Journal of Counseling Psychology 1997, Vol. 44, No.

4,390-399

Copyright 1997 by the American Psychological Association, Inc. 0O22-O167/97/S3.00

Experiences of Novice Therapists in Prepracticum: Trainees', Clients', and Supervisors' Perceptions of Therapists' Personal Reactions and Management Strategies
Elizabeth Nutt Williams, Ann B. Judge, Clara E. Hill, and Mary Ann Hoffman
University of Maryland College Park
The experiences of prepracticum trainees were explored with a combination of qualitative and quantitative methodologies. Specifically, changes in trainees' anxiety, self-efficacy, countertransference management, and therapeutic skills were investigated over the course of a semester. Trainees', clients', and supervisors' perceptions of trainees' reactions during counseling were also examined as well as the strategies that trainees used to manage their reactions. Quantitative analyses indicated that trainees became less anxious and developed greater skills over the semester. Qualitative results suggested that trainees experienced a range of reactions during sessions, some of which interfered with their ability to provide maximally effective counseling, and that trainees most often managed their reactions by focusing on the client, using self-awareness, and suppressing their feelings.

Although novice therapists can learn basic helping skills relatively quickly (Baker, Daniels, & Greeley, 1990), they often find themselves concerned about their ability to manage actual counseling interactions. As Hill, Charles, and Reed (1981) proposed, trainees' abilities to provide effective counseling may also be related to their understanding of higher order counseling skills (e.g., timing, appropriateness of intervention, understanding of client dynamics, and self-confidence) in addition to basic communication skills. Others have suggested that what trainees really need to learn is how to manage their anxiety and other personal reactions (Kagan et al., 1965; Van Wagoner, Gelso, Hayes, & Diemer, 1991). We wanted to understand more fully the types of reactions with which beginning therapists struggle during counseling sessions as well as their awareness of these reactions. For example, research has suggested that trainees often feel

Editor's Note. Charles D. Claiborn served as the action editor for this article.CEH Elizabeth Nutt Williams, Ann B. Judge, and Clara R Hill, Department of Psychology, University of Maryland College Park; Mary Ann Hoffman, Department of Counseling and Personnel Services, College of Education, University of Maryland College Park. Elizabeth Nutt Williams is now at the Department of Psychology, St. Mary's College of Maryland. A version of this article was presented in June 1996 at the annual meeting of the Society for Psychotherapy Research in Amelia Island, Florida. We express our appreciation to Charles Gelso, Nicholas Ladany, and the participants of this study for reading drafts of the article and providing us with comments. Correspondence concerning this article should be addressed to Elizabeth Nutt Williams, Department of Psychology, St. Mary's College of Maryland, St. Mary's City, Maryland 20686. Electronic mail may be sent via Internet to enwilliams@osprey.smcm.edu.

anxious about their performance (Friedlander, Keller, PecaBaker, & Oik, 1986) or struggle with countertransference feelings (Van Wagoner et al., 1991), but we wondered what other types of feelings and reactions trainees experience in their role as therapists. In addition, we know very little about how beginning therapists manage their personal reactions during counseling sessions (Hayes, Gelso, Van Wagoner, & Diemer, 1991). However, we speculated that a beginning therapist's inability to manage his or her reactions effectively would have an adverse impact on the therapist's ability to provide therapy, as has been shown for experienced therapists (Singer & Luborsky, 1977). Thus, we set out to investigate the types of personal reactions trainees have and the ways in which they attempt to manage those reactions during counseling sessions. In addition to investigating trainees1 reactions and general management strategies, we thought several other variables related to the experiences of trainees in prepracticum also seemed relevant to examine: basic skills, anxiety, selfefficacy, and countertransference management. For example, both anxiety and basic skills have been cited as important factors in the beginning stages of therapists' training (Baker et al., 1990; Friedlander et al., 1986; Hill & Corfoett, 1993). Furthermore, researchers have also found counseling self-efficacy to be an important factor in therapist training (Johnson, Baker, Kopala, Kiselica, & Thompson, 1989; Larson et al., 1992; Sharpley & Ridgway, 1993). Specifically, self-efficacy has been linked to trainees' performance (Friedlander et al., 1986), effectiveness (Ridgway & Sharpley, 1990), and level of training (Sipps, Sugden, & Faiver, 1988). Finally, the issue of how to manage countertransference reactions has also been recognized as a potentially important factor in therapeutic performance in general and therapist training in particular (Gelso, Fassinger, Gomez, & Latts, 1995; Goldrried, 1982; Hayes & Gelso, 1991; Lecours & Bouchard, 1995; Watkins, 1985). We used both qualitative and quantitative methods to

