ETHICS & BEHAVIOR, 25(5), 427–441

Copyright © 2015 Taylor & Francis Group, LLC

ISSN: 1050-8422 print / 1532-7019 online
DOI: 10.1080/10508422.2014.947415

Ethics in Supervision: Consideration of the Supervisory

Alliance and Countertransference Management of
Psychology Doctoral Students

Shirley Pakdaman, Edward Shafranske, and Carol Falender

Graduate School of Education and Psychology
Pepperdine University

Clinical supervision provides the foundation for cultivating ethical practice and professionalism
for mental health trainees. Exploration and management of a supervisee’s personal reactivity or
countertransference (CT) is a critical component of supervision and has clear ethical implications for
clinical management and the development of clinical competence. This article discusses supervision
practice and presents the results of a study that investigated the influence of supervisor–supervisee
relationship on clinical and counseling doctoral students’ CT disclosures. Respondents completed the
Working Alliance Inventory–Supervisee form and the Personal Reaction Disclosure Questionnaire,
which assessed respondents’ comfort and likelihood of reporting CT reactions to hypothetical clinical
interactions. Results of this analogue study demonstrated positive associations between supervisory
alliance and reported comfort and likelihood of CT disclosures, highlighting the importance of the
alliance and drawing attention to supervisors their responsibility to particularly attend to the bond
dimension of the relationship.
Keywords: countertransference, ethics, clinical supervision, supervisory alliance, clinical training

Clinical supervision provides the means by which the foundation for the ethical practice of
applied psychology is established. Supervisors facilitate the development of clinical competence
through oversight and by engaging trainees to reflect upon and apply principles of evidence-
based practice (American Psychological Association, Presidential Task Force on Evidence-Based
Practice, 2006), incorporating ethics throughout. In addition to training functions, supervisors
bear the responsibility of ensuring that services provided to clients under their supervision uphold
patient welfare. Effective clinical supervision not only protects the client and enhances the techni-
cal competence of supervisee but also encourages self-reflectivity and instills values and a “lived
world” appreciation that ethics govern every aspect of conduct, leading to professionalism. This
perspective is particularly important when focusing supervisory attention to the role of therapist
personal factors and countertransference (CT) in psychotherapy. In this article, we discuss thera-
pist personal reactivity or CT from a transtheoretical framework (Falender & Shafranske, 2012;
Shafranske & Falender, 2008), ethics and practice standards specific to the management of CT,

Correspondence should be addressed to Shirley Pakdaman, Graduate School of Education and Psychology,
6100 Center Drive, Pepperdine University, Los Angeles, CA 90045. E-mail: spakdaman@gmail.com
428 PAKDAMAN, SHAFRANSKE, FALENDER

findings of a recent empirical study of supervisory alliance and CT disclosure, and implications
for best practices in clinical supervision.

THERAPIST PERSONAL FACTORS, REACTIVITY AND COUNTERTRANSFERENCE

The personal factors of the therapist, for example, attitudes, beliefs, values, biases, conflicts, and
problems—in fact all personal experiences—inevitably influence a clinician’s understanding and
relating to his or her client and the conduct of treatment. In the best of circumstances (and usual
course), these personal factors in part enable the therapist to empathically understand the client’s
experience and lead to appropriate professional responsiveness. However, at times, CT reactions
may occur, marked by heightened emotional arousal and characterized by personal reactivity,
which consequently suspends empathic engagement with the client (Falender & Shafranske,
2014). Differences in client and therapist values as well as the arousal of therapist sensitivities
and conflicts by virtue of the clinical material or client personality characteristics may trigger
CT reactions. For example, “Clients who have values deeply disparate from their treating psy-
chologist may represent special challenges as their behaviors and attitudes evoke strong feelings
in the therapist” (Behnke, 2008). Similarly, psychotherapists may feel reactions toward patients
that are based on their own life experiences such as relationships, family dynamics, and sexual
preferences and attractions.
CT is described as a complex phenomenon jointly created by client and therapist, which plays
a pervasive role in treatment, and can result in atypical therapist behavior (Gabbard, 2001; Gelso
& Hayes, 1998). Among the competencies that are addressed in supervision, management of
CT, also referred to in other theoretical frames as reactivity, is integral to ethical and effective
practice

