this article we define harassment as
unwanted or inappropriate remarks, behaviors, and interactions
based on aspects of identity (e.g., gender identity, race or ethnicity,
sexual orientation, and other minority identities) that are directly
experienced by trainees or witnessed by another person. These
interactions can originate from patients, family members of patients,
strangers, or others from within the training environment within a
healthcare system. Our definition extends beyond the legal defini-
tion of harassment as a part of employment discrimination based on
protected statuses from the U.S. Equal Employment Opportunity
Commission, n.d.) which does not include harassment that may

JENNIFER M. DORAN is the Associate Director for Mental Health at the VA

Lynette Adams https://orcid.org/0000-0001-6972-139X
LYNETTE ADAMS is a clinical psychologist with the Department of Veterans
Affairs and has been involved in training and education of psychology
trainees for over a decade. They received their doctorate from Southern
Illinois University Carbondale and completed a clinical internship at Color-
ado Mental Health Institute-Fort Logan. Research and professional interests
include disparities in underserved populations, diversity issues within train-
ing, and acceptance based treatments for emotion dysregulation.
GEORGINA GROSS is a clinical psychologist in Post Traumatic Stress
Disorder Program Evaluation at the Northeast Program Evaluation Center
(NEPEC), Office of Mental Health and Suicide Prevention, VA Central
Office. Georgina Gross received their doctorate from the University of North
Carolina at Greensboro and completed a clinical internship at the Durham
VA Medical Center. Their professional and research interests include PTSD
program evaluation, suicide prevention, military sexual trauma, and the
mental health of LGBTQ Veterans.
VISN 1 Clinical Resource Hub. She is also an Assistant Professor in the
Department of Psychiatry at Yale School of Medicine. Jennifer M. Doran
currently serves as the President-Elect of the Connecticut Psychological
Association. She earned her doctorate from The New School for Social
Research in New York City. Her professional and research interests are
focused on treatment engagement and retention among veterans with PTSD,
psychotherapy process and outcome, and education and training issues in
psychology.
MEAGHAN STACY is a clinical psychologist and Associate Professor of
Psychiatry at Yale University School of Medicine. She attended Johns
Hopkins University for her undergraduate degree and received her doctorate
from American University. Research and professional interests include
organizational culture, systems change, training, and recovery-oriented care.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Lyn-
ette Adams, VA Connecticut Healthcare System, West Haven, CT 06516,
United States. Email: Lynette.Adams@va.gov