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391
Method

examine trainees' personal reactions and how they managed those reactions as well as their level of anxiety, counseling self-efficacy, therapeutic skills, and ability to manage their countertransference feelings across the course of a semester. We used both kinds of methods to obtain a richer description of the trainees' experiences. Hence, we used several standardized measures to examine trainees' perceptions of their level of anxiety and counseling self-efficacy. We also examined quantitative measures completed by supervisors to address the issues of therapist skill level and countertransference management. Because we considered the present study to be exploratory, we also wanted to allow constructs to emerge directly from the data that might not be predicted from theory. Thus, we used a qualitative method called consensual qualitative research (CQR; Hill, Thompson, & Williams, in press) to examine trainees* personal reactions and how they managed those reactions. CQR is based on a discovery-oriented approach to data (Mahrer, 1988) and the use of consensus (i.e., a team approach to data analysis and the use of an outside auditor to check the work of the primary research team). The CQR process involves three general analytic steps. First, responses to open-ended questions are divided into domains (i.e., general topic areas). Second, core ideas (i.e., brief summaries of the raw data) are constructed for all the data under a domain in each case. Finally, a cross-analysis (i.e., the clustering of core ideas across cases into categories) is conducted to explore consistent findings in the sample. CQR also relies on a systematic means for examining results across a small number of cases. This provides greater evidence for the representativeness of the results to the sample being studied. Thus, we chose to use CQR in the present study because it would allow us to study a small number of cases intensively and to provide a vivid and full description of the phenomenon being studied. In addition, CQR is also appropriate for exploratory work, in which an understanding of the data is derived from an analysis of the participants' perspectives (Erickson, 1986) rather than from the testing of a priori constructs. We also wanted to address the issue of "triangulation" (i.e., the use of different sources of data) to enhance the richness of the research. Therefore, we examined the client and supervisor viewpoints, in addition to trainee self-report, so that we could capture more information about the effects of the trainees1 reactions on the counseling sessions. Thus, through the use of both qualitative and quantitative methods, we investigated the trainees', clients', and supervisors* perceptions of the trainees' personal reactions and management strategies during counseling sessions. To focus our investigation, we articulated several specific purposes for the present study. The first purpose was to determine what kinds of persona! reactions prepracticum trainees experience during counseling sessions. The second purpose was to investigate the types of strategies trainees typically use to manage their reactions. The third purpose was to examine change overtime in trainees' anxiety level, counseling self-efficacy, countertransference management, and therapeutic skills.

Participants
Seven (6 female, 1 male; 1 African American, 6 White) prepracticum trainees in a doctoral counseling psychology program served as participants. They ranged in age from 22 to 44 years (M = 32.57; SD = 7.87). Three of the trainees had some previous counseling experience, having seen an average of 35.67 clients (SD = 29.94; range = 15-70 clients). The other 4 trainees had never conducted therapy before. The trainees were not informed of the purposes of the study. Thirty volunteer clients (17 female, 13 male; 5 African American, 5 Asian American, 1 Asian Indian, 1 Hispanic, and 18 White), who also served as participants, were recruited from introductory psychology courses and received course credit for their participation in mis study. They ranged in age from 17 to 28 years (M = 18.83; SD - 2.23). Despite their volunteer status, the clients were asked to participate only if they had genuine concerns that they were willing to discuss with a therapist. Clients typically discussed roommate problems, interpersonal and relationship difficulties, family conflict, and adjustment to college. The volunteer clients were not informed of the purposes of the study. Seven (5 female, 2 male; 2 African American, 2 Asian American, and 3 White) advanced graduate students in the same doctoral training program as the trainees also served as participants in their capacity as peer supervisors. They ranged in age from 24 to 40 years (M= 28.14; SD - 5.46). Three of the supervisors had previous experience supervising the clinical work of therapists in training. T\vo of the supervisors were also participants in the research and authors of this study (Elizabeth Nutt Williams and Ann B. Judge). The remainder of the supervisors were not informed of the purposes of the study. All of the supervisors participated in a weekly group supervision session which was led by a White female professor in counseling psychology who was also an author of this study (Mary Ann Hoffman). The research team was composed of the four authors: two White female advanced doctoral students in counseling psychology (Elizabeth Nutt Williams and Ann B. Judge) and two White female professors in counseling psychology (Clara E. Hill and Mary Ann Hoffman). Elizabeth Nutt Williams, Ann B. Judge, and Clara E. Hill were the primary research team, and Mary Ann Hoffman served primarily as an auditor. The auditor, who provided an outside viewpoint not biased by the group consensus, began meeting with the team only after the first stage of analysis (development of domains and core ideas) was complete.

Measures
Demographic information. Demographic information about the prepracticum trainees and supervisors was collected with a one-page questionnaire that asked about gender, race, age, highest degree achieved, and experience level in counseling. The trainees also provided brief demographic information (e.g.f gender, race, and age) for each client. Trainee postsession measure. Created for this project, the trainee postsession measure was an open-ended questionnaire that assessed trainees' reactions during counseling sessions and the types of strategies used to manage those reactions. Specifically, the measure asked trainees to describe their overall experience in the session, the part of the session in which they felt the most emotion, any issues the client brought up that were similar to their own, how trainees managed their feelings during the session, their awareness of themselves in the session, and their comfort level during the session.

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WILLIAMS, JUDGE, HILL, AND HOFFMAN is .97 (Van Wagoner et al., 1991). Both content (Hayes et al., 1991) and construct (Van Wagoner et al., 1991) validity have been established for the CFI; experts on the topic of countertransference have assessed the measure as important to the issues of countertransference management, and the CFI has been used to differentiate excellent and average therapists. Higher scores on the CFI indicate greater effectiveness in managing countertransference reactions. Supervisor's Report (Jones, Krasner, < Howard, 1992). This 25-item questionnaire is used by supervisors to assess supervisees' therapeutic skills and performance, typically in psychodynamic psychotherapy. The items are based on a 5-point Liken scale ranging from 1 (poorly) to 5 (outstanding). In addition to the total score (which was used in this study), the measure yields three major groupings of items: psychotherapeutic techniques, educational alliance between supervisor and supervisee, and a global assessment of the counselor's skill fulness in comparison with peers and with an expert therapist. Items include questions related to the trainee's abilities to empathize with the client, facilitate understanding, use appropriate therapy interventions, and establish a working alliance with both the client and the supervisor. The test-retest reliabilities for the three subscale scores range from .77 to .87 (Spearman-Brown corrected; Krasner, Jones, & Howard, 1994), with internal consistency scores (alpha) ranging from .90 to .92. Jones et al. (1992) also demonstrated validity by comparing scores of skillfulness across different theoretical orientations. Higher scores on the Supervisor's Report indicate greater therapeutic skill.

