The Supervision of Psychotherapy: Theory, Research, and 30+ Years of Experience

1. The supervision of psychotherapy: theory, research, and what I think I have learned from 30+ years of doing it James E. Maddux Department of psychology Center for the advancement of well-being George Mason UniversitY Fairfax, virginia, usa jmaddux@gmu.edu

2. Borrows GREATLY from... • Joint presentation with Jonathan Mohr, University of Maryland. • Joint presentation with Stephen M. Saunders, Marquette University J

3. USEFUL RESOURCES FUNDAMENTALS OF CLINICAL SUPERVISION BY JANINE BERNARD & RODNEY GOODYEAR (2009, PEARSON) CRITICAL EVENTS IN PSYCHOTHERAPY SUPERVISION: AN INTERPERSONAL APPROACH BY NICHOLAS LADANY, MYRNA FRIEDLANDER, & MARY LEE NELSON (2008, AMERICAN PSYCHOLOGICAL ASSOCIATION) . • Nicholas Ladany (2005) in Koocher, Norcross, & Hill (Eds.) Psychologists’ Desk Reference.

4. USEFUL RESOURCES • Bradley, L.J. & Ladany, N. (Eds.). (2001). Counselor supervision. Philadelphia: Brunner-Routledge. • Falender, C.A., & Shafranske, E.P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. • Watkins, C.E. (Ed.). (1997). Handbook of psychotherapy supervision. New York: Wiley. J

5. What is supervision and why is it important? Models of supervision Best practices based on THEORY, research, and experience. Suggestions and tips based on my own experiences. Time for questions and discussion OVERVIEW

6. UNFORTUNATELY… • NOT MUCH RESEARCH ON WHAT MAKES GOOD SUPERVISION. • WHAT I WILL PRESENT IS BASED ON A COMBINATION OF… • THEORY • RESEARCH • BEST PRACTICES (APA SUPERVISION GUIDELINES) • MY OWN 30 YEARS OF EXPERIENCES

7. QUESTIONS FOR YOU • Who has been supervised as a therapist in training? • Who has been a psychotherapy supervisor? • Who has received formal training in psychotherapy supervision? J

8. QUESTIONS FOR YOU • GOOD EXPERIENCE AS A SUPERVISEE? • BAD EXPERIENCE AS A SUPERVISEE? • GOOD EXPERIENCE AS A SUPERVISOR? • BAD EXPERIENCE AS A SUPERVISOR? • AS A SUPERVISOR, WHAT ARE YOU GOOD AT? • HOW WOULD YOU LIKE TO IMPROVE?

9. WHY IS SUPERVISION IMPORTANT? • Third most common activity among practicing psychologists in the u.s. • Required for licensure in us. • Essential part of professional self-regulation (Gate-keeper role). • Can have a impact on more people than providing direct services. • It's fascinating and fun--and a great way to learn.

10. WHAT IS SUPERVISION? "Supervision is an intervention provided by a more senior member of a profession to a more junior member or members of that same profession.” SENIOR DOES NOT MEAN OLDER—BUT MORE EXPERIENCED Bernard & Goodyear (2009)

11. SUPERVISION IS EXPERIENTIAL LEARNING • DELIBERATE PRACTICE—AIMED AT IMPROVING SPECIFIC SKILLS. • FEEDBACK FROM AN EXPERT • THAT IS IMMEDIATE, CLEAR, AND CONSISTENT • PROVIDES CLEAR UNDERSTANDING OF WHAT AN INCORRECT RESPONSE IS • AND WHAT A CORRECT RESPONSE IS. MORE LATER ON EVALUATION & FEEDBACK

12. SUPERVISION VERSUS CONSULATION SUPERVISION IS… • IMPOSED OR REQUIRED (USUALLY). • HIERARCHICAL (CLEAR POWER DIFFERENCES) • EVALUATIVE & JUDGMENTAL • EXTENDS OVER TIME • WIDE-RANGING.

13. SUPERVISION VERSUS CONSULATION CONSULTATION TYPICALLY IS… • FREELY SOUGHT--NOT IMPOSED. • NON-HIERARCHICAL (BETWEEN EQUALS). • NON-EVALUATIVE. • MORE OFTEN A ONE-TIME EVENT. • MORE PROBLEM-SPECIFIC. • FREEDOM TO "TAKE IT OR LEAVE IT."

