Brian McNeill on the Art of Supervision

Brian McNeill: That’s a very good question. I think my reading of the psychotherapy literature might be a little bit different from yours, in that I see research on effectiveness of psychotherapy converging into what’s known as the “common factors” across divergent therapies. Wampold and his colleagues did a great deal of research on these factors in his most recent edition of the Great Psychotherapy Debate. Their research suggests primarily that we need to get away from the idea of manualized treatments, especially for training programs, where there’s way too much emphasis on it. I know it’s easy, I know it gives students something to get a handle on, but it discounts those common factors that account for so much of the variance across diverging approaches—relationship building skills, therapist qualities, world view—things that are now consistent with what APA has adopted as evidence-based psychology practice.

BM: Yes

BM: I think it’s very attractive particularly for beginning counselors, because it provides a template for what to do in a given session. For example, for many cognitive behavioral approaches we set the agenda in the first 10 minutes; the next 10 to 15 minutes we review homework, and then we get into the agenda for the session.

It has its place at times, but I think it’s overused because it helps reduce a lot of that initial anxiety in beginning therapists, which comes from not knowing what to do if a session doesn’t go as planned. If the client stops talking, for example, it gives them something to fall back on. It’s harder to go in and listen very closely, very carefully—to really attempt to understand what your clients are saying as well as what’s not said and what the meaning is behind non-verbal behaviors, voice inflection. In other words, what a client is not saying, but trying to communicate nonetheless.

BM: I think it gives supervisors a break in the sense that if you’re promoting a treatment manual approach, it’s much easier to go in there and say, “Okay, you followed these directions correctly. You could maybe have included these items on your agenda, or reviewed things in a different way, or implemented these particular kinds of cognitive challenges, or engaged in more of a Socratic dialogue.” A manualized approach is easier than trying to train your students to be more reflective, or to examine themselves in terms of who they are as a person how that impacts their professional practice.

BM: Yes, absolutely.

BM: From the model that I work from, I believe that what they’re missing are the personal aspects that really play a large part in this journey to becoming an effective psychotherapist. I like the idea of competencies and the competency movement, and I think it provides good kinds of behavioral anchors for various stages of therapist development, but what they’re missing is the journey and the process of what it takes to become an effective therapist. That’s where therapists need to integrate their personal identity with their professional identity. To look at who they are as a person, how that impacts their work in this field, how it impacts their relationships with their clients, how they can engage in reflective practice and be self aware in their interactions with their clients.

Especially from an interpersonal process orientation, how they can use their self-reflections, their feelings in the session, in the moment, in a way that’s effective and helpful for clients, by sharing their perceptions, by giving clients feedback in the moment—those kinds of interactions.

BM: Well, to me they’re grown. I know a lot of people gravitate to our field because they believe that they have some natural helping abilities or skills; they’ve maybe been told by friends that they’re good listeners and whatnot, but I think while that can be a nice start for folks, we still need skills and abilities that only training can provide. Becoming a therapist is different than becoming a biologist, or an engineer, in that it requires self-examination and a very high level of self-awareness.

BM: Yeah, if you’re willing. If you are motivated enough, then just about anyone can go through that process. People who are resistant to self-examination are definitely going to struggle in this field. If you’re suffering from a personality disorder, it’s going to be much harder to engage in that kind of self-examination and be insightful. But for the most part, I do believe that people who are motivated to really want to help others can learn the skills to be effective in this field

BM: Yes

BM: I think that is where we’re still very far behind. I never have believed that the traditional selection variables of college GPA and GRE scores have ever been predictive of someone’s interpersonal skills or abilities to interact personally on the level that we do as clinicians and therapists.

With my program, and I know others out there as well, we try to expand those selection variables a bit, but it’s still very difficult. We try to read into what could be some of those qualities through letters of recommendations or statements of purpose, or past life experiences, a kind of outlook—variables that just aren’t very easy to quantify.

BM: We are thankfully moving away from the idea that to be an effective supervisor you just need to be an experienced effective clinician. Over the past 30 years we have come to understand that these are very different domains. It’s taken awhile, as you can see from the just recently published supervisor competencies that the APA put out.

