Psychotherapy Articles

Psychotherapy Articles

A Supervisor’s Deliberate Practice Journey

Editor’s Note: This article is part of the “Deliberate Practice in Psychotherapy” Series. Each article in this series elaborates on the experiences of a psychotherapy supervisor or trainee engaging in Deliberate Practice (DP) supervision, following the Sentio Supervision Model, developed by the Sentio Marriage and Family Therapy MA program (www.sentio.org) and the Sentio Counseling Center (SCC; www.sentiocc.org). The SCC is committed to several evidence-based distinctive features for best supervisory practices, including: All therapy sessions are videotaped; all counselors use routine outcome monitoring every session with every client; all counselors have weekly individual supervision, group supervision, and DP skills training; all supervision sessions are videotaped; and every week, SCC supervisors meet to provide feedback to each other’s videotaped DP supervision sessions.

For more on the Sentio DP Supervision Model, see the introductory article in this series. (https://societyforpsychotherapy.org/deliberate-practice-supervision-series-from-the-sentio-marriage-and-family-therapy-program/)

Call to adventure

In March 2023, Hanna Levenson, one of my colleagues at the Wright Institute, invited Alex Vaz and Tony Rousmaniere, the dynamic duo of Sentio Counseling Center (SCC), to do a 6-hour training on deliberate practice and the Sentio Supervision Model (SSM) for our community. They were looking for volunteers to be in the hot seat, and I’ve always been the kind of clinician who loves roleplays so I volunteered.

Using a supervision preparation form they provided as my guide, I reflected on a recent psychotherapy session where a client’s behavior had caught me off guard and I artlessly stumbled over my words. I was going to see the client again the next week and, frankly, I was dreading it. The supervision form itself was valuable; it helped me figure out the exact moment that had thrown me off my game.

As a training group, we collectively identified the challenge the client presented in that moment, and the therapist deficit that left me ill-equipped to respond well. We came up with a learning goal for me, rooted in my clinical style. Then, Alex did a pitch perfect impression of the client behavior, and I practiced intervening more effectively about half a dozen times. After each behavioral rehearsal, the facilitators and participants gave me constructive feedback before I tried it again. With each behavioral rehearsal, I felt myself moving towards a more effective intervention. The exposure to Alex’s pastiche of my client even flushed out my countertransference without my having to name it explicitly. Outside of my psychotherapeutic life, I’m an athlete, and the SSM feels like pre-game drills, complete with coaching.

So much of my consultation stops at conceptualization and gaining thought partnership around clinical intervention a decade into my career was a breath of fresh air. I felt supported and playful during the behavioral rehearsal. During that next session I had been dreading, my client repeated the behavior and I effortlessly responded with the skill I had practiced in the training. The client’s demeanor shifted and we had our most productive session to date. I signed up for the Sentio Counseling Center’s deliberate practice supervision residency the next day.

Belly of the whale

As a professor, I’ve recorded my lectures and watched my lecturing improve due to reviewing those recordings. Since I received my clinical training during the era when tape recorders had actual tape in them, I had never seen video of myself performing clinical or supervisory work. During our first “supervision of supervisors” meeting, I sweat through my shirt watching myself on video. Is that how I sound when I’m thinking out loud? How did I miss how lost my trainee was? Why am I sitting like a shrimp?

But within a handful of meetings, I began focusing on opportunities to do something differently and more skillfully. My heart wasn’t pounding anymore. I began to look forward to seeing a recording of myself while making a mistake. The quality of the feedback from my colleagues and facilitators helped me laugh at myself, play with a new way of doing things, and improve clinically.

Ultimate boon

It feels good to be in a parallel process with my supervisees. They know someone is reviewing my recordings the same way I review theirs. They know I’ve been assigned deliberate practice homework the same way I assign them homework. They see me make mistakes, lose my train of thought, or forget things. My experience with relational supervision taught me that those moments can cause ruptures or can impact the supervisee’s trust in me as their supervisor. This can lead to a learning experience by engaging in process conversations about how we felt at the moment of my imperfection. The SSM asserts learning is a lifelong process and mistakes are an opportunity for play and experimentation. It flattens the ineffective parts of the power differential between supervisor and supervisee, while still honoring the differing levels of knowledge and experience in the room.

Click here for video Structuring supervision with a trainee through the Sentio Supervision Model.