14. SUPERVISION VERSUS PSYCHOTHERAPY SIMILARITIES… • IT INVOLVES EXAMINATION OF THOUGHTS, FEELINGS, AND BEHAVIOR THAT ARE PROBLEMATIC. • REQUIRES A STRONG WORKING ALLIANCE. • A MAJOR GOAL IS PERSONAL GROWTH

15. SUPERVISION VERSUS PSYCHOTHERAPY • BUT…IN SUPERVISION… • THE OVER-RIDING GOAL IS HELPING THE SUPERVISEE BECOME MORE EFFECTIVE WITH CLIENTS. • TO PROVIDE "THERAPY" THAT HAS BROADER GOALS IS UNETHICAL • CREATES A DUAL RELATIONSHIP—CONFUSING & POTENTIALLY HARMFUL • SUPERVISION IS EVALUATIVE BY DEFINITION AND BY NECESSITY. • DIFFERENCE IS, OF COURSE, A FINE LINE.

16. SUPERVISION IS A COMPLEX ACTIVITY THAT HAS MULTIPLE GOALS • SUPERVISEE PROFESSIONAL DEVELOPMENT • CLIENT WELFARE • PROTECTION OF PUBLIC • PROTECTION OF PROGRAM AND PROFESSION—GATEKEEPER ROLE Especially important when there are no laws regulating practice—or weak laws.

17. MOST DIFFICULT BALANCE TO STRIKE • CLIENT WELFARE VERSUS SUPERVISEE DEVELOPMENT. • HOW MUCH DO YOU TELL THEM WHAT TO DO? VERSUS • LETTING THEM USE THEIR OWN JUDGMENT? • LETTING THEM MAKE MISTAKES?

18. MODELS OF SUPERVISION • MOST Models based on theories of psychotherapy • you supervise the way you do therapy. • WILL DISCUSS FOUR—NOT MUTUALLY EXCLUSIVE—CAN BE INTEGRATED

19. Person-centered models (e.g., Carl Rogers) • Belief in growth potential. • Emphasis on conditions THAT FACILITATE THE SUPERVISORY RELATIONSHIP. • Empathy, genuineness, warmth • Providing these facilitates trust required for supervision. • Supervisor is also modeling these skills for supervisee.

20. ADVANTAGES OF Person-centered models • Most CONCERNED WITH BEING supportIVE of supervisee • Less didactic & directive than other models • ENCOURAGES AUTONOMY • Emphasizes but also normalizes fears/anxiety • “This is difficult for you. Is this harder than you expected?” • “It is difficult to confront patients.” • “I remember how nervous I was when …” • Can be EASILY integrated other models SJ

21. Cognitive-behavioral models • Psychotherapy is a set of teachable, learnable skills. • Skills can be CLEARLY defined and measured. • Supervision should have specific goals • aND should address specific THOUGHTS BEHAVIORS. • What do to more of? What to do less of? • includeS examinATION OF supervisee’S thoughts and beliefs that interfere with THEIR WORK WITH CLIENTS

22. COGNITIVE-BEHAVIORAL MODELS Challenge maladaptive beliefs of trainees • Technique: Stop tape and ask trainee: • What were you thinking and feeling when you made that response? • HOW DID THAT AFFECT YOUR BEHAVIOR? • HOW WELL DID THAT WORK? • What could you think differently next time that might help you respond more effectively? J

23. COGNITIVE-BEHAVIORAL MODELS(FROM BECK ET AL, 2008) Structure of therapy sessions 1. Mood check 2. Set agenda 3. Bridge from last session 4. Prioritize agenda 5. Discuss problems 6. Homework 7. Summary/Feedback Structure of supervision sessions 1. Check in 2. Set agenda 3. Bridge from last session 4. Prioritize agenda 5. Discuss cases, problems 6. Homework 7. Summary/Feedback JS

24. ADVANTAGES OF COGNITIVE-BEHAVIORAL MODELS • Emphasis on specific skills. • TEACHES SELF-MONITORING AND SELF-REFLECTION • Takes an incremental rather than entity view of psychotherapY TRAINING.

25. Psychodynamic models • AttenTION to the relationship • Between therapist & client • Between supervisor & supervisee • “What is it like for you to be in supervision?” • “What is it like for you during our interactions?” • “When I criticize you, what are your feelings?” J

26. Advantages of PSYCHODYNAMIC MODEL • Focuses on supervisee’s concerns and anxieties. • Focuses on supervisee’s feelings toward client & supervisor. • Deals with transference and counter-transference issues. J

27. Developmental models • NOT LINKED TO A SPECIFIC THEORY OF THERAPY • Supervisees go through different stages of development. • A different supervisory approach is needed for each stage. • Stages based on: • Self-other awareness. • Motivation. • Autonomy

28. Simplified integrative “model” • Good therapy consists to a large degree of specific behaviors or skills. • These behaviors can be defined, taught, learned, and measured. • You have to have goals. You have to know what needs to be learned. • Self-efficacy beliefs must be developed along with skills. • A STRONG WORKING ALLIANCE & TRUST ARE ESSENTIAL

29. Simplified integrative “model” • Everyone learns at a different pace. • People move back and forth between “stages” depending on the challenge. • So you have to adjust your approach person to person and moment to moment. • You are constantly modeling, so practice what you preach. • Feelings can help or hurt. You must attend to them—THE CLIENTS’, THE SUPERVISEE’S & YOURS • you must attend to the relationshipS—YOU & SUPERVISEE AND SUPERVISEE & CLIENT.

