Supervising trainees who counsel clients with borderline personality characteristics: implications for training and practice.
This article presents findings from an exploration of clinical supervisors "perspectives of the process of supervising trainees who counsel clients with borderline personality characteristics. Six supervisors, from private practice settings, nonprofit agencies, and counseling and training centers, participated in three rounds of interviews. They explored the supervision process with trainees who counsel clients who exhibit these characteristics and the influence these characteristics had on the supervision process. Recommendations based on these findings are offered for supervision in clinical practice, counselor education, and training.
Current literature on the process of supervising trainees supports the general notion that supervision is required for development as a counselor (Bernard & Goodyear, 2004); however, the literature is very limited in addressing supervision of trainees who counsel clients with specific personality characteristics. Holloway (1995) noted "the relevance of these characteristics has not been studied within the context of supervision, training or both" (p. 94). While myriad mental health issues may be addressed in counseling and supervision processes, one that may be particularly difficult for preservice counselors to deal with is borderline personality disorder (BPD). Also, clinicians in training may find clients with BPD characteristics more challenging than those actually identified as having BPD. Characteristics associated with BPD are exhibited by clients who do not meet all five DSM-IV-TR diagnostic criteria (American Psychiatric Association, 2000). An individual with borderline characteristics will vacillate among the behaviors characteristic of clients with BPD. The characteristics exhibited may be less intense than those of clients diagnosed with BPD and thus much more difficult for a clinician in training to recognize. The client with borderline characteristics may present as clingy, helpless, resentful, and stubborn, with hostile outbursts, expressions of self-pity, and self-denigrating guilt (Millon, 1981).
The National Institute of Mental Health (NIMH; 2007) described BPD as a pervasive instability of interpersonal relationships and emotional regulation leading to a high risk of suicidal ideation and self-injurious behavior. Ebner-Priemer, Welch, Grossman, Reisch, Linehan, and Bohus (2007) indicated that the "emotion dysregulation in BPD comprises increased sensitivity to emotional stimuli, unusually strong reactions, the occurrence of complex emotions, and problems identifying emotions" (p. 266). While its exact cause or source is not known, Mayo Clinic staff (2006) suggested that BPD may be the result of harmful childhood experiences; other researchers have alluded to potential genetic or neuro-biological causal factors (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004).
According to Lawson (2000), BPD is the most common personality disorder, affecting nearly six million individuals in the United States; supporting data suggests that it reportedly affects over 2 percent of adults (NIMH, 2007). The Mayo Clinic staff(2006) contended that as many as one out of every 33 women suffers from BPD. Complications affect the individual's life by straining relationships with significant others; causing instability in employment, school, or work life; hampering social activities; and fostering negative self-image and self-worth (Mayo Clinic staff). Moreover, individuals with BPD reported greater internal aversive states of tension that those considered mentally healthy (Stiglmayr, Grathwol, Linehan, Ihorst, Fahrenherg, & Bohus, 2005). Symptoms that may affect the counseling process include volatile behavior, self-destructiveness, manipulation, impulsivity, and fear of abandonment. Moreover, therapists may not at first recognize BPD, especially when suicidal ideation and depression are not manifesting (Lawson). However, in spite of the inherent difficulties faced by individuals with BPD, including the challenges for clinical trainees who counsel them, effective intervention can promote positive growth and change in these clients (Mayo Clinic staff; NIMH; Lawson). Therefore, attention to BPD and the supervision process is an important consideration in counselor education and training programs.
As indicated by the Mayo Clinic staff (2006), psychotherapy is the core treatment for individuals with BPD characteristics. Clinical supervisors are challenged by the experiences of supervising trainees who counsel clients with these behaviors. According to Buechler (1996), to minimize the feelings of frustration for clinical supervisors and trainees, supervision should focus on the relationship with the trainee; but Buechler only briefly explored the relationship and parallel process issues in supervision with trainees who counsel clients with BPD characteristics. Glickauf-Hughes (1997) stated, "The client with borderline personality is not capable of establishing a relationship with the therapist, which can be considered the most significant part of the therapy process" (p. 106). Concomitantly, as Buechler noted, "The lack of the relationship between the client with borderline personality characteristics and the trainee is often repeated with the trainee and the clinical supervisor" (p. 89).