I’ve supervised over 20 pre-licensed clinicians and taught hundreds of masters-level students. Common among them is a sincere desire to do the right thing in the therapy room, which can lead to an occasionally-incapacitating level of anxiety. The SSM is containing and supportive. Tony orients trainees to the model by showing a recording of him getting a client’s name wrong and doing nothing about it. With a rakish smile, he dares them to show him a recording of them doing worse. The learner’s mindset is showcased and welcomed at every level of the organization and is reinforced by the SSM itself. Supervisees leave supervision with a clear sense of what to do during future sessions and concrete skills to practice. This focus on skill acquisition also creates stronger, more competent clinicians. The trainees I supervise at SCC have been seeing clients for under a year, but their clinical acumen is on par with that of associates with years more experience.

I now think of clinical skills acquisition in a materially different way. Gone are 20-minute back-and-forth roleplays where we imagine what a client might say or do. I am now stronger at breaking an intervention down into its component parts, describing them, and walking a supervisee through practicing them. This makes skills more digestible and makes it more likely a supervisee will be able to use them in the room with a client. Gone are the days of suggesting a supervisee use an intervention and hearing “I forgot” at the next supervision meeting. I am also increasingly able to tie a skill to a particular client challenge or therapist deficit. There are themes in challenges and deficits, and themes in the interventions used to address them. Those themes are thrown into sharp relief by learning goal creation, and responses to them honed by behavioral rehearsal.

Crossing of the return threshold

My enthusiasm for deliberate practice has suffused itself into all facets of my work, from the classroom to the clinic. At SCC, the SSM is held within a complete infrastructure package. I walked into a system covering everything from OQ®-Analyst feedback-informed treatment to automatic video recordings to weekly supervision of supervision meetings. Metaphor Therapy, the for-profit corporation where I serve as CEO, president, clinical supervisor, psychotherapist, administrative assistant, and janitor, doesn’t have the same economy of scale as a 501(c)(3) nonprofit training organization, and some of this infrastructure is costly. While I love fidelity to a model, I know that perfect is the enemy of the good. In the year I’ve been delving into deliberate practice, I’ve slowly begun to build out my own infrastructure. I’ve led supervisees in exercises from the APA series of deliberate practice books. I’ve shifted from roleplays to deliberate practice drills in supervision and the classroom. Next month, I’m investing in a platform so I can focus supervision meetings on video recordings. At SCC, having the whole infrastructure package means I see trainee progress happen in leaps and bounds, and figuring out how to achieve similar results in my modestly-sized practice requires more experimentation.

Even though I am sold on the utility of deliberate practice and the SSM, I do still sometimes yearn for the less effective relational supervision of yore. As a professor, I am drawn to the most information-dense topics where content is king. My own education focused on case conceptualization rather than interventions. I love to ruminate over the why and how of a case with a colleague. I love to pontificate on psychoeducational trivia. And, if I’m being honest, I miss phoning it in sometimes. In relational supervision, I can let a supervisee run their mouth for the duration of our time together while nodding sagely and asking, “What’s your impulse here? Go with that.” However, within the SSM, case conceptualization and didactic content are privileges for when a supervisee has sufficiently mastered the skills necessary to serve their clients. At the beginning of a clinician’s career, there are so many skills to learn and practice. There is no room to phone it in.

When I applied to graduate school, my undergraduate advisor wrote in his letter of recommendation that I had grown bored of the abstract nature of political theory and needed praxis to be satisfied in my career. Deliberate practice is a fantastic synthesis of the theoretical and the practical, the educational and the applied. It has reinvigorated my love for supervision and psychotherapy alike. I’m proud of the work I’ve done and am chuffed to be a part of Sentio Marriage and Family Therapy MA Program’s teaching cohort for the 2024-25 academic year. The foundational structure of my classroom and practice have fundamentally changed as a result of my time with the Sentio Supervision Model, and I couldn’t be more excited about it.

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MacKenzie Stuart is a Licensed Marriage and Family Therapist who works with adults, couples, partners, and families. She specializes in nontraditional relationship structures, including polyamory and other forms of consensual nonmonogamy, as well as chronic depression and suicidality. Her other clinical interests include psychosis, psychopharmacology and drugs, LGBTQIA2-S and GNC/non-binary communities, kink and BDSM practices, and sex work. MacKenzie enjoys psychodynamic case conceptualization, the enneagram, biofeedback, narrative and solution-focused interventions, and dialectical behavioral therapy (DBT) and cognitive-behavioral therapy (CBT) skills. She is a member of core faculty at The Wright Institute in Berkeley and leads a private practice in Alameda. MacKenzie is a supervisor at the Sentio Counseling Center.

Cite This Article

Stuart, M. (2024, April). A supervisor’s deliberate practice journey. Psychotherapy Bulletin, 59(2). 8-11.

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