Feature

A key part of many clinicians' work is supervising psychologists-in-training-a task that requires its own set of unique skills to effectively guide practicum, internship and postdoc trainees and beginning therapists as they develop into successful practitioners.

At the same time, clinical supervisors should foster their own skills, says Mary Ann Hoffman, PhD, professor of counseling and personnel services at the University of Maryland, who conducts research on supervision.

Indeed, drawing from psychological research and theory on supervision can provide psychologists with insight into such challenges as providing difficult feedback or handling a mismatch between supervisor and trainee, as well as finding ways to help trainees flourish.

Best foot forward

At the onset of these relationships, experts encourage supervisors to be warm, empathic and helpful to trainees, so when trainees have a problem they'll feel that they can ask for guidance, says psychologist Judith Beck, PhD, director of the Beck Institute for Cognitive Therapy and Research and clinical associate professor of psychology at the University of Pennsylvania. In fact, the best supervisors are often described by trainees as being knowledgeable, genuine, respectful and supportive, according to psychologists Carol Falender, PhD, and Edward P. Shafranske, PhD, in "Clinical Supervision: A Competency-Based Approach" (APA, 2004).

Besides that, be sure to make yourself available, adds Cory Newman, PhD, director of the University of Pennsylvania's Center for Cognitive Therapy.

"Sometimes you have to go the extra mile to be present and to be available," says Newman, who provides his personal phone number to his trainees so they can reach him after hours if an emergency with a patient arises. "I want to be there for them when they are facing a very critical decision."

However, many practicum students report they don't receive adequate supervision and others express feeling undervalued or ridiculed as trainees, which may cause them to be reluctant to approach their supervisors to discuss shortfalls, according to a survey of 321 doctoral psychology practicum students by psychologist Steven Gross, PsyD, in the June 2005 issue of Professional Psychology: Research and Practice (Vol. 36, No. 3, pages 299-306).

One way the University of Maryland helps supervisory relationships get off to a good start is by offering a counseling session before supervisees begin seeing clients at which supervisors individually meet with their trainees and review their model of supervision, philosophy and expectations. Supervisors also can gauge their skill level so they can adequately tailor the supervision.

"It's important for the supervisor and supervisee to talk about their relationship and their expectations for both the clinical and supervisory experience, including what they want out of it," says Hoffman.

Theoretical orientation

Many supervisors tap psychological theories to back up their approach to supervision, believing that the theoretical approaches they use in therapy will also help trainees develop new skills and model approaches the trainees can use with clients.

For example, Beck, president of the Academy of Cognitive Therapy, uses a cognitive therapy orientation to approach supervision sessions. She sets an agenda with the trainee on what will be discussed, asks trainees to summarize and agree on homework assignments, and elicits feedback from trainees throughout the session. At the end of each session, she asks trainees such questions as "What did you think of supervision today? Is there anything you didn't agree with? Anything you would like to do differently for the next session?" Such questions prompt trainees to realize the relationship is a collaborative one, in which they will be able to offer feedback too.

"I directly model what I would like them to do in a therapy session," Beck says. "You are giving them experience of what structure and collaboration are like." Beck outlined this cognitive therapy supervision approach in a chapter in "Handbook of Psychotherapy Supervision" (John Wiley & Sons, 1997).

Other supervisors might use a psychodynamic, feminist or developmental approach to supervision, depending on their own therapeutic orientation and whether they view themselves as teachers and mentors or as communication facilitators between clients and trainees.

Some supervisors may also integrate elements of these approaches to tailor their supervision. For example, psychologist Janine M. Bernard, PhD, of Syracuse University developed a discrimination model to supervision, which combines the supervisor role as "teacher" when the supervisor is instructing a trainee, "counselor" when assisting trainees in working with client problems, or "consultant" when working with trainees on patient cases. Her model is detailed in "Fundamentals of Clinical Supervision" (Allyn & Bacon, 2004).

Psychologists Cal D. Stoltenberg, PhD, Ursula Delworth, PhD, and Brian McNeill, PhD, developed the Integrated Developmental Model (IDM) to explain the stages a trainee goes through as they gain confidence as a therapist, and how supervisors can aid that development. In this model, trainees pass through three developmental levels, and as they gain experience, structured supervision decreases. The model includes:

  • Level one: Trainees are highly anxious as they test their new skills and benefit from a high level of structure in supervision sessions. They need supervisors to provide specific direction on working with clients, assessment, case notes and case conceptualizations. Supervisors can assign trainees homework to practice their skills.

  • Level two: As trainees gain confidence as a therapist, their focus shifts more to the client and understanding the client's worldview. Supervisors can allow trainees more autonomy and consider catalytic interventions, such as having trainees reflect on their experiences with a client and on client's reactions.

  • Level three: Trainees increasingly empathize with the client and reflect on what they know about theory and research in a given situation. As the supervisory relationship becomes more collaborative, supervisors may introduce other perspectives to broaden their view and might be more willing to provide negative feedback.