MANAGEMENT OF COUNTERTRANSFERENCE AS A CLINICAL COMPETENCE

AND ETHICAL REQUIREMENT

According to the APA Ethics Code (American Psychological Association [APA], 2010), clinical
literature, and findings from recent empirical research, it is clear that the ability to effectively
manage CT is a required competency for clinicians (Behnke, 2008), which is initially developed
in clinical supervision. As part of the responsibility for their supervisees’ patients, supervisors
must assist trainees in navigating issues pertaining to their own personal reactions to patients. This
helps the supervisee be a more effective therapist and gives the supervisor an undistorted view of
what is actually happening in the therapy. Identifying and understanding CT is necessary to avoid
tainting the supervisor’s perception of the patient and assisting the supervisee to understand the
dynamics that are influencing their behavior (Fink, 2007).
Broadly considered, all forms of personal factors, including those derived from a clinician’s
multicultural identities (Falender, Shafranske, & Falicov, 2014), require consideration and
acknowledgment of personal biases in order to ensure respect for the “dignity and worth of
all people” (APA, 2010). Further, given that the reactions that clients evoke in psychotherapists
have been found to negatively impact the conduct of treatment and even treatment outcomes
(Dalenberg, 2004; Erasmus, 2005; Rosenberger & Hayes, 2002), management of CT is an
essential skill to be developed in clinical supervision. Also, there may be instances in which a
 ALLIANCE AND COUNTERTRANSFERENCE DISCLOSURE 429

psychologist’s or trainee’s personal problems may interfere with professional performance, and
the APA Ethics Code requires that “appropriate measures [must be taken] taken, such as obtain-
ing professional consultation or assistance and determine whether they should limit, suspend or
terminate their work-related duties” (Section 2.06(b)). Awareness of those personal problems
or feelings that would inhibit a psychologist from performing work-related duties adequately
allows the clinician to remediate the difficulty by seeking professional help or consultation
(Section 2.06), or supervision in the case of trainees. To facilitate the supervisee’s development
of competence in the management of CT (as well as in all other areas of professional practice),
the clinical supervisor must be competent and ensure that that each functions with his or her
boundaries of competence (2.01(a)). Given the aforementioned ethical standards and with emerg-
ing guidelines for supervision (American Psychological Association, Task Force on Supervision
Guidelines, 2013), understanding the role CT or reactivity management is essential.

ADDRESSING CT IN CLINICAL SUPERVISION

The development of competence in awareness of personal factors and CT (or reactivity) man-
agement builds upon the supervisee’s ability for self-awareness and understanding of clinical
processes, akin to Schön’s (1983) notion of “reflection-on-action.” Increasing the capacity for
self-reflection and understanding as it relates to clinical work requires at least some degree of
voluntary self-disclosure on the trainee’s part. Two interrelated issues converge when consider-
ing supervisee self-disclosure, particularly when addressing personal factors and CT: ethics and
respect for privacy and the supervisory alliance. We first take up the ethical guidelines involv-
ing disclosure of personal information. This issue is quite relevant since exploration of personal
reactivity or CT is personal by definition.

Ethics When Exploring Countertransference

Addressing personal factors that result in personal reactions is complicated by Section 7.04 of the
Ethics Code, which states that “supervisees are not to be required to disclose personal informa-
tion in course- or program-related activities regarding personal history.” The principle clarifies
that students may be asked to disclose personal information in the case of evaluating if the stu-
dent’s personal problems (perhaps triggered as a reaction to a particular patient in the case of
CT) could prevent them from performing their patient activities competently or if the program
clearly identified this requirement in its admissions and program materials (APA, 2010, 7.04 (1)).
Care should be taken to tether any inquiry to professional performance (i.e., how personal factors
are directly impacting the trainee’s ability to empathically engage with the client and to per-
form appropriate treatment). Supervision should never involve inquiry or exploration beyond this
parameter; supervisors therefore should avoid the slippery slope of offering therapeutic interven-
tions (Falender & Shafranske, 2012, 2014; Shafranske & Falender, 2008) and keep the focus on
the relationship of the supervisee’s perceptions, attitudes, and behavior to the client.
In keeping with this ethical standard, many psychology doctoral programs identify the expecta-
tion of supervisee’s disclosure of personal characteristics and issues and personal exploration that
are relevant to client interventions, professional effectiveness, and success as part of their training
model. Similarly, it is common for internships to make similar statements in the training pro-
gram description, notifying trainees that self-disclosure will be part of the supervisory experience,
430 PAKDAMAN, SHAFRANSKE, FALENDER

used to help the trainee gain understanding of the dynamics and characteristics they bring into
interactions and how they influence client and supervision interactions and client interventions,
consistent with APA ethics (APA, 2010, 7.04).

