Psychotherapy Research, 2018

Vol. 28, No. 4, 517–531, https://doi.org/10.1080/10503307.2016.1252071

EMPIRICAL PAPER

A trans-theoretical training designed to promote understanding and

management of countertransference for trainee therapists

CLAIRE CARTWRIGHT1, CARRIE BARBER2, SUE COWIE2∗ , & NEIL THOMPSON3

1
School of Psychology, University of Auckland, Auckland, New Zealand; 2School of Psychology, University of Waikato,
Hamilton, New Zealand & 3Department of Psychology, University of Canterbury, Christchurch, New Zealand
(Received 6 June 2016; revised 11 October 2016; accepted 12 October 2016)

Abstract
Objective: There is evidence that awareness of countertransference (CT) in combination with a conceptualization of CT
facilitates its management. This study examines the impact of a trans-theoretical training designed to make the construct
of CT accessible to trainee therapists in programs oriented towards cognitive-behavioral therapy. The training aimed to
enhance trainees’ awareness, understanding, and management of CT. Method: Academics at five New Zealand
universities introduced the training into their curriculum. Five academics and 54 clinical psychology trainees evaluated it,
responding to open-ended questions on the impact of the training on awareness, understanding, and management of CT.
They also rated the training’s effectiveness. Results: The majority of trainees reported increased awareness and
conceptualization of CT. They rated the training as useful for professional practice and reported increased commitment to
monitoring CT. Academics also observed trainees’ increased awareness and understanding of CT and openness to
discussing it. Trainees and academics were less confident in trainees’ abilities to manage CT in clinical practice, although
trainees reported gains in this area. Conclusions: The training appeared to enhance awareness and conceptualization of
CT, processes that support its management. However, future research into training models needs to examine the impact
on CT management in clinical practice.

Keywords: countertransference; countertransference management; training; countertransference training; therapeutic

relationship

The tripartite model of the therapeutic relationship
proposes that this relationship has three com-
ponents—the real relationship, the therapeutic alli-
ance, and the transference–countertransference
(CT) configuration (Gelso, 2014; Gelso & Carter,
1994). This paper focuses on the construct of CT
that originated with Freud and developed within psy-
choanalytic and psychodynamic paradigms. Despite
these psychoanalytic origins, therapists and trainees
from all therapeutic approaches experience the chal-
lenges of CT in their therapeutic practice (Gelso &
Hayes, 2007), even when they do not use the term
(Betan, Heim, Conklin, & Westen, 2005). The
current paper presents a study of a trans-theoretical
training that was developed to make the construct
of CT accessible to clinical psychology students in
training programs oriented to cognitive-behavioral
therapy (CBT) and to promote awareness, under-
standing, and management of CT. Before presenting
the training, it is important to briefly consider the
development of the CT construct within psychody-
namic paradigms and more recently within CBT
frameworks.
Psychodynamic Perspectives on CT
The construct of CT developed mostly through clini-
cal writing and analysis (Gelso & Hayes, 2007). Four
main conceptualizations of CT have been defined
(Gelso & Hayes, 2007). The first is Freud’s classical
view of CT as the patient’s influence on the

Correspondence concerning this article should be addressed to Claire Cartwright, School of Psychology, University of Auckland, Auckland,
New Zealand. Email: c.cartwright@auckland.ac.nz
∗
Current address: School of Psychology, University of Auckland, Auckland, New Zealand

© 2016 Society for Psychotherapy Research

518 C. Cartwright et al.
psychoanalyst’s unconscious feelings (1910/1959).
This classical view, in which CT was seen as an impe-
diment to therapy, dominated psychoanalytic think-
ing until the 1950s when Heimann introduced the
notion that “the analyst’s immediate emotional
response” points to the patient’s unconscious pro-
cesses and is therefore a source of potential under-
standing about the client (1950, p. 83). This view of
CT was termed the totalistic perspective (Kernberg,
1965). At a similar time, Winnicott (1949) introduced
the notion of two aspects of CT—objective and sub-
jective. He proposed that objective CT was a realistic
response to the sometimes provocative behaviors of
the client which in turn related to the client’s early
object experiences, while subjective CT results from
the therapist’s unresolved conflicts. In the third
“complementary” conceptualization, CT is seen as a
complement or counterpart to the client’s personality
or style of relating (Gelso & Hayes, 2007). This view
emphasizes the role of the “pulls” that the client
exerts on the therapist (the objective aspect of CT)
and the therapist’s CT responses, which in turn
impact the client (e.g., Kiesler, 2001). The fourth
“relational” perspective overlaps with the comp-
lementary perspective but places more emphasis on
the co-creation or co-construction of CT by the thera-
pist and client. In this view, CT is seen as a product of
the client’s and therapist’s conscious and unconscious
dynamics (Gelso & Hayes, 2007).
Gabbard (2001) identified a number of areas of
agreement and disagreement that have emerged in
regards to clinical conceptualizations of CT in the
psychodynamic literature. Areas of agreement
include the notions that the client will attempt to
transform the therapist into a transference object;
the therapist and the client both influence the CT
response; and the therapist must work to protect the
client and the therapeutic relationship from CT beha-
viors or enactment. Areas of disagreement revolve
around the relative influence of the therapist and
client on CT (Gabbard, 2001).
Gelso and Hayes (2007), in their empirical work on
CT, have expressed concern about the ongoing
inconsistency around definitions of CT and argue
for an alternative “integrative” perspective. They
define CT as “the therapist’s internal or external
reactions that are shaped by the therapist’s past or
present emotional conflicts and vulnerabilities”
(Gelso & Hayes, 2007, p. 25). In their work, they
consider the origins, triggers, manifestations, man-
agement, and effects of CT. From their perspective,
the origins of CT are rooted in the therapist’s
emotional conflicts or vulnerabilities, while the trig-
gers are the therapy events or patient qualities that
touch upon or bring out the therapist’s unresolved
conflicts or vulnerabilities (Gelso & Hayes, 2007).
Other researchers continue, however, to use different
perspectives of CT, including the totalistic perspec-
tive (e.g., Betan et al., 2005); the influence of the
client on the therapist’s CT (objective CT) (e.g., Haf-
kenscheid & Kiesler, 2007); recurrent and deviant
feelings of the therapist (e.g., Holmqvist, 2001); the
feelings that therapists are conscious of as part of
the total CT (e.g., Dahl, Røssberg, Bøgwald,
Gabbard, & Høglend, 2012); and CT as a prototype
(Hofsess & Tracey, 2010).
Cognitive Perspectives on CT
Cognitive-behavioral therapists have traditionally
paid little attention to CT. However, in recent years
there is increased attention to the therapeutic relation-
ship and discussion of CT (Leahy, 2007). Beck, the
founder of cognitive therapy, and his colleagues, in
their discussion of therapy with clients with personal-
ity disorders, note a preference for referring to CT as
“therapist emotions” in order to “avoid confusion”
with psychodynamic assumptions about CT (Beck,
Freeman, & Davis, 2004, p. 108). While emphasizing
emotions, they note the importance of observing phys-
ical sensations, mood shifts, and changes in behavior
that could indicate CT or “therapy-related thoughts
and emotions” (Beck et al., 2004, p. 109). The
sources of therapist emotions (or CT) include the
therapist’s beliefs and values about his/her role, and
his/her learning history. The authors suggest that
these therapy-related thoughts and emotions can
result in problematic behaviors and can be understood
and managed if therapists use traditional cognitive
therapy approaches to examine their own thoughts
and feelings.
Leahy (2007) and Newman (2013), both leading
CBT therapists and theorists, use the term CT.
Leahy (2007) views CT as resulting from the thera-
pist’s personal schemas about the self, interpersonal
schemas about others, and history of relationships.
According to Leahy (2007), therapy events can acti-
vate therapists’ CT schemas (e.g., demanding stan-
dards for self and client, and sensitivity to rejection)
and can then lead to problematic therapist behaviors.
Newman (2013), on the other hand, views CT as the
therapist’s “cognitive, emotional, and behavioral
responses” to the client that are “a normative response
to the particular client” and less of a reflection on the
therapist’s individual personality and history (pp. 55–
56). According to this view, CT is reflective of the
client’s problematic psychological impact on others
and can provide information that is useful in formu-
lation and treatment planning (Newman, 2013).
Hence, CBT perspectives on CT also emphasize
the emotions, cognitions, and behaviors of the