1
 2 ADAMS, GROSS, DORAN, AND STACY
originate from non-employees (e.g., patients, family members of
patients, etc.) within healthcare systems.
Existing estimates of prevalence of identity-based harassment
come largely from the healthcare field and suggest that a majority of
medical trainees experience harassment during their training (e.g.,
Fnais et al., 2014). Within mental healthcare, 58% of psychi-
atry residents experienced “unwanted advances” from patients
(Dvir et al., 2012) and 7–13% of psychiatry trainees have reported
sexual harassment by an educator or staff member (Coverdale et al.,
2009). Much of the existing literature on trainees describes the
deleterious effects of experiencing harassment, such as conse-
quences for psychological well-being (Dvir et al., 2012), increased
work-related stress (Beyond Blue, 2019), and negative impact on
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
educational experiences (Nora et al., 2002) or career advancement
This document is copyrighted by the American Psychological Association or one of its allied publishers.
(Sánchez et al., 2015). There is, however, a surprising lack of data
and scholarship on the specific experiences of psychology trainees
witnessing or experiencing harassment in mental health settings.
The limited literature that exists highlights that psychology trainees
commonly report experiences of sexism and sexual harassment,
racism, and/or heterosexism from both clients (Bertsch et al., 2014;
Cencirulo et al., 2020; deMayo, 2000; Hartl et al., 2007) and
clinical supervisors (Bertsch et al., 2014) during their clinical
training.
Though harassment of psychology trainees is likely a common
occurrence, some trainees may experience barriers to discussing
these experiences with clinical supervisors. These barriers may
include trainee factors such as feeling uncertain that it was worthy
of supervision time, an expectation that they will be judged (Hartl
et al., 2007), perceiving the topic as unimportant (Ladany et al.,
1996), reluctance to be viewed as a victim, and/or a fear that one is
being “too sensitive” (Wear et al., 2007). Barriers may also include
trainee perceptions surrounding safety in making such disclosures.
Supervisors might be the perpetrators or might be affiliated with the
perpetrators of harassment. Beyond the possibility that the supervi-
sor might be directly or indirectly involved in the harassment itself,
supervisees might also withhold this information because they feel
unsupported by supervisors (Morgan & Porter, 1999), have con-
cerns about supervisor perceptions or negative reactions, have fears
of damaging their career (Ladany et al., 1996), experience their
supervisors as lacking in multicultural competence and the supervi-
sory working alliance as already tenuous (Bertsch et al., 2014), or
fear repercussions for voicing their concerns about harassment
(Cencirulo et al., 2020). Additionally, concerns about making per-
sonal disclosures about aspects of identities related to the harass-
ment (e.g., sexual orientation, gender identity, religious affiliation,
etc.) may be exacerbated if a trainee does not feel supported or has
concerns about the above-listed perceptions.
There is also a dearth of information on how clinical supervision
may be best used or structured to address harassment in clinical
settings, though deMayo (2000) found that of psychology super-
visors who reported that trainees they worked with had experienced
sexual harassment, the majority had talked about the harassment in
supervision. Hartl et al. (2007) provide excellent recommendations
for how supervisors and training programs can better support
trainees who experience sexual harassment, such as: encouraging
trainees to report incidents and then tracking these incidents, using
supervision to process experiences and conceptualize concerns, and
offering program-wide didactics for both trainees and supervisors
on managing harassment. These suggestions provide a useful
foundation on which to begin to consider and address harassment
of psychology trainees. However, much of what is currently avail-
able for supervisors focuses on gender-based or sexual harassment
and does not address current dilemmas faced by a more diverse
group of trainees and early career psychologists of many different
intersecting identities (Pedrotti & Burnes, 2016).
Supervisors also experience barriers to supporting trainees who
experience harassment. One barrier may be that some supervisors
lack the skills needed to address multicultural competence and
sensitivity generally, which has been identified as a concern among
psychology trainees belonging to underrepresented groups
(Gregus et al., 2020). This raises the question of whether super-
visors lacking multicultural competence are also able to effectively
and sensitively navigate discussions about trainee concerns about
identity-based harassment. Other harassment-specific barriers
include lacking details about the incident leading to “softer” (i.e.,
less effective) responses to trainee disclosure (deMayo, 2000), lack
of comfort or knowledge in how to address harassment (Hartl et al.,
2007), and failure to address experiences, which may impact the
supervisory working alliance (Bertsch et al., 2014). We are unaware
of any studies that have directly surveyed psychology supervisors
about what they perceive to be barriers to responding to trainee
reports of harassment.
Given the lack of recent scholarship directly focusing on the
experiences of supervisors, the aim of the present study was to
identify and contextualize current experiences, concerns, and chal-
lenges related to trainee harassment reported by clinical supervisors
of psychology trainees. The study was designed to better understand
how supervisors view trainee harassment and their role in addressing
it, as well as to identify perceived barriers to addressing identity-
based harassment as part of routine supervision.
Method
In order to examine supervisory experiences, we chose to include
both quantitative and qualitative items in a convergent (one-phase)
mixed methods design. Note that this was not a true convergent
design, which involves quantitative and qualitative measurement of
the same construct(s) (Creswell & Creswell, 2018). Instead, we
included quantitative items assessing harassment experiences, opi-
nions, conversations with trainees, and confidence addressing
harassment in supervision, and a qualitative item assessing super-
visors perceived barriers to having conversations with trainees
regarding harassment. The rationale for this was the lack of previous
research and pre-existing measures in the area of barriers to having
these conversations with trainees. Thus, instead of pre-determining
what supervisor’s barriers might be, we preferred to leave it open
ended. Further, due to the nature of the survey and to minimize
response burden, we were unable to include both quantitative and
qualitative assessment for each concept.
Participants and Procedures
Psychology supervisors of trainees in a large academic Veterans
Affairs (VA) Healthcare System in the Northeast were invited to
participate in a 90-min training on addressing the needs of trainees
who experience harassment as part of a quality improvement project
designated as non-research by the local Institutional Review Board.
The training was offered by the first author who is an expert in the
 ADDRESSING TRAINEE HARASSMENT
organization on the topic of harassment. Participation was voluntary
and open to all interested staff in the department. The training
consisted of didactic information (e.g. general prevalence of harass-
ment; suggested strategies for intervention; the role of the supervisor
in supporting trainees), as well as some experiential reflection and
case discussions. Time was left at the end for open discussion and
questions.
Supervisors were also asked to complete a pre- and post-training
questionnaire to evaluate the effectiveness of the training. Results of
the pre-training questionnaire are reported here. The trainings were
offered in two separate sessions at two different training sites within
the same healthcare system. The first session was held face to face
and the survey was administered immediately prior to the beginning
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
of the seminar. The data were collected on paper and returned
This document is copyrighted by the American Psychological Association or one of its allied publishers.
following the training by either leaving the form in an envelope in
the training room or returning the survey anonymously through
interdepartmental mail. The second training was held virtually due
to social distancing requirements amidst the COVID-19 pandemic.
Survey data for the second training were collected and managed
using REDCap electronic data capture tools hosted at the facility
(Harris et al., 2009, 2019). REDCap is a secure, web-based software
platform designed to support data capture for research studies,
providing (a) an intuitive interface for validated data capture;
(b) audit trails for tracking data manipulation and export procedures;
(c) automated export procedures for seamless data downloads to
common statistical packages; and (d) procedures for data integration
and interoperability with external sources. Links to the REDCap
pre-training survey were emailed to all psychologists who were part
of the psychology training committee prior to the training, and
participants were asked to use the first 5 min of the training to
complete the survey.
Measures
Demographics
Survey questions included basic demographics such as age, self-
identified gender identity, years as a supervisor, years since in
training, and years working at the VA. We chose to limit demo-
graphical information collected to these variables in order to encour-
age participation and enhance anonymity.
Harassment Experiences, Opinions, Conversations With
Trainees, and Confidence Addressing Harassment
Quantitative survey questions included whether supervisors:
Thought harassment of trainees was a problem at the VAMC
(adapted from Relyea et al., 2020 originally asking whether harass-
ment of women veterans was a problem at the VAMC); witnessed
harassment of trainees; experienced harassment based on some
aspect of their own identity; and ever had a conversation/supervision
with a trainee about harassment encountered by the trainee.
Responses for these items were “yes,” “no,” or “unsure.” Finally,
participants responded to 5-point Likert-type scales regarding how
likely they were to initiate a discussion with a trainee regarding
harassment (1 = not at all likely, 5 = definitely likely), and how
confident they felt in addressing harassment directly witnessed or
experienced, or addressing harassment with trainees (1 = not con-
fident, 5 = very confident). There was a total of 10 quantitative
3
questions. Given that established psychometric tools were unavail-
able for measuring these constructs, the items were developed by the
first author based on expertise in anti-harassment initiatives and
experience as a clinical supervisor. The second and last authors
provided input on the items and two clinical supervisors from
another setting outside of the current facility reviewed the content
during the item development.
Qualitative Barriers and Coding
Participants were also asked to provide an open-ended, narrative
response to a question about the top three barriers they experienced
in having conversations with trainees about harassment. This quali-
tative item was included within the same survey including the
quantitative items described above. Narrative data were coded by
an independent rater who is trained in multiple methods of qualita-
tive data analysis. This rater was not previously part of the research
team or privy to the training seminars or quantitative data that were
collected. This was done to ensure an independent and relatively
unbiased perspective in terms of qualitative data analysis, to limit
the influence of preconceived ideas or groupthink by the research
team, and to add the perspective of someone who regularly utilizes
qualitative methodologies.
Given the relatively simple nature of the narrative data that were
collected, it was determined that the best approach would be a
general thematic analysis using an open coding procedure, rather
than employing a formal qualitative coding paradigm. Several
approaches were considered, including grounded theory (Corbin &
Strauss, 2015) and consensual qualitative research (Hill et al.,
1997). Data analysis was inductive and interpretive in nature,
with a focus on the creation of categories and identifying emergent
themes. The thematic analysis utilized in the present study drew
from the constructivist coding approach (Charmaz, 2006, 2014), a
type of grounded theory analysis, and was also influenced by the
process of generating core ideas and domains found in consensual
qualitative research (Hill et al., 1997). The goal of the analysis was
neither to generate a unique theory nor support an existing one, but
rather to identify perceived barriers in an exploratory way and begin
to categorize those barriers into coherent themes for further consid-
eration and use.
Results
Quantitative
Demographics
Of the 58 psychologists invited to participate as part of the local
psychology training committee, 30 (51.7%) provided responses.
Two respondents indicated no current or past supervisory experi-
ence and were removed from the dataset leaving a total sample of 28,
resulting in a response rate of 50.0% (28/56). It should be noted that
not all psychologists who were invited were eligible to participate,
since the training committee includes psychologists who may not
provide clinical supervision yet are involved in training in other
ways (e.g., seminars, research mentoring). Eight (28.6%) of parti-
cipants identified as men and 20 (71.4%) identified as women. The
average age was 44.14 years (SD = 7.95, range: 30–64). Regarding
experience, supervisors reported an average of 12.54 (SD =
8.13, range: 1–40) years since they were trainees, 11.25 years
 4 ADAMS, GROSS, DORAN, AND STACY