30. SUPERVISORY RELATIONSHIP • Necessity of a good supervisory alliance • Without trust and openness, then none of the tasks of supervision are possible • Can put clients/patients at risk J

31. SUPERVISORY RELATIONSHIP • WHAT THE RESEARCH SAYS: • SUPERVISORY ALLIANCE PREDICTS • SUPERVISEE WILLINGNESS TO SELF-DISCLOSE • CLIENT PERCEPTION OF THERAPEUTIC ALLIANCE • SUPERVISORY ALLIANCE RELATED TO • SUPERVISOR ETHICAL BEHAVIOR • USE OF EFFECTIVE EVALUATION PRACTICES • SUPERVISOR SELF-DISCLOSURE (PROFESSIONAL)

32. SUPERVISORY RELATIONSHIP • The alliance between the supervisor and the supervisee is the responsibility of the supervisor • Explicit attention to relationship issues facilitates the development of an alliance • Need transparency regarding roles and role conflicts, evaluation processes, expectations and requirements, etc. • WILL RETURN TO THIS LATER J

33. BUILDING A GOOD SUPERVISORY RELATIONSHIP WHAT CAN THE SUPERVISOR DO? J

34. Creating an STRONG supervisory alliancE: WHAT CAN HELP? • ATTENTIVE • DEPENDABLE • Non-authoritarian • COLLABORATIVE (IN SETTING GOALS, EVALUATION) • Empathic & Supportive • ENTHUSIASTIC & MOTIVATING • RESPECTFUL OF BOUNDARIES • TRUSTHWORTHY • OPEN TO NEW IDEAS. • FLEXIBLE. JS

35. Creating an STRONG supervisory alliancE: WHAT CAN HELP? • Provide clear and simple conceptual framework • Work to reduce anxiety, including your own. • Normalize mistake making (e.g., self-disclosure) • ASK FOR FEEDBACK (“How are we doing?”) • “Practice what you preach” (Be a good model) • MODEL GOOD PROFESSIONAL ETHICS TO DO ALL OF THIS, YOU MUST VIEW SUPERVISION AS A IMPORTANT PROFESSIONAL ACTIVITY. SJ

36. INITIAL QUESTIONS TO ASK TO DEVELOP TRUST & RAPPORT & SET GOALS • What are your previous experiences with supervision? • What was helpful? • What was not helpful? • What are your goals? • What are your expectations? • What are your fears? Concerns? J

37. INITIAL QUESTIONS TO ASK TO DEVELOP TRUST & RAPPORT & SET GOALS(ADAPTED FROM CAMPELL, 2006) • WHAT WOULD YOU LIKE TO GET OUT OF SUPERVISION WITH ME? • DO YOU HAVE SPECIFIC AREAS OF IMPROVEMENT IN MIND? • WHAT WOULD HAVE TO HAPPEN IN HERE TO MAKE THIS WORTH YOUR TIME & EFFORT? • WHAT IS THE MOST IMPORTANT THING YOU WOULD LIKE TO GET FROM THIS EXPERIENCE. • HOW CAN I BE OF MOST HELP TO YOU? • WHAT PARTICULAR NEEDS OF PARTICULAR CLIENTS CAN I BE HELPFUL WITH? J

38. THE “GOLDEN RULE” OF SUPERVISION(CAMPBELL, 2006) “Treat supervisees in the same way you wish to be treated and the same way you wish them to treat clients.” S

39. STRUCTURING A SUPERVISION SESSION • SUPERVISEE MUST COME PREPARED! • WHICH CLIENTS DO YOU WANT TO DISCUSS TODAY? • WHY THOSE CLIENTS? • HOW MUCH TIME DO YOU WANT TO SPEND ON EACH ONE? • WHICH ONE DO YOU WANT TO START WITH? • WHAT SPECIFIC CONCERNS DO YOU HAVE ABOUT YOUR LAST SESSION WITH THIS CLIENT? • PLAY A SECTION OF THE TAPE THAT WAS A PROBLEM FOR YOU. • TELL ME AT WHAT POINTS YOU WERE STUCK OR UNCERTAIN OR WHERE YOU THINK YOU WENT WRONG. • WHAT COULD YOU HAVE DONE DIFFERENTLY? • WHAT DIFFERENCE WOULD THAT HAVE MADE?