therapist. These, however, are seen as emanating
from the therapists’ beliefs and schemas and/or in
response to the problematic behaviors of the client,
rather than from unresolved conflict or unconsious
dynamics as in psychodynamic conceptualizations.
As in psychodynamic perspectives, CT reactions are
seen as potentially problematic for the client and
therapy and need to be managed (Beck et al.,
2004). Hence, CBT perspectives of CT are evolving.
There are different emphases within these perspec-
tives and these appear to reflect, in part, the debate
in the psychodynamic literature in regard to the rela-
tive contribution of therapist and client to CT.
Understanding and Managing CT
Since the 1950s, therapists have focused on two
aspects of CT—the value of CT as a potential
source of insight into the client’s experiences, and a
source of risk to the client and the therapeutic
relationship if therapists act from CT or engage in
CT behaviors (Gabbard, 2001). These clinically
derived ideas about CT have received empirical
support. A recent meta-analysis of 10 quantitative
studies that examined the effects of CT on therapy
outcomes concluded that CT reactions are related
inversely and modestly to therapy outcomes (Hayes,
Gelso, & Hummel, 2011). A second meta-analysis
of seven quantitative studies concluded that the suc-
cessful management of CT is associated with better
therapy outcomes (Hayes et al., 2011). Hence, as
therapists have argued, CT can hinder therapy; and
on the other hand, successful management of CT
appears to be associated with more positive outcomes
(Hayes et al., 2011).
There is evidence that therapists vary in their ability
to manage CT (Hayes et al., 2011) as do trainee
therapists (Latts & Gelso, 1995; Robbins & Jolkovski,
1987). However, little, as yet, is known about the
factors that facilitate CT management (Hayes et al.,
2011). Two independent studies conducted with
doctoral psychology trainees examined a two-part
model that proposed that therapists who are more
aware of their CT feelings and have a theoretical fra-
mework for understanding these feelings will engage
in less CT behavior (Latts & Gelso, 1995; Robbins
& Jolkovski, 1987). It was proposed that a theoretical
framework for understanding CT is important as it
allows the therapist to cognitively process CT,
which in turns facilitates management (Robbins &
Jolkovski, 1987). In both of these studies, trainees
viewed video therapy sessions and were asked to
rate their responses as therapists to the clients at
intervals across the sessions. CT was operationalized
as withdrawal of involvement from clients by Robbins
Psychotherapy Research 519
and Jolkovski (1987) and as approach and avoidance
behaviors by Latts and Gelso (1995). The two-part
model was supported in both studies where trainees’
awareness of CT in combination with a conceptual or
theoretical framework for understanding CT resulted
in the lowest levels of CT behavior (Latts & Gelso,
1995; Robbins & Jolkovski, 1987). On the other
hand, having a strong conceptual framework
without personal awareness of CT responses was
associated with the highest levels of CT behaviors
(Latts & Gelso, 1995; Robbins & Jolkovski, 1987).
There is also some evidence that the therapist’s
empathic ability—“the ability to partially identify
with, and put one’s self in the other’s shoes”—
focuses the therapist on the client’s needs and may
prevent CT behavior (Hayes et al., 2011, p. 89); for
example, in a study with 20 male trainees, empathic
ability was associated with less CT behavior with
seductive clients although not with hostile clients
(Peabody & Gelso, 1982). The role that empathy
plays in CT management also emerged in a qualitat-
ive study with 12 experienced therapists (Baehr,
2004).
Five therapist qualities thought to promote CT
management, and characteristic of reputedly expert
therapists, have also been defined and researched
(Gelso & Hayes, 2007; Van Wagoner, Gelso,
Hayes, & Diemer, 1991). These include self-
insight, self-integration, empathy, anxiety manage-
ment, and conceptualizing ability. The Countertrans-
ference Factors Inventory (CFI; Van Wagoner et al.,
1991) assesses these five therapist qualities and has
been used to measure CT management indirectly
(Gelso & Hayes, 2007). Research has provided
mixed though generally positive support for the five
therapist qualities that comprise the CFI (Gelso &
Hayes, 2007). As discussed, there is evidence that
awareness of CT in combination with the ability to
conceptualize CT facilitates CT management (Latts
& Gelso, 1995; Robbins & Jolkovski, 1987), as does
the ability to empathize with clients (Baehr, 2004;
Peabody & Gelso, 1982). Further, a better level of
self-integration appears to result in fewer CT
responses (Gelso, Latts, Gomez, & Fassinger,
2002); and the ability to manage anxiety may
reduce CT-based anxiety (Gelso, Fassinger,
Gomez, & Latts, 1995). Gelso and Hayes (2007) con-
clude, however, that there is less empirical support
for the fifth therapist quality measured by the CFI—
therapist self-insight.
Background to the Study
The current trans-theoretical approach to teaching
CT was developed in New Zealand. A recent survey
520 C. Cartwright et al.
of program directors of clinical psychology training
programs in New Zealand and Australia found that
all programs in New Zealand and the majority in Aus-
tralia offer core training in CBTs and do not offer
training in psychodynamic therapy (Kazantzis &
Munro, 2011). Hence, an approach was developed
to allow the construct of CT to be accessible to
trainee therapists from a range of different thera-
peutic modalities, including CBT. Prior to conduct-
ing this national study, the training was piloted with
a group of New Zealand psychologists in 2008–
2009 (Cartwright & Read, 2011) and with a small
group of clinical psychology trainees in Australia in
2013 (Cartwright, Rhodes, King, & Shires, 2015).
Following this, the training was revised. These revi-
sions included increased emphasis on strategies for
managing CT and the use of therapist empathy.
Trainee therapists generally appear to struggle with
understanding and managing their CT responses
(Brody & Farber, 1996; Cartwright, Rhodes, King, &
Shires, 2014). For example, in a study comparing trai-
nees with more experienced therapists, trainees
reported that their emotional responses to clients were
too strong and too frequent, expressed more regret
about what they said to clients, and felt that they had
to defend against their emotional responses (Brody &
Farber, 1996). Trainee therapists also report being con-
fused about their CT responses, having some awareness
of CT behaviors, but having difficulty understanding
and managing these reactions (Cartwright et al.,
2014). Trainees also report struggling with their
emotional responses to clients and over- or under-iden-
tifying with them (Hill, Sullivan, Knox, & Schlosser,
2007). Therefore, it seems likely that trainee therapists
may be susceptible to the “pulls” of the client.
The current training aimed to increase trainees’
awareness and conceptualization of CT. While
there is some evidence that these two components,
in combination, increase the likelihood of CT man-
agement (Latts & Gelso, 1995; Robbins & Jolkovski,
1987), a third component was added to the training.
This included teaching around possible strategies for
managing CT responses in therapy sessions, includ-
ing an emphasis on the use of empathy. Hence, the
training could also contribute to the development of
three of the five therapist qualities thought to be
associated with CT management (Gelso & Hayes,
2007; Van Wagoner et al., 1991). These include
awareness, which is an aspect of self-insight, concep-
tualization, and empathy.
Definition of CT
The training used Shafranske and Falender’s (2008)
definitions of objective and subjective CT as these
are complementary to a CBT perspective. The
authors define objective CT as the therapist’s reac-
tions that are induced by the client’s perceptions,
affects, and behaviors and are consistent with signifi-
cant others’ responses to the client; and subjective
CT as maladaptive reactions emanating from per-
sonal factors of the therapist. We decided to include
the notion of objective CT as these emotional
responses can be powerful, as demonstrated by Win-
nicott’s (1949) descriptions of love and hate in CT.
While objective CT may be seen as a realistic
response, nevertheless these responses in which the
therapist is embedded in the client’s interpersonal
cycle can be difficult to recognize (Safran & Muran,
2000) and may also be difficult to understand and
manage for trainees—especially for those who are
not psychodynamically trained and are not familiar
with the notion of CT as a source of information
about the client.
Within the definition used, both objective and sub-
jective aspects of CT are viewed as cognitive-affective
responses of the therapist that can manifest in CT
behaviors if not managed successfully. We agree
with Gelso and Hayes (2007) that not all emotional
responses of the therapist can be considered counter-
transferential. As Kiesler (2001) argued, in addition
to subjective and objective CT, it is important to con-
sider a third set of therapists’ emotional responses
that can be described as “real”—unique to the
relationship with the client and free of any distortion
on the part of the therapist, perhaps often times in
response to a healthy part of the client. This could
include such responses as sadness for a client who
speaks of his grief, happiness for a client who has
had a success after considerable struggle, or amuse-
ment at a client’s joke.
Preparation for the Study
The current study was influenced by action research
methods. According to Reason and Bradbury (2001),
action research is “a participatory democratic
process” that aims to develop knowledge in regard
to issues that are of concern to people (p. 1). Action
research involves processes of action and reflection,
theory and practice, in participation with others.
The people who were engaged in this current study
were academic staff from clinical psychology pro-
grams in New Zealand and clinical psychology trai-
nees. The “concern” at the center of the study was
the enhancement of trainees’ understanding and
management of CT.
In the planning stage of the study, 12 academics
from 6 universities in New Zealand met at the host
university (University of Auckland) and took part in