Clients with BPD characteristics seem to suffer from a lifelong history of unstable relationships (Lawson, 2000; Mayo Clinic staff, 2006; Millon, 1999; NIMH, 2007), a situation which may limit development of trust and rapport within the therapeutic alliance. The counselor education curriculum in clinical supervision does not specifically address how to supervise trainees who counsel clients with particular characteristics (Borders, Cashwell, & Rotter, 1995; Holloway, 1995). Holloway defined a need for further research in the areas of supervision and client characteristics by indicating that while the client is always present in supervision, there is little research that examines how client characteristics affect the supervision process. Thus, while this issue is of importance, there is a dearth of literature to support understanding of supervision for trainees counseling clients with BPD.
This article reports on grounded theory research, utilizing a three-stage coding process of fragmented data (Grbich, 2007), into the perceptions of clinical supervisors who supervise trainees who counsel clients with BPD characteristics. The paradigm reported is a discovery-oriented, exploratory methodological approach. Werstlein and Borders (1997) viewed discovery-oriented research as a necessary first step in systemic inquiry into a phenomenon, with the goals of describing what is actually happening and generating hypotheses for future study. Inasmuch as grounded theory "uses the inductive approach (which relies heavily on observation to develop understandings, processes, laws and protocols)" (Grbich, p. 71), this study was designed to answer the research question, What are clinical supervisors' perceptions of the supervision process with trainees who counsel clients with BPD characteristics?
Six participants were selected based on purposive sampling in order to gather data from a small, manageable sample of participants. In grounded theory research, study participants inform the researchers about an embedded social phenomenon within a given context and with greater depth (Miles & Huberman, 1994), and this type of sampling is appropriate for this approach (Grbich, 2007). Glesne (1999) discussed how the logic and power of purposive sampling for qualitative research lies in selecting information-rich cases. Specifically, purposeful sampling is the process of selecting 6-10 participants who will yield cases from which the researcher can learn a great deal about issues central to the purpose of the research (Rossman & Rallis, 2003). Among the criteria applied in selecting clinical supervisors to participate in this study were having (a) an interest in this topic, (b) three to five years of supervision experience, (c) a license as a professional counselor, (d) at least one experience with supervising trainees who have counseled a client with BPD characteristics, and (e) a willingness to meet for three interviews lasting 45-60 minutes each.
Before the investigation began we made several ethical assumptions, including the necessity of beneficence, respect, and justice (Robinson & Curry, 2007). First, the Human Subjects Committee (Institutional Review Board) granted approval (Rossman & Rallis, 2003). Second, for the purpose of field notes, transcription, and analytic memos, participants were given fictitious names to protect their identity and maintain confidentiality and anonymity. The informed consent protocol stated that participation was voluntary and participants had the right to terminate at any time (Rossman & Rallis). All participants granted permission for use of their information and experiences in this and future articles.
Participants were recruited from counseling and training centers, universities, and nonprofit counseling agencies. A call to participate was issued through the researcher's state Licensed Professional Counselor Board list of approved supervisors. There were six volunteers, five female and one male. Five participants were Caucasian and one Asian. Five had earned a Ph. D., and one an M. Ed. Participants also reported years as a licensed professional (2-13), years of supervising (3-9), and age (28-55).
In the grounded theory approach, the analysis and collection of data continues until "all of the major concepts and their interrelationships have been theoretically saturated and the researcher can find no additional data which embellish the theory" (Zaruba, Toma, & Stark, 1996, p. 441). The data collection and analysis procedures allowed for redundancy in emerging themes and patterns related to clinical supervisor perceptions of the supervision process with trainees who counsel clients with BPD characteristics. It also allowed the first author (the researcher) to look in depth at the interactions to see how the supervisors defined and experienced supervision involving clients with BPD (Grbich, 2007).
Individual interviews were conducted with clinical supervisors meeting the selection parameters who agreed to participate in the study. Each of the three interviews lasted about 60 minutes. All were audiotaped and transcribed by a professional transcriber, which contributed to the use of low-inference descriptors during analysis to satisfy reliability criteria (Silverman, 2001). However, Silverman cautioned that transcription may weaken reliability due to exclusion of critical data, such as participant pauses, hesitations, and dialectical overlaps. We attempted to counter this potential limitation by use of journals, memos, and observations recorded during the interview process. Interviews were scheduled about three weeks apart; this allowed time for analysis and preparation for subsequent interviews (Lichtman, 2006). Simultaneous analysis of the transcripts allowed the researcher to reformulate and narrow the focus of interview questions for the next interview.
