Clinical Impact Statement: The described critical incidents reflect the benefit and impact pre-practicum supervision can have on the professional development of counselors-in-training while underscoring potential areas of focus in early-career supervision.
Pre-practicum (PP) supervision is counseling trainees’ first introduction to the tremendously complex and comprehensive process of supervision. Supervision is vital for counseling trainees’ professional development as it is one of their first steps towards the development of competence as psychotherapists and lays the groundwork for subsequent training (Hatcher & Lassiter, 2007; Hill et al., 2007). Novice counseling trainees’ personal narratives of critical incidents (CIs; i.e., significant moments that are catalysts for change) during supervision have demonstrated to be useful in illuminating valuable supervision techniques for training including supervisory support, treatment planning, advice, and direction (Ellis, 2010; Furr & Carroll, 2003; Howard et al., 2006). These descriptions have helped guide the implementation of more effective supervisory practices in training. Despite PP’s significance, to our knowledge, only one study has examined supervisees’ CIs in PP supervision at the doctoral level (Ellis, 2010).
Given the importance of PP supervision, we believe discussing CIs in our doctoral PP experiences can shed light on important themes in novice counselors’ training. Given the lack of literature on this topic, we believe this discussion is warranted in order to highlight strength areas of supervision and further the discourse on the impactful and often intimidating early-career supervision experiences for counseling trainees.
The purpose of this paper is: for each of us as authors to examine a notable supervisory action and its discernible impact on our professional development thus far. We will also discuss the empirical support (or lack thereof) of each of these CIs. All of our CIs come from the same PP supervision, which consisted of six first-year PP students and four upper-level graduate practicum students (ULGS). The supervisor was a female counseling psychology faculty member with a strong psychodynamic theoretical orientation, who asked the group to use a psychodynamic perspective throughout the semester. Even with the same PP supervision, we each identified very different CIs. This difference in perspectives is also reflected by our distinct backgrounds: a 23-year-old white woman (The Role of Immediacy), a 24-year-old white male (Group Role-Playing: The Family-Sculpture), and a 28-year-old Latina woman (Therapeutic Letter-Writing with Clients). We were all first-year counseling psychology doctoral students in a large, APA-accredited southwestern university. The beginning of PP marked our first introduction to clinical practice and our first experience with practicum supervision.
Three Critical Supervisory Encounters
The role of immediacy
Early in the semester of group supervision, an ULGS showed the tape of a therapy session that they said was particularly difficult. After a couple of minutes of watching, the room was visibly tense and at least mildly annoyed, no doubt due to the client’s oppositional attitude and resistance. Reading the room, the supervisor stopped the tape and asked the student-therapist how they were feeling; unsurprisingly, they said frustrated. Understandingly, the supervisor suggested an intervention that had never even crossed my mind: tell that to the client. The supervisor explained that the genuine emotions felt in the room were a result of how the client was behaving, which is vital information that should be shared with the client transparently. The supervisor felt strongly that this transparency is important for the client to hear as part of the corrective relationship, despite the discomfort the counselor may feel disclosing. The supervisor addressed this discomfort, noting that this type of self-disclosure or therapist immediacy is something younger students are often hesitant or scared to do, particularly female students.
Even from the role of observer, I was eager to use immediacy with my own PP client, which is undeniably rooted in this supervision experience. I used the intervention because of its relevance to my client and their issues, but also because it was normalized throughout the semester. After seeing and experiencing the benefit of immediacy with a client, particularly somewhat confrontational immediacy, I now recognize it can be a crucial part of the therapeutic relationship and is something I have been incorporating with other clients. For me, this intervention is not just a therapeutic skill I have developed, but it is also becoming an integral part of my therapeutic style.
The emphasis on immediacy in our psychodynamic-focused supervision experience is very much in line with the theoretical orientation’s leanings. When done correctly, the benefit of immediacy interventions has been shown to improve the therapeutic relationship and experience for clients, but appears to be client and context-dependent, and maybe further impacted by the clinician’s level of experience (Shafran et al., 2017; Hill et al., 2014).
