As anyone who tries it soon discovers, the practice of good therapy is not something you can learn quickly or easily. You cannot just read a book, or attend a workshop, and then go off and do good CBT: effective clinical training demands a much longer process of learning, in which you bring together what you have learned about theory and therapeutic strategies with the complex reality of the clients you see. Clinical supervision is one of the main ways in which this continued learning can occur. It can take different forms (see below), but the basic idea is that by having someone else to discuss or directly observe your therapy, you can examine how well it is going, identify problems, find solutions and develop your skills. The need for supervision applies to CBT practitioners at any level, but most crucially for novices.
These views of the positive value of supervision would probably gain support from most CBT practitioners. However, embarrassingly for an approach that values empiricism as CBT does, there is not yet much evidence about whether supervision actually makes a difference, either to the supervisee’s skills or to the outcomes for clients. There is one important recent study (Mannix et al., 2006) that found that clinicians receiving supervision after training in CBT did better in maintaining and improving their CBT skills than people who did not get supervision, but much more evidence is needed. What follows is, therefore, based mostly on the clinical experience and beliefs of ourselves and others, rather than on a strong evidence base. Much of what we have to say can and should be challenged as new evidence emerges.
Goals of supervision
Although we are unaware of any single generally agreed definition of clinical supervision in CBT, there is agreement that clinical supervision can help achieve any or all of the following goals:
The balance between these different components will vary according to factors such as the characteristics and experience of therapist and supervisor, the context of the supervision and so on.
In thinking about the last of the goals, i.e. evaluation, it is worth considering the distinction between summative and formative evaluation.
A useful tool to evaluate cognitive-therapy skills for both summative and formative purposes is the cognitive therapy scale (CTS: Young & Beck, 1980; Dobson, Shaw & Vallis, 1985; or a revised version, the CTS-R – see Blackburn et al., 2001).
Modes of supervision
We can distinguish two important dimensions of supervision: first, whether the supervision is for an individual therapist or a group; second, whether the supervision is from one person considered to be more expert to another considered less expert or is between people of roughly equal expertise. Combining these categories gives us four modes of supervision, which we have given arbitrary names, illustrated in Table 19.1.
It is sometimes thought – wrongly in our view – that all supervision must have an identified leader. We feel that peer supervision can be very useful, even if none of the participants is highly expert. We would draw an analogy with CBT therapy: just as the therapist may be able to help the client in an area about which she knows little, through a process of guided discovery, so peers may be able to use the same processes to open up new ways of thinking for the therapist in supervision. Although there is a danger of ‘the blind leading the blind’ if none of the participants has any CBT experience, such supervision can be better than nothing at all in situations where access to expert supervision is limited.
Table 19.1 Modes of supervision
There are pros and cons to each of these modes.
This is probably what most people think of as typical supervision: a skilled and experienced practitioner meeting a relative novice, one to one, to develop the novice therapist’s skills. It is undoubtedly a good model, with excellent scope for detailed examination and rehearsal of therapy skills, finely tuned to the supervisee’s needs. The main disadvantages are that it is relatively extravagant in its use of the leader’s time (and thus expensive); and because there is only one supervisor, the range of views and expertise available to the supervisee is limited.
2 Led group
The main selling point of the led group is that it has the advantages of the apprenticeship model in terms of offering expertise, whilst being more economical and therefore more practical in many settings. Another advantage is that supervisees can learn from hearing about other practitioner’s cases as well as their own. Possible disadvantages include the fact that each person in the group gets less individual time and that it can sometimes become more like a seminar – although this too can sometimes be helpful.
We use this term to refer to a similar set-up to apprenticeship – i.e. two individuals meeting for supervision – but in this case they are roughly equally skilled, so neither one is an ‘apprentice’. For very experienced practitioners, this may well be the only available mode of supervision, since there may be no one with more expertise available. Consultation can either be one-way – one of the pair consults the other for supervision – or can be mutual, where each supervises the other.
4 Peer group
The advantages of the peer group include its being relatively cheap and easy to set up; that it allows vicarious learning; and that by being more egalitarian it may encourage less experienced participants to be creative and to share their ideas. Disadvantages include the risk that ‘the blind can lead the blind’, with no one really knowing what they are talking about; that, as with any form of group supervision, each supervisee gets less time; and that there is no leader to take responsibility for group dynamics.
Alternative channels for supervision
In addition to the above modes, it is worth considering that some of them can be practised using other means of communication, such as telephone and e-mail. These alternative channels probably work best with individual supervision: managing group interactions without any face-to-face contact is not easy! Such methods may lose some of the subtleties of face-to-face communication, especially when it comes to emotional issues, and there are possible technical difficulties in playing audio- or video-tapes. Nevertheless, they can offer a useful alternative if no supervisor is available to meet your needs.