(SD = 7.48, range: 1–38) serving as a supervisor, and 12.02
(SD = 7.95, range: 1–38) years employed at the VA.
Harassment Experiences, Opinions, Conversations With
Trainees, and Confidence Addressing Harassment
Table 1 displays results from the quantitative harassment survey
items. Most supervisors (82.1%) reported that harassment of trai-
nees is a problem at their facility, and over half (64.3%) reported
directly witnessing it. Most supervisors (82.1%) also reported
experiencing harassment themselves. Similarly, most (89.3%) re-
ported discussing harassment with a trainee on at least one occasion,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
analysis of narrative data, which include: (1) Lack of Knowledge
or Skill, (2) Trainee Factors, (3) Limitations of Supervision,
(4), Negative Feelings, (5) Relational Issues, and (6) Negative
Outcomes. Nearly all individual responses were ultimately assigned
a single thematic code. Table 2 includes each theme with its
frequency of occurrence, operational definition, and two represen-
tative quotes.
Lack of Knowledge or Skill
Many participants (n = 17; 27.8%) identified a lack of knowl-
edge or skill as a major barrier, such as not necessarily recognizing
when something might be considered or perceived as harassment,

and a combination of the trainee and supervisor broaching the topic and concern about not being well-equipped to adequately address
This document is copyrighted by the American Psychological Association or one of its allied publishers.

(vs. just the trainee, or just the supervisor) was the most frequent
impetus for those conversations (64.0%). On average, supervisors
reported being very likely to initiate such a discussion and reported a
range of confidence levels regarding addressing harassment in
different contexts (see Table 1).
Qualitative
Qualitative responses to a question about barriers in having
conversations with trainees about harassment were provided by
25 out of 28 (89.28%) participants. There were 61 total barriers
provided in the narrative text. Six broad themes emerged in the
these issues. Participants self-identified as having “a skill deficit” or
“limitation.” They also referenced it being “hard to know how to talk
about it [harassment],” and experiencing “uncertainty” or being
“unsure of how to bring it up.” Several also pointed to a poor
understanding of available resources and relevant processes that
would help facilitate their discussion of this issue.
Trainee Factors
A number of responses (n = 14; 22.9%) shifted the focus back
toward the trainee, such as indicating that addressing any harassment
that occurred would be their responsibility. Responses included

Table 1
Supervisors’ Experiences, Opinions, Conversations With Trainees, and Confidence Addressing Harassment of Trainees

Harassment experiences/opinions/conversations Responses (N = 28)

Harassment of trainees is a problem at this facility Yes: 23 (82.1%)

No: 1 (3.6%)
Unsure: 4 (14.3%)
Ever witnessed harassment of trainees Yes: 18 (64.3%)
No: 9 (32.1%)
Unsure: 1 (3.6%)
Ever experienced harassment based on some aspect of your identity Yes: 23 (82.1%)
No: 4 (14.3%)
Unsure: 1 (3.6%)
Ever experienced conversation or supervision with a trainee about harassment they encountered Yes: 25 (89.3%)
No: 3 (10.7%)
If yes, in what way does it most frequently come up as a topic? Trainee initiated: 7 (28.0%)
Supervisor initiated: 2 (8.0%)
Combination: 16 (64.0%)
Any other ways the conversation came up? “observed directly”
“witnessed it”
How likely are you to initiate a discussion with trainee? (1) not at all likely–(5) definitely likely Range = 3–5
M (SD) = 4.00 (0.77)

Confidence addressing harassment in supervision (1) not confident–(5) very confident

Confidence addressing harassment that you directly witness or experience Range = 2–5
M (SD) = 3.32 (0.77)
Confidence addressing harassment with trainees Range = 3–5
M (SD) = 3.54 (0.58)
Confidence training others to address harassment with trainees Range = 1–5
M (SD) = 2.71 (0.98)
Confidence training others to address harassment they directly witness or experience Range = 1–5
M (SD) = 2.79 (0.92)
 ADDRESSING TRAINEE HARASSMENT 5