Supervisory Alliance

Studies of effective clinical supervision revealed the importance of the relationship between
supervisor and supervisee, the working alliance (Efstation, Patton, & Kardash, 1990; Ellis
& Ladany, 1997; Goodyear & Bernard, 1998; Ladany, Ellis, & Friedlander, 1999; Patton
& Kivlinhan, 1997) and the resultant emotional bond, respect, and mutual trust (Ladany &
Friedlander, 1995). It is logical to conclude that the supervisory alliance plays a pivotal role
in exploring personal reactivity. A strong alliance would provide a safe environment for trainees
to candidly explore roadblocks to treatment, and a weak alliance has been found to be the cause of
nondisclosure of important matters that could lead to poor treatment outcomes, ethical violations,
and CT behaviors (Ladany, Hill, Corbett, & Nutt, 1996). Supervisory relationships characterized
by trust, respect, integrity, attention to professional boundaries, and ethics provide a foundation
on which CT can be effectively addressed. In addition, it is important for supervisors to reflect
on the supervisee’s likely experience of CT and the vulnerability they may feel when addressing,
perhaps for the first time, their reactivity within the clinical setting, for example, frustration, loss
of control, or sexual arousal.
It is common for beginning therapists to feel as if they lack clinical mastery—as this percep-
tion is to some degree a reality. This feeling may be inadvertently transferred onto the patient, if
it is not adequately addressed in supervision. The novice therapists’ CT in particular may be prin-
cipally determined by how self-efficacious they feel during the session (Tobin, 2006). Beginning
clinicians are at particular risk for experiencing strong CT reactions, for example, when treating
difficult patients (e.g., patients diagnosed with personality disorders) or if they overidentify with
a patient. The more a client talks about issues related to the therapist’s personal conflicts, the
less the therapist perceived herself or himself to be socially attractive, trustworthy, and an expert,
even if she or he was aware of the personal conflict (Rosenberger & Hayes, 2002). When patient
material touched on a therapist’s unresolved issues, the supervisor found the therapist’s interven-
tion to be inadequate (Cutler, as cited by Gelso & Hayes, 2001). The consequences of such CT
if left unchecked can range in severity and can include therapist feelings of ineffectiveness, poor
treatment outcomes, premature termination, inappropriate therapist self-disclosure, or therapist’s
emotional withdrawal from the patient (Davis, 2002).
Supervisees may feel confusion, embarrassment, or conflict when experiencing sexual attrac-
tion to a client, even while knowing that such experiences are normative. Nearly 90% of therapist
trainees reported having been sexually attracted to their clients, at least on occasion (Pope,
Keith-Spiegel, & Tabachnick, 1986). More than half of the therapists surveyed reported feel-
ing confused, guilty, or anxious about such attraction; however, often they did not receive any
guidance or training on this issue, and the attraction remained undisclosed to their supervisors
(Pope et al., 1986). If not appropriately understood and managed, boundary crossings, ineffective
therapy, or even exploitation or harm to the patient may result.
Managing CT reactions requires willingness to self-disclose, and we hypothesized that will-
ingness would likely be affected by the supervisory alliance. We tested this hypothesis in a series
 ALLIANCE AND COUNTERTRANSFERENCE DISCLOSURE 431

of studies of clinical and counseling psychology students and interns. For example, Daniel (2008)
found a positive association between the supervisory working alliance and likelihood of disclo-
sure of CT, and greater comfort in disclosing in clinical and counseling psychology interns. The
following section describes a recent study of clinical and counseling psychology doctoral stu-
dents, using methodology developed by Daniel, Shafranske, and Falender (Daniel, 2008). The
following study differed in a number of ways: The population was expanded to include clinical
and counseling psychology students at all levels of training; the recruitment strategy to involve
academic directors of training rather than internship directors; and an enhanced the statistical
analysis of data was conducted.

SUPERVISORY ALLIANCE AND THE LIKELIHOOD AND COMFORT IN CT

DISCLOSURE

Method

This study involved a replication and expansion of a previous study of the effects of the supervi-
sory alliance on self-reported comfort and likelihood of CT disclosure in supervision by doctoral
psychology interns (Daniel, 2008). An online survey was administered using an analog approach
involving CT vignettes to obtain self-report data of supervisees.

Participants

Participants eligible for the study were students enrolled in APA-accredited clinical or
counseling doctoral programs participating in clinical practicum/clinical training between
September 2010 and August 2011. The participants were recruited by an e-mail solicitation
forwarded by the directors of training at APA-accredited doctoral programs (N = 285). Three
hundred ninety-two doctoral students participated in this study. Sixty were excluded due to miss-
ing data, resulting in a final sample of 332. Ideal sample size to achieve adequate confidence
was determined by the use of an accepted statistical procedure. To obtain information accurate
at a 95% confidence level with a confidence interval of six, a sample of at least 263 participants
was required (Kazdin, 2003). Of the participants who reported ethnicity, 84.6% of respondents
were White (non-Hispanic; n = 281), 4.2% were Asian/Pacific Islander (n = 14), and 2.7%
were Latino/Hispanic (n = 9); the remainder of the participants were African American (n = 8),
Native American (n = 1), or biracial/multiracial (n = 10). The sample was 80.7% female (n =
268), 18.1% male (n = 60), and 0.9% other (transgender, intersex, androgynous; n = 3). The
participant pool was 86.1% heterosexual (n = 286), 6.6% bisexual (n = 22), 3% lesbian (n =
10), 2.7% gay (n = 9), and 0.9% other (n = 3).