The authors have several supervisees who get clinical supervision from us by phone (usually because they have no appropriate supervisor within a reasonable travelling time). In fact in some cases we have never actually met the supervisee face-to-face. Such supervisory relationships can work well despite the restrictions of this format. As with any mode that excludes some non-verbal aspects of communication, the potential for misunderstanding is increased, so it may need particular attention from both parties to ensure clear summarising and feedback in order to avoid such problems. A more recent innovation is doing supervision over the Internet, using webcams so that the parties can both see and hear each other. Some such systems even allow tapes to be played. This approach can work well, but it does need reasonably powerful technology and a fast internet connection at both ends.
Supervision or therapy?
It is recognised in all forms of therapy that there may be times when the therapist’s own problems or beliefs may impinge on therapy. Is such material suitable for exploration in supervision, or should it be considered as personal therapy that should take place in another setting? Is there a limit to the personal material dealt with in supervision sessions? If so, where will you go with material that it is agreed should not be part of supervision? There are no right answers to these questions, but most CBT practitioners would say that such material should only be part of supervision to the extent that it has a direct impact on your work with your clients (e.g. Padesky, 1996b). If one of your own beliefs (for example, ‘I must never do anything that clients will find distressing’ or ‘I am solely responsible for my clients’ progress’) is blocking you from implementing a therapeutic strategy that appears relevant in other respects, then it may be appropriate to look at that in supervision. If it appears that the belief is part of a wider problem, it probably cannot be dealt with in the limited time available in supervision. If it is not something that directly affects your work with patients, then it should probably be taken elsewhere.
Use of tapes
The use of audio or video recordings of client sessions (just ‘tapes’ from here on, although of course many such recordings are now digital) has always been a distinctive feature of CBT supervision. Instead of the supervisor having to rely on the supervisee’s account of therapy, the supervisee records sessions and plays back (parts of) the tapes during supervision so that the supervisor can observe what happens more directly. Although almost everyone initially feels anxious about presenting their therapy openly to others in this way, it gets easier and is extremely useful once the initial inhibitions have been overcome. We therefore strongly advise using tapes. Advantages include:
If you are using tapes then you need to consider the practicalities of how to do so effectively and ethically:
Choosing a supervisor
In some situations, particularly when training, you may have no choice about who your supervisor is because he or she is allocated to you, but if you have a choice then you may want to consider the following:
Negotiating supervision arrangements
Whether you are choosing a supervisor or have one allocated to you, it is always important to have a preliminary meeting in order to clarify hopes and expectations. You may want to consider:
See the Appendix to this chapter for an example template for a supervision agreement, provided by the British Association for Behavioural & Cognitive Psychotherapy (BABCP, 2005).
For any kind of group supervision, similar questions will arise, and there will also be others unique to the group setting. For example, how will the available time be divided between the group members? Options include equal time for all group members in every session; or one person presenting at each session (with possibly long intervals between supervision sessions for any one individual); or a combination of these, in which one person takes a larger chunk of time in a session but others also take smaller amounts of time. There may be more need for explicit feedback from the supervisee(s) to the group and/or the leader about their experience of supervision. If, as sometimes happens, most or all of the group members disagree with a supervisee’s approach, the supervisee can be left feeling very exposed and isolated. Careful attention to group process may be needed to avoid excessively painful and off-putting experiences for supervisees.
Preparing for a supervision session
You will get the most out of supervision if you prepare carefully for it. This does not need to take hours, but it needs more than taking two minutes to think before supervision starts, grabbing the client’s notes and running off to meet the supervisor! In particular, we would recommend that you identify a reasonably clear supervision question for each client you will discuss. This does not necessarily mean a simple question but, rather, what it is that you want to focus on. The potential range of questions is limitless, but might include:
Preparation is also important in using tapes for supervision. It is almost impossible for supervisors to listen to complete tapes of all your clients, as that would take many hours. It is therefore best to make this a two-stage process. First, listen to your tapes yourself. This alone will provide you with useful insights about how you might improve. As you listen, make a note of any points where problems seem to emerge: those are the issues you might want to take to supervision. Select segments of a few minutes that illustrate the points you want to discuss, then, before the supervision session, have your tape ready to run from those points. With this kind of preparation, tapes can be used effectively and economically.
In preparing for supervision, Padesky’s (1996b) questions for supervisors can be helpful for supervisees as well. These questions include the following sequence of factors that might contribute to difficulties in therapy:
Michael found it useful to go through this checklist in relation to a client with whom he was struggling. By doing so he realised that the problem seemed to be around Step 4: he had what seemed like a reasonable formulation and treatment plan, and he was following them, but it just did not seem to be working. The client’s dominant emotions were depression and anger, and she was preoccupied with justifying her anger, rather than working towards any of her other overt treatment goals. Having identified this point, Michael recognised that something seemed to be missing in the formulation, because this preoccupation with ‘justified anger’ was not currently adequately explained. Exploring further with his client, Michael realised that she had beliefs that meant that the only way she could assert her needs was to get angry; and that recognising that her anger might sometimes be excessive therefore seemed to her like subjugating herself to the other person. With this re-formulation, the patient was able to start working on other ways of asserting herself.
