Psychotherapy Bulletin Editors’ Note: This article is part of a special student series on supervision and training that will be featured in Psychotherapy Bulletin issues throughout 2019.
Supervision will be introduced to students in many graduate cohorts as an aspect of their training they will both enjoy and endure. Framing it this way inherently leads students to start to question what they want in a supervisor. Some will think of the worst and ponder what it would be like to have a negative experience during the supervision process. Others might review their previous supervision experiences and make note of their own shortcomings. Whatever the reaction may be, with supervision on the horizon, it is the start of a new chapter in each student’s life. Even though the clinical supervision process is defined as two professionals working together, one with considerably more experience than the other, students can sometimes experience the relationship as more of an authoritarian dictatorship. This term is employed because clinicians in training will often hear “in the end of the day, it is your supervisor’s license on the line—so do whatever they say.”
Supervisors extend an opportunity for clinicians in training to practice their skills without a license. This should not be taken lightly, given the great deal of effort, time, and money it takes for a clinician to become licensed. With this in mind, it is important for clinicians in training to understand the responsibility that accompanies the role of being a supervisor. A supervisor must balance being a teacher while also being a gatekeeper. Trainees should therefore strive to develop a relationship founded upon respect and trust so their supervisors can confidently provide opportunities for their trainees to grow into independent and autonomous professionals.
The Humanity of Self-Care
The trainee had just started working at a new practicum site and was still getting acclimated to the environment, the policies, and her supervisor. She had 10 days of orientation before beginning to see clients. Once her training was over, the trainee’s schedule was full; she was seeing multiple clients every day, going to class, attending supervision, working part-time, and also trying to spend time with her family. She found the transition difficult during the first few weeks. The trainee realized she had not come to terms with the fact that perhaps she had taken on more than she could handle. Toward the end of her third week, she realized she had paperwork that needed to be submitted, but the trainee did not have the time to do it. The trainee was prepared to work through the night, as this is the graduate student’s diet, however her practicum site was closing. The trainee’s supervisor noticed her scrambling to get things done and simply told her to finish her work on Monday. The trainee was stubborn in nature, and waiting to complete work on Monday was not something she could easily accept. The trainee found solace after deciding she would come back to her practicum site bright and early Saturday morning to finish her paperwork.
The trainee spent most of Saturday working and then went home to enjoy the weekend. She felt a sense of resolve and empowerment that she was able to complete her work before Monday. She thought her supervisor would be impressed and bask with her in the accomplishment. The trainee received an unexpected call from her supervisor shortly after returning home. Her supervisor was neither delighted nor angry, but confused. The supervisor asked the trainee why she had decided to come into work on a Saturday. The supervisor also noted that taking time for oneself is extremely important. The supervisor’s confusion was met with the trainee’s own confusion. The trainee was so certain that getting work done would only serve her. She did not think that time for herself was more important than having her work completed on a weekend, rather than the next business day. She thought coming to work on Saturday would only prove her dedication. The trainee did not realize that her actions reflected the lack of importance she gave self-care. Her supervisor still wanted an answer. The trainee told her supervisor she had managed her time improperly and added that she appreciated her supervisor’s concern. A few days later the supervisor provided the trainee with resources that focused on self-care. The most valuable piece of information that the trainee took from the resources was the following statement: You are a human before being a psychologist.
The call the supervisor made was not to scrutinize the trainee’s work or the display of inadequate time management. The call was made to advocate for the trainee as a human, and support the fact that the trainee can and needs to prioritize self-care. The next few weeks at the site, the trainee dedicated time to learning how to balance her professional and personal life. She was empowered to work her hardest at the practicum site while fully enjoying herself during her time off. She felt it was the first time she was able to relish in her time away from work. The trainee was able to decompress and relax and just be a human. The trainee will be forever grateful to her supervisor and this experience. The trainee learned that to be a psychologist one must first learn to be human.
The literature fully supports the supervisor’s actions and clearly outlines the benefits of advocating for self-care (Barnett & Cooper, 2009; Shallcross, 2011; Thompson, Frick & Trice-Black, 2012). There is an abundance of research regarding the importance of self-care as well as evidence that supports it as an efficacious way to avoid burnout (Barnett, 2017). Supervisors who are able to advocate for self-care, and provide resources for their trainees will help them both in the short and long term. If trainees find themselves frequently overwhelmed and unable to keep up with their workloads, self-care might come in the form of reassessing priorities, determining the quality of their training, ensuring they have access to the support they need to meet the demands of the setting, and integrating task management strategies.
