Seven Mistakes in Clinical Supervision and How to Avoid Them

• Supervision and Clinical Impact
• Rethinking Clinical Supervision
• References

Clinical supervision is the “signature pedagogy” of choice in psychotherapy (1). I’ve benefited a great deal from the lessons of my supervisors. Some of their words from a decade ago not only still echo but have become first principles I keep close in my own clinical and supervisory work and teaching. Most of us regard clinical supervision as highly integral to our professional development. It’s hard to imagine not having someone to turn to for case consultation and guidance, especially when stuck in a rut and not making expected or desired progress with a particular client.

Supervision and Clinical Impact

Given the benefit we often feel from clinical supervision, the logical next question to ask is whether clinical supervision actually translates into meaningful impact on our client's wellbeing? About 8 years ago, Edward Watkins Jr., a researcher from the University of North Texas, conducted a review of 18 empirical studies that examined the impact of supervision on client outcomes. Based on the big picture analysis, Watkins said “…the collective data appears to shed little new light on the matter. We do not seem to be able to say anything new now, (as opposed to 30 years ago), that psychotherapy supervision contributes to client outcomes.” (2)

More recently, a team of researchers set out to investigate this question based on a large five-year dataset comprising 6521 clients seen in naturalistic settings by 175 therapists and guided by 23 clinical supervisors (3). Not only did factors such as supervisors’ experience level, profession (social work vs. psychology), and qualifications not predict differences between supervisors, the role of clinical supervisors explained less than 1% of the variance in client outcomes. Said in another way, and contrary to expectations, clinical supervision as we know it has little to no significant impact on improved outcomes in the lives of our client's lives.

Taken together, we may very well feel the benefit from clinical supervision, but it doesn’t seem to translate into improved clinical outcomes.

Rethinking Clinical Supervision

This begs the question. Why is clinical supervision not translating to actual improvement of client outcomes? Given that we invest so much time and effort in our "signature pedagogy," perhaps we need to rethink our current practices in supervision. Drawing from the existing psychotherapy evidence and the development of expertise literature outside of our field (4), here are seven supervisory mistakes I see us making, along with speculation on how these relate to apparent clinical stalemate:

1. Too Much Theory Talk

2. Pat-on-the-Back

3. Lack of Monitoring Client Progress

4. Lack of Monitoring Engagement Level in Supervision

5. Not Analyzing the Game

6. Overemphasis on the Self and Neglecting the Impact on Client

7. Lack of Focus on Therapist's Learning Objectives

1. Too Much Theory-Talk

Often, the clinical supervision encounter revolves around cases discussion, case formulation and theorizing about the clinical pathology. This fits under the umbrella of clinical conceptual knowledge and does not actually delve into moment-by-moment interactional patterns that unfold in a therapy hour. We often end up waxing lyrical on how a case may be conceptualized in a psychodynamic framework or in an emotion focused or from a CBT perspective. Not only does this disembody the conversational nature of reality in therapy, we assume that the key is to obtain a thorough case formulation of the problem at hand. In 1939, Carl Rogers aptly pointed out, “…A full knowledge of psychiatric and psychological information, with a brilliant intellect capable of applying this knowledge, is of itself no guarantee of therapeutic skill.” (5)

2. Pat-on-the-Back

In my work with supervisors and therapists, I often hear this chant, “…But your client still comes back to see you right?” In actuality, a small percentage of clients (~10%) account for the largest percentage (~60-70%) of behavioral health care expenditures, showing a continued use of services without successful outcomes (6).

While it is vital to take care of the supervisee’s sense of self, what feels good doesn’t equate to what helps us grow. About a third of our clients continue therapy without experiencing reliable improvement in their well-being. If we continue to bolster their esteem with praises or consolations without helping them identify their growth edge and improve the outcomes of "stuck" cases, we are doing our therapists and clients a disservice.

3. Lack of Monitoring Client Progress

We therapists are an optimistic bunch. In the absence of real-time monitoring of outcomes and engagement, session-by-session, we fail to detect deterioration and dropouts. A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduces deterioration in client well-being by a third, but cuts drop-out by half, and as much as doubles the overall effectiveness of therapy (7). Even when we use routine outcome monitoring devices, like the Outcome Rating Scale (ORS) & Session Rating Scale (SRS), Outcome Questionnaire (OQ-45),or Clinical Outcome Routine Evaluation-Outcome Measure (CORE-OM),we fail to meaningfully integrate this into the supervisory process. We stick to using the measures as an assessment tool, and not as a conversational tool.