The initial interview questions included: (a) How would you describe your reactions when supervising trainees who counsel clients with BPD characteristics? (h) What are your perceptions about how such reactions influence the relationship between you and the trainees? and (c) What are your perceptions about the differences and similarities during the supervision process with trainees who counsel clients with BPD characteristics compared with trainees who counsel clients who do not exhibit BPD characteristics? Later interviews continued until dominant themes were saturated and thickly described and a conceptual framework pertinent to the supervision process emerged.
Participants were involved in discussions about themes and patterns that emerged during each round of interviews, thus allowing them to confirm the findings of this study. Themes and patterns enhanced and narrowed the data from each round. Data were analyzed by case and across each round of interviews. Patterns and emergent themes were sought both to better understand supervisors' perceptions and to conceptualize a model of the supervision process.
To verify the authenticity of data and their interpretation, as well as to bracket researcher biases, several verification procedures were implemented. We kept a journal of theoretical memos, participant observation notes (Wolcott, 2001), and analytical reflections made during interviews. The journal was also meant to capture issues of researcher reflexivity during the dialogue with participants and to help bracket any biases or assumptions that arose. Specific attention was given to how bias may have affected the data collection process (Rossman & Rallis, 2003). Several techniques were employed throughout to protect against researcher biases, among them spacing the interviews, peer consultation, "rich" data, and consultation with experts in counselor education.
The study used a coding process. As Strauss and Corbin (1998) state, the process of analysis and coding is "dynamic and fluid" (p. I01). Data gleaned from the individual interviews and the researcher's journal were coded by using open, axial, and selective coding (Grbich, 2007) and then presented in conceptually ordered displays. The reason for using so many layers of coding is "to expand, transform, and re-conceptualize data, opening up more diverse analytical possibilities" (Coffey & Atkinson, 1996, p. 29). First we began content analysis (Wolcott, 2001) by utilizing open coding, the process of assigning tags or labels to "chunks" of information that may or may not be connected to the study. We were able to assign data to categories of general themes and patterns with the intention of defining these themes and patterns more specifically (Strauss & Corbin).
Next, data were axial-coded, which meant specifying the categories that surround specific concepts and creating properties to define the concepts (Christensen & Kline, 2001). Strauss and Corbin (1998) define axial coding as "the process of relating categories to their subcategories ... at the level of properties and dimensions" (p. 123). It was used here to identify specific themes and patterns as they continued to emerge and assign meanings to categories and subcategories. The next step was selective coding, in order to further specify themes, patterns, and concepts and use data to explicate theoretical constructs. The information obtained through previous data analysis was integrated to identify the dimensions, relationships, directionality, and concepts of the themes and patterns emerging from the research (Strauss & Corbin).
An arrangement of data gleaned from the coding process into clear themes and patterns is a conceptually ordered display. This matrix will "best capture all the dimensions I am interested in and arranges all the pertinent data in readily analyzable form" (Miles & Huberman, 1994, p. 183). The themes and patterns became clearer, which allowed us to compare the data. In comparing data, we determined which cases had recurrent themes. This display facilitated design of a conceptual framework of clinical supervision when clients exhibit BPD characteristics.
Supervisor conceptualizations emerged as a finding. Conceptualizations pertain to supervisor thoughts, understandings, and ideas about the supervision process with trainees who counsel clients with BPD characteristics. The research found four major themes, each with subthemes encapsulated (see Table 1): (1) the influence on the supervisory relationship; (2) identification of differences during the supervision process with trainees who counsel clients who exhibit BPD characteristics and with trainees counseling clients who do not; (3) identification of similarities in supervision of trainees with or without BPD clients; and (4) enhanced understanding of the characteristics related to BPD.
Theme 1: Influence on the Supervisory Relationship
Awareness of the influence on the supervisory relationship was defined as a developmental process that occurred over a period of time. Participants indicated that the relationship between trainees and supervisors was crucial to the supervision process. As participants described specific aspects of the influence of the supervisory relationship, they consistently referred to three subthemes: collaboration, mentoring, and modeling.