Instrumentation

The survey was compiled of three parts: participant demographic questionnaire, the
Working Alliance Inventory–Supervisee Form (WAI-S), and the Personal Reaction Disclosure
Questionnaire.
432 PAKDAMAN, SHAFRANSKE, FALENDER

Working Alliance Inventory–Supervisee Form. The WAI-S (Bahrick, 1990) was modeled
after Horvath and Greenberg’s (1989) Working Alliance Inventory (WAI). The WAI-S is a 36-
item questionnaire and employs a 7-point Likert scale. The three components of the alliance
(goals, task, and bond) are each assigned 12 items.

Countertransference Reaction Disclosure Questionnaire. This instrument was devel-

oped by Daniel to determine how likely a supervisee is to disclose CT feelings and behaviors to
their supervisor in a number of hypothetical CT situations. Use of this measure holds constant
the CT stimuli and limits the intensity of personal reactions related to actual real-life scenarios.
Using hypothetical situations as stimuli limits the amount of variability that would arise as a
result of trainees being directed to reflect on their own experiences. It should be noted, however,
that it is possible that one or more hypothetical scenarios could resemble the participant’s actual
experience, thus triggering an actual CT response. The possibility of intense CT response could
increase response variability and poses a potential limitation. Eight hypothetical scenarios are
presented (based on Betan, Heim, Conkin, & Western, 2005), and the participant is asked to rate
his or her likelihood of disclosing CT reactions using a 7-point Likert scale ranging from 1 (not
at all likely) to 7 (would definitely disclose), and, in like manner, to rate their level of comfort in
disclosing CT reactions.

Results

As a first step in data analysis, the distribution of the WAI-S variable was examined. It was deter-
mined that there was a positive skew in the WAI-S as a majority of trainees report adequate or
above rapport with their supervisors. The results may be interpreted with caution as they apply
to generally positive supervisory alliances; however, statistical skew in perception of the super-
visory relationship may reflect actual competencies or strengths of supervisors in facilitating
supervisory relationships. Nonetheless, the skew and kurtosis of the distributions indicated an
adequate distribution, which supported the statistical analysis conducted for this study.

Supervisory Alliance and Likely Comfort in CT Disclosure

Correlational analysis revealed that all three WAI subscales (Task, Bond, Goal) were found to
be significant and adequate in strength in predicting a trainee’s level of comfort in disclosures,
with Bond being the strongest, followed by Task and Goal (Task r = .50, Bond r = .56, Goal
r = .44, p < .01). Multiple regression analysis was conducted to examine if different components
of the working alliance would explain the levels of comfort in disclosing CT reactions. Results
with level of comfort as the criterion variable and three components of the working alliance
(Task, Bond, Goal) as predictor variables suggest that approximately 33.7% of the variances in
supervisees’ level of comfort can be explained by the three components of working alliance (R2 =
33.7%), F(3, 328) = 55.61, p < .001. Further, stronger alliances in Task and Bond predicted
higher levels of comfort in supervisee, β = .42, p < .001, η2 = (.201)2 = .04 and β = .49,
p < .001, η2 = (.335)2 = .11. However, stronger alliances in the Goal component of working
alliance predicted lower level of comfort in the supervisees in this study, β = –.33, p = .005,
η2 = (–.156)2 = .02.
 ALLIANCE AND COUNTERTRANSFERENCE DISCLOSURE 433

Supervisory Alliance and Likelihood of CT Disclosure

Statistical analyses found that 35.9% of the variances in supervisees’ likelihood to disclose can
be explained by the three components of working alliance (R2 = 35.9%), F(3, 328) = 61.1, p <
.001. Further, stronger alliances in Task and Bond predicted higher levels of supervisee likelihood
of disclosure, β = .37, p < .001, η2 = (.14)2 = .02 and β = .51, p < .001, η2 = (.36)2 = .13.
However, stronger alliances in the Goal component of working alliance predicted lower level of
likelihood to disclose, β = –.19, p = .005, η2 = (–.09)2 = .008.
Comfort and likelihood were found to be correlated with each other (r = .73).

Comfort in CT Disclosure and CT Content

Multivariate analyses of variance were conducted to examine if there were significant differ-
ences in levels of comfort in disclosing between CT content areas. Results indicated that there
were significant differences between different vignettes, Wilks’s Lambda = .19, F(7, 318) =
197.60, p < .001, η2 = .813. Trainees reported their comfort to disclose the eight content areas
in the following order: positive, overwhelmed/disorganized, mistreated/criticized, disengaged,
special/overinvolved, parental/protective, helpless/inadequate, and sexualized (M = 6.07, M =
5.23, M = 5.35, M = 5.17, M = 5.10, M = 4.67, M = 4.67, M = 2.75, respectively).
Repeated measures multivariate analyses of variance were conducted to examine if there were
significant differences in levels of likelihood in disclosing different content areas. Results indi-
cated that there were significant differences between different vignettes, Wilks’s Lambda = .35,
F(7, 321) = 90.82, p < .001, η2 = .664. Trainees reported their likelihood to disclose the eight
content areas in the following order: mistreated/criticized, positive, overwhelmed/disorganized,
disengaged, parental/protective, special/overinvolved, helpless/inadequate, sexualized (M =
6.10, M = 5.82, M = 5.62, M = 5.52, M = 5.37, M = 5.08, M = 4.95, M = 4.01, respectively).