a 2-day workshop in which they participated in the
training and then discussed its suitability for clinical
psychology training in New Zealand. Following the
workshop, five of the university clinical psychology
programs committed to introducing the training
into the curriculum in 2015 as either a one- or two-
day workshop. An academic from each of the five uni-
versities was nominated to facilitate the training and
to participate in its evaluation. Hence, the partici-
pants engaged in this current study were academic
staff from five clinical psychology programs and clini-
cal psychology trainees. The aim of the study was the
enhancement of trainees’ understanding and man-
agement of CT.
The research questions guiding this study were:
(1) Does the training increase trainees’ aware-
ness of CT responses?
(2) Does the training increase trainees’ ability to
conceptualize CT?
(3) Does the training enhance trainees’ ability to
manage CT?
Method
Participants
Trainee participants. Clinical psychology train-
ing in New Zealand involves a three- to four-year
post-graduate program. Trainees complete a
masters or Ph.D. alongside a three-year Post-Gradu-
ate Diploma in Clinical Psychology; or alternatively,
an Honors Degree in Psychology, and a three-year
Doctorate of Clinical Psychology. In all programs,
trainees are registered in their final year as Intern Psy-
chologists with the New Zealand Psychologists
Board. They work four days a week in clinical ser-
vices. In the first and second professional years, trai-
nees complete practicums in the University
Psychology Clinics and in clinical services in the
community under the supervision of clinical
psychologists.
Clinical psychology programs in New Zealand
have between 5 and 11 trainees per year. Sixty-one
clinical psychology trainees from five clinical psychol-
ogy programs completed the training titled “Reflec-
tive Practice: Understanding and Managing
Countertransference.” The size of the training
groups ranged between 6 and 13 trainees. Fifty-four
(89%) participated in the evaluation. Trainees were
given the opportunity to decline to provide demo-
graphics if they were concerned this would identify
them. This was particularly relevant for male partici-
pants. The age and gender of one participant was
unknown. Of the 53 participants who identified
their gender, 46 (87%) were females and 7 (13%)
were males. Twenty-four (45%) of the participants
Psychotherapy Research 521
were aged 25–29 years, and 13 (24.5%) were aged
30–34 years. Six (11%) were 20–24 years, and 10
(19%) were 35 years or older. Forty-one (77.5%) of
the participants identified as New Zealand European;
8 (15%) as M!aori or Pacific Islander, and 4 (7.5%) as
Asian. At the time of the training, 22 participants
(41%) were in their internship year (third and final
post-graduate training year); 29 (54%) were in their
second or third semester of working with clients; 2
(4%) were in their first semester; and 1 trainee
reported having worked with clients for 4 years.
Academic participants. Five academic partici-
pants, one from each university, took part in the
study. One participant was a program director, two
were Psychology Clinic directors, and two were clini-
cal educators. All participants were clinical psycholo-
gists. The participants had been in their current
university roles between 1 and 10 years (M = 7.6
years). Two of the academic participants from non-
host universities are also authors (second and
fourth) of the current paper.
Training Intervention
This section presents a brief overview of the training.
The training had three components: being aware of
CT; conceptualizing CT; and managing CT. The
second component—conceptualizing CT—was the
most demanding and required approximately half of
the training time. The one-day and two-day trainings
covered the same material; however, the two-day
training allowed more time on each component, on
learning activities, and case discussions.
The training made use of a number of concepts
compatible with a range of therapeutic perspectives,
including CBT. These included self and other rep-
resentations and the parent–adult–child (PAC)
model. The concept of self and other representations
(or self-other representations) is used by number of
models including the social-cognitive model of trans-
ference (Miranda & Andersen, 2007), attachment
theory (Bretherton, 1985), and some psychodynamic
approaches (e.g., Gabbard, 2004). Self and other rep-
resentations also fit with the concepts of core beliefs
or schemas about self and others in cognitive
therapy (e.g., Beck, 2011; Leahy, 2007) and recipro-
cal roles in cognitive-analytic therapy (Ryle & Kerr,
2002). The PAC model, originally developed by
Berne (1961), can be used to consider transference
and CT within a psychodynamic paradigm (Brown
& Pedder, 1991). The PAC model was used to
assist trainees to develop hypotheses about the inter-
personal processes in therapy and to provide a visual
representation of potential transference and CT
522 C. Cartwright et al.
responses. Both the concept of self-other represen-
tations and the PAC model reflect contemporary
psychological thinking, which emphasizes the multi-
plicity of self-states that individuals experience
(Safran & Muran, 2000).
Monitoring and being aware of CT responses.
This component of the training aimed to increase
openness to the notion of CT and awareness of CT
feelings and thoughts. Initially, trainees were intro-
duced to two studies that examined reports of CT
experiences—one study of trainees’ experiences of
CT (Cartwright et al., 2014) and the second of psy-
chiatrists’ and clinical psychologists’ reports of CT
(Betan et al., 2005). They were then introduced to
definitions of transference and CT from different
therapeutic perspectives. The concepts of positive
(such as wanting to look after a client or being over-
protective of a client) and negative CT (such as
having critical thoughts or withdrawing from a
client) were introduced and the potential effects of
both positive and negative CT were discussed.
Activity. Trainees were initially asked to talk about
a positive CT they had each experienced when
working with a client. This process was then repeated
with a negative CT. The trainer also talked about
some personal CT experiences. This activity aimed
to normalize CT, increase awareness of potential
CT responses, and to support trainees to become
comfortable talking about CT.
Conceptualizing CT—part one. This segment
introduced trainees to the notions of objective and
subjective CT as defined by Shafranske and Falender
(2008). While the training focused mainly on under-
standing objective CT (understanding the ways in
which clients can evoke responses in therapists), the
importance of reflecting on subjective CT and the
“hook” in the therapist’s personality was also empha-
sized. In regard to objective CT, trainees were intro-
duced to the notion that CT can be a valuable source
of information about the client’s experience in
therapy. The concept of self-other representations
provided trainees with a means of considering the
client’s interpersonal patterns of relating to others.
In regard to subjective CT, trainees were introduced
to Leahy’s (2007) cognitive definition of CT and its
emphasis on the therapist schemas that influence
the CT.
Activities. Trainees were given a hypothetical case
outline and asked to work in groups to hypothesize
the client’s self-other representations. Trainees then
presented their hypotheses to the class and these
were discussed. Trainees were then asked to work
in groups to think about the potential transference
and CT reactions that could occur based on the
hypothesized self and other representations of the
client. Once again, they presented their ideas to the
class and these were discussed.
Activities. In their own time, trainees were encour-
aged to consider their own constellation of self-other
representations developed during their unique
history of relationships in order to gain more insight
into their own CT response patterns to clients.
Conceptualizing CT—part two. In this
segment, trainees were introduced to the PAC
model that provides a visual map for reflecting on
the interpersonal processes that occur between the
therapist and client. The PAC model is also useful
as it provides a third position (the Adult). This
Adult position can represent the therapist’s response
when s/he is not triggered into a CT reaction. CT
responses can be viewed as involving a shift out of
the Adult position. Alternatively the Adult represents
a position to which the therapist can shift when s/he
notices an identification with the client. The thera-
peutic alliance can also be represented by the
Adult-to-Adult position (Brown & Pedder, 1991).
The model was also used to illustrate complementary
and concordant CT as defined by Gabbard (2004).
According to his definition, in a complementary
CT, the therapist identifies with an other-represen-
tation of the client; in a concordant CT, the therapist
identifies with a client’s self-representation. It is
important to note that it was emphasized to trainees
that these CT reactions do not necessarily lead to
CT behaviors and ideally the therapist will work
toward understanding and managing these CT
feelings.
Activity. Some trainees took turns volunteering to
present a case for discussion. This included infor-
mation about the client’s background and history of
relationships, the presenting problems, the trainee’s
CT, and what was happening in therapy at the time
of the CT. They then worked with the trainer and
also in groups to use the concepts of self-other rep-
resentations and the PAC model to map their hypoth-
eses about the interpersonal processes occurring
between therapist and client. The hypotheses were
discussed and compared to each other for their fit
to the therapeutic situation being discussed. This
activity was repeated a number of times when time
allowed.
Managing CT. This last segment aimed to intro-
duce trainees to strategies they could use to manage
their CT feelings. Trainees were encouraged to use
calming strategies they teach to clients (breathing
techniques, self-calming thoughts, or adopting a