This supervisory experience provides anecdotal evidence that supportive and challenging supervision may buffer against a new clinician’s resistance to immediacy. This may, in turn, lead to improved outcomes for the client, which is empirically supported in the extant literature. Finally, while supervisory encouragement and challenges are likely beneficial for all trainees, there may be particular value for women who are clinicians-in-training and who might be more passive therapists (especially early in training) or who are especially uncomfortable with new confrontational interventions.
Group role-playing: The family-sculpture
During PP supervision, the group asked the supervisor if we could see them in therapeutic action. The supervisor suggested an experiential group role-playing intervention called “Family-Sculpture” (see https://www.betterhelp.com/advice/therapy/family-sculpting-psychodrama-for-family-therapy/ for an example of details), in which they would act as the therapist, and we would portray group members. The supervisor stated the exercise would highlight the importance of client engagement and the power of visualization in therapy.
I was initially frustrated with this exercise as it seemed irrelevant to my professional development, given PP counselors only conduct individual therapy, and individual therapy is my desired professional focus. Although I was resistant, I was an active member of the group and placed in a scene that visually reflected the sculptor’s family dynamics. The supervisor explained that the genuine emotions being felt in the room were a result of how the client was behaving, which is vital information that should be shared with the client transparently. The supervisor felt strongly that this transparency is important for the client to hear as part of the corrective relationship, despite the discomfort the counselor may feel disclosing it. Speaking more to that discomfort, the supervisor noted that this type of self-disclosure or therapist immediacy is something younger students are often hesitant or scared to do.
Due to this supervision experience, I was heartened to use immediacy with my own PP clients. I used the intervention because of its relevance to my client and their issues, but also because it was normalized throughout the semester. After seeing and experiencing the benefit of immediacy with a client, particularly somewhat confrontational immediacy, I now recognize it can be a crucial part of the therapeutic relationship and is something I have been incorporating with other clients. This intervention is not just a therapeutic skill I have developed, but it is also becoming an integral part of my therapeutic style.
This CI was, in my opinion, one of the most effective actions taken by our supervisor during PP supervision. Moments in which the supervisor provided experiential learning and gave specific therapeutic directions or treatment plans were the most impactful on my professional development as a clinician; these feelings are in line with those of other PP students. Novice counselors-in-training frequently describe difficulties bridging theory and practical application, echoed in their desire for supervisor direction and experiential learning (Ellis, 2010; Flasch et al., 2016; Skovholt & McCarthy, 1988). Role-playing is a common experiential learning exercise in supervision that brings lessons to life and allows counselors-in-training to hone their therapeutic skills with real-time feedback from supervisors. Research shows role-playing exercises in both group and individual supervision are essential to the effective development of counselors-in-training’s therapeutic competence and can improve trainees’ career self-efficacy and role comfort (Kozina et al., 2010; Wilkins, 1995), which supports our supervisor’s actions.
Therapeutic letter-writing with clients
A ULGS in our group supervision class had two clients with unresolved conflict, which our supervisor noted continued to contribute to their presenting problems. To address these, the ULGS attempted to implement various therapeutic techniques that were ineffective in facilitating the deeper discussions needed for the clients to open up about their respective conflict. Given the clients’ apprehension in expressing and confronting these heavily emotional issues, the supervisor noted that a more direct approach was needed and suggested therapeutic-letter writing. The psychodynamic supervisor reasoned that clients are authors of their behavior yet are often unaware of relevant defense mechanisms they employ in response to these types of concealed deep-rooted emotions, which can result in maladaptive behaviors and coping. Letter-writing, the supervisor explained, could serve as a safe outlet for these clients to be as expressive and uncensored about their feelings as needed. The supervisor further advised this treatment plan to include having the clients read the letters aloud in therapy, which would require the ULGS to be ready to help their clients process any strong emotions that may arise. These specific instructions for a treatment plan bridged the gap between recommendation and implementation, which was helpful for us new students who struggle not only to acquire the ability to implement these interventions but also then use them therapeutically.