Subtheme A: Collaboration
Collaboration referred to working with others while providing feedback to enhance the supervision process. It referred to participant conceptualizations of supervisory relationships. It also referred to the necessity of a positive relationship and the importance of feedback for trainees who counsel clients with BPD characteristics. This was identified as critical because clients with these characteristics can elicit feelings of anxiety in the counselor in training, which may exacerbate power struggles during the supervision process. Following is how one participant described this subtheme:
I think my trainees were receptive to the feedback that I was giving and felt supported as we developed collaboration. They would say that feedback had helped them or that they felt it was a really positive supervision relationship.
Subtheme B: Modeling
Some participants qualified one characteristic of the supervisory relationship as modeling. Modeling, for this investigation, was defined as providing an example for the trainee to imitate or emulate. Supervisors expected this type of modeling to increase the counselor trainee's feelings of efficacy in helping clients with BPD characteristics. For instance, one participant said:
I've tried to help counselors develop relationships when they are working with individuals who have borderline characteristics. I help them to become motivated and know that they are competent and that they do have the tools and skills to help these individuals, I become open and more intimate with them, and I model how to become more open and intimate in their relationships with clients.
Subtheme C: Mentoring
Some participants used the word mentoring to represent the entire supervisory relationship. Mentoring referred to guiding trainees and establishing a sense of universality while helping them to become effective counselors. The mentoring process was also described as mutually growth-producing and reciprocal for both supervisors and trainees. As an example of the mentoring subtheme:
I work very hard at mentoring my supervisees. I think I'm pretty open with my supervisees and ask them for feedback about our supervision process.
Participants indicated that building and maintaining healthy relationships was particularly necessary while supervising trainees who counsel clients with these characteristics because of the frustration and emotional struggles many trainees experience. These findings support those of Buechler (1996), who noted that a focus on the supervisory relationship is a way to minimize frustration and anxiety for both clinical supervisors and trainees. Agreeing with Buechler, Borders and Fong (1991) cited the importance of understanding relationship variables that affect the supervisory relationship, among them collaborating, mentoring, and modeling, which the findings on Theme #1 of this study confirmed.
Theme 2: Differences During the Supervision Process
Participants revealed that they could identify distinct differences during the supervision process between trainees who counseled clients with BPD characteristics and those whose clients did not exhibit these characteristics. This was apparent in two main subtheme categories. Subtheme D involves acknowledging trainee frustration when the client exhibits BPD characteristics, and Subtheme E indicates substantial growth and development opportunities for the trainee.
Subtheme D: Acknowledging Trainee Frustration
Supervisors indicated that they acknowledged and affirmed the difficulty for trainees who counsel clients with BPD characteristics. Inherent in this subtheme is validation that the client is indeed presenting the counselor with unique challenges. Here is an example of this subtheme:
When trainees have a borderline client, they see little progress. It's very stressful for the trainees. The counseling process zaps a lot of their energy. I acknowledge the stress for the trainees during my supervision sessions.
Subtheme E: Trainee Growth and Opportunity
Conceptually, participants identified the major difference in the supervision process for trainees who counsel clients with BPD characteristics is acknowledging the trainees' frustrations and difficulties with these clients. Participants also identified how experiences of counseling and supervision for trainees are more comprehensive and afford more personal growth, and how the supervision process creates a challenge for trainees because of client characteristics. Two examples of this subtheme:
The intensity of the issues with clients with borderline personality characteristics is so different, especially when the client has had a psychiatric diagnosis. The issues are not the norm, and if they were, we would handle it differently. It is a big difference and a challenge that can lead to personal growth and development of supervisees.
I think the trainees' experience is richer when they finish their supervision because they have learned more than probably some trainees who have not dealt with this type of client.... The counseling process is difficult.... The supervision and counseling process is more challenging, but I think after the supervision and counseling process, trainees have experienced more personal growth.
Theme # 3: Similarities During the Supervision Process
The participants identified general similarities during the supervision process as an emergent theme. The responses indicated that participants viewed specific similarities as interventions and relationship building, which included addressing trainee anxiety. They thought these similarities were not just characteristics of the supervision process with trainees who counsel clients with BPD characteristics but could be applied to any type of supervision. Participants chose interventions as their initial choice of methods with trainees in order to provide effective services to clients. They discussed several general similarities about the supervision process. These findings are supported by Bernard and Goodyear (1998), who reinforced concern for trainee stress and anxiety during the supervision process: "Anxiety experienced anywhere in the multiperson system that comprises supervision can shape the entire system" (p. 75). Additionally, as Buechler (1996) noted, supervision can be driven by these anxieties if not managed properly through the development of the supervisory relationship.