40. SUPERVISEE SHOULD BE REQUIRED TO… • BRIEFLY STATE THE CLIENT’S OVERALL GOALS. • BRIEFLY STATE THE GOALS FOR THAT SESSION. • STATE THE REASON FOR SELECTING THAT PART OF THE SESSION FOR REVIEW. • BRIEFLY SUMMARIZE WHAT HAPPENED BEFORE THAT SECTION (SET THE STAGE). • EXPLAIN WHAT HE/SHE WAS TRYING TO ACCOMPLISH IN THAT SECTION OF SESSION. • CLEARLY STATE THE SPECIFIC HELP DESIRED FROM THE SUPERVISOR.

41. USING AUDIO & VIDEO RECORDINGS OF SESSIONS • Essential • VIDEO IF POSSIBLE. • You need to see as well as hear what goes on in the session. • Cannot rely on supervisee’s report • NOT HAVING SAMPLES OF THERAPY SESSIONS TO SEE AND HEAR EASILY LEADS TO ABSTRACT THEORETICAL DISCUSSIONS • AND VAGUE SUGGESTIONS S

42. HOW TO USE RECORDINGS OF SESSIONS. • You don't need to listen to an entire session. • You can teach more through a micro-examination of just five minutes HERE AND THERE. • REQUIRE SUPERVISEE TO REVIEW RECORDING BEFORE SUPERVISION. • ASK SUPERVISEE TO PLAY A SECTION WHERE HE/SHE HAD DIFFICULTY. • AND A SECTION WHERE IT WENT WELL. • The opening minute or two of a therapy session are crucial. • USE “INSTANT REPLAY” • FOCUS ON GENERAL PRINCIPLES AND SKILLS.

43. REVIEWING BRIEF SECTIONS OF AUDIO- OR VIDEO TAPES(ADAPTED FROM CAMPBELL, 2006) • AS YOU WATCHED THAT SEGMENT, WHAT WERE YOU MOST AWARE OF? • HOW ARE YOU FEELING AT THIS POINT? • WHAT WERE YOU THINKING & FEELING RIGHT THEN WHEN THE CLIENT SAID THAT? • WHERE DID YOU WANT TO GO WITH THAT COMMENT? WHAT WAS YOUR GOAL? • WHAT DO YOU WISH YOU HAD SAID INSTEAD? • WHEN THE CLIENT BEGAN TO TALK ABOUT ____, YOU CHANGED THE TOPIC. WHAT WAS GOING ON? S

44. WHAT TO DO IF CONFLICTS ARISE—AND THEY WILL! • conflict IS INEVITIBLE BECAUSE • Supervisor is supportive, but… • also must evaluate • Supervisee wants to learn, BUT… • also wants to demonstrate he/she is competent • AND AVOID APPEARNING INCOMPETENT

45. POSSIBLE CONFLICTS in SupervisION • Supervisor perceived as unempathic, uncaring, unfair, unavailable, unmotivated • Supervisee seems unmotivated • Role confusion: Friends or boss/employee? • Diversity/Multicultural issues impacting relationship • Inappropriate self-disclosure by supervisee with clients or with supervisor • Inappropriate self-disclosure by supervisor. JS

46. POSSIBLE CONFLICTS IN SUPERVISION • Excessive agreement and compliance with supervisor • Excessive anxiety during supervision. • Non-disclosure by supervisee; hiding potentially negative information • Resistance or defensiveness in response to feedback. • Disagreement over TREATMENT strategies. JS

47. THINGS SUPERVISEES SOMETIMES HIDE OR FAIL TO DISCLOSE • Negative or overly positive feelings about clients (fear, anger, attraction) • Negative feelings about supervisor • Mistakes during sessions • Anxiety about working with clients • Anxiety about being supervised/evaluated S

48. “RED FLAGS” (1) • Sudden change in supervisee behavior with clients or supervisor • Excessive anxiety • Reluctance to interact with clients or supervisor • Withdrawn, aloof, apathetic • Preoccupied with A PARTICULAR client • Late or misses supervision • Forgets tapes, progress notes • LACK OF PREPARATION SJ

49. “RED FLAGS” (2) • Defensive in response to critical feedback • Angry towards clients • “They are not cooperating” • “They are not making progress” • Over-compliance with suggestions from supervisor J

50. Ethical and legal issues • Responsible for client welfare and supervisee development. • Informed consent IS ESSENTIAL • INFORMED CONSENT OF CLIENT • INFORMED CONSENT OF SUPERVISEE.