4. Lack of Monitoring Engagement Level in Supervision

For those of you who are already using routine outcome measures as a source of feedback, you know that it’s hard for clients to give feedback to the therapist. It’s also hard, if not harder, for a supervisee to provide feedback about the engagement levels in supervision — especially if the supervisor is a colleague.

The reality is, supervisors have a tough enough job of ensuring that their input has a ripple effect not only on the therapist, but also on their clients. Having some kind of formal procedure to elicit what’s been working for the learner can help the process of focus. In addition, given that supervisors and supervisees might have overlapping roles or collegial bonds outside of supervision, having a formalized feedback procedure in supervision allows for both parties to take a pit stop and address issues in real time — not 6 months down the road when it’s too late — that might be brushed aside.

5. Not Analyzing the Game

In any other domain of performance (e.g., sports, music), if one were to seek a coach's help in improving their game, it would be unheard of for the performer not to analyze her performance. Yet, in the field of psychotherapy, we do less of examining the moment-by- moment dynamics of the therapy hour and more theorizing (see point #1). Most supervisors do not use the practice of watching snippets-segments of the video recording highlighting specific areas that the therapist can work on.

Much like other fields (music, sports), it’s important to record sessions in order to receive feedback about actual performance rather than feedback about a perceived or reported performance. Feedback is useful when it’s based on a well-defined objective, observables, and specifics.

6. Overemphasis on the Self and Neglecting the Impact on Client

You may not agree with this point, but there is an over-emphasis on the self of the therapist at the expense of impact on the client. Too much supervisory time is spent on superfluous issues such patting the supervisee on the back (see # 2), while not enough time is spent on using real-time progress monitoring to guide the conversation (see #3).

7. Lack of Focus on Therapist's Learning Objectives

Finally, I would argue that there is a lack of focus on the therapist’s learning objectives. This is one of the four tenets in deliberate practice (8). (Stay tuned as we will cover this in future blog posts). This may be the most vital yet lacking element in a practitioner’s professional development. Too often, we engage in clinical supervision on a case-by-case basis, with no coherent thread weaving in the therapist’s learning needs and clinical case concerns. Even when we do so, there is often a lack of systematic tracking of the supervisee’s development. As useful as client feedback is to clinical practice — spotting anything glaring or missing and pointing out if the session is on-track or not — this does not help therapists improve on their therapeutic skill, based on the developmental stage of their profession.

Consider another example: A top musical performer does not benefit from the feedback of the crowd (the decibels of the audience’s applause, the verbal comments about the performance, etc.), as much as the nuanced and specific feedback they might receive from their maestro or producer.

***

In the upcoming blog posts, I will cover each of the seven points raised about the flaws in our default ways in clinical supervision, and I will provide specific pathways out for each of them.

References

(1) Watkins, C. E. (2010). Psychotherapy Supervision Since 1909: Some Friendly Observations About its First Century. Journal of Contemporary Psychotherapy, 1-11

(2) Watkins, C. E. (2011). Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. The Clinical Supervisor, 30(2), 235-256.

(3) Tony G. Rousmaniere, Joshua K. Swift, Robbie Babins-Wagner, Jason L. Whipple & Sandy Berzins (2014): Supervisor variance in psychotherapy outcome in routine practice, Psychotherapy Research, 26(2), 196-205.

(4) A. Ericsson, K. A., Hoffman, R., Kozbelt, A., & Williams, A. (Eds.). (2018). The Cambridge Handbook of Expertise and Expert Performance (2 ed.). Cambridge: Cambridge University Press. B. Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.

Miller, S. D., Hubble, M., & Chow, (2020). Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. American Psychological Association.

(5) Carl Rogers, 1939, p. 284 The Clinical Treatment of the Problem Child.

(6) Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is It Time for Clinicians to Routinely Track Patient Outcome? A Meta-Analysis. Clinical Psychology: Science and Practice, 10(3), 288-301.

(7) Schuckard, E., Miller, S. D., & Hubble, M. A. (2017). Feedback-informed treatment: Historical and empirical foundations. Prescott, David S [Ed]; Maeschalck, Cynthia L [Ed]; Miller, Scott D [Ed] (2017) Feedback-informed treatment in clinical practice: Reaching for excellence (pp 13-35) x, 368 pp Washington, DC, US: American Psychological Association; US, 13-35.

(8) Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. In D. S. Prescott, C. L. Maeschalck, & S. D. Miller (Eds.), Feedback-informed treatment in clinical practice: Reaching for excellence (pp. 323-355). American Psychological Association.



Questions for Thought and Discussion

What kind of clinical supervision do you value and why?

Which of the author’s seven mistakes have you or do you currently engage in?

What have you done recently to improve the quality of your clinical skills?

What style of supervision do you practice, or would like to practice?

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