Additional Analyses

T tests were used to determine if demographic characteristics and matches in

supervisor/supervisee demographics influence CT disclosure. Due to a lack of differences in
ethnic background of participants, no statistically significant comparisons can be made using
ethnicity as a factor. Matches in supervisor/supervisee gender, sexual orientation, or theoretical
orientation were not found to have a significant relationship with overall likelihood or comfort in
CT disclosure.
Male supervisees in this study reported significantly higher likelihood to disclose sexualized
CT than their female counterparts, t(325) = –2.04, p = .042, p = .128. Based on this finding, a
post hoc analysis was conducted to further examine if gender pairing in the supervision dyad was
a factor in this significant finding. Results from the one-way analysis of variance indicated that
there were significant differences in the likelihood to report sexualized CT in supervision based
on the gender pairing of the supervision dyad, F(3, 322) = 2.93, p = .034, but no differences
were found in the level of comfort based on gender pairing.
More specifically, results from the Dunnete T3 post hoc (homogeneity not assumed) Levene’s
F(3, 344) = 4.58, p = .004, revealed that, with opposite gender pairing, male supervisees (with
434 PAKDAMAN, SHAFRANSKE, FALENDER

female supervisors) are more likely to report sexualized CT than female supervisees (with male
supervisors).
There were no significant differences between theoretical orientations for overall comfort and
likelihood of disclosure. However, post hoc analyses revealed significant differences in theoreti-
cal orientations with regards to comfort and likelihood of disclosing certain themes. Trainees who
identified themselves as psychodynamic reported themselves as more likely to disclosed sexual-
ized CT than family systems trainees (M = 1.35, SE = .45). Psychodynamic trainees were more
likely to admit feeling disengaged compared to trainees who identified themselves as primarily
family systems (M = –.95, SE = .31) and cognitive-behavioral (M = –.52, SE = .16).
Results of the Simple Linear Regression analyses, using levels of comfort and likelihood as
criterion variables, and years of supervised experiences as predictor variable, suggested that years
of supervised experience was not predictive of the comfort or likelihood of CT disclosures in
supervisees.

DISCUSSION

Trainees and interns face a number of stressors during clinical training—such as being inex-
perienced in the application of psychological knowledge, being evaluated for their clinical
competence, and dealing with clinical material or interactions, which arouse strong emotional
reactions. Further, some trainees may have or perceive they have a lack of support in the super-
visory relationship. The work of psychotherapy requires clinicians to be consistently purposeful
and aware of personal reactions that influence their interactions with their patients, but such stres-
sors can lead to a state of reactivity that in turn dulls a clinician’s awareness and sense of personal
responsibility, possibly causing the therapist to put their own experiences or needs ahead of those
of the patient.
The findings in this study demonstrated that the supervisory alliance influences both a trainee’s
comfort and likelihood of disclosing CT reactions. This is consistent with theory and research,
which finds that alliance is an integral part of success and satisfaction in supervision it is also cru-
cial to trainees’ effective and ethical practice of psychotherapy (Ellis & Ladany, 1997; Ladany &
Friedlander, 1995; Mehr, Ladany, & Caskie, 2010). These findings emphasize the critical quality
of the supervisory relationship and the cultivation of a supportive environment in supervision.
Supervisees feel more comfortable disclosing CT in the context of a strong working alliance.
Being able to feel confident that they are liked and respected by a supervisor frees the supervisee
from worry of losing respect, being judged harshly, or evaluated poorly. A positive working
alliance also increases the likelihood that supervisees will discuss CT reactions, and therefore
have the opportunity to work through them effectively. These findings taken together suggest
supervisory alliance to be the key factor is CT disclosure; however, other factors may play a
role. For example, the likelihood to report CT (in contrast to comfort in disclosing) may also be
influenced by professional responsibility or personal ethics. Conversely, supervisees are apt not to
disclose and to avoid supervisory input when the supervisory alliance is weak (Mehr et al., 2010),
resulting in poorer understanding of patients and less effective work (Quarto, 2003). A weak
alliance is one of the most frequently cited reasons for nondisclosure and could lead to poor treat-
ment outcomes, ethical violations, and CT behaviors (Ladany et al., 1996, Mehr et al., 2010).
Although no literature was found to explain why a strong agreement on the goal component
 ALLIANCE AND COUNTERTRANSFERENCE DISCLOSURE 435