Table 2
Barriers to Addressing Harassment: Qualitative Coding

Themes # % Operational definition Representative quotes

Lack of 17 28 Respondent cites a lack of knowledge or skill pertaining
knowledge to this issue, including not recognizing something as
or skill harassment, feeling poorly equipped to address
harassment, being unsure of available resources or
appropriate systemic process, and/or recognizing a
skill deficit or limitation in terms of having these types
of conversations
Trainee factors 14 23 Respondent places the onus to discuss or address this
issue on the trainee (trainee responsibility), and/or
respondent appears to blame the trainee for their
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Q1: Feeling that my own abilities to deal with harassment
are limited, so I don’t have much to offer
Q2: Level of comfort with how to provide guidance : : : I
may not know the best/most acceptable way in the
current context to express my thoughts
Q1: I generally let them (trainee) bring it up, which is not
ideal, but it is not the first thing that comes to mind for
me with supervision

response to the harassment or their approach to Q2: Comfort of the trainee in discussing harassment
This document is copyrighted by the American Psychological Association or one of its allied publishers.

addressing or minimizing it in supervision

Limitations of 12 20 Respondent references the parameters of supervision and/ Q1: (There are) no easy solutions or steps to solve these
supervision or constraints such as not having time to discuss issues systemic issues
like harassment, competing priorities/agenda or the Q2: Other direct clinical concerns have taken precedence
need to focus on clinical cases, not thinking to ask if there is not a direct occurrence of harassment that
about it as a general rule, and/or not having any we are addressing emergently
practical solutions to the problem
Negative 9 15 Respondent acknowledges negative feelings about the Q1: (I have) some fear that I may say something that is not
feelings harassment or how they would feel trying to address it, current/up to date or politically correct
including embarrassment, anticipated awkwardness, Q2: Frustration that I can’t stop or fix the harassment,
discomfort, anxiety or worry about saying the “wrong” especially from patients
thing, and/or general frustration about the fact that it is
occurring and the lack of ability to “fix” the problem
Relational 8 13 Respondent points to a relational issue between Q1: Power differential
issues themselves and the trainee, such as differential power Q2: I have a different identity than the trainee
dynamics, lack of trust, a lack of awareness of the
trainee’s identity factors that might play a role or guide
the discussion, and/or a concern about the role of their
own identity (such as having a different identity than
the trainee)
Negative 3 5 Respondent brings up a concern about a negative Q1: Not wanting to overstep or intrude
Outcomes outcome that might arise from the discussion, such as a Q2: How to have difficult conversations with veterans
negative impact on the therapy relationship between when they are concerned about rapport
the trainee and their patient or a negative impact on the
supervisory relationship
Note. Percentages rounded up.