We now have more of a developmental approach to supervision. We know that beginners are going to be exhibiting certain kinds of qualities and have certain needs, versus intermediate or advanced trainees. It takes a skilled supervisor to assess where a given trainee is at developmentally and to provide the appropriate supervision environment that is going to enhance acquisition of skills—not only in terms of interventions, but abilities to be self-reflective, to develop as a therapist personally and professionally.

BM: We look at three levels of psychotherapist development. At the beginning level we have trainees that are obviously just entering the field. It’s a novel situation for them and they’re typically highly invested. In most programs, probably 80% of your students want to be clinicians, even though we do obviously take a scientist practitioner kind of approach.

It’s anxiety producing for beginners, and as supervisors we need to help them reduce that anxiety, to help them take the focus off themselves early on during sessions and give them some structure and support. We focus on formulating relationships with their clients and learning those important listening skills.

Then we look at dependency versus autonomy. Obviously a beginning student is going to be very dependent upon their supervisor for structure, direction, and support. We look at self-awareness, both in the cognitive and affective realms and, again, a beginner is not going to be very self-aware in terms of how they come off in a session.

We believe that if you attend to the appropriate level of structure, direction and support, especially at the beginning level, that helps them progress onto an intermediate level.

BM: Students get anxious. They feel like they need to do something, that listening isn’t enough. And that’s when they want to fall back on a manualized approach, but even a manualized approach, at least in my mind, is not going to be effective unless you have that base of all effective therapeutic intervention and that is the relationship. Things can go awry if students aren’t acculturated to the research about the therapeutic relationship being the basis of all later therapeutic intervention.

That’s the thing that I harp on the most, because I think that that’s what I see going awry the most. The lack of appreciation for developing those basic interpersonal skills early on.

BM: Yes, and that I need to effectively listen and communicate empathy.

BM: Well, much like the therapeutic relationship, the supervisory relationship serves as the base of any kind of supervisor effectiveness as well. If for whatever reason the trainee and the supervisor don’t hit it off personally, the supervision isn’t likely to go well. I see that the most where the supervisor is not focusing in on the beginning trainee’s needs; they take an old line perspective that they shouldn’t be providing advice to their supervisees.

BM: Yeah, sink or swim. Or we’ll also see supervisors get hung up on their approach to psychotherapy and apply it to supervision. So if they’re very psychodynamic or interpersonally oriented, they want to get in there with the beginning supervisee and start processing with them, whereas the supervisee is really more concerned about what do I do with this client in the next session.

BM: They then move into second stage or level two. At this point they’ve had some experiences with success in their interventions with clients and they’ve also had some failures. In other words, they’ve been through a couple of semesters of actually seeing clients and engaging in clinical work, so they have a greater sense of the complexity involved in providing psychotherapy. They’ve come to the realization that maybe it’s not as easy as they thought it might be.

It’s hard at times. Clients don’t come back and you’re left asking yourself what happened. Or the client is very resistant. In these cases, the supervisee’s motivation then can fluctuate—they start to question themselves and in some cases they might question whether they’re suited for this field because of some of the failures that they’ve experienced.

At the same time, hopefully they’ve had some success and so they want to develop a sense of autonomy or independence. They are becoming more self-aware. They’re not only able to focus on what they’re experiencing during the session, but they start to be able to focus in and sometimes at this level maybe a little bit too much towards what the client’s experience is. A pitfall for students in the intermediate stage is that they can get a little bit overly enmeshed in their client’s issues.

This calls for a different kind of supervisory environment—one where you have to give them a little bit more autonomy. You do have to allow them to try out things that they’re interested in. Let them make some decisions. Of course, overriding all of this is the concern of client welfare, so you constantly have to monitor client welfare and make sure that ultimately your trainees are still following what you would see as required kinds of interventions in the interest of client welfare. But, they want to be able to come up with some more things on their own. They’re less dependent upon the supervisor. And so you’ve got to give them some leeway here.

They’re also more open to some examination of who they are as a person and how that impacts their clinical work. In fact, at this stage they really want that kind of self-examination. They want to look at transference, counter transference kinds of reactions and those kinds of implications because they’re getting a little bit more advanced in their abilities, their skills, their knowledge. So you have to be flexible as a supervisor and be able to assess where your trainee is at.