of alliance would decrease the likelihood or comfort of disclosure, it may be hypothesized that
dyads that sharply focus on therapeutic and professional goals may deemphasize discussion of
the therapeutic relationship and personal reactions. Future research would be useful to further
clarify the meaning of this finding. Supervisors must be mindful of supervisee CT to prevent it
from hindering treatment for which the supervisor is ultimately responsible.
Clinician CT prompts a number of ethical challenges, not just for students and interns but
for all levels of clinicians. When APA randomly surveyed its members, asking them to describe
actual situations that required challenging ethical decisions, some of the main response categories
were specifically related to CT reactions and behaviors (Pope & Vetter, 1992). Ethical concerns
cited included issues pertaining to dual relationships and roles (positive, special/overinvolved,
parental/protective CT), competence (overwhelmed/disorganized, helpless/inadequate, disen-
gaged CT), payment issues (special/overinvolved, parental/protective CT), questionable or
harmful intervention (positive, criticized/mistreated CT), sexual involvement (sexualized CT),
and termination (disengaged, criticized/mistreated CT).
As it has been shown that trainees are careful to avoid appearing incompetent in conversations
with supervisors (Goodman, 2005), it follows naturally that the type of CT trainees are most
comfortable to disclose is a positive one, where they feel a liking toward the patient, sessions flow
smoothly, and the therapy is effective. However, a positive CT has the potential to lead to ethical
pitfalls, such as a dual relationship in the case of befriending a patient or crossing professional
boundaries. The therapy may also begin to be less effective and function as a social visit if the
therapist’s liking for the patient interferes with the desire to effectively confront the patient when
necessary.
Trainees also reported high likelihood to disclose feelings of being mistreated or criticized,
perhaps in an attempt to elicit supervisor help, support, or empathy when faced with a difficult
patient. The beginner’s susceptibility to self-doubt via projective identification when working
with difficult patients can create a cycle of possible failures and feelings of inadequacy (Brody,
1990). Such feelings make it difficult for the therapist to be effective and gain a sense of con-
fidence. The therapist may feel compelled to disclose such reactions, as these feelings can be
quite strong, propelling the new and uncertain therapist to seek help. Nondisclosure of such
feelings about a patient may leave the therapist with little capacity to help the patient, or
premature or unethical termination. The therapist experiencing overwhelmed/disorganized or
helpless/inadequate CT may be indicative of patient characteristics; however, it is also possi-
ble that the therapist feels this way because the patient’s situation requires care that is beyond the
therapist’s level of competence or confidence in his or her ability. Trainees must disclose their
feelings of overwhelm for the supervisor to be able to effectively help the therapist with the case,
encourage the therapist to use already established clinical skills, or intervene if necessary to make
sure the patient is receiving competent care.
Trainees reported being least likely and least comfortable disclosing their sexualized CT.
Although supervision has the potential to make trainees feel personally exposed in general (Davis,
2002), trainees are more likely than licensed clinicians to view their emotional reactions to
patients as too strong, too frequent, potentially detrimental to treatment, and something to be
defended against (Brody, 1990). Findings of this study suggest that they may want to do away
with sexualized feelings even more than other types of CT. Whereas acting on sexual attraction to
a patient is a clear and very serious ethical violation, trainees may feel uncomfortable and shame-
ful of feeling attraction to patients at all. Once the supervisor is aware of trainee sexualized CT,
436 PAKDAMAN, SHAFRANSKE, FALENDER