Client postsession measure. Created for this project, the client postsession measure was an open-ended questionnaire that assessed the client's experience of the trainee during the counseling session. The measure was designed to be conceptually related to the trainee postsession measure in order to facilitate our exploration of trainees' reactions from the three different perspectives (trainee, client, and supervisor). The measure asked clients to describe their overall experience in the session, the part of the session that was most emotional for them, whether they felt there were any issues that their therapists had a hard time understanding, and whether they left anything unsaid in the session. Supervisor postsession measure. Also created for this project, this open-ended questionnaire assessed the supervisor's evaluation of the trainee's management of his or her personal reactions during counseling sessions. The measure was also designed to be conceptually related to the trainee postsession measure. The supervisor postsession measure asked about the supervisor's overall impression of the session, in what part of the session he or she thought the trainee experienced the most emotion, how well the supervisor thought the trainee managed his or her reactions in the session, and whether the trainee's personal reactions seemed to interfere with the counseling. Counseling Self-Estimate Inventory (COSE; Larson et al., 1992). The COSE is a 37-item questionnaire that assesses therapists* self-efficacy in counseling situations. The responses are made on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly agree). The total score (which was used in this study) comprises four general factors: Microskills, Counseling Process, Dealing With Difficult Client Behaviors, and Cultural Competence. Items include questions related to feeling confident about appearing competent, feeling that one has enough fundamental knowledge to be an effective counselor, and comfort level for working with unmotivated or diverse client populations. Larson et al. (1994) reported an internal consistency of .93 for the total score and test-retest reliability over a 3-week period of .87. Both convergent and discriminant validity have been established for the COSE (Larson et al., 1992) in that counseling self-efficacy was found to be positively related to counselor performance, self-esteem, and performance expectations and negatively related to state and trait anxiety and defensiveness. Higher scores on the COSE indicate greater counseling self-efficacy. State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushem, Vagg, & Jacobs, 1983). The STAI is a widely used measure of state and trait anxiety. We used the 20-item State Anxiety subscale (STAI-S) to assess trainees* anxiety about their ability to be therapists. Thus, we made a slight modification of the directions from "indicate how you feel right now" to "indicate how you feel right now as a therapist." Although we encourage using caution when interpreting measures that have been modified from their original form, the STAI-S has been modified in similar ways in the past (see Hayes & Gelso, 1991). Reliability and validity data for the STAI are extensive and impressive (Spielberger et al., 1983). Higher scores on the STAI indicate greater levels of anxiety. Counter-transference Factors Inventory (CFI; Van Wagoner et al, 1991). The CFI is a 50-item questionnaire that asks for supervisors' perceptions of their supervisees' ability to manage countertransference reactions. The responses are made on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). In addition to the total score (which was used in this study), there are five general factors: Self-Insight, Self-Integration, Empathy, Anxiety Management, and Conceptualizing Ability. Items include questions related to the trainee's ability to label client emotions accurately, to attain self-awareness (of own feelings, impact on the client, anxiety, and needs), and to conceptualize the client and the relationship dynamics. The internal consistency for the total score

Procedure
Recording biases. CQR is based on the principle that all data should be understood from the participants' perspectives. In other words, researchers should make every effort to set aside their own interpretations of the data and attempt to generate constructs based directly on the participants' words and meanings. Thus, it is important that the research team members explore their potential biases around the topic area and explicate their expectations about the outcomes of the study prior to analyzing the data. It is also important for team members to attempt to set aside their biases and approach the data with objectivity. Thus, team members are asked to explain their potential biases and expectations, to attempt to "bracket" them, and to provide enough information about themselves that readers may determine for themselves whether those biases had an impact on the data analysis. All four team members in the present study noted that they believed that trainees would have difficulty managing their anxiety and other personal reactions and that this difficulty managing their reactions could interfere with trainees' ability to help their clients. All four also believed that trainees' ability to manage their feelings and reactions would increase over the course of a semester. The team members reported that they adhered to a variety of theoretical orientations in counseling and supervision (Elizabeth Nutt Williams and Ann B. Judge had an integrative approach that combined psychodynamic, cognitive-behavioral, and humanistic approaches, Clara E. Hill had a humanistic-psychodynamic approach, and Mary Ann Hoffman had a psychodynamic approach). Recruiting trainees. The trainees in the present study were taking part in a required prepracticum graduate course in counseling theories and strategies as part of a doctoral program in counseling psychology (Clara E. Hill and Mary Ann Hoffman were the instructors for the course). The course requirements included both a didactic and an experiential component, each of which was conducted independently. The didactic component involved a review of helping skills and an overview of major theories of counseling. As part of the experiential component, trainees participated in role plays of practice interviews over the course of several