Overcoming the Challenge of Countertransference
A supervisor who had a strong impact on this second clinical trainee was a motivating and charismatic psychologist. The supervisor’s personality type encouraged the trainee to look forward to his supervision time and open up concerning his clinical work. The supervisor was open and compassionate, but most importantly, was able to offer constructive feedback. The clinical supervisor was skilled at offering criticisms in a disarming manner that assisted in the trainee’s development. This approach allowed the trainee to markedly improve his case presentation abilities as well as his clinical skills. An example that reflects this is when the supervisor asked the trainee to present a difficult client from his caseload during individual supervision.
Throughout the case presentation, the supervisor asked questions that helped the trainee learn how to become a more skilled student therapist by exploring specific areas that he had not thought about during the session. The supervisor also asked the trainee about possible transference and countertransference that occurred during therapy sessions. The trainee responded that the client’s physical characteristics reminded him of his grandfather. A particular challenge that the trainee experienced with this client was that he would deflect most questions, and seek other topics to distract from the purpose of the session. The supervisor helped the trainee by providing strategies that would help navigate the client back to the topic of discussion. The supervisor also provided the trainee a platform to explore the impact the client’s resemblance to his grandfather had on his objectivity.
Transference and countertransference can be difficult to handle, especially as an entry-level clinician. In one therapy session, this second trainee’s client had accurately guessed his religious affiliation. The client also appeared to have noticed the trainee’s physical response. The trainee decided in the moment to self-disclose because he thought that the honesty would assist in building rapport and trust with the client. However, the information caused more distraction from the purpose of the session. The supervisor helped the trainee to further explore how this countertransference impacted the remainder of the session. The supervisor also prepared the trainee for upcoming sessions, and taught him how to respond in a manner that was objective and maintained rapport.
According to Barnett, Erickson Cornish, Goodyear, and Lichtenberg (2007), an effective supervisor is committed to the trainee’s professional development, emotionally invested, and collaborative; in addition, an effective supervisor provides constructive feedback in a nonthreatening and supportive manner, creates a safe environment in which trainees feel comfortable to share their work and address insecurities or concerns, and provides the freedom to try new strategies in therapy. An effective supervisor also demonstrates empathy and respect for their trainees (Barnett et al., 2007). The supervisor’s actions, demonstrated in this case example, portray compassion, empathy, support, and constructive feedback in a nonthreatening and supportive environment fostered by the supervisor.
The supervisor’s focus on countertransference is also supported by research indicating that its exploration is an important clinical responsibility and informer of treatment, as it may help direct or limit therapy (Falender & Shafranske, 2014). The supervisor’s actions will have a lasting impact on the trainee’s professional development. This experience enabled the trainee to better realize the potential impacts of transference and countertransference, as well as the value mentorship and diligent supervision can have on one’s professional development.
Guiding Trainees Toward a Balanced Life
As psychology trainees advance in their training, they transition to advanced practicum sites. Working in a psychiatric inpatient unit can be a challenge for practicing psychologists; for some psychology trainees, it can be a nightmare. Patients often have more severe symptomatology, are usually lower functioning, and may be at risk of harming themselves or others, which can make providing therapy more difficult. In this setting, the supervisor is a critical source of support to help guide psychology trainees. Providing treatment for an acute population requires modified treatment approaches, therapeutic techniques, and treatment expectations. For young psychology trainees, it is not uncommon to be idealistic and overemphasize the positive impact of their treatments.
The third psychology trainee worked in such an inpatient hospital setting. The focus of the training was conducting group psychotherapy, but there were opportunities available to conduct various assessments and individual psychotherapy sessions. The trainee was eager to prove himself and accepted every opportunity available. If a patient needed an assessment, he was the first to volunteer. If patients requested an individual session with him, he would not hesitate to offer his time. Yet, as much as he enjoyed taking advantage of the various opportunities, he still had other graduate school obligations, which included coursework and research. It was clear to everyone (but the trainee) that his overachieving attitude would lead to a “burnout effect.”
During an individual supervision, the supervisor was direct in voicing this concern. The supervisor praised the trainee’s dedication and work ethic, but warned him about his own mental health and other responsibilities. The supervisor emphasized the importance of being present during each session, and the problems with being stretched so thin that one’s quality of work could decline. The supervisor then shared with the trainee a book, Five Good Minutes: 100 Morning Practices to Help You Stay Calm and Focused All Day Long (Brantley & Millstine, 2005). The supervisor was able to relate to the trainee’s ambitious state of mind, but shared the importance of being mindful to avoid burnout. The supervisor told the trainee that the book was on the supervisor’s desk, and that the trainee could read it at any time.