The analogy we draw is that it’s almost like dealing with an adolescent. They’re gaining some skills and perhaps they want to demonstrate their autonomy. If you can’t lighten up a bit, or deal with that kind of therapeutic adolescence, it’s going to create some resistance, and even some rebellion at this point. If you want to just stay with a completely structured kind of approach of always directing your trainee, we’re saying that that’s not going to work at this stage. You have to help them through stages or periods where they feel like their motivation is low because they’re discouraged with some clients or certain client types. You have to be able to identify that when you’re reviewing recorded sessions.

In that sense it does take a lot of work on the part of the supervisor to accurately assess and intervene with their trainees to foster their continued development as a therapist.

BM: Yes, absolutely. It can be very challenging, but ultimately very rewarding.

BM: At this point, we’re probably looking at a trainee at the advanced stage of level two moving off into internship. Typically what we would see as a level three trainee is in my mind developed during that internship year.

They’ve kind of weathered that storm of level two in terms of that dependency/autonomy conflict and they’re able to pretty much operate at an independent level. Motivation is high. They understand the complexities of this endeavor of our field. They go into their work with an understanding that, yeah, there’s going to be successes but there’s going to be some failures, there’s going to be difficult clients. There’s going to be some client types or populations or diagnostic categories that I work best with and others that maybe just push my buttons and that I’ve got to be careful with.

BM: Exactly. They demonstrate that high level of self-awareness and self-insight on both cognitive as well as affective levels. They’re self-aware enough to know that if there’s something that isn’t working for them, if they need some help on something, or if they don’t have the experience in a given domain—maybe marriage and family therapy as opposed to doing individual therapy—they know and have the awareness to consult with somebody run it past their supervisor.

And they’re not going to be reluctant to do that. They just understand that that’s really part of what they need to do to develop their skills, and that ethically that’s what’s called for. Hopefully that occurs by the end of internship or is fully developed out there with some post-doctoral supervision. That’s what we envision as the advanced psychotherapist and one that hopefully develops into later years as a master psychotherapist.

BM: Post-doctoral supervision used to be in name only. As long as you had an identified supervisor, it really wasn’t necessary to meet or document. Maybe if you had a problem or some questions you’d go and consult with your post-doc supervisor. It was also the norm that your post-doc supervisor just had to be a clinician with three years of experience.

I think we have made progress on that front, too. For example, APA and our programs now requiring training in supervision.

BM: It puzzles me how programs can get accredited by saying that they offer a workshop on supervision, or they implement a module during practicum training. That’s really not enough, but I think that’s the case with the majority of programs.

In that sense I’m happy to see APA publish the supervisor competencies, which I think is going to help a lot. More strictly enforcing that APA requirement that all trainees receive training in supervision is going to help.

BM: Well, if an advanced trainee has that attitude, that’s definitely problematic. More often than not there are areas where they need to develop and to grow, as well as weaknesses they need to attend to.

We run the risk of just assuming that because someone has completed their coursework and internship and training requirements that that’s all there is. The journey does continue to becoming a master therapist and some of those qualities manifest themselves later down the road. Experience matters and learning doesn’t stop. You can always learn from a mentor at any point in your career.

BM: Yes, absolutely.

BM: I would say that a lot of clinicians gravitate to training programs at the internship and post-doc level because it’s tough work to just be seeing clients all the time. It’s easy to get burned out just seeing clients. Supervising can be a nice break, a way to stay current, and also just really enjoyable to have the opportunity to work with trainees. The relationship with trainees can be long-lasting, and you may get calls from them in the future for advice not just about clients, but about their careers or other aspects of their lives. It’s very rewarding to have the wisdom that you’ve developed over a number of years valued later on.

BM: Well, I listen to a lot of music, a lot of jazz. And I draw a lot of parallels for how we operate in the moment as clinicians, as supervisors based on our accumulated experience and skills. One of my idols, a jazz bassist named Charlie Hayden, passed away recently, and I remember reading an interview with him in which he said, “to be a good musician, to really communicate as a good musician, you have to be a good person.” What he meant was a good, humble individual who is willing to look closely at him or herself and implement that humility in their work.

I strongly believe that as clinicians, and by extension trainers and supervisors, that if we work on being a good person—and that can take many forms in terms of personal development, spirituality, etc.—it helps us to be good clinicians, good supervisors, trainers of our students. And it affects our clientele. So I tell my students all the time to be a good clinician, try to do your best to develop yourself as a good person.

BM: Thank you so much for the opportunity.