PREPRACTICUM TRAINEES class sessions. Trainees were then required to conduct a minimum of nine 50-min counseling sessions with a minimum of two recruited clients, and it is from this component of the prepracticum course that the data were collected for the present study. All 8 students in the course consented to participate, although 1 trainee was later dropped from the analysis because that person had difficulties responding to some of the postsession questionnaires (English was a second language). Given the qualitative nature of the analyses, we were not certain we could accurately understand this participant's meaning and use of words. After providing informed consent, the trainees completed the demographic form, the STAI, and the COSE prior to seeing volunteer clients. Protection of confidentiality. Because the study was conducted in the context of a required course, we used several safeguards to protect the participants' confidentiality: anonymous questionnaires and data collection procedures, typing of questionnaire responses by an undergraduate research assistant so the research team would not see the participants' handwriting, and coding and recoding of the cases to disguise participants' identities as much as possible. At the start of the semester, we carefully explained to trainees their potential role in the study and that participation in the study was their choice. The right to withdraw from the study at any time was discussed with the participants, and they were informed that participation had no bearing on their grade in the course. In fact, to further protect the confidentiality of the participants, we did not begin data analysis until after the course was completed. The clients and supervisors were also advised of the voluntary nature of their own participation in the present study and their right to withdraw at any time. We asked the trainees to assign themselves a confidential 5-digit code number to use throughout the semester and to share this number only with their supervisors. Trainees and supervisors were asked to place this code number on all questionnaires and postsession measures. The trainees and supervisors were informed of the careful considerations that were made to code and recode the data so as to disguise the identity of all participants from the research team. Participants were told that an undergraduate assistant would type up their responses and assign new code numbers to each case (i.e., Cases 1-7, with each of the 7 trainees representing a case) to further mask their identities and preserve anonymity. Counseling sessions within cases were also assigned code letters to mask the sequence of sessions. Hence, the research team members were unaware of the case, client, and session number during the data analysis because of the careful coding and recoding of the data. Recruiting volunteer clients. Volunteer clients were recruited from introductory psychology classes. Potential participants were asked to indicate how willing (either hesitant, willing, or very willing) they were to talk with a therapist in training. Those who indicated they were hesitant to meet with a therapist, were unable to meet with the therapists at the times available, old not complete the measures as instructed, were already in therapy, or did not have a genuine concern to discuss with a therapist were removed from the potential client pool. Counseling sessions. Each trainee completed between 9 and 11 sessions {M = 9.86, SD 0.90) with between 2 and 7 volunteer clients (Af = 4.29, SD - 1.70) for an average of 2.27 sessions (SD - 2.02). Trainees met individually with volunteer clients for 50-min counseling sessions. Immediately after each session, therapists, clients, and supervisors completed their respective postsession measures. All forms were kept confidential and anonymous. Clients placed their responses in an envelope provided by the therapists and signed over the seal to preserve the anonymity of their comments from their therapists. Therapists put their confidential code numbers on the envelope and then turned in their clients'

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envelopes along with their own completed questionnaires. Therapists used carbon paper to fill out their questionnaires so that they could keep copies for themselves. Finally, supervisors also turned in their questionnaires alter each session. It was up to the supervisor and trainee to decide how much of the responses to the questionnaires, if any, they wanted to discuss in supervision sessions. All questionnaires and postsession measures were placed in a larger envelope and given directly to the undergraduate research assistant for typing. Supervision. In addition to meeting with clients as part of the requirements for the course, each trainee met with a peer supervisor on a weekly basis to discuss his or her therapeutic work and growth as a counselor. Supervisors were assigned to the trainees on the basis of the experience level of the supervisors (both with conducting therapy and with providing supervision) and of the experience level and needs of the therapists as determined by the course instructors (Clara E. Hill and Mary Ann Hoffman). Supervisors watched the counseling sessions live via video monitors and met with the trainees later for supervision. Administration of the measures at the end of the semester. At the end of the semester, the trainees all completed the STAI and the COSE again. Each supervisor completed a demographic form, the CFI, and the Supervisor's Report on his or her supervisee as both posttests and retrospective pretests. In this study, we chose to use retrospective pretests for the supervisors' ratings of the trainees' initial skill levels on both the CFI and the Supervisor's Report because the supervisors did not know their supervisees well enough at the beginning of the semester to assess their levels of functioning accurately. Howard (1980, 1982) also advocated the use of retrospective assessments as one way to remove the confounding effects of response shifts (i.e., changes in a person's perception of his or her initial level of functioning) when self-report measures are used. Data analysis. After the questionnaire responses had been typed and recoded by the research assistant, the three primary team members began the data analysis using the CQR method (Hill et al., in press). The team members examined each case individually, looking separately at the responses of the trainee, supervisor, and client. Each team member independently read through each case and placed each block of data related to the same idea into initial domains (i.e., topic areas). Disagreements about domains and how to block the data were discussed until the team reached consensus. Seven domains emerged from the data: (a) feelings and reactions (i.e., feelings and reactions reported by the trainees), (b) personal concerns (i.e., trainees' personal concerns evoked by the client), (c) concerns shared by therapist and client (i.e., trainees' perceptions of their own concerns that were similar to those of their clients), (d) management strategies (i.e., trainees' reports of strategies used to manage their reactions in the session), (e) difficulty managing feelings and reactions (i.e., supervisors' perceptions of trainees' difficulty in managing their feelings and reactions in the session), (f) client response (i.e., clients' perceptions of the trainees during counseling), and (g) things left unsaid (i.e., things the client chose not to say to the therapist in the session). After blocking all of the data into domains, the three primary team members independently read over all of the data within a given domain and wrote down the core ideas (i.e., a summary of the data in fewer and more concise terms) for each case. The team then met as a group to discuss their independent judgments and to argue to consensus about the core ideas and how to word them. All case write-ups were then sent to the auditor (the fourth member of the team, who had not been a part of the initial analyses), who read them, suggested additions and deletions, and returned them to the primary team for further discussion and revision. The primary team then went back through each case to make