participants “not [being] informed when it occurs,” or “not knowing
it is happening.” Several participants referenced specific incidents
and appeared to almost “blame” the trainee for how they handled the
situation or placed the onus on the trainee to bring up and discuss
incidents in supervision. This was captured in responses such as their
[the trainee’s] “receptiveness,” “insight,” “different perspective,”
“dis/comfort” or “embarrassment.” A few responses pointed to a
trainee “not wanting to make a big deal of it,” and one pointed to a
trainee erroneously “making assumptions about the intent of the
interaction.”
Limitations of Supervision
Participants also pointed to the structure and limitations of clinical
supervision as a reason for not addressing harassment (n = 12;
19.6%). A common factor was feeling there was “not enough
time,” with a particular emphasis on “competing priorities” given
the need to adequately review and discuss clinical cases and concerns
(such as “direct clinical concerns have taken precedence,” and
“pressing clinical concerns leave less space for these important
conversations”). Several participants also noted failing to think about
harassment as an agenda item or a general part of clinical supervision,
making comments along the lines of “it [harassment] isn’t prioritized”
or acknowledging “I just haven’t addressed it as much as I should
have.” Other responses stated that participants did not address harass-
ment due to a lack of practical solutions to the problem, such as “[there
are] no easy solutions or steps to solve these systemic issues,”
indicating that they felt unable to really help or “fix” the problem.
Negative Feelings
Participants also shared having negative feelings about harass-
ment itself or the prospect of trying to address it (n = 9; 14.7%).
Emotions such as “shame”/“embarrassment,” “discomfort with the
topic,” and “some fear” (anxiety) were all identified, as were things
such as anticipated “general awkwardness” and a lack of confidence
or worry about “saying the wrong thing.” One response also noted
“frustration” about being unable to stop the harassment from
occurring in a clinical context.
Relational Issues
Several relational issues between participants and their trainees
were identified (n = 8; 13.1%), including a “power differential,” or
 6 ADAMS, GROSS, DORAN, AND STACY
a “lack of trust” in the relationship. Responses also referenced not
being aware of their trainees’ identity factors that might play a role in
either the harassment itself or how to address it. Concerns about the
participants’ own identities also emerged in select responses, such as
feeling that having a different identity than the trainee would hinder
the process or discussion in some way (with “gender” and “age”
specifically mentioned).
Negative Outcomes
A few responses (n = 3; 4.9%) pointed to concerns about poten-
tial negative impacts from having these discussions, pertaining
to the therapy relationship between a trainee and their patient
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
(“concerned about rapport”) or the supervisory relationship (“not
This document is copyrighted by the American Psychological Association or one of its allied publishers.
wanting to overstep or intrude”). One participant noted “fear of
evaluation” as a barrier.
Discussion
Addressing harassment is an important clinical skill that can be
learned by psychology trainees through clinical supervision. How-
ever, the existing literature on trainee harassment largely comes
from medical fields (as opposed to psychology training programs),
describes prevalence rates without recommendations for change
(deMayo, 2000), and/or is primarily limited to sexual harassment
(deMayo, 2000; Hartl et al., 2007). Some work has examined
trainee perceptions of experiencing harassment based on aspects
of identity (Cencirulo et al., 2020); however, to our knowledge
recent studies have not examined supervisor perspectives on ad-
dressing harassment in today’s sociocultural clinical training envi-
ronment. This study is the first to systematically assess psychology
supervisors’ experiences of using supervision to address trainee
harassment, with a focus on identifying perceived barriers to
doing so.
The results demonstrated that many of the supervisors surveyed in
this study are aware of trainee harassment, which is consistent with
high rates of harassment reported by trainees (Cencirulo et al., 2020;
deMayo, 2000). A substantial number of supervisors in the present
study also reported directly experiencing harassment. Further, some
reported not only struggles with assisting trainees who experience
harassment but also with navigating their own reactions and re-
sponses to harassment, which undoubtedly affects one’s feelings of
efficacy in addressing it with trainees.
Despite the supervisors in this study clearly reporting awareness
of trainee harassment and belief that it is a problem, they also
highlighted several perceived barriers to addressing harassment in
supervision. These included perceived lack of knowledge or skill for
how to address it, putting the responsibility to address harassment on
the trainee, limitations of supervision, negative feelings of the
supervisor, relational issues in the supervisory dyad, and trainee
concern about negative outcomes. Narrative data also suggest that
many supervisors in this sample may wait for trainees to bring up
harassment in supervision. This is problematic as there are a number
of reasons trainees may not do so. Specifically, several barriers
identified in this study are consistent with existing literature, such as
trainee beliefs that addressing harassment is not worthy of supervi-
sion time or is not important (Hartl et al., 2007; Ladany et al., 1996),
concerns about not feeling supported (Morgan & Porter, 1999),
concerns about negative evaluation (Ladany et al., 1996), or
concerns about supervisor competency to address harassment
(Bertsch et al., 2014). As such, it is imperative that supervisors
take responsibility for broaching the topic with trainees, express its
importance and place in supervision, and frame addressing harass-
ment as an essential clinical skill for navigating many professional
relationships. This is particularly important considering that several
supervisors in this study referenced power differentials or differ-
ences in “identity” as barriers. It is possible that power differentials
are exacerbated when identities within the supervisory dyad differ.
Supervisor awareness of the ways in which their areas of privilege
might amplify the power differential and in turn, create additional
barriers to supervisees feeling comfortable to disclose harassment
incidents seems especially important. Additional system related
barriers like lack of clarity on policies and procedures may reinforce
structural forms of oppression, further exacerbating harassment and
the acceptance of harassment by leaders and those with more power
and privilege.
The supervisor should strive to create an environment where
conversations about identity are encouraged and safe, while recog-
nizing that the various identities of the trainee, supervisor, perpe-
trator of the harassment, and/or anyone else involved in the situation
intersect in complex and relevant ways. Furthermore, while addres-
sing harassment is a useful goal in its own right, it is also important
to consider the role that harassment may play in shaping clinical
formulations and treatment interventions. Patients who perpetuate