mindful position) when they became aware of CT
feelings. They were also encouraged to consider
coaching themselves, using the calming strategies,
back into the Adult position (“It’s okay. I’m having
a CT response. I can stay calm, move back into my
Adult, and think/talk about this after the session”).
Given the evidence that empathy for the client may
decrease CT behaviors (Hayes et al., 2011), trainees
were also encouraged to consider an empathic view-
point of the client and to include this in their self-
talk (“She is being very critical but this comes from
her abuse history. She’s doing the best she can in
this situation given how hard it is for her to maintain
relationships”).
Activity. Trainees were asked to consider ways in
which a therapist could manage some of the CT
responses discussed earlier. This included consider-
ing what self-talk a therapist could use to calm or
center themselves, or to re-orient to an internal
empathic response to the client and his or her situ-
ation. They were also encouraged to make use of
the insight they developed into the client’s experi-
ences through the process of conceptualization of
the CT described above.
Measures
Trainees’ online questionnaire. Trainee
participants completed an anonymous online ques-
tionnaire. The questionnaire contained a series of
5-point Likert-type scale questions (strongly disagree
through to strongly agree) and open-ended questions
designed to encourage trainees to reflect on their
experiences of the training. The first question asked
them to rate how often they noticed their CT
responses prior to the training on the 5-point
Likert-type scale. This was then followed by a series
of open-ended questions designed to gain insight
into what was central for the trainees. These were:
has this changed since doing the training in reflective
practice and CT, and if so how? Has your under-
standing of CT changed as a result of the training
and if so how? Has the training in CT been meaning-
ful for you in your professional development and if so
how? What other comments would you like to make
about the training and what changes, if any, would
you recommend?
Participants were then asked to rate six items on a
5-point Likert-type scale (strongly disagree through
to strongly agree) to evaluate the training on a
number of criteria related to the research questions:
(i) The training will be useful for my professional
practice; (ii) The training helped me to understand
the concept of countertransference; (iii) The training
provided me with ideas about how to manage
Psychotherapy Research 523
countertransference; (iv) I am committed to monitor-
ing my own CT; (v) Countertransference can provide
insight into the client’s experience; and (vi) Overall, I
was satisfied with the training.
Academics’ online questionnaire. Academic
participants completed an online questionnaire con-
sisting of Likert-type scale questions and open-
ended questions. These were: (i) Please write about
any positive benefits that you have observed trainees
experiencing as a result of taking part in the training;
(ii) What does the training add, if anything, to the
professional development of trainees that was other-
wise missing; (ii) Have you experienced any personal
value from taking part in this training—either as a
teacher, supervisor, or therapist? (iv) Please write
about any problematic or challenging aspects of the
training or any areas that could be improved; (v)
Do you plan to continue on with this training or an
adaptation of it in your program and please
comment on what issues impact decisions in this
regard? And (vi) what changes would you make to
the training, if any?
The academic participants were then asked to rate
6 items on a 5-point Likert-type scale to evaluate the
training on a number of criteria related to the
research question: (i) I am pleased that our students
took part in this training; (ii) I observed an increase
in awareness of countertransference with students I
worked with following the training; (iii) I observed a
better understanding of countertransference with stu-
dents I worked with following the training; (iv) I
observed a decrease in countertransference behaviors
in sessions with students I worked with following the
training; (v) I recommend this training, or an adap-
tation of it to other programs; and (vi) I hope to con-
tinue offering this training, or an adaptation of it in
our program.
Procedure
The trainings were completed at different times
across the academic year. The first author conducted
the trainings. Two universities had two-day trainings
while the remaining three were one-day trainings.
The trainees were given a participant information
sheet approved by the University Ethics committee
prior to the training, which made it clear that partici-
pation in the study involved the completion of an
anonymous questionnaire to assist with an evaluation
of the training and that participation was voluntary.
Trainees were sent the link to the anonymous
online questionnaire approximately three weeks
after completing the training and a reminder email
approximately two weeks later. Academic
524 C. Cartwright et al.