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WILLIAMS, JUDGE, HILL, AND HOFFMAN

sure they had been consistent over time and to be certain that they had remained true to the participants' perspectives. Revisions were made to the domains and to what was included in the domains for each case. The team added notes where appropriate to help them remember issues and questions that occurred to them but that were not directly stated in the data. Then every case was examined again by the team members, who argued to consensus over changes. As part of the cross-analysis (i.e., an examination of core ideas across cases), the team next developed categories within each domain based on the content of the core ideas. At this point, the auditor joined the primary team, and each of the four team members independently placed each core idea (within a specified domain) into a category. Then the team again argued to consensus about the placement of the core ideas. The domains and categories were continually modified throughout the process to reflect the team's ongoing understanding of the data. Finally, narrative summaries were written for two case examples. All of the results and case examples were then shown to the participants for verification of their experiences. Lincoln and Guba (1985) referred to this as "member checking" and recommend it as an important part of establishing the validity, or trustworthiness, of the results.

.01. Univariate repeated measures tests, with an adjusted alpha of .0125 (.05/4), indicated that anxiety decreased, F(ly 6) = 14.67,/? < .01, skill in managing countertransference increased, F(1, 6) = 20.23, p < .01, and overall therapeutic skill increased, F{\, 6) = 13.44, p < .01. The increase in counseling self-efficacy scores was not statistically significant. We also examined possible differences between the scores of the 2 supervisors who were also authors of the study and the scores of the other 5 supervisors. No significant differences were found.

Qualitative Analyses
To determine the extent to which each category was representative of the sample as a whole, we employed a system used in CQR (Hill et al., in press) that allowed us to establish an estimate of frequency. A category was considered general for a case (i.e., each of the 7 trainees represented a case) if it applied to every session in a case, typical if it applied to more than half of the sessions in a case, and variant if it applied to more than two but fewer than half of the sessions in a case. Table 2 presents the domains and categories we discovered in this study along with the number of cases for which each category was typical and variant (none were reported as general). Categories that applied to only one or two sessions across all cases were dropped from the analysis. Feelings and reactions. We discovered a total of six categories in this domain relating to the in-session feelings and reactions reported by the trainees: (a) anxiousuncomfortable; (b) distracted-unengaged or self-focused; (c) empathic-caring; (d) comfortable-pleased; (e) frustratedangry; and (f) inadequate-unsure of self. All trainees reported having some positive and some negative feelings in their sessions. All trainees described feeling anxious or uncomfortable (this was typical for 3 trainees and a variant for 4 others). For example, trainees reported feeling anxious with silences and termination issues, nervous about certain issues raised by the client (e.g., sex), uncomfortable with cultural differences, overwhelmed by the client's issues, and worried about their own performance. Most of the trainees also typically described feeling distracted or unengaged (e.g., distracted by personal issues) in the counseling sessions (this was typical for 3 trainees and a variant for 3 others). Trainees commented that they often felt distracted by their self-awareness (of their feelings, of intervention planning), sometimes felt bored, and occasionally were distracted by feeling that there was an agenda to follow or by doubts about what the client was saying. In addition, 2 trainees reported feeling frustrated or angry with the client (e.g., frustrated by the client's resistance) in at least half of the sessions (only 1 trainee reported this as a variant), and 1 trainee felt inadequate during more than half of the sessions. One other trainee also occasionally felt inadequate or unsure of him- or herself, but the 5 other trainees rarely reported feeling this way. Thus, all trainees reported negative feelings that may have distracted them from full participation in the sessions. Despite experiencing a variety of negative feelings, the

Results
Quantitative Analyses Table 1 shows the means and standard deviations for each of the four measures completed by trainees and supervisors at the beginning and end of the semester. Despite the small sample size, which is typical and expected for studies using a qualitative methodology such as CQR, we found statistical significance on several of the quantitative variables. A one-way repeated measures multivariate analysis of variance on the total scores of the COSE, STAI-S, CFI, and Supervisor's Report was significant, F(3, 4) = 24.14, p <

Table 1 Means and Standard Deviations for Self-Efficacy, Anxiety, Countertransference Management, and Basic Skills at the Beginning and End of the First Semester in a Counseling Psychology Doctoral Program
Semester beginning Measure COSE STAI-S CFI SupRep M 4.27 1.94 3.05 2.46 SD 0.82 0.41 0.52 0.54 Semester end M 4.63 1.51 3.63 3.09 SD 0.70 0.36 0.41 0.36 F 5.52 14.67* 20.23* 13.44*

Note. N = 7. COSE - Counseling Self-Estimate Scale (higher scores indicate more self-confidence); STAI-S = State Anxiety subscale of the State-Trait Anxiety Inventory (higher scores indicate more anxiety); CFI = Countertransference Factors Inventory (higher scores indicate greater ability to manage countertransference); and SupRep = Supervisor's Report (higher scores reflect greater therapeutic skill). The COSE and STAI-S were completed by trainees at the beginning and the end of the semester. The CFI and SupRep were completed by supervisors about their supervisees at the end of the semester (the pretests were retrospective). The repeated measures multivariate analysis of variance across all four measures was significant, F(3, 4) - 24.14, p < .01. Univariate tests, reported in the table, used an adjusted alpha of .0125.

*p<.QU5.

