Supervision in Cognitive Behavioural Therapy

By Jacinta Kennedy, Senior Clinical Psychologist

Cognitive-behavioural therapy has been described by Beck (1979) as “an active, directive, time-limited, structured approach based on an underlying theoretical rationale that an individual’s affect and behaviour are largely determined by the way in which s/he structures the world.” In keeping with this theoretical rationale, supervision in cognitive behavioural therapy focuses largely on the skill behaviours of the therapist, and this includes how the therapist is behaving, thinking and feeling. This contrasts with a psychotherapeutic model, where the supervisory relationship in itself might be viewed as the primary source of learning or therapeutic growth. Despite this difference, a growth enabling supervisory relationship is regarded as a necessary if not sufficient requisite for developing neophyte skills, and for affirmation and development of more experienced practitioners.

Presently, all psychologists who specialise in clinical work are given training in cognitive behavioural therapy. This, like the therapy itself, has a didactic component, as in lectures and recommended reading; a behavioural component, as in opportunities to observe and model oneself on experienced clinicians, and opportunities to have one’s work directly observed by the supervisor either in vivo, by tape, video and self-report, and by review of case notes. The cognitive component is dealt with in supervision by exploration of the supervisee’s thoughts and feelings during the therapy, and by exploration of more core beliefs about how therapy should be done, and how they see themselves as a therapist.

In the initial supervision session, attention is paid by the supervisor to the supervisee’s past supervision history, their expectancies of supervision, and what they feel their strengths and weaknesses are in terms of the therapeutic process. In an atmosphere of collaboration, warmth and support, the supervisor will aim to assess what the supervisee’s needs are, and may use observation, checklists etc. to form an initial impression. Then, supervisor and supervisee collaborate to make a series of goals for the supervisee in terms of enhancing therapeutic skill and knowledge, and will also make a plan as to how the goals may be achieved. The supervisor will make undertakings to provide not just supervision time, but specific training and therapeutic skills, for example, teaching the trainee how to carry out a relaxation session, or a desensitisation procedure. The supervisor will also be clear that an agenda for supervision will have to be negotiated and both parties’ priorities are reviewed, and often a contract is formally drawn up with possibilities for review mid-way through the supervision and at termination, the dates of which are specified. This reflects the structured focus of cognitive-behavioural work, but does not mean that an extreme rigidity is adopted. Frequently, goals have to be reviewed, and flexibility is needed if a trainee encounters a particular difficulty. But, nevertheless, limits are always present, and the supervisee is encouraged to take responsibility and remedial action both within and outside the supervisory session. This could include the supervisee entering therapy herself to deal with personal issues or work on difficulties such as excessive anxiety within the therapeutic situation.

Once the agenda is set, a typical supervision session with a neophyte supervisee would involve working on a difficulty related to early stages in assess­ment, for example feeling uncomfortable when interviewing clients, especially when asking intimate questions. The cognitive behavioural supervisor may then make a plan to observe the trainee, in order to establish what specific difficulties there are in behaviour, and lead the supervisee in a process of guided discovery to what they are thinking during the session (he might get angry if I ask about … she’s old enough to be my mother, I can’t ask her about her marital relationship etc.) and help the supervisee to generate alternative rational thoughts. Underlying beliefs such as “I am a bad therapist if my client doesn’t like what I ask” might also be gently challenged so that the supervisee has an opportunity to consider how necessary it is to be liked all the time. As the session progresses, the super­visee might then be asked to role play the difficult questions, to try out the new thoughts and check on how she is feeling now.

The focus of feedback on behavioural observation is usually positive, based on Skinner’s famous experiments which showed conclusively that positive reinforcement enhances learning and motivation, whereas punishment does not change behaviour but induces a conditioned negative emotional response to the person that delivers the punishment. So, the supervisor will focus on what went well, and encourage the trainee to own his or her strengths. Where there is a difficulty to be dealt with, the trainee will be asked for his or her opinion on the section of the tape which includes the inappropriate behaviour (e.g. interrupting the client), and if the supervisee fails to notice the behaviour, it is brought to their attention, and a discussion of factors leading to the interruption might take place, with role play to show the trainee how it feels to be interrupted, and how interruption may be done when necessary with empathy.

One of the biggest problems for supervisees in cognitive-behavioural work is how to carry out specific aspects of therapy programmes. For example, they may know that their depressed client has identified negative thinking, but feel unable to help the client to deal with it by using strategies of questioning the thoughts in case they appear to be haranguing the client. Here, the supervisor will model how alternative thoughts may be elicited from the client, by verbal challenging using role play where the supervisee takes the client role initially, while the supervisor models verbal challenging and then the role of the therapist with the supervisor. This is best persisted with (behavioural rehearsal) until the supervisee has found a style that works for him or her so that confidence in the procedure is established.

As supervision progresses, and the supervisee develops basic skills, less time is devoted to specific skills training, and more to issues around when to select specific strategics with specific clients, and what the impact of interventions are likely to be with particular clients. Supervision now corresponds with level 2-3 of the developmental model proposed by Hawkins and Shohet (1989), where the supervisee discovers that skills and interventions are effective in some situations but not in others. This can have a dramatic effect on the supervisee’s confidence, and he or she may take the blame for not “doing it properly”, rather than looking at wider issues. Now it is time for the supervisor to broaden the scope of the discussion to enable the supervisee to move from a strict application of procedure to becoming more flexible and reflective in their practice. Gradually, the supervisee begins to understand in a real sense that it is the meaning of the intervention to the client that determines the outcome rather than the intervention per se. For example, as Safran (1990) pointed out, a depressed client with an internal working model of interpersonal relations in which s/he is inadequate and others are critical, may experience the cognitive therapist’s attempt to examine the evidence relevant to a particular belief as invalidating and critical. The supervisee might then learn that rather than use disputation techniques with this client, an alternative might be to provide disconfirmatory experience within the therapeutic relationship by valuing the client’s observations, pointing out competencies, and creating situations where abilities can be demonstrated by graded task assignment and “homework” where the client tries out new activities that have less evaluative focus from the past, and are close to the client’s desires for themselves.

Cognitive-behavioural supervision would always include ethical issues on the agenda, and knowledge and use of ethical codes of practice is required. For psychologists working within institutions and large public services, conflicts can arise between what may be best for the client and what may be best for the institution or service. Research evidence (Hayman & Covert 1986) shows that most clinicians solve such problems in a pragmatic manner rather than referring to professional guidelines, so the discussion of difficulties in relation to guidelines is an essential part of supervision. Other important ethical issues would include a clear understanding of ethical boundaries, sexual relationships and contact, confidentiality and duty to warn, and the reporting of sexual abuse, threat of violence and suicide.

At termination of supervision, the cognitive-behavioural approach involves evaluation both of supervisee and supervisor. Generally, this will involve review of the contract, feedback on progress, difficulties, and where further work needs to be done. Both parties review whether they kept to their commitments, and indeed comments on the supervisee’s ability to use supervision effectively and the supervisor’s ability to provide supervision effectively are included. In training, formal reports are written, the supervisee is asked to comment on the accuracy of feedback, and to complete a supervisor evaluation. This, of course, has a very motivating effect on both parties, but can lead to “games” in supervision, such as “you be nice to me and I’ll be nice to you” etc. Generally, it is preferable for feedback on progress to be regular and explicit so that final evaluations are less threatening and there is more focus on ongoing learning and development.