Participants recognized the need to manage trainee stress and anxiety by developing and maintaining a relationship regardless of client issues or characteristics. Statements from this category focused on direct interventions that were similar for trainees regardless of client characteristics. The following is an example:
Some of the similarities are staying focused on the treatment plan during supervision regardless of the client characteristics. Additionally, talking about self-care during supervision and not getting too involved with clients. These are all fairly similar.
Theme # 4: Client Characteristics
This category included disparities in the supervisors' views of clients with BPD characteristics. For instance, one participant conceptualized these clients as needy and dependent. Another described how such clients never take responsibility for their actions. Such divergence in supervisor conceptualization may decidedly impact trainee conceptualization and understanding of BPD characteristics. This finding is supported by Millon and Davis (2000), who described behaviors of clients with BPD characteristics as follows: intense and urgent closeness in relationships, frequent ups and downs with attachments to significant individuals in their lives (including trainees during the counseling process), emotional rather than logical processing of all experiences, and strong bouts of spontaneity and creativity. Following are examples of these varied conceptualizations:
I think clients with borderline personality characteristics are probably most needy. People with borderline traits portray that constant feeling of, "I hate you; please don't go away."
Taking responsibility for their actions is not always what they want to do. This can create stress for trainees, as they might think they need to be responsible for the client's progress during counseling.
Participants focused on several themes related to the supervision process, among them the influence of the supervisory relationship, similarities and differences during the supervision process, theoretical orientation, and client characteristics (see Figure 1).
Buechler (1996) described the need to focus on supervisory relationships with trainees who counsel clients with BPD characteristics. Specifically, he suggested that supervisors need to go beyond solely teaching clinical skills; they should foster the professional identity and growth of trainees as distinct individuals, which are enhanced by attention to supervisory relationships. Participants maintained that if they could model support and empathy for their trainees, the trainees could better support and empathize with clients with BPD characteristics. As Millon (1981) contended, these clients have difficulty establishing a therapeutic alliance with trainees because of behaviors manifested during the counseling process that include "intensity of their affect, changeability of their actions, rapid shifts from one mood and attitude to another, a self-ingratiating depressive tone, anxious agitation or impulsive outbursts and inappropriate anger or temper" (p. 349). Participants acknowledged the fact that clients with these characteristics have difficulty developing and maintaining relationships with trainees, so that it is even more crucial that supervisory relationships be well maintained.
[FIGURE 1 OMITTED]
Participants conceptualized similarities and differences during the supervision process. They identified several global similarities in terms of supervision, such as interventions and relationship building, and thought that trainees' anxiety was similar during the supervision process regardless of client characteristics.
One finding of interest was that participants did not report varying their theoretical orientation in supervising trainees who counsel clients with BPD characteristics. All described their theoretical orientation as constant in both counseling and supervision regardless of client characteristics. All further cited the importance of developing collaborative relationships in which they could mentor and model behaviors for trainees regardless of client characteristics. However, they noted how specific client characteristics could affect supervisory relationships.
Participants conceptualized several differences related to the supervision process. On a cognitive level, one major difference was to identify how important it is to acknowledge trainees' frustrations and recognize their difficulty in counseling clients with BPD characteristics. Four of the six participants mentioned the importance of acknowledging the increase in frustration and difficulty in counseling such clients, and how these client characteristics influence the supervision process and create a challenge for trainees.
When participants discussed their competence and experiences with trainees who counsel clients with these characteristics, two interesting findings emerged. The first was that four of the six participants thought that previous clinical experiences with this population of clients is critical for effective supervision. Of the four, one wondered if her feelings of inadequacy were due to her lack of clinical experiences with this population.