the supervisor may assess whether there is a loss in therapist objectivity or potential for ethical
boundary crossings. Supervisors then have the opportunity to normalize sexualized CT as a phe-
nomenon that may occur across a psychologist’s career and as part of the human experience in a
nonshaming way, while holding firm that that therapist must work carefully, monitor their reac-
tions, and engage in self-reflection (at times with the recommendation that the trainee consider
addressing this in his or her own personal psychotherapy). This provides an excellent opportunity
to explore the therapist’s reactions from the perspective of the mutually created intersubjectivity,
which contributes to sexualized CT (Southern, 2007). Where an emphasis is placed on facilitating
exploration, client welfare must always be the first priority. Supervisors must continue to closely
monitor the CT and set in place safeguards to maintain professional boundaries, for example,
review of videotaped sessions.
Although the finding that sexual attraction was predicted to be the least comfortable and least
likely to be disclosed for both genders, men reported being significantly more likely to disclose
sexualized CT than women under certain supervision conditions. Post hoc analysis revealed that
male supervisees were more likely to report their sexualized CT to a female supervisor than any
other gender combination of supervisory dyad.
It has been noted that gender stereotypes and biases, products of a lifetime of socialization,
may confound the outcome of supervision (Bernard & Goodyear, 2009). Supervisory approach
is also informed by socialization, with women (i.e., perception of female supervisor) socialized
to provide a “voice of care” (p. 139), which includes concepts such as reciprocal love, listening,
and response. The finding that male trainees are more likely to report sexualized CT to a female
supervisor may indicate the expectation of love and understanding. Sexual discussion by men is
also generally acceptable in narratives of masculinity. Sexual orientations or match of orientations
of the supervisor and supervisee were not found to be significant in regards to CT disclosure;
however, there is the possibility of subconscious sexual posturing from male supervisee to their
female supervisor, or vice versa, perhaps contributing to the increased likelihood to disclose to
female supervisors.
The inclination to not disclose these same feelings to a male supervisor may be explained by
Wester and Vogel’s (2002) concept of Gender Role Conflict applied to male psychologists and
trainees. Being in a subordinate position as trainee could exacerbate Gender Role Conflict in rela-
tion to the male pattern of Success, Power, and Competition. For example, a male trainee may feel
too uncomfortable to sexualized CT if he believes it to be indicative of an ethical failure, espe-
cially with a male supervisor with whom he may feel competitive. These findings highlight the
importance of supervisors attending to narratives of gender and sexuality in supervision and their
responsibility to facilitate discussion of how these issues may influence professional behavior.
There was also a difference in likelihood of discussing sexualized CT among some theoreti-
cal orientations. Study participants who consider themselves primarily psychodynamic reported
being more likely to discuss sexualized CT and feelings of being bored/disengaged as compared
to family systems trainees. This difference may be attributed to the fact that it is acceptable
and even encouraged within the psychoanalytic tradition for the therapist to use his or her own
associations and reveries as a way of making sense of the patient’s world (Ogden, 1994). Thus,
sexualized CT may be informative and not a risk for ethical violation as long as it remains in
the realm of the analyst’s fantasy. This open attitude toward the process of discovery extends to
the polar concepts of both therapist attraction and boredom. Attraction and boredom may pro-
vide powerful clues about the therapeutic relationship, possible transferences, and the projection
 ALLIANCE AND COUNTERTRANSFERENCE DISCLOSURE 437

of the patient’s unconscious world. In a psychodynamic context (as well as in other theoretical
orientations), personal reactivity or CT feelings such as boredom and attraction can be brought to
attention and, when explored carefully and skillfully, can be useful to therapeutic work. Failure
to disclose and work through feelings of boredom or disengagement in the therapy may lead to
questionable treatment of the patient or early patient drop-out. Supervisors may help the therapist
understand their boredom or disengagement from a clinical standpoint. Further, supervisors may
refer supervisees for personal therapy when it becomes apparent that personal issues or reactions
are impacting on professional practice and when previous discussions had failed to address the
issue (Grant, Schofield, & Crawford, 2012).
This study’s findings, consistent with supervision theory and previous investigations, rein-
force the importance of the supervisory relationship as it bears on CT disclosure (Shafranske
& Falender, 2008). This finding has serious implications for the ethical practice of navigat-
ing personal reactions in psychotherapy, which is a shared responsibility for supervisor and
supervisee.

Implications for Clinical Supervision

The findings of this study are consistent with current research that examines the significance of the
supervisory alliance (e.g., Falender & Shafranske, 2004; Ladany et al., 1996; Mehr et al., 2010).
Assessing and prioritizing the working alliance is an ethical imperative for clinical supervisors;
failure to discuss CT has been shown to result in poor therapeutic progress (Friedman & Gelso,
2000), and potential legal/ethical violations (Ladany, Lehrman-Waterman, Molinaro, & Wolgast,
1999).
Trainees’ reluctance to disclose sexualized CT is an important demonstration of shortcomings
in the training system in regards to addressing unwanted CT in general (Pope, Sonne, & Greene,
2006). Inattention in training to the topic of sexual attraction to clients may be at least in part due
to the taboo nature of the topic and the belief that this phenomenon is “dangerous and antithera-
peutic” (p. 106; Pope et al., 1986). The lack of empirical research on this topic leaves students in
the dark about how to handle these reactions and teachers without material to rely on. Through
their ignoring and stigmatizing behavior, programs and training sites suggest that sexualized CT
is not an acceptable topic of discussion, making it understandable that therapists feel very unset-
tled about having these feelings or working through them in supervision (Pope et al., 1986). To be
successful, training programs and supervisors must begin to recognize that it is human for per-
sonal reactions including attractions to clients to occur. The stigma against discussing this topic
and other types of CT that students are reluctant to share must be eradicated before open and seri-
ous discussions about therapists’ reactions to clients can take place. In addition to being an ethical
check point, exploration of CT is believed to be clinical skill and a tool to use toward therapeutic
progress according to contemporary views on intersubjectivity and CT (Jacobs, 1999).
As trainee anxiety results in general nondisclosure and a lower overall willingness to disclose
in the supervision session, it appears that trainees would be more willing to disclose information if
the supervision environment was less anxiety provoking (Mehr et al., 2010). There are strategies
that supervisors can employ to increase trainee comfort in supervision, such as balancing being
supportive and challenging, providing structure in supervision, and engaging in role induction
with the supervisee (Bernard & Goodyear, 2009). Supervisors can also normalize and effectively
438 PAKDAMAN, SHAFRANSKE, FALENDER