harassment, for example, demonstrate evidence of problematic and
potentially damaging interpersonal behavior that may negatively
impact other aspects of their lives (for additional discussion of this
issue, see deMayo, 2000; Hartl et al., 2007). Finally, incorporating
client harassment behavior into case formulations may be consid-
ered part of providing effective and ethical client treatment.
Limitations
Before presenting recommendations, there are several limitations
of the present study that are important to note. First, the study
utilized a relatively small sample from a quality improvement
project at one VA Healthcare system, which necessarily limits
the generalizability of the results. This is particularly important
to note as the Veterans Healthcare Administration (VHA) follows
federal policies (Veterans Health Administration, 2015) prohibiting
harassment and discrimination between employees and requires
employees to complete annual trainings on the contents of those
policies. The VHA has also recently made efforts to raise awareness
of experiences and perceptions of patients who have experienced
harassment while on VHA grounds (Dyer et al., 2019; Klap et al.,
2019) and to call employees to action to eliminate harassment and
assault in VHA settings (Veterans Health Administration, 2020).
It is unknown to what extent supervisors in other clinical training
settings would report similar experiences or barriers. For example,
supervisors in clinical settings without a heavy focus on the reduc-
tion of harassment may lack awareness of the scope of the problem.
Accordingly, they may not report having experienced barriers to
addressing harassment with trainees, or trainees may not feel
empowered to bring it up in supervision. Supervisors working in
more or less diverse areas than the present study may receive reports
of trainee harassment at different frequencies, influencing their skill
and experience addressing harassment. Relatedly, knowing more
about the demographic background of participants would be useful
 ADDRESSING TRAINEE HARASSMENT
in understanding context for the relatively high rates of reports of
experiencing harassment and interpreting the reported barriers. For
example, it would be interesting to know if White or male super-
visors (who may have fewer experiences with directly experiencing
harassment) are more likely to report barriers to addressing harass-
ment, compared to supervisors who identify as a racial or ethnic
minority, female, or Lesbian, Gay, Bisexual and/or Transgender, who
may have personally experienced harassment. Rates of reports of
experiencing harassment in this VHA setting, however, were similar
to rates found in another recent study of faculty at a medical school
outside the VHA, so regardless of the setting, it is apparent that
experiences of harassment are likely widespread in healthcare settings
(Vargas et al., 2020). Finally, it is unclear the degree to which federal
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
regulations and reporting requirements related to Title IV and Sexual
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Violence Sexual Harassment (SVSH) policies impact a training
program’s willingness to openly discuss, report, and act on incidents
of harassment that occur in the context of a training program. While
an in-depth exploration of this issue was beyond the scope of the
study, it merits further consideration pertaining to this topic. In all, the
data provide an important first step in understanding the barriers that
exist for supervisors in effectively responding to trainee harassment in
a psychology training program, which may also represent the needs of
trainees in other medical training programs.
We expect that additional awareness and/or barriers would
emerge within the context of the national social reckoning with
systemic racism that has occurred since the collection of this data.
Relatedly, we did not specify “types” of harassment (i.e., based on
specific aspects of identity such as race, gender or gender identity,
sexual orientation) or ask about other aspects of training climate-
related issues such as experiences with racism, heterosexism, or
other “-isms” in order to encourage genuine responses in the event
that disclosing types of harassment would inadvertently identify
participants. Accordingly, it is possible that respondents may have
considered a narrower focus on sexual or gender-based harassment
in their responses, which may or may not extend to many aspects of
identity. This study was conducted within the context of a training
on supporting psychology trainees who have experienced harass-
ment, and it is possible that participants who had a higher interest in
this topic, were more aware of occurrence of harassment of trainees,
had more experiences with harassment either personally or with
discussing with trainees, or felt they were in more need of training
on this topic were more likely to attend and thus participate in this
survey. These factors (e.g., greater interest, level of awareness,
experiences, or perception of need for training) may have impacted
which barriers were reported by attendees. Additionally, respon-
dents may have attempted to provide socially desirable responses. In
an effort to mitigate this risk, we minimized the demographic
information collected in order to decrease the likelihood any respon-
dent would be identified, with the intention of helping to assuage
concerns about the identifiability of their responses.
Recommendations for Training
These results from this study on supervisors at one training site,
paired with existing research on trainee harassment inform several
recommendations on how to specifically address the barriers iden-
tified by supervisors in this study. The data obtained from this study
were synthesized in order to inform the recommendations offered
below for training programs and clinical supervisors.
7
The following recommendations are designed to specifically
target supervisor negative feelings, relational issues, and trainee
factors. While these recommendations may be generalizable to all
types of harassment based on identity, it is important to consider that
experiences of harassment are nuanced and unique. The individual
context, such as, but not limited to, the demographic makeup of the
supervisory dyad, is important to consider with these recommenda-
tions. Normalizing discussions of harassment as a valid topic for
supervision and inviting trainees to share their experiences will
allow avenues for discussion, especially when done early in the
supervisory relationship. Supervisors should increase their comfort
in addressing these concerns while recognizing that power differ-
entials, trainee identity, and/or trainee discomfort may impact the
discussion (Hartl et al., 2007). Acknowledging that harassment in
healthcare settings is common and proactively asking how the
trainee would like to handle it with the supervisor when (not if)
it comes up will also increase the success of managing concerns as
they arise (Goldenberg et al., 2019). When trainees do report
experiences with harassment, supervisors should support the trai-
nee’s perception of their experience and directly address or ask
about trainee concerns. Coaching, role plays, and case scenarios
(Zook, 2018), as well as case conceptualization (Bartoli & Pyati,
2009; Hartl et al., 2007) may be useful as specific strategies when
talking about options for responding in the future. Approaching
problem-solving based on the severity of the harassment is impor-