participants were also sent a link to the academic staff Results

online questionnaire approximately six weeks after all
training workshops were completed.
Data Analysis
Qualitative data analysis—trainees’
questionnaire. To reduce bias, two independent
researchers (one post-doctoral researcher and one
Ph.D. student experienced in qualitative research)
conducted the initial analysis of the qualitative data
from the four open-ended questions in the trainees’
questionnaire. The method of thematic analysis
described by Braun and Clarke (2006) was used for
each set of analyses. Following familiarization with
the data, units of data were examined and systemati-
cally coded for content and meaning. The codes were
then examined for their relationship to each other and
sets of related codes were grouped, leading to the
development of the initial proposed themes. These
were then reviewed by the first and third authors,
inconsistencies were identified and adjusted, and
the themes were finalized.
Qualitative data analysis—academics’
questionnaire. The thematic analyses of the data
from the academics’ questionnaire were conducted
independently by the second and fourth authors, aca-
demic participants from the non-host university,
using the method described above (Braun & Clarke,
2006). The codings completed by the two authors
were compared and found to be similar. The pro-
posed themes were then reviewed by the first,
second, and fourth authors, and finalized.
Trainee Responses on Qualitative and
Quantitative Questions
The results of three thematic analyses are presented
below. These include the analysis of data pertaining
to changes in awareness and understanding of CT,
to the meaningfulness of the training for professional
development, and any other comments or rec-
ommended changes.
Changes in awareness and understanding of
CT. Six themes were defined pertaining to changes
in awareness and understanding of CT (see
Table I). Quotes are provided in Table I to illustrate
the themes. In the first theme, More aware of my coun-
tertransference reactions, the majority of participants
reported that they were more “aware,” “conscious,”
or “mindful” of the possibility of experiencing CT,
were more aware of or paid “more attention” to
their responses to clients, noticing these more often
in sessions.
The second, third, and fourth themes all related to
participants’ observations of increases in their analy-
sis and/or understanding of their CT reactions. In
the second theme, Reflect on or analyze countertransfer-
ence, participants wrote about reflecting more on their
CT responses to clients, questioning themselves or
their “motivations” more often, and thinking about
the meaning of their CT reactions. In the third
theme, A better theoretical understanding, participant
statements related to having a better understanding
of CT or of using the theoretical model of CT that
was introduced in the training. Some commented
on the usefulness of particular concepts that were

Table I. Trainees’ reports of changes in awareness and understanding of CT.

Theme n = 54 Example

More aware of my countertransference
responses
Reflect on or analyze
countertransference
A better theoretical understanding
Countertransference and the
therapeutic relationship
Can manage countertransference better
No or have not worked with a client
since the training
49 Yes, I often notice them more now, even the subtle ones that don’t cause a strong
emotional reaction in me. I’m also better at noticing them in the moment rather than
whilst reflecting on the session.
29 I find myself checking in with some frequency. What is going on here? Why am I thinking
this etcetera. What is my motivation here? Where has this come from?
29 I didn’t know a lot about countertransference before the course and had always found it
difficult to grasp. I really appreciated that the course was practical and grounded within
a CBT/psychodynamic framework as I could relate and incorporate this with what I
already knew. From the course, I can conceptualize countertransference as being
relational and happening in the room, as opposed to my previous preconception of it
being far removed and theoretical.
27 Yes, I think it has made me more aware in total but also given me a way to describe and
utilize the feelings I might experience during a session as information about myself, the
client, or our relationship.
17 Yes, I am now much more aware of countertransference situations when they arise, and
am therefore able to make changes to my practice as I work.
5 I haven’t had a chance to see a client since the course in countertransference.
No, not really.
 Psychotherapy Research 525

used in the training. Some said that they now under-
stood that CT is “common,” that their responses are
“normal,” and do not signify that something is wrong
with them. In the fourth theme, Countertransference
and the therapeutic relationship, participants indicated
that reflecting on their CT informed their under-
standing of what was happening within the thera-
peutic relationship. Some indicated that having a
CT response triggered them to reflect on what was
happening for clients and themselves.
The fifth theme, Can manage countertransference
better, focused on changes that participants had
experienced in their ability to manage CT or included
comments on positive benefits they observed in their
practice. Some also commented on how important it
was for their practice to understand CT.
I respond to clients.” Some thought the training
had validated their emotional responses to clients.
Some reported that they now valued their CT
responses rather than seeing them as “problematic”
or “representing something I was lacking.” Some
commented that they felt more confident in regard
to their CT. In the third theme, Increases understand-
ing of the therapeutic relationship, 22 participants wrote
about the value of the increased depth of understand-
ing they now had in regard to the interpersonal pro-
cesses between themselves and their clients. This
included having a better understanding of “client
issues,” being more attuned to the “dynamics” in
the therapy relationship, and being more “empathic”
to clients. Some commented that this increased
understanding was important or “essential” as part
of clinical practice.