It was during this same supervision session that the trainee shared his frustration regarding a difficult group psychotherapy session. The group consisted of 10 patients, with the majority experiencing severe symptoms of depression. Two of the clients were experiencing active hallucinations, and one client was expressing paranoid thoughts and disrupting the group cohesion. The trainee described his unrealistic expectations for an acute inpatient group. He took responsibility for the disruption of the patients, and his inability to redirect the patients experiencing active hallucinations. He also took responsibility for two patients with severe depression who left the group.
Before the trainee could continue being self-critical, the supervisor interrupted him. The supervisor asked him what appeared to be a random question. The supervisor asked if the trainee watched baseball and, when he said yes, the supervisor went on to describe the statistics of home runs in Major League Baseball. The supervisor then emphasized that those relatively few home runs were what the best athletes could do—and invited the trainee to now imagine what the expectations were for minor league or college baseball players. The supervisor brought the focus back to the psychology trainee in a reassuring way. The supervisor said to the trainee, “you are still in training; why would you expect to accomplish what licensed psychologists don’t expect of themselves?” The supervisor went on to discuss statistical averages and told the trainee “as you progress in your training, your average group session will improve, yet there will still be some groups like this past one that fall below the average and some groups that fall above the average.” The two of them then discussed the variables outside the control of any healthcare provider and some positive ways to respond.
The trainee greatly benefited from his supervisor’s actions. The supervisor treated the trainee as a human first and the advice given demonstrated his genuine concern. The supervisor helped give the trainee some perspective on his current situation, which included the discrepancy between his expectation for himself and the expectation of the training site. The supervisor emphasized that the trainee’s role was to learn and improve his abilities, which helped the trainee adjust his expectations to be more realistic. With more realistic expectations, the trainee adjusted his treatment approaches, therapeutic techniques, and treatment outcomes to better fit the population he was serving. The trainee found that with more appropriate treatment expectations, he has become a more effective treatment provider.
In this case example, the supervisory relationship was the foundation of the supervision work. The supervisor’s concern for the trainee’s wellness was critical for his professional development. Self-care is a crucial training component for preventing burnout and stress (Barnett & Cooper, 2009). Supervisors are professional role models, and their actions significantly influence their trainees (Barnett & Molzon, 2014). By sharing their own self-care techniques, supervisors demonstrate the importance of prioritizing one’s own wellness. It is how the supervisors conduct themselves in supervision that impacts how the trainee is able to overcome clinical challenges (Barnett & Molzon, 2014). The supervisor was supportive when challenging the trainee’s unrealistic expectations, which helped the trainee be more receptive to feedback. Now, the trainee provides a similar supportive approach when challenging his patients’ unrealistic expectations.
The interactions you have during supervision will vary as each supervisor approaches the process in a unique way. Depending on their personal training and theoretical beliefs, one supervisor may hold an hour of individual supervision and an hour of group supervision, whereas another supervisor may provide didactic training in addition to, or as a dominating characteristic of, group supervision. The individual and group supervision may also be implemented differently in distinct training settings. Due to the stark differences in theoretical orientations among clinical supervisors, many trainees will receive a broad experience of supervision.
The supervision process of each trainee will be whatever they make it out to be. If they adopt a passive approach to this part of their training, they will most likely see little to no return on their investment. However, if trainees play an active role in the supervision process, they can establish a rich, professional relationship that will only serve to benefit their clinical training. Supervisors are often incredibly busy, so it will be important for trainees to take a proactive role in building this strong relationship. It is up to the trainee to put in the effort so their supervisor can clearly understand when they are ready to take on more responsibilities.
Your supervisor might not be walking the path you want to follow, but they have taken the steps to achieve your current goal of becoming a licensed clinician. Take the opportunity to learn from their choices and mistakes. They provide you a platform to explore a field about which you are both passionate, so do not miss out on basking in the challenges together. Your supervisor will support you as well prevent you from taking on that which you cannot handle. This invaluable learning opportunity should not be gone unnoticed.
Authors’ Note: The information in the case examples provided has been de-identified in order to protect the confidentiality of the clients and the supervisors. Some information about the clients has also been altered in order to further protect their identities.
Cite This Article
Saltzman, H. R., Nijmeh, J. S., & Davich, J. A. (2019). If you give a supervisor a trainee: Examples of influential clinical supervisors. Psychotherapy Bulletin, 54(1), 24-29.
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