During a supervision session
The form of a supervision session can usefully follow the model of a CBT session, as outlined in Chapter 11. Thus, supervision might go through the same sequence:
Other aspects of your contribution to successful supervision include: keeping on track; being as open as possible, rather than feeling you have to show only competence; and not being defensive about admitting difficulties. You will not learn much from supervision if you say everything is OK and your supervisor says that sounds fine! Everyone does imperfect therapy, and your best chance of getting more skilled is through openness about what goes wrong.
Finally, remember that supervision can involve a range of techniques beyond straightforward verbal discussion of cases. It is useful to use role play, in either of two ways. Either you play the client and the supervisor models how you might respond to that client; or the supervisor plays the client whilst you rehearse a particular strategy as therapist (tapes come in useful here – it is much easier for supervisors to play your clients if they have heard or seen them on tape). There may also be times when straightforward didactic teaching or recommended reading is a useful part of supervision.
Problems with supervision
Not being able to find a supervisor
Although we must stress the importance of securing regular, competent supervision, you might sometimes find yourself between supervisors or unable to contact your supervisor. We would then suggest that you first consider self-supervision. Set aside time to listen to your therapy recordings and to review your supervision question (perhaps using the Padesky guidelines above) and critically reflect on your practice and resources – in short, discover whether you can resolve the difficulty yourself. If you cannot, you could consider trying to obtain a one-off consultation from a colleague or external ‘expert’. Do not simply resign yourself to not having supervision.
Problems with the supervisor
Common problems include a lack of commitment from the supervisor (e.g. regularly being late or interrupting supervision sessions to take phone calls, etc.); or feeling poorly supported by the supervisor. It is possible that such problems arise because a supervisor and supervisee are not well matched and an alternative arrangement is needed. However, it is worth considering if the working relationship can be improved. Is the supervisor aware of your needs? If not, why not? Are your expectations of your supervisor realistic, or do you need to supplement your supervision with further support or personal therapy? Investing time in establishing a mutually agreeable contract can often prevent or minimise problems arising in the supervisory relationship.
Feeling unable to bring along tapes of sessions for evaluation
Try to discover what is handicapping you. Perhaps you need to think through the reasons for using tapes; or perhaps you need to do a BE to see whether the pros or cons are as you imagine them to be.
Is the problem performance anxiety or fears of being ‘found out’ as incompetent? That kind of worry is extremely common, even in experienced therapists, and it is important to try to work with it. Use guided discovery to help you unpack the reason(s) for your reluctance, and consider taking the problem along to supervision.
Agreeing strategies that are not carried out
Again, you need to understand the thoughts and beliefs that account for this. For example, is it over-compliance with your supervisor, agreeing to take actions that you do not really agree with? If so, what makes it difficult for you to tell your supervisor that you disagree?
Or is it that you genuinely think the plans are good, but then in your therapy sessions you get sidetracked? Again, try to understand what leads to that. Therapy tapes may be very helpful in looking at where therapy sessions go off track. And, as always, you can take these questions to supervision.
Negative beliefs about supervision
We have occasionally come across therapists who have negative views about supervision. For instance, the primary purpose of supervision may be seen as ‘overseeing’ or making sure that it is done ‘right’, and it may therefore be perceived as an aversive experience in which you are likely to be subjected to managerial control or trenchant criticism. On review, it might well become apparent that the primary purpose of supervision is usually to help you get better at what you do and to be able to help your clients more effectively. Supervision could therefore be seen as an opportunity to learn, not as a threat. As in our clinical work, it is crucial to identify the negative beliefs that interfere with progress. Thus, you need to be aware of your own unhelpful beliefs and use your CBT skills to evaluate them.
Review and reflection:
Taking it forward:
We are not aware of any other significant texts on receiving supervision, as opposed to doing supervision. The following are therefore suggested as useful references on the general topic of CBT supervision.
Bennett-Levy, J. (2006). Therapist skills: their acquisition and refinement. Behavioural and Cognitive Psychotherapy, 34, 57–78.
An interesting and influential attempt to build a model of how therapists become more skilled and how different aspects of skill may need different learning methods.
Kennerley, H., & Clohessy, S. (2010). Becoming a supervisor. Chapter 16 in M. Mueller, H. Kennerley, F. McManus, & D. Westbrook (Eds.), Oxford guide to surviving as a CBT therapist. Oxford: Oxford University Press.
A guide for new supervisors on the challenges that arise and the skills that are needed for good supervision.
Milne, D. (2009). Evidence-based clinical supervision: principles and practice. Chichester: Wiley–Blackwell.
Derek Milne, one of the leading UK researchers in supervision, provides a summation of the available evidence about supervision, and a guide to best practice based on that evidence.
Padesky, C. (1996). Developing cognitive therapist competency: teaching and supervision models. In P. Salkovskis (Ed.), The frontiers of cognitive therapy. New York: Guilford Press.
In this chapter Padesky argues that CBT supervision can usefully parallel the approach of CBT therapy; and she also outlines the useful ‘supervision checklist’ referred to earlier in this chapter.