Has the training been meaningful for your

professional development?. One participant
reported that the training had not been meaningful
and two made positive statements but also commen-
ted on some aspect of the training they did not under-
stand. Three themes emerged from trainees’ positive
responses to this question. In the first theme, I have
learnt important knowledge and skills, 23 participants
wrote general statements about a range of knowledge
and skills they had gained from the training that was
important to their professional development. These
included being more “self-reflective” or developing
a “reflective attitude,” being better able to “identify”
CT, and “conceptualize” CT. Some also talked
about gaining “useful knowledge” that “added
value” to their clinical practice. In the second
theme, Personal gains and insights, 25 participants
talked about other personal effects of the training.
This included understanding or questioning “my
own reactions” and having more awareness of “how
Other comments and recommendations for
change. Thirty-four participants responded to the
fourth question asking for further comments or rec-
ommendations for change (see Table II). Twenty-
six commented on positive aspects and 24 made com-
ments about problematic aspects of the training or
recommendations for changes. The positive com-
ments were placed together in the first theme titled
Positive comments. These comments often overlapped
with previous comments and there were also some
positive comments about the trainer’s style. The
second theme, More time, included comments about
having more time for the training and for related
activities. The third theme, Clarifying concepts,
included comments about some confusion or the
need for more clarity in regard to concepts taught
in the training. The fourth theme, More on managing
countertransference, related to the desire to have
received more training in managing CT and some

Table II. Other comments and recommendations.

Theme n = 34 Example

Positive comments
More time
Clarifying concepts
More on managing
countertransference
Other
26 I think it’s an integral part of training to be a clinical psychologist and it must absolutely
remain a part of training for students.
The presenter had a manner which was non-intimidating and encouraged interaction from
attendees. The content was interesting and varied in its content.
6 Because it’s so complex and relatively new to me apart from bits and bobs I’ve read from
textbooks, I felt like I needed to reflect on this more and a two-day course would probably
be more helpful for me to grasp this concept more clearly.
4 Great training course, however the parent child and self-model became confusing for me—
otherwise great overall.
10 Answering above did make me think that if we had more time, more practice examples could
be given about how to manage countertransference.
4 I believe it may have been beneficial to provide an overview of transference and
countertransference prior to providing the group with examples as most of us are not aware
of these concepts.
526 C. Cartwright et al.

related this to having more time overall for the

0.03
0.33
0.17

0.22

0.17
0.99
d
training.

.89
.24
.54

.43

.52
.00
p

0.14
1.18
0.62

0.80

0.65
3.93
Trainee participants’ quantitative

t
evaluations of the training. Of the 54 trainee par-

For this item, the total sample size, and the one-day, two-day, before internship, and after internship group sizes were n = 53, n = 26, n = 27, n = 30, and n = 22, respectively.
ticipants, 6 (11%) reported often noticing their CT

4.59 (0.50)
4.68 (0.57)
4.73 (0.46)

4.00 (1.02)

4.68 (0.65)
4.86 (0.36)
internship
reactions prior to the training, 45 (85%) occasionally

(n = 22)
During
or sometimes, 2 (4%) never, and 1 did not complete
the question. Forty-nine (91%) participants reported

M (SD)
that this had increased since the training.
Participants were also asked to rate the training on
a number of criteria using a 5-point Likert-type scale

4.61 (0.62)
4.48 (0.63)
4.65 (0.49)

3.81 (0.75)

4.57 (0.63)
4.26 (0.73)
internship
(n = 31)
Before
(strongly disagree through to strongly agree; see

Table III. Participants’ evaluations of CT training, by total sample, and by one-day versus two-day workshops, and before versus during internship.
Table III). The highest mean scores related to the
training helping participants to understand the
concept of CT (M = 4.69, SD = 0.47), for agreement
with the idea that CT can provide insight into the

0.38
0.64
0.13

0.17

0.52
0.15
d
client’s experiences (M = 4.62, SD = 0.63), and for
participants’ increased commitment to monitoring

.17
.03
.64

.51

.07
.61
p
their own CT (M = 4.61, SD = 0.56). The training

1.41
2.28
0.47

0.66

1.87
0.51
was also highly rated for being useful for the partici-

t
pants’ professional practice (M = 4.57, SD = 0.60),

4.71 (0.54)
4.75 (0.44)
4.71 (0.46)

3.96 (0.92)

4.78 (0.51)
4.56 (0.58)
and overall satisfaction with the training was high

Two-day
(n = 28)
(M = 4.51, SD = 0.67). The lowest rating was for
the training providing ideas on how to manage CT
(M = 3.89, SD = 0.86).

For this item, the sample and group sizes were n = 53, n = 26, n = 27, n = 31, and n = 21, respectively.
4.50 (0.58)
4.38 (0.70)
4.65 (0.49)

3.81 (0.80)

4.46 (0.71)
4.46 (0.76)
Independent t-tests were conducted to compare
One-day
(n = 26)
M (SD)

participants’ evaluations of the training for those in

the one-day versus two-day training, and in their

Note: All items measured on a 5-point scale (strongly disagree through to strongly agree).
internship (final year) versus pre-internship (see

4.61 (0.56)
4.57 (0.60)
4.69 (0.47)

3.89 (0.86)

4.62 (0.63)
4.51 (0.67)
Table III). Levene’s test for testing the assumption
(n = 54)
sample
Total

of homogeneity of variance between the groups

was significant for “The training will be useful for
my professional practice” (one versus two days),
“CT can provide insight into the client’s experi- Countertransference can provide insight into the client’s experiencesa
ences” (one versus two days), and “Overall, I was
satisfied with the training” (pre-internship versus
during internship); therefore, the adjusted degrees
I am committed to monitoring my own countertransference
The training provided me with ideas about how to manage

of freedom t-test results have been reported for

The training will be useful for my professional practice

these items.
The training helped me to understand the concept of

Participants attending the two-day workshop rated

the usefulness of the training for their professional
practice (M = 4.75, SD = 0.44) significantly higher
than participants attending the one day workshop
Overall, I was satisfied with the trainingb

(M = 4.38 SD = 0.70), t(42) = 2.28, p = .03. Based

on Cohen’s (1988) rules of thumb, the mean differ-
ence of 0.37 (95% CI [0.04, 0.69]) represents a
medium to large effect size, d = 0.64. Participants
who were in their internship rated their overall satis-
countertransference

countertransference

faction with the training (M = 4.86, SD = 0.36) sig-

nificantly higher than participants who were pre-
internship (M = 4.26, SD = 0.73), t(46) = 3.93, p
< .001. The mean difference of 0.60 (95% CI
[0.29, 0.91]) represents a large effect size, d = 0.99.
Items