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Table 2 Qualitative Findings

Domains and categories Feelings and reactions Anxious-uncomfortable Distracted-unengaged or self-focused Empathic-caring Comfortable-pleased Frustrated-angry with client Inadequate-unsure of self Personal concerns Therapeutic skills and performance Therapeutic role Difficult clients and conflict in the therapeutic relationship Reactions to specific client content Concerns shared by therapist and client Personal stressors Interpersonal stressors Management strategies Focusing on client Using self-awareness Suppressing own feelings and reactions Difficulty managing feelings and reactions Displaying negative or incongruent behaviors Avoiding affect or issues Overfocusing-becoming overinvolvedlosing objectivity Client response Positive feelings toward therapist Negative feelings toward therapist Things left unsaid Typical 3 Variant 4 3 1 2 1

3
3 2 2 1 3 I 1 1 3 2 2 2 1 4 1

1 3
3 2 3

3
3 3 0 3 1 1 1 0 0 2

1
7 1 0

Note. N = 1 cases. Each trainee saw from 2 to 7 recruited clients for from 1 to 8 sessions. "Typical" indicates that the category occurred in more than half of the sessions in a case (each of the 7 trainees represented a case); "variant" indicates that the category occurred in more than two but fewer than half of the sessions in a case. The first four domains ("feelings and reactions," "personal concerns," "concerns shared by therapist and client," and "management strategies") were derived from the trainees' responses to the trainee postsession measure. The domain of "difficulty managing feelings and reactions" was derived from the supervisors1 responses to the supervisor postsession measure. The two domains of "client response" and "things left unsaid" were derived from the clients' responses to the client postsession measure.

trainees also experienced positive feelings and reactions in the sessions. Most of the trainees described feeling empathic or caring toward their clients (this was typical for 3 trainees and a variant for 1 other). For example, trainees reported empathizing with their clients' sadness, feeling concerned about their clients, and feeling connected with their clients. In addition, 2 trainees described feeling comfortable or pleased (e.g., they felt more active, engaged, and pleased about performance) in at least half of the sessions, and 2 other trainees reported this as a variant. Personal concerns. Under this domain, which related to the types of trainees' personal concerns evoked by the client, we discovered four categories: (a) therapeutic skills and performance, (b) therapeutic role, (c) difficult clients and conflict in the therapeutic relationship, and (d) reactions to specific client content. Trainees reported many issues that

related to themselves as therapists (e.g., performance anxiety and their roles as therapists) as well as to their clients (e.g., conflict in the therapeutic relationship or reactions to what the client presented in the session). Specifically, most of the trainees reported concerns with therapeutic skills and performance (this was typical for 3 trainees and a variant for 3 others). For example, trainees reported feeling anxious about staying focused on the client, uncomfortable about handling termination, hesistant to probe the client's feelings, uneasy identifying a focus with the client, and frustrated with not knowing what to say or do. Most of the trainees also reported struggling with how to understand and define their role as therapists and the limits or boundaries of this role (this was typical for only 1 trainee but was a variant for 3 others). For example, (rainees reported feeling a strong need to rescue the client, wanting to side with the client, feeling aware of wanting to jump in and solve the client's problems, feeling responsible for easing the client's frustration, and having difficulty holding back from giving advice. Three of the trainees also expressed concern over working with difficult clients and the potential for conflict in the therapeutic relationship (this was again typical for only I trainee but was a variant for 2 others). For example, trainees reported feeling angry that the client didn't follow their lead, shut out by a distant client, immobilized by client resistance, and frustrated with the client's cognitive or external focus. In addition, 4 trainees reported issues related to specific client content (this was typical for 1 trainee but was a variant for 3 others). For example, they reported feeling sad about a client's poor relationship with his or her father and becoming nervous when a client brought up sexual orientation issues. Concerns shared by therapist and client. We found two main categories in this domain (personal stressors and interpersonal stressors), which highlighted the trainees' concerns they felt were similar to those of their clients. For example, most of the trainees reported having had personal stressors that were similar to those of their clients, such as adjustment to college, academic concerns, and dealing with loss. This was typical for 3 trainees and a variant for 3 others. Relatedly, most of the trainees also reported having had interpersonal stressors that were similar to those of their clients, such as concerns related to family and other relationships. This was typical for 2 trainees but was a variant for 3 others. Despite the fact that trainees typically shared both personal and interpersonal stressors with their clients, no one trainee seemed to be "hooked" consistently by any one issue across clients, nor were there consistent issues across trainees. Management strategies. We discovered three main categories in this domain (focusing on the client, using self-awareness, and supressing own feelings and reactions), which addressed trainees' reports of strategies they used to manage their reactions in the session. The majority of the trainees focused on their clients as a strategy to help them manage their feelings and reactions in the session (this was a typical strategy for 2 trainees and a variant strategy for 3 others). For example, trainees tried to focus on the client or