After watching tape of the letter-reading sessions, it became evident how beneficial the letter-writing had been for these clients. Both clients expressed deep emotions and reflections that provided content that had previously been avoided. Consequently, the ULGS was able to understand better how their clients had been coping with abuse and loss, which would lead to more targeted interventions. The supervisor highlighted this new disclosure and mentioned that when using a psychoanalytic approach--in the context of letter-writing—the therapist needs to challenge relevant defenses while realizing their initial adaptive development.
Overall, I was impressed by the benefits that therapeutic letter-writing produced to both the client and therapist in the following session, but also in their subsequent progress as it opened therapeutic directions that had previously seemed closed. Considering the various commonly practiced writing-based techniques in psychotherapy (journals, thought logs, etc.), I previously did not think too favorably of letter-writing, but have since come to realize it can be an incalculably powerful tool that can enhance and advance the work done in a session. It is now an intervention that I consider in therapeutic situations where difficulties in communication and emotional expression are present.
Consistent with my experience in group supervision, supervisor support in the form of treatment plan development has been identified as a beneficial and desirable technique in counselor training (Ellis, 2010; Skovholt & McCarthy, 1988), supporting our supervisor’s actions. Further, utilizing therapeutic letter-writing, which has been used for over a hundred years (Brand, 1979), in a treatment plan has been shown to help clients identify and process challenging emotions thereby allowing these letters to be a physical manifestation of their problems awaiting to be confronted (Zimmerman & Shepherd, 1993). This practice has been used and modified to work with a variety of different psychotherapeutic orientations such as psychoanalytic, narrative, and cognitive therapy (Wojcik & Iverson, 1989; France et al., 1995). It is important to note that simply writing about emotional trauma has been associated with positive outcomes including physical health benefits such as improved immune functioning (Smyth et al., 1999) and mental health outcomes (e.g. psychological well-being, psychological functioning; Smyth, 1998), highlighting that writing in any form can be a powerful tool that has a demonstrated place in the therapeutic process.
Given previous research and our anecdotal experiences, there is evidence that counselors-in-training’s initial clinical experience sets a precedent for their ideas of how therapy and supervision will be. It pairs a steep learning curve with an invaluable opportunity in which clinical skills are developed and honed. For this reason, the first interaction with the supervision of any form (in our case PP) is an indispensable opportunity for novice counselors-in-training to try different theoretical orientations, techniques, and interventions, all under the advisement and supervisory eye of a faculty member. Consistent with our experiences, counselors-in-training’s exposure to experiential exercises and less commonplace or comfortable interventions—and potential ways of delivering those interventions—may increase trainee’s enthusiasm for developing and conceptualizing interventions with clients in group or individual therapy. We recommend supervisors provide these opportunities, coupled with specific therapeutic direction, to supervisees to foster an environment conducive and effective for training. In our experience, this environment can lead to supervisees’ collaborative thinking about and discussing client problems, trying new therapeutic skills, and adding novel techniques to their growing toolbox—ultimately creating a maximally beneficial supervisory experience for its recipients (whether they be novice or upper-level).
Our experiences displayed a possible influence of gender norms on supervision and the willingness or likelihood of supervisees to incorporate certain techniques. Further exploration into gender roles’ impact on the supervisory processes could reveal gender differences and may help supervisors address potential biases in supervision (Isacco et al., 2016). Our experiences also provide support for role-playing psychodramas within supervision (e.g., Kozina et al., 2010). However, limited research has examined the efficacy of role-playing psychodramas as an experiential exercise in PP supervision (Scholl & Smith-Adcock, 2007). This is an area for future exploration, given its reported effectiveness in therapy and one of our PP experiences.
Cite This Article
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