Trainees may fall in any one of these levels depending on their experience in different domains of practice, Stoltenberg says. For example, a trainee may be operating at a level three when working with depressed clients but at a level one when conducting marital therapy.

"It's very important for supervisors to continually be aware of the different developmental levels trainees might be functioning at," says Stoltenberg, an educational psychology professor and director of training at the University of Oklahoma.

Stoltenberg, who is working on research to validate the IDM, details the model in the November 2005 issue of the American Psychologist (Vol. 60, No. 8, pages 857-864). Stoltenberg is also teaming with McNeill to update the IDM in a new book expected to be published late this year or in 2007.

Giving difficult feedback

Regardless of the model supervisors use and trainees' level of experience, Stoltenberg emphasizes the use of supportive and facilitative interventions, in which supervisors provide support and encourage the development of the trainee through praise and attentive listening.

However, some feedback may be harder to give than others, especially in situations when it's based on personality or professional issues, such as situations in which the feedback concerns a supervisee's behavior outside of supervision with other interns, Hoffman says.

Indeed, research has shown that many supervisors report withholding feedback from trainees, such as negative reactions to trainees' counseling and professional performance. In particular, supervisors report it is difficult to provide feedback when clinical issues are subjective, when they are uncomfortable with imposing their opinions on trainees and when the feedback concerns something outside the supervisory relationship, according to a January 2005 study in the Journal of Counseling Psychology (Vol. 52, No. 1, pages 3-13). For example, the study, which was conducted by Hoffman, Clara Hill, PhD, Stacey Holmes, PhD, and Gary Freitas, PhD, found that supervisors had difficulties deciding whether supervision should include discussing a supervisee's personality characteristics that might affect the trainee's clinical or professional success. The study included interviews with 15 counseling center supervisors about their feedback to intern trainees.

"By not raising important feedback, clinical work doesn't go as well and the supervisory relationship may suffer," Hoffman says.

In providing difficult feedback, Hoffman suggests using a videotape or audiotape to demonstrate or support the supervisor's feedback. The University of Maryland's counseling department also uses a group supervision model to augment individual supervision. The group, which includes peers and a faculty supervisor, helps draw out difficult conversations about clinical issues that might not come up in individual supervision. The group can be effective because peers can be attentive to identifying such issues as anger or attraction toward a client and are good at confronting trainees on such issues, Hoffman says.

Supervisors also may face challenges when providing feedback via technology such as e-mail, telephone or videoconference-a practice known as telesupervision, says Jennifer Wood, PhD, a postdoc at Veterans Administration Hospital in San Antonio.

In the April 2005 issue of Professional Psychology: Research and Practice (Vol. 36, No. 2, pages 173-179), she found, among other challenges, that the absence of nonverbal cues can lead to miscommunication between the supervisor and trainee, Wood says.

"Communication should be more specific," Wood says. "It may require elaboration to convey tone and humor."

Despite some challenges, telesupervision can lead to trainees being more candid and honest with their supervisors, due to its perception as less confrontational than face-to-face meetings, research has shown.

Handling a mismatch

Whether through videoconferencing or face-to-face interaction, the supervisor and trainee may find that their differing orientation styles, personalities or worldview may clash in their supervisory sessions.

According to Gross's study, practicum trainees reported several challenges in supervision, including laxness in supervision time and structure, conflicting expectations and communications from supervisors, and differing therapeutic orientations between the trainee and supervisor. Gross suggests that many of these issues can be resolved through candid dialogue about them.

However, what might appear a mismatch at the beginning may end up being a perfect match. For example, Newman describes a time early in his career when he was the new supervisor of an older professor on sabbatical to receive clinical training.

"We disagreed on cases and knocked heads," Newman says. "But I looked at it as a challenge to find ways to collaborate and compromise and provide the best clinical training and patient care. It was actually very enlightening for both of us."

Hoffman has found through her research that when supervisors believed that their supervisee perceived that they, the supervisor, had something valuable to offer them-such as skills or a theoretical orientation-or felt they had something to learn from the supervisor, that the supervisory relationship was stronger, even when the supervisee and supervisor didn't necessarily match on gender, race and ethnicity or theoretical orientation.

"Just as therapists may need to change their style in therapy," says Beck, "supervisors may need to change their style when supervising trainees." For example, supervisors who are straightforward and blunt may need to adjust their style when supervising a sensitive trainee. If that doesn't help, she suggests raising the issue with the trainee and talking about the advantages and disadvantages of switching to a new supervisor.

Just listening to tapes of sessions can really help supervisors hone their own clinical skills, says Beck.

"There are a lot of parallels between supervision and therapy," Beck says. "By working in a different arena, it helps to inform and widen one's perspective of what to do in a therapy session as well."

Melissa Dittmann Tracey is a writer in Chicago.