There were no other significant differences between

b
a

groups for the remaining evaluation items (ps > .05).
Non-parametric Mann–Whitney U tests were also
conducted on the evaluation data; the results con-
firmed the independent t-tests reported here.
Academic Responses on Qualitative and
Quantitative Questions
Qualitative analysis of academics’ responses.
The first theme, Provides a language and a framework,
included comments about helpful aspects of the
training, such as providing “a vocabulary,” a “scaf-
folding or framework,” and a “systematic way” to
consider CT issues. The second, Validates and
increases awareness of emotional responses, captured
comments about how the training “gives legitimacy”
to emotional experiences, encourages trainees to
reflect on them, and seems to stimulate more aware-
ness of feelings. The third theme, Increases awareness
of interpersonal processes, expanded this to the inter-
action between therapist and client, as most partici-
pants commented on how the training enhanced
trainee awareness of “relational issues in therapy
process,” “process issues,” and “complexities of the
therapeutic relationship.” The fourth theme, Increases
openness to or use of in supervision, addressed how the
training and the theoretical perspective affected the
supervisory relationship, both bringing more open
reflectiveness on the part of the trainee, and also
bringing increased complexities, as the supervision
relationship expands to include not just cognitive
but affective learning.
Three academic participants commented on a
challenge or concern they had in regard to the train-
ing. The first concern was about the impact of intro-
ducing CBT trainees to new and different models, as
the quote below illustrates,
Introducing other models (e.g., TA), which have
some subtle differences from CBT, may confuse
them at this stage of their training. Having said
that, I haven’t seen any evidence to support my
worry!
A second participant reported that trainees had diffi-
culty with the notion of developing “hypotheses
about their clients.” They still feel a need to “get it
right” or “deal only with facts.” The third challenge
or concern related to the extra demands and com-
plexity that the training model brought with it to
the supervisory relationship,
The model requires being willing to explore and hold
trainees’ issues more openly than training in a
specific cognitive model. This can bring demands
to supervision, which sometimes leans toward a
more therapeutic relationship.
Psychotherapy Research 527
Table IV. Mean scores and standard deviations for academics’
evaluations of the training.
Mean
Item score SD
I am pleased that our students took part in this 4.80 0.45
training (n = 5)
I observed an increase in awareness of 4.20 0.45
countertransference with students I worked
with following the training (n = 5)
I observed a better understanding of 4.20 0.84
countertransference with students I worked
with following the training (n = 5)
I observed a decrease in countertransference 3.25 1.26
behaviors in sessions with students I worked
with following the training (n = 4)
I recommend this training, or an adaptation of 4.40 0.55
it, to other programs (n = 5)
I hope to continue offering this training, or an 4.80 0.45
adaptation of it, in our program (n = 5)
All participants reported that their programs were
planning to continue the training, or an adaptation
of it, attributing this to “positive student feedback,”
the “usefulness” and “importance” of the topic, and
the “positive impact” for trainees and clients. There
was one suggestion for change to the training which
was to include “real therapy transcripts illustrating
the concepts” taught in the workshop.
Academic participants’ quantitative
evaluations of the training. The academic partici-
pants reported they were pleased their program had
taken part in the training (M= 4.8) and hoped to con-
tinue offering the training (M = 4.8; see Table IV).
They reported observing an increase in trainees’
awareness of CT (M = 4.2) and a better understand-
ing of CT (M = 4.2). There was a lower level of agree-
ment, however, with observating a decrease in
trainees’ CT behaviors following the training (M =
3.25).
Discussion
In line with the first aim of the training, the majority
of trainees reported increased awareness of CT and
an increase in actively reflecting on CT. Similarly,
the academics reported observing an increase in trai-
nees’ awareness of CT accompanied by more open-
ness to talking about CT in classroom situations or
in supervision. In line with the second aim, the
majority of trainees indicated through their written
statements and ratings that their understanding of
CT had increased as a result of the training. They
reported finding it helpful to have the theoretical
model and its associated language to make sense of
528 C. Cartwright et al.
and communicate about CT. The academic partici-
pants made similar observations and noted that trai-
nees now had a “language” for talking about CT,
and a “framework” or “scaffolding” to help them to
make sense of these experiences.
While the training focused primarily on under-
standing what is termed objective CT, the impor-
tance of the “hook” in the therapist’s personality
was acknowledged throughout the training along
with the notion that many CT responses contain
influences from both the client and therapist. Trai-
nees were also encouraged to reflect on their own
internalized self-other representations. In their reflec-
tions, trainees appeared to hold this in mind as evi-
denced by the way they talked about increased
understanding of the “complexity” or the “dynamics”
of the therapeutic relationship; and having an
increased understanding of “myself, my client and
our relationship,” “my own dynamics” or “motiv-
ations” and “what I bring to therapy.”
The trans-theoretical model of CT used in the
study aimed to introduce the trainees to the psycho-
dynamic notion that CT can be a source of infor-
mation and understanding about the client (e.g.,
Gabbard, 2001). Trainees responded positively to
the notion and rated the relevant item highly. Some
reported they now responded to CT as a signal to
attend to what is happening for the client. Some com-
mented that the concept of self-other representations
was helpful in this regard. Academics also commen-
ted on the enhanced understanding of the complexity
of the therapeutic relationship. One commented that
“the clash” s/he expected students to experience
between the trans-theoretical and CBT models did
not appear to happen. The translation of the con-
structs used into CBT terms throughout the training
may have contributed to the trainees’ acceptance and
understanding of the model.
There is some previous evidence that trainees
defend against their CT reactions (Brody & Farber,
1996). Some trainees and academic participants
observed that trainees felt their CT reactions had
been normalized or validated or that they no longer
felt uncomfortable or “wrong” in regard to CT.
The format of the training may have contributed to
this. Trainees were immersed in discussions about
CT for one or two days, had the opportunity to
hear about others’ CT experiences, and to work
together to make sense of these. They used the
PAC model regularly to consider if they had moved
out of the “Adult” position into a CT response.
The trainer observed that this appeared to normalize
CT and increase awareness and conceptualization.
The two-day format, in particular, appeared to
provide a more intensive immersion in thinking and
talking about CT. This was reflected in trainees’
ratings. All of the six items were rated higher by the
two-day trainees, and one item, the usefulness of
the training for professional development, reached
significance. Interns, final year trainees, also rated
five of the six items higher than pre-internship trai-
nees, and the item regarding overall satisfaction
with the training reached significance. This increased
satisfaction may reflect the developmental stage of
these senior trainees who are working more inten-
sively with clients and have more experience of their
own CT and therapy processes.
Given that awareness and understanding of CT
(Latts & Gelso, 1995; Robbins & Jolkovski, 1987)
may promote management of CT, we could expect
the training to lead to some gains in this area. Some
trainees wrote about increased confidence in mana-
ging CT. The modest rating (M = 3.89) of the train-
ing’s provision of ideas about how to manage CT,
while lower than other ratings, may represent the
beginning of the trainee therapist’s life-long process
of learning to manage CT. However, the academic
participants also gave the lowest rating (M = 3.25)
to the statement “Following the training, I observed
a decrease in CT behaviors in students I worked
with.” As will be discussed, this lower rating is
likely to reflect the empirical attitude of the academic
participants who were hesitant to make definitive
claims about changes in CT behaviors based on
observations of trainees as opposed to measurement
of CT behaviors of individual participants. This
leads us to the limitations of the study.
An important aspect of the current study was the
extension of the training into CBT-oriented clinical
psychology programs that do not offer training in
CT. The data collection methods used in this study
were appropriate for the university programs and
for the participatory nature of the study. However,
as noted, the study relies on trainees’ self-reports
and the observations and self-reports of participating
academics. While the data the academics provided is
important, especially in regard to understanding the
programs’ responses to the CT training overall,
their data are based on subjective observations
rather than measurement of changes in management
of CT in individual trainees. Further, the trainee data
were collected approximately three weeks after the
training was completed. This gap was designed to
allow trainees to reflect on the training before evalu-
ating it. However, this is still a relatively small
amount of time for trainees to translate what they
learnt into practice. If the training was indeed
helpful in providing ideas about how to manage
CT, it seems likely that trainees would take more
time to trial different strategies.
A small number of previous studies of CT manage-
ment in clinical practice (not in training) have used