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task as a way to stay connected with the client. In addition, 2 trainees typically used self-awareness as a management strategy (none of the trainees used this strategy as a variant). For example, trainees used their own feelings as a guide to interventions and to managing their feelings. Less typically used as a strategy was suppression of their own feelings and reactions (1 therapist used this strategy in every session, and 3 trainees used it as a variant). For example, some of the trainees reported trying to manage their feelings and reactions by controlling them or by trying to stay patient. Difficulty managing feelings and reactions. In this domain, which addresses supervisors' perceptions of trainees* difficulty in managing their feelings and reactions in session, we found three categories: (a) displaying negative or incongruent behaviors, (b) avoiding affect or issues, and (c) overfocusing-becoming overinvolved-losing objectivity. Over half of the supervisors noted evidence of trainees typically displaying negative or incongruent behaviors in their sessions. For example, some trainees slipped into a peer role; became overactive; appeared visibly annoyed, shaken, or distant; offered their own opinions too much; broke silences with questions and attempts to problem-solve for the client; ended sessions abruptly; seemed to get stuck; or had some difficulty establishing rapport with the client. In addition, 2 supervisors noticed that trainees avoided affect or certain issues (e.g., date rape, substance abuse, race, termination) either typically or as a variant. Finally, 2 supervisors noticed that trainees overfocused on a problem or became overinvolved in an issue (e.g., took client's side against parents, seemed overinvolved in client's relationship issues, perhaps became too attached to client) either typically or as a variant. Client response. We noted two overall categories in this domain (positive feelings toward the therapist and negative feelings toward the therapist), which highlighted clients' perceptions of the trainees during counseling. Clients typically described the trainees in a positive way, using terms such as nice, supportive, good at listening, warm, trustworthy, helpful, and concerned. One therapist, however, was also typically viewed in a negative way (e.g., awkward, tense, quiet, and passive), although clients occasionally noted that most of the trainees did not understand something they had said at some point in the sessions. For example, clients sometimes felt that the therapist did not understand their feelings, overstated their feelings, or was confused by the complexity of their lives. Things left unsaid. Clients did not typically report leaving anything unsaid (it was reported as a variant with only 2 trainees). When they did leave things unsaid, however, clients cited three main areas: (a) embarrassing or shameful issues (e.g., client did not reveal her behavior when drunk; client did not bring up the topic of masturbation), (b) relationship issues (e.g., client did not tell therapist everything about boyfriend; client did not bring up some events related to his or her father), and (c) feelings about the therapist and the therapist's reactions (e.g., client did not bring up a particular issue because he or she was afraid the therapist would have a negative reaction; client did not express how much he or she would miss the therapist).

Case Examples
In order to illustrate the different feelings and reactions experienced by the prepracticum trainees and their ability to manage these reactions during counseling sessions, we present two narrative case examples. Because the majority of the trainees and clients in this study were women, and because we wish to preserve the confidentiality of the participants, we refer to the trainees and clients in each prototypical case as "she" whether or not the participants were actually women. Case A. This trainee reported feeling more inexperienced, insecure, and anxious than did the other trainees. She typically felt anxious and uncomfortable, inadequate and unsure of herself, and distracted and unengaged. She was very concerned about not having adequate therapeutic skills. This trainee struggled with issues such as having problems with silences, knowing what to say in sessions, problem solving prematurely, and being overwhelmed by her own feelings. She managed her reactions by either trying to focus on the client or by trying to control or not experience her feelings. In terms of the clients' perspective, as with all trainees, clients indicated positive reactions, but the clients of this trainee typically included adjectives such as "nice" rather than "insightful" or "understanding." Her clients also had some negative reactions to her, tended to leave things unsaid, and more often than other clients indicated that the trainee had a hard time understanding what they did say. From the supervisor's perspective, the trainee displayed signs of anxiety in sessions, and the supervisor wondered whether the trainee's feelings of inadequacy and negative self-talk got in her way during counseling. Case B. In contrast to the other trainees, who typically focused on either the client or themselves when describing their reactions to sessions, this trainee often indicated that she was attuned to the therapeutic relationship. Overall, this trainee felt positive during the sessions. She noted that she typically felt empathic and caring, and she never reported feeling frustrated or angry. However, she also reported a fair amount of self-criticism. For example, she reported feeling more unsure of herself than did 5 of the other trainees. She also reported having concerns about her skills, especially with regard to termination. She managed her reactions by relying on self-awareness and focusing on the client. Both supervisor and client ratings of this trainee were very positive. Her supervisor reported few concerns about her behaviors, affect, and session management. In terms of client perceptions, she was the only trainee who was perceived as providing insight and for whom no negative reactions were reported. In addition, her clients described her in very positive and "therapeutic" terms such as helpful, sensitive, understanding, concerned, and genuine.

Discussion
Over the course of a semester the group of trainees became less anxious overall, developed greater therapeutic skills, and grew more adept at managing their countertrans-