tant as some incidents may require more direct supervisory inter-
vention (deMayo, 2000). Additional recommendations for clinical
supervisors, drawn from the extant literature on trainee harassment
in medical training programs outside of psychology, are provided
immediately below.
Recommendations for Clinical Supervisors
Clinical Supervisors are advised to:
1. Introduce the topic of harassment with trainees and
frame it as an appropriate and important topic to address
early on in supervision.
2. Normalize the experience of harassment in healthcare
settings and invite trainees to share incidents of harass-
ment when they occur, considering incidents of harass-
ment beyond traditional gender or sexual based examples.
3. Work collaboratively with trainees to proactively plan for
how to address incidences of harassment when they occur.
4. Consider the power dynamic inherent in the supervisory
relationship and how this may impact the discussion of
harassment with trainees.
5. Work to increase their own comfort and competence with
addressing harassment.
6. Endeavor to understand and support the perceptions and
experiences of trainees when they are shared, rather than
challenging or confronting them.
7. Use core clinical skills to address experiences of harass-
ment, including case conceptualization, coaching, role
playing, and problem solving.
 8 ADAMS, GROSS, DORAN, AND STACY
8. Increase awareness of policies and procedures for addres-
sing harassment in their institutions and help trainees
navigate these processes when the trainee desires to do so.
9. Inquire about the trainee’s comfort level and goals in
addressing harassment and be able and willing to differ-
entiate their own preferences or goals from that of their
trainees. If clinically indicated, support the referral of
clients to another clinician if the trainee is feeling unsafe
or is unable to serve the client due to harassment.
10. Approach learning how to address and respond to harass-
ment as an important clinical skill and work on develop-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ing it accordingly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Training programs can elevate reports of harassment to a “training
committee” level issue and not an individual trainee or supervisor
issue to better address supervisor barriers such as lack of knowledge
or skill, limitations of supervision, or concerns about negative
outcomes. Identifying processes and policies around reporting early
on (Leisy & Ahmad, 2016) during the orientation process and in
handbooks further creates an atmosphere that the training program
takes harassment seriously. It may also be useful to debrief and
discuss reported incidents as a group (Whitgob et al., 2016).
Including climate surveys that ask about experiences of harassment
when getting feedback from trainees about their overall experiences
with the program (Jamieson et al., 2015; Whitgob et al., 2016)
allow for trainees to provide feedback on experiences that could be
improved if they are not comfortable discussing them directly with
supervisors or training directors. Didactics for all clinical staff,
including supervisors and trainees (deMayo, 1997), on how to
effectively respond to experiences of harassment will also increase
the skills and knowledge needed by both trainees and supervisors to
effectively address harassment. Supervisors may experience an
increase in efficacy as well as a decrease in negative affect relating
to addressing harassment if they engage in professional develop-
ment in this area and are supported by the larger system that they
work in. Finally, in the unfortunate event that supervisors are
perpetuators of harassment themselves, leaders must set clear
standards that harassment will not be tolerated (Jamieson et al.,
2015). We provide recommendations for training programs synthe-
sized from scholarly articles on trainee harassment below.
Recommendations for Training Programs
Training Programs are advised to:
1. Identify policies and processes surrounding harassment
and its reporting early on in the orientation process.
2. Work to create a culture where harassment is treated as a
serious problem and not tolerated.
3. View harassment as an important issue and strive to
address concerns collectively as a department and/or
training committee.
4. Elevate concerns and complaints to leadership to ensure
that addressing harassment is a systemic issue and
initiative.
5. Communicate the prevalence of harassment in healthcare
settings to trainees and promote the role of clinical
supervision as a mechanism to address it.
6. Provide didactics for all clinical staff and trainees on
harassment and review strategies and tools for addres-
sing it.
7. Offer trainings to supervisors as needed to support their
own skill development related to increasing multicultural
competence and awareness of own’s own identity to
effectively address harassment.
8. Collect feedback about experiences of harassment out-
side of the supervisory relationship.
9. Regularly include climate surveys that ask about trainee
experiences of harassment when eliciting feedback about
their training experience.
10. Demonstrate that harassment will not be tolerated in the
training program and swiftly address any harassment
occurring by supervisors, other staff, or patients.
Future Directions and Conclusion
Future research should focus on other methods of data collection,
such as further qualitative inquiry (e.g., interviews or focus groups)
or development and psychometric validation of measures to assess
supervisors’ experiences of and barriers to addressing harassment in
supervision. Larger samples would provide additional information
and potentially identify other salient experiences and barriers that
did not emerge in the current sample. Despite limitations, the present
study demonstrates that while the supervisors in this study report
awareness that harassment of trainees is occurring and discuss
harassment with them in supervision, multiple barriers to effectively
addressing this as part of their supervisor role exist. Additional
research should also aim to identify strategies that are most effective
in supporting trainees who experience harassment to directly
address these barriers. This will serve and support trainees who
experience this harassment and will also provide guidance for
clinical supervisors striving to provide more effective supervision.
References
Bartoli, E., & Pyati, A. (2009). Addressing clients’ racism and racial
prejudice in individual psychotherapy: Therapeutic considerations. Psy-
chotherapy: Theory, Research, & Practice, 46(2), 145–157. https://
doi.org/10.1037/a0016023
Bertsch, K. N., Bremer-Landau, J. D., Inman, A. G., DeBoer Kreider, E. R.,
Price, T. A., & DeCarlo, A. L. (2014). Evaluation of the critical events in
supervision model using gender related events. Training and Education in
Professional Psychology, 8(3), 174–181. https://doi.org/10.1037/te
p0000039
Beyond Blue. (2019). National Mental Health Survey of Doctors and
Medical Students. https://www.beyondblue.org.au/docs/default-source/re
search-project-files/bl1132-report-nmhdmss-full-report_web.
Cencirulo, J., McDougall, T., Sorenson, C., Crosby, S., & Hauser, P. (2020).
Trainee experiences of racism, sexism, heterosexism, and ableism (the
“ISMs”) at a department of veterans affairs (VA) healthcare facility.
Training and Education in Professional Psychology. Advance online
publication. https://doi.org/10.1037/tep0000312
 ADDRESSING TRAINEE HARASSMENT