supervisor ratings (e.g., Gelso et al., 2002) and this
may be desirable given the evidence that trainees
have difficulty accurately assessing their own CT
management (Hofsess & Tracey, 2010). In terms of
CT measures, Hayes et al. (2011) note that the CFI
(Van Wagoner et al., 1991) or a shortened version,
for example, the CFI-D (Gelso et al., 2002) is the
most commonly used measure of CT management.
Had this fit within the scope of the current study, it
would have been interesting to examine the changes
in the CFI from pre- to post-intervention, especially
given the overlap, noted previously, between the
training components in this study and the five CT
management factors measured by the CFI (Van
Wagoner et al., 1991). As Fatter and Hayes (2013)
note, however, it is also desirable that studies of CT
management use measures that examine actual
changes in CT behaviors. One such measure, the
Inventory of Countertransference Behavior has ade-
quate reliability and concurrent validity with the
CFI (Fauth, 2006). It measures positive CT beha-
viors (e.g., “The counselor seemed to agree too
often with the client in the session”) and negative
CT behaviors (e.g., “The counselor treated the
client in a punitive manner in the session”) (Fried-
man & Gelso, 2000, pp. 1227–1228).
Hence, while there is some evidence that trainees
may have gained some ideas about how to manage
CT, without pre- and post-intervention measure-
ment of changes in CT management or CT beha-
viors, we cannot be confident that the reported
learnings translated to changes in clinical practice.
It is also possible that trainees and academics may
have rated the training or aspects of it highly out of
appreciation of a new training being provided by an
academic from another university, although alterna-
tively they may have rated the training more highly
if they were familiar with the trainer.
In terms of future directions, it is important to con-
tinue to study training approaches to CT manage-
ment given the potential deleterious effects of CT
on therapy outcomes and the positive benefits of
understanding and managing CT (Hayes et al.,
2011). It is important to note, however, that Hayes
et al. (2011) remind us that little is known conclus-
ively about the CT management factors that modify
CT reactions. The current study was based on a
small amount of evidence that awareness of CT in
combination with an ability to conceptualize CT
may enhance CT management (Latts & Gelso,
1995; Robbins & Jolkovski, 1987), as may empathic
ability (Baehr, 2004; Peabody & Gelso, 1982).
These three competencies overlap with the five thera-
pist qualities measured by the CFI and thought to
promote CT management (Gelso & Hayes, 2007;
Van Wagoner et al., 1991). Therefore, ongoing
Psychotherapy Research 529
research into factors that facilitate CT management
is needed (Hayes et al., 2011) and defining these
factors will contribute to the development of training
in CT. A recent study, for example, found that trai-
nees’ meditation experience and their non-reactivity
(one aspect of mindfulness) were positively correlated
with supervisors’ ratings of CT management qualities
(Fatter & Hayes, 2013). Studies such as this are infor-
mative about therapist factors associated with CT
management, and activities, in this case, that trainees
can engage in to enhance their ability in this area.
In addition to research into therapist factors associ-
ated with CT management, it may be helpful to study
trainees’ experiences of learning about CT. Qualitat-
ive methods have proven useful in psychotherapy
training research. Hill et al. (2007), for example,
used weekly reflective journals to study the key chal-
lenges faced by novice trainees’ in the initial phase of
their training. Interview studies have also shone light
on a range of experiences that have important impli-
cations for training, such as the impact of trainee self-
criticism during training (Kannan & Levitt, 2015),
and trainees’ views and experiences of personal dis-
closure in client work (Bottrill, Pistrang, Barker, &
Worrell, 2010). Such studies help to provide insight
into the development of therapeutic competencies
and the obstacles to learning that occur, as well as
defining future training and research directions.
In the current study, the final year trainees
(interns) rated the training more highly. It was also
observed that individual trainees, as found previously
(e.g., Latts & Gelso, 1995) appeared to vary in their
awareness of CT. They also appeared to vary in the
ability to understand and apply the concepts in case
analysis. Hence, it is important to develop trainings
that assist those who are less aware and/or have
greater difficulty conceptualizing CT. Engaging trai-
nees in qualitative studies, either using interviews or
reflective journals/diaries at early, middle, and later
stages of training may help to answer important ques-
tions such as: How does awareness and understand-
ing of CT develop across training and what
experiences during training foster these abilities? It
is also important to note that some trainees in this
study suggested that more time be given to CT man-
agement strategies. As Fatter and Hayes (2013) point
out, little is known about the strategies that therapists
use in CT management. Studying the strategies of
experienced therapists may contribute to understand-
ing of what underlies successful management. These
strategies, once defined, could be introduced into
training programs in a developmentally appropriate
way.
In conclusion, this study examined the impact of a
trans-theoretical training designed to be accessible to
trainee therapists that are not psychodynamically
530 C. Cartwright et al.
trained. Trainees in this study came from CBT-
oriented programs in which CT theory was not
taught. The training aimed to enhance awareness of
CT, provide a method for conceptualizing CT, intro-
duce strategies for managing CT, and thereby
promote CT management. The results of the study
are promising. Trainees and academic participants
reported trainees’ increased awareness and conceptu-
alization of CT, and trainees reported gaining some
ideas about how to manage CT. However, the
results rely on qualitative data and self-report of the
trainees and academic participants and are therefore
inconclusive in regard to the translation of learning
into clinical practice. For future directions, further
research is needed into the factors that promote CT
management in order to enhance evidence-based
trainings. It is also important to define the strategies
that experienced therapists use to effectively manage
CT, in order to further develop training strategies.
Acknowledgement
We would also like to thank the Clinical Psychology
staff and students who took part in this study.
Disclosure statement
No potential conflict of interest was reported by the
authors.
Funding
We would like to thank Ako Aotearoa New Zealand:
National Centre for Tertiary Teaching Excellence for
funding this study.
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