assist in identifying trainee CT by modeling appropriate discussion of their own reactions to

the patient the trainee presents in supervision. Supervisor disclosure of CT actually increases
trainees’ discussion, understanding, and use of their own CT responses (Williams, Judge, Hill, &
Hoffman, 1997).
Of the three components of working alliance, the bond component is the most highly corre-
lated with comfort and likelihood of disclosure. This parallels the importance of a strong bond
in psychotherapy (Bordin, 1983). An emotional bond is more likely to grow in a nonjudgmental
atmosphere of mutual respect and encouragement. Supervisors can actively take steps to culti-
vate an emotional bond through use of clinical skills, such as reflections, empathy, and positive
regard. Along with employing basic therapeutic techniques to strengthen alliance and model-
ing appropriate disclosure of CT, supervisors must consider the factors behind weak alliance
and nondisclosure to inform the process of supervision. Some main points are highlighted next;
however, guidelines are available in detail (i.e., Bernard & Goodyear 2009; Mehr et al., 2010).
In the event of a weak or high conflict supervisory relationship, delaying resolution can neg-
atively affect both supervisee and patients, whereas preemptively discussing the relationship and
possibility of ruptures can stimulate insight, flexibility, and a corrective emotional experience
(Nelson & Friedlander, 2001; Safran & Muran, 2000). Avoiding a discussion of the supervisory
relationship, especially after a strain or rupture, increases the possibility that a supervisee will be
excessively guarded in supervision. Supervisors should be open to discussing and repairing rup-
tures should they occur through demonstrating an open and nondefensive attitude to supervisee
feedback so as to cultivate a positive supervisory experience instead of engendering unwillingness
to seek consultation, even when it is necessary for the patient (Ladany et al., 1996).
Supervisors can be candid about the power differential in this relationship and take steps
to empower the trainee to discuss the relationship as well, modeling appropriate discussion as
necessary. It is the supervisor’s responsibility to be able to elicit the necessary information to
assist a supervisee exploring CT dynamics yet not intrude past the trainee’s privacy boundaries.
Supervisors may take special care to observe the trainee’s comfort level in supervision and with
self-disclosure and initiate a dialogue about the discussion of their emotional reactions to patients
in order to understand CT dynamics. Supervisors may be candid about why they ask about CT
by explaining how exploration of CT may lead to better understanding of the patient and is an
ethical imperative and competency benchmark (Fouad et al., 2009).
Because trainees are sensitive to the evaluative nature of the supervision process, care should
be taken to provide ongoing feedback and to explain that their formal evaluation will take into
consideration the amalgamation of all experiences with the trainee, not a single event or topic.
Feelings of incompetence, particularly for supervisees of earlier developmental stages, can be
normalized by the supervisor or peers sharing similar experiences. Although it is important to
process feelings of inadequacy, it is necessary to talk about therapist strengths and areas where
the trainee has demonstrated growth.
A separate but related topic worthy of further review concerns CT within the supervisory
relationship. There are many parallel aspects between a therapy relationship and a supervisory
one. Supervision is a two-way relationship in which supervisors and supervisees will at times
have strong personal reactions to each other. It would benefit even experienced supervisors to
be aware of this possibility and attend to the needs of the supervision relationship by seek-
ing consultation or their own psychotherapy around this issue when needed. Lack of awareness
of supervisor/supervisee CT poses the possibility of leading to harmful multiple roles, sexual
 ALLIANCE AND COUNTERTRANSFERENCE DISCLOSURE 439

involvement, impairment in objectivity, and using supervision as a social visit. Supervisor CT

may also make supervision less effective by making it difficult for the supervisor to critique or
intervene with the trainee when necessary. Careful attention to all types of CT during training may
not only instill values related to the awareness and management of CT as a clinical responsibility
but also encourage future consultation with peers or experts. For example, psychologists may
choose to participate in consultation groups and help each other with the task of checking one
another’s blind spots, which for beginning clinicians is a key component of clinical supervision.

CONCLUSION

Ethics requires all therapists to be aware of personal vulnerabilities and to recognize personal
reactivity or CT, such as anger, boredom, attraction, and so on, which may interfere with effective
psychotherapy and potentially lead to unethical behavior. Ethical awareness requires clinicians
and supervisors to accept the clinician’s humanity in an honest attempt to minimize ethical
conflicts and errors in behavior or judgment. Supervisors can responsibly use their position
of authority to create an environment where discussing the therapist’s reactions to patients is
acceptable and even welcomed, to facilitate clinician growth and the best possible care for the
patient.

ACKNOWLEDGMENTS

Sincere gratitude is extended toward Anat Cohen, Ph.D., for her help and support in completion
of the dissertation on which this article is based.

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