Charmaz, K. (2006). Constructing grounded theory: A practical guide
through qualitative analysis. Sage Publications.
Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage
Publications.
Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and
procedures for developing grounded theory (4th ed.). Sage Publications.
Coverdale, J. H., Balon, R., & Roberts, L. W. (2009). Mistreatment of
trainees: Verbal abuse and other bullying behaviors. Academic Psychiatry,
33(4), 269–273. https://doi.org/10.1176/appi.ap.33.4.269
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative,
quantitative, and mixed methods approaches (5th ed.). Sage Publications.
deMayo, R. A. (1997). Patient sexual behavior and sexual harassment: A
national survey of female psychologists. Professional Psychology,
Research and Practice, 28(1), 58–62. https://doi.org/10.1037/0735-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
7028.28.1.58
This document is copyrighted by the American Psychological Association or one of its allied publishers.
deMayo, R. A. (2000). Patients’ sexual behavior and sexual harassment: A
survey of clinical supervisors. Professional Psychology, Research and
Practice, 31(6), 706–709. https://doi.org/10.1037/0735-7028.31.6.706
Dvir, Y., Moniwa, E., Crisp-Han, H., Levy, D., & Coverdale, J. H. (2012).
Survey of threats and assaults by patients on psychiatry residents. Aca-
demic Psychiatry, 36, 39–42. https://doi.org/10.1176/appi.ap.10060090
Dyer, K. E., Potter, S. J., Hamilton, A. B., Luger, T. M., Bergman, A. A.,
Yano, E. M., & Klap, R. (2019). Gender differences in veterans’ percep-
tions of harassment on veterans health administration grounds. Women’s
Health Issues, 29(Suppl. 1), S83–S93. https://doi.org/10.1016/j.whi.2019
.04.016
Fnais, N., Soobiah, C., Chen, M. H., Lillie, E., Perrier, L., Tashkhandi, M.,
Straus, S. E., Mamdani, M., Al-Omran, M., & Tricco, A. C. (2014).
Harassment and discrimination in medical training: A systematic review
and meta-analysis. Academic Medicine, 89, 817–827. https://doi.org/10
.1097/ACM.0000000000000200
Goldenberg, M. N., Cyrus, K. D., & Wilkins, K. M. (2019). ERASE: A new
framework for faculty to manage patient mistreatment of trainees.
Academic Psychiatry, 43, 396–399. https://doi.org/10.1007/s40596-018-
1011-6
Gregus, S. J., Stevens, K. T., Seivert, N. P., Tucker, R. P., & Callahan, J. L.
(2020). Student perceptions of multicultural training and program climate
in clinical psychology doctoral programs. Training and Education in
Professional Psychology, 14(4), 293–307. https://doi.org/10.1037/te
p0000289
Harris, P. A., Taylor, R., Minor, B. L., Elliott, V., Fernandez, M., O’Neal, L.,
McLeod, L., Delacqua, G., Delacqua, F., Kirby, J., Duda, S. N., & the
REDCap Consortium. (2019). The REDCap consortium: Building an
international community of software platform partners. Journal of Bio-
medical Informatics, 95, Article 103208. https://doi.org/10.1016/j.jbi
.2019.103208
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G.
(2009). Research electronic data capture (REDCap)—A metadata-driven
methodology and workflow process for providing translational research
informatics support. Journal of Biomedical Informatics, 42(2), 377–381.
https://doi.org/10.1016/j.jbi.2008.08.010
Hartl, T. L., Zeiss, R. A., Marino, C. M., Zeiss, A. M., Regev, L. G., &
Leontis, C. (2007). Clients’ sexually inappropriate behaviors directed
toward clinicians: Conceptualization and management. Professional Psy-
chology, Research and Practice, 38(6), 674–681. https://doi.org/10.1037/
0735-7028.38.6.674
Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to
conducting consensual qualitative research. The Counseling Psychologist,
25, 517–572. https://doi.org/10.1177/0011000097254001
Jamieson, J., Mitchell, R., Le Fevre, J., & Perry, A. (2015). Bullying and
harassment of trainees: An unspoken emergency? Emergency Medicine
Australasia, 27(5), 464–467. https://doi.org/10.1111/1742-6723.12465
9
Klap, R., Darling, J. E., Hamilton, A. B., Rose, D. E., Dyer, K., Canelo, I.,
Haskell, S., & Yano, E. M. (2019). Prevalence of stranger harassment of
women veterans at Veterans Affairs medical centers and impacts on
delayed and missed care. Women’s Health Issues, 29(2), 107–115.
https://doi.org/10.1016/j.whi.2018.12.002
Ladany, N., Hill, C. E., Corbett, M. M., & Nutt, E. A. (1996). Nature, extent,
and importance of what psychotherapy trainees do not disclose to their
supervisors. Journal of Counseling Psychology, 43(1), 10–24. https://
doi.org/10.1037/0022-0167.43.1.10
Leisy, H. B., & Ahmad, M. (2016). Altering workplace attitudes for resident
education (A.W.A.R.E.): Discovering solutions for medical resident
bullying through literature review. BMC Medical Education, 16,
Article 127. https://doi.org/10.1186/s12909-016-0639-8
Morgan, J. F., & Porter, S. (1999). Sexual harassment of psychiatric trainees:
Experiences and attitudes. Postgraduate Medical Journal, 75, 410–413.
https://doi.org/10.1136/pgmj.75.885.410
Nora, L. M., McLaughlin, M. A., Fosson, S. E., Stratton, T. D., Murphy-
Spencer, A., Fincher, R. M., German, G. C., Seiden, D., & Witzke, D. B.
(2002). Gender discrimination and sexual harassment in medical educa-
tion: Perspectives gained by a 14-school study. Academic Medicine,
77(12), 1226–1234. https://doi.org/10.1097/00001888-200212000-00018
Pedrotti, J. T., & Burnes, T. R. (2016). The new face of the field: Dilemmas
for diverse early-career psychologists. Training and Education in Profes-
sional Psychology, 10(3), 141–148. https://doi.org/10.1037/tep0000120
Relyea, M. R., Portnoy, G. A., Klap, R., Yano, E. M., Fodor, A., Keith, J. A.,
Driver, J. A., Brandt, C. A., Haskell, S. G., & Adams, L. (2020).
Evaluating bystander intervention training to address patient harassment
at the Veterans Health Administration. Women’s Health Issues, 30(5),
320–329. https://doi.org/10.1016/j.whi.2020.06.006
Sánchez, N. F., Rankin, S., Callahan, E., Ng, H., Holaday, L., McIntosh, K.,
Poll-Hunter, N., & Sánchez, J. P. (2015). LGBT trainee and health
professional perspectives on academic careers—Facilitators and chal-
lenges. LGBT Health, 2(4), 346–356. https://doi.org/10.1089/lgbt
.2015.0024
U.S. Equal Employment Opportunity Commission. (n.d.). Harassment.
www.eeoc.gov/harassment
Vargas, E. A., Brassel, S. T., Cortina, L. M., Settles, I. H., Johnson, T. R. B.,
& Jagsi, R. (2020). #MedToo: A large-scale examination of the incidence
and impact of sexual harassment of physicians and other faculty at an
academic medical center. Journal of Women’s Health, 29(1), 13–20.
https://doi.org/10.1089/jwh.2019.7766
Veterans Health Administration. (2015). VHA directive 1124. Equal employ-
ment opportunity policy.
Veterans Health Administration. (2020, October 22). White ribbon VA.
https://www.va.gov/health/harassment-free/
Wear, D., Aultman, J. M., & Borges, N. J. (2007). Retheorizing sexual
harassment in medical education: Women students’ perceptions at five
U.S. medical schools. Teaching and Learning in Medicine, 19(1), 20–29.
https://doi.org/10.1080/10401330709336619
Whitgob, E. E., Blankenburg, R. L., & Bogetz, A. L. (2016). The discrimi-
natory patient and family: Strategies to address discrimination towards
trainees. Academic Medicine, 91(11), S64–S69. https://doi.org/10.1097/
ACM.0000000000001357
Zook, R. (2018). Teaching staff to handle a patient’s sexually inappropriate
behavior. Journal for Nurses in Staff Development (JNSD), 16, 181–183.
https://doi.org/10.1097/00124645-200007000-00009
Received September 14, 2020
Revision received May 14, 2021
Accepted June 1, 2021 ▪