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ference reactions. Thus, as a group, the trainees displayed evidence of their growth as therapists in spite of the sometimes negative and overwhelming feelings and issues with which they were contending. Fortunately, training seemed to be a positive experience overall for these trainees. The results of the present study also indicate that prepracticum trainees experienced a range of both positive and negative feelings and reactions during counseling sessions and that most trainees demonstrated adequate skills and developmental growth. However, the use of qualitative procedures and the viewpoint of three different perspectives (trainee, supervisor, and client) allowed us to examine more closely the trainees' struggles and to draw inferences with regard to the developmental issues of therapists in training. The trainees in this study often reported feeling comfortable, empathic, and caring in their counseling sessions, although they also had feelings of anxiety, frustration, inadequacy, and distraction. Specifically, the trainees noted that they at times struggled with negative feelings (e.g., anxiety) around silences, termination, cultural differences, and their own skills. Trainees also struggled with personal concerns related to conflict with their clients, reactions to specific client issues (e.g., parents, guilt, sex, abortion), and their concerns about their roles as therapists (e.g., wish to rescue or side with the client, desire to give advice or be like a friend or teacher, difficulty sticking with time limits). However, no one personal concern was reported by all or nearly all of the trainees, which suggests that each trainee faced unique challenges in learning to be a therapist. The data also suggest that trainees' feelings and reactions did, at times, interfere with their ability to provide maximally effective counseling. Supervisors suggested that this interference often appeared in the form of negative or incongruent behaviors (such as displaying annoyance or anger, pushing one's own agenda, becoming very directive, talking a lot, shutting down). Supervisors also noted that evidence of trainees' difficulty managing their feelings and reactions included avoidance and overinvolvement behaviors, which have been described in detail in the literature (Bandura, Lipsher, & Miller, 1960; Cutler, 1958; Gelso et al., 1995; Peabody & Gelso, 1982; Singer & Luborsky, 1977; Watkins, 1985). Trainees did try to manage their reactions, most typically by focusing on the client, using self-awareness, and suppressing or controlling their own feelings. The first two strategies seemed to us to be the most productive in helping clients. Indeed, the use of self-awareness (as has been noted in the self-talk literature, e.g., Nutt-Williams & Hill, 1996) can be effective because it helps the trainees examine useful self-information (e.g., feelings and reactions) in relation to their clients. Focusing on the client may have helped trainees be more attentive to the clients themselves and the task at hand. Suppressing or controlling their feelings seemed more self-focused (without the added step of using that information or awareness to guide interventions) and may be less effective in helping trainees learn to cope with the inevitable feelings and reactions that surface during counseling. We also found, after writing summary descriptions of each case, that some of our results seemed to relate to the

experience level of the trainees. For example, given the different levels of experience of the trainees in our sample, we viewed Case A as a possible example of a beginning trainee and Case B as a possible example of a more experienced trainee. Although we did not initially plan to study this aspect of individual differences, we find it interesting that the trainees may have been at very different levels of expertise and self-awareness and, therefore, may have had very different training needs. Relatively inexperienced trainees may need more basic skills training as well as techniques to help them deal with their anxiety and negative self-talk, whereas more experienced trainees may need more help with confidence building. The importance of exploring different levels of experience and their relation to developmental differences across the span of therapist training has already been addressed in the literature (e.g., Hogan, 1964; Stoltenberg, 1981; Stoltenberg & Delworth, 1987). The results of the present study also suggest that there may be large variability even within a prepracticum experience of a doctoral program. Similarly, Johnson et al. (1989) found large individual differences at the prepracticum level that persisted over the beginning stages of training. Yet, from the present study, we cannot say definitively that differences were due to experience level, personal style, or other variables. However, the study does raise possible considerations for prepracticum instructors in terms of figuring out how to best meet the needs of trainees at very different levels of experience. Several limitations of the study need to be mentioned. One limitation was that the results might not be representative of all graduate students because the study used a small sample from one doctoral program. Although we may not be able to generalize to other groups of trainees from this particular sample, we wanted to use this information to generate ideas about training issues in an exploratory, discovery-oriented manner (Mahrer, 1988). Another limitation of the study was the use of pencil-and-paper questionnaires rather than interview data. We used questionnaires to ensure the anonymity of the participants and to reduce the time commitment given that participants completed measures every week, but we may have ended up with less rich or "thick" data than we would have liked. Another potential limitation is that we could examine only the types of reactions and management strategies the trainees chose to share with us. Although they were aware of the ways in which the research team was protecting their anonymity, it is possible that they engaged in a certain amount of impression management and reported only those reactions that they felt were appropriate. Finally, it is also important to note the intimate involvement of the authors in the prepracticum course itself. Although there is a precedent for researchers' contributing data in qualitative studies (e.g., Rennie, 1992; Rennie & Brewer, 1987; Rhodes, Hill, Thompson, & Elliott, 1994), we acknowledge that the fact that 2 of the supervisors were also authors of the study is a potential limitation. Several areas for future research stand out. One area suggested by this study, given trainees' reliance on selfawareness as a management strategy, is a longitudinal

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examination of trainees' self-talk. As found by NuttWilliams and Hill (1996), the self-talk of trainees seems to have a profound effect on therapists' perceptions of themselves and their clients in sessions and may, in fact, have an effect on their in-session behaviors. Thus, it would be useful to investigate how self-awareness and self-talk change over time and how these, in turn, relate to the effectiveness with which trainees manage their feelings and reactions in sessions. More strategies and programs need to be developed for helping trainees attend to and use their self-talk during counseling sessions. In a related vein, the results of this study should be replicated with other methods. Measures could be developed based on the ideas that emerged in the qualitative analyses. It would be of particular interest to develop measures about how trainees manage difficult issues that distract them during sessions. Although at least one measure of countertransference management has been developed (Van Wagoner et al., 1991), the development of a valid and reliable measure of how trainees manage other in-session reactions (e.g., anxiety, self-doubt, frustration) could help us further understand how to train therapists more effectively. Such a measure would also give us a way to empirically examine the relationship between trainees' management strategies and their therapeutic effectiveness. Another fruitful area for future research to address is how to train therapists at different developmental levels within the same practicum. Given the models of supervision and therapist development that focus on the use of differential techniques for addressing developmental issues at different training stages (e.g., Loganbill, Hardy, & Delworth, 1982), studies relating these models to the practical application of varying training techniques would be useful in helping us fine-tune our training curricula. Further research in this area may also help us develop new and better techniques for teaching trainees to manage and use the normal and inevitable feelings and reactions that they will likely face.

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63, 356-359.

Received October 30,1996 Revision received May 21,1997 Accepted May 21, 1997

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