The second finding that emerged was the lack of formal training for supervisors, as well as trainees, in working with clients who exhibit BPD characteristics. Four of the six participants discussed the need for training future therapists on interventions, behaviors, and issues that may emerge when counseling such clients. Participants also thought they were not adequately trained to supervise trainees who counsel clients with BPD. To provide adequate supervision, they consulted, researched issues pertaining to BPD characteristics, and sought clinical experiences with this population. Their experiences support the notion that the educational curriculum in clinical supervision does not specifically address supervision of trainees who counsel clients with specific personality characteristics (Borders, Cashwell, & Rotter, 1995; Holloway, 1995).
This study is subject to the major limitations of qualitative research. Because the sample is small and purposive, there is no guarantee of representation, so the findings are not generalizable. However, they may be transferable to similar supervision scenarios. Further, while we were cognizant of our own biases, the reflexive and interactive nature of qualitative research is in essence a complex and varied reciprocal exchange between researcher and participants. Therefore, the composite research data are interpreted through the researcher's own paradigm--making it a personal construction of meaning during data analysis (Rossman & Rallis, 2003). Moreover, findings from this study are "tentative and conditional" (Rossman & Rallis, p. 134), given that it used only one technique (individual interviews) to explore the research question. Additionally, the sample was self-selected in order not to guarantee representation and generalization of the findings to the supervision process.
AREAS FOR FUTURE RESEARCH
The purpose of this study was to explore supervisors' cognitions about the supervision process; specifically, to investigate the relationship between the supervisor and trainees who counsel clients with BPD characteristics. Its limitations included issues related to trainees' perspectives, cultural diversity, specific client characteristics, and different perceptions of masters versus doctoral-level supervisors; they yield many avenues for future research. Exploring the supervision process from the trainees' point of view might also elicit a fuller understanding of perceptions of the supervision process when the clients possess certain personality characteristics. As trainees' perspectives are explored, client services may eventually be enhanced; this study explored only supervisor perceptions. Examining similarities and differences with trainees who counsel clients with these personality characteristics and trainees who counsel clients with other characteristics, such as depression and anxiety, may help supervisors analyze the entire supervision process.
Another important avenue for future studies would be to explore how cultural diversity influences the perceptions of clinical supervisors about supervising trainees. While the participant pool was diverse in many ways, only one participant was nonwhite, only one was male, and only one did not hold a doctoral degree. A fruitful area for future research might compare male and female perceptions, particularly since BPD afflicts significantly more women.
If the research of Buechler (1996) and Adelson (1995) had implications for how clinical supervisors provide supervision to trainees who counsel clients with BPD characteristics, it seems logical that knowledge gleaned from this study, given the limitations and findings, might inform curriculum and training in the areas of supervision and counseling practices. Clinical supervisors provide supervision in a variety of settings with a variety of client populations, many with particular personality characteristics. The results of this research suggest that clinical supervisors have specific conceptualizations that are directly related to how they perceive the supervision process with trainees who counsel clients with BPD characteristics.
Participants in this study indicated that they were not trained on how to supervise trainees who counsel clients with BPD characteristics. Accordingly, they acknowledged that the knowledge they impart to their trainees is a direct result of their own clinical experiences with clients. In identifying differences in supervising trainees who counsel clients with BPD characteristics, participants supported the need to teach specific supervision strategies, models, and techniques for this client population.
Participants who lacked previous experience counseling clients with BPD characteristics wondered if that lack directly influenced their lack of awareness about how they were conceptualizing the supervision process, which exacerbated feelings of inadequacy or incompetence as a supervisor. A second implication for clinical education and training is the need to teach strategies and techniques specific to counseling clients with BPD characteristics, including what behavior patterns must be targeted for change (Linehan, 2000). Within this scope of competence, future supervisors may need to acquire skills to research appropriate theoretical models and therapeutic interventions for such clients.
Trainees need to be challenged to think about developing specific strategies to work with clients with these characteristics. Staying current with contemporary innovations in research and practice is also important, for example, new developments in dialectical behavior therapy for individuals with BPD (Linehan, 2000). Counselor educators should ensure that once trainees are placed for internships, their site supervisors are prepared to provide adequate supervision when they counsel clients with these characteristics. As Holloway (1995) so eloquently stated, "The supervisor's 'raison d'etre' is to ensure that the trainee can deliver effective services to the client" (p. 92).
Adelson, M. J. (1995). Clinical supervision of therapists with difficult-to-treat patients. Bulletin of the Menninger Clinic, 59, 32-52.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston: Allyn & Bacon.
