2021 President’s Column 56(3)
Training and Supervision in Psychotherapy: A Preview of the Upcoming Chapter in the 7th Edition of the Bergin and Garfield's Handbook of Psychotherapy and Behavior Change
The Seventh Edition of Bergin and Garfield’s Handbook for Psychotherapy and Behavior Change, edited by Michael Barkham, Wolfgang Lutz, and Louis Castonguay, and published by Wiley, is due out this summer (Amazon says September 22, 2021)! This book is considered the “lodestar” or “bible” for psychotherapists and psychotherapy researchers…it reviews the major research in the field and is a good way to catch up on major trends in the field.
This is the 50th anniversary edition. I so clearly remember studying the 1st edition for comps when I was in graduate school. We have come a long way since then and it’s good to celebrate what we know and where we need to go to continue to advance the field.
I thought for this column, I would give a few of the highlights from the chapter on training and supervision that Sarah Knox and I wrote for the Handbook. First of all, in terms of the rationale, the need for studying training and supervision is probably pretty obvious given that we have all been trained and supervised as students and many of us have spent out careers providing training and supervision. If we require students to be trained and supervised, we really should know if and how these experiences work. Surprisingly, though, there is actually not much research on the outcomes of training and supervision.
In terms of training, the most research has been done on helping skills training, coming out of a long tradition starting with Rogers and continuing through Truax, Carkhuff, Ivey, Egan, Corey, and myself. Training in this tradition started with teaching microskills (e.g., questions, reflections of feelings, challenges) without context but has since evolved into teaching skills in the context of theory, clinical wisdom, culture, case conceptualization, and evidence-based research. Hence, we know that all the skills work, but the question is when and how to use them for the best clinical outcomes.
Much of the old research on helping skills training was badly flawed. Often researchers tested only a single training group with one trainer and “taught to the test” (e.g., had students write responses to verbal stimuli, and then taught them how to use reflections of feelings in response to such stimuli, and then tested them again on the same verbal stimuli) rather than examining how students performed in actual clinical settings. My students and I have now conducted a number of studies trying to improve on the methodology, and we have found some promising results for outcomes of training on my model (Hill, 2020): students improve in self-efficacy for using the skills, they use more of the skills in sessions with volunteer clients, and they use fewer words in sessions (reflecting that they allow clients to talk more). We have also found evidence for the effectiveness of components of training (instruction, modelling, practice, and feedback) but students have enthusiastically let us know that practice is by far the most important skill. Many students have told us that the skills sound easy when they read about them, but when they go to practice them with real people, they begin to realize how difficult it is to use the skills effectively. The evidence for the efficacy of practice fits well with the recent trend toward deliberate practice…we do not yet have evidence comparing different types of practice but I would guess that the main element is simply the practice and the more different types of practice, the better.
Although we found a few studies on training graduate students in various theoretical approaches, it is surprising to note that there are few systematic research programs in this area. We also know very little about the best sequence of training. In my experience, it works best to have helping skills training first because we cover the range of theoretical orientations (with the exploration stage based on client-centered humanistic therapy, the insight stage based on psychodynamic therapy, and the action stage based on behavioral and cognitive therapies), and then have students go on to study theoretical approaches in greater depth. But we need more research to determine the best sequences of training.
In terms of the supervision literature, there is evidence that supervisees like some of their supervision experiences and that supervision can lead to personal growth for supervisees, although there is also evidence of the harmful effects of some supervision experiences on supervisees. We have less evidence, however, about the impact of supervision on client outcomes. I should mention though that in a recent study (Gerstenblith et al., in press), we found evidence for links between the supervisory alliance, the therapeutic alliance, and session outcome. And in a qualitative study that we are currently writing up, doctoral students reported that supervisors helped them considerably in overcoming problems with clients, thus providing links between supervision and client outcomes (Friedlander et al., in preparation). It is obviously hard to study the links between supervision, therapy, and client outcomes because not all supervision is helpful, supervisees do not need help with all their clients and indeed may not even talk about their problems with their supervisors, supervisees do not necessarily implement what they learn in supervision, and clients do not necessarily implement what they learn in therapy.
In terms of what make supervision effective, we found some evidence in our review for the influence of supervisor and supervisee attachment styles, personal traits of supervisors, empathic attunement between supervisor and supervisee, use by supervisors of good skills, and supervisors providing supervisees with client feedback. But more evidence is needed.
It is perhaps not surprising that there is not more research on training and supervision because it is hard and messy to do this type of research. I would love to see more research in this area, though, given that we need evidence that our training and supervision are effective. Collaborative efforts across sites could enable researchers to gather enough data and sort out the effects of trainers and trainees.
Cite This Article
Hill, C. (2021). 2021 president’s column 56(3): Training and supervision in psychotherapy: A preview of the upcoming chapter in the 7th edition of the Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change. Psychotherapy Bulletin, 56(3), 2-4.
Friedlander, M. L., Heatherington, L., Hill, C. E., Knox, S., Eubanks, C., Angus, L., & Xu, M. (in preparation). Good supervision, better therapy: The radiating effects of effective clinical supervision.
Gerstenblith, J. A., Kline, K., Hill, C. E., & Kivlighan, D. M. Jr. (in press). Triadic effect: Associations among the supervisory working alliance, therapeutic working alliance, and therapy session evaluation. Journal of Counseling Psychology.
Hill, C. E. (2020). Helping skills: Facilitating exploration, insight, and action (5th ed). Washington DC: American Psychological Association. https://doi.org/10.1037/0000147-000
Knox, S., & Hill, C. E. (2021). Training and supervision in psychotherapy: What we know and what we need to know. In M. Barkham, W. Lutz, & L. G. Castonguay (Eds.), Bergin and Garfield’s Handbook of psychotherapy and behavior change (7th ed., pp. xxx-xxx). New York: Wiley.