Buechler, S. (1996). Supervision of the treatment of borderline patients. Contemporary Psychoanalysis, 8, 86-92.
Borders, L. D., Cashwell, C. S., & Rotter, J. C. (1995). Supervision of counselor licensure applicants: A comparative study. Counselor Education and Supervision, 35, 54459.
Christensen, T. M., & Kline, W. B. (2001). The qualitative exploration of process-sensitive peer group supervision. Journal for Specialists in Group Work, 26, 81-99.
Coffey, A., & Atkinson, P. (1996). Making sense of qualitative data: Complementary research strategies. Thousand Oaks, CA: Sage Publications.
Ebner-Priemer, U. W., Welch, S. S., Grossman, P., Reisch, R., Linehan, M. M., and Bohus, M. (2007). Psychophysiological ambulatory assessment of affective dysregulation in borderline personality disorder. Psychiatric Research, 150, 265-275.
Glesne, C. (1999). Becoming qualitative researchers (2nd ed.). Burlington, VT: Longman.
Glickauf-Hughes, C. (1997). Teaching students about primitive defenses in supervision. Clinical Supervisor, 15, 105-113.
Grbich, C. (2007). Qualitative data analysis: An introduction. London: Sage Publications Ltd.
Holloway, E. (1995). Clinical supervision: A systems approach. Thousand Oaks, CA: Sage.
Lawson, C. A. (2000). Understanding the borderline mother: Helping her children transcend the intense, unpredictable, and volatile relationship. Northvale, NJ: Jason Aronson, Inc.
Lichtman, M. (2006). Qualitatative research in education: A user's guide. Thousand Oaks, CA: Sage Publications.
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. Lancet, 364 (9432), 453-461.
Linehan, M. M. (2000). Commentary on innovations in dialectical behavior therapy. Cognitive and Behavioral Practice, 7, 478-481.
Mayo Clinic Staff. (2006). Borderline personality disorder. Retrieved online October 19, 2007, at http://www.mayoclinic.com/health/borderline-personality-disorder/DS00442
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis. (2nd ed.). Thousand Oaks, CA: Sage.
Millon, T. (1981). Disorders of personality DSM-III: Axis II. New York: John Wiley & Sons.
Millon, T. (1999). Personality guided therapy. New York: John Wiley & Sons. National Institute of Mental Health. (2007). Borderline personality disorder. National Institute of Health Publication number #01-4928. Retrieved October 19, 2007, from http://www.nimh.nih.gov/health/publications/ borderline-personality-disorder.shtml
Robinson, E. H., & Curry, J. R. (2007). Institutional review boards and professional counseling research. Counseling and Values.
Rossman, G. B., & Rallis, S. F. (2003). Learning in the field: An introduction to qualitative research. (2nd ed.). Thousand Oaks, CA: Sage Publications.
Silverman, D. (2001). Interpreting qualitative data: Methods for analyzing talk, text and interaction. London: Sage Publications.
Stiglmayr, C. E., Grathwol, T., Linehan, M. M., Ihorst, G., Fahrenberg, J., Bohus, M. (2005). Aversive tension in patients with borderline personality disorder: A computer-based controlled field study. ACTA Psychiatrica Scandinavica, 111, 372-379.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. (2nd ed.). Thousand Oaks, CA: Sage Publications.
Werstlein, P. O., & Borders, L. D. (1997). Group process variables in group supervision. Journal for Specialists in Group Work, 22, 120-136.
Wolcott, H. F. (2001). Writing up qualitative research. (2nd ed.). Thousand Oaks, CA: Sage Publications.
Zaruba, K. E., Toma, D., & Stark, J. S. (1996). Criteria used for qualitative research in the refereeing process. Review of Higher Education, 19, 435-460.
The authors are affiliated with Louisiana State University. Correspondence concerning this article should be addressed to Laura Fazio-Griffith, 122 Peabody Hall, Louisiana State University, Baton Rouge, Louisiana 70458. Email: email@example.com.
Table 1. Finding Theme Categories and Subthemes Theme Subtheme 1. Influence on the supervisory A. Collaboration relationship B. Modeling C. Mentoring 2. Identification of differences D. Acknowledging the trainee's frustrations E. Trainee growth and opportunity 3. Identification of similarities 4. Understanding of BPD characteristics