In recent years there has been growing emphasis on training and supervision methods that demonstrably improve therapist competencies and client outcomes. Right now, I’m supervising a particular trainee who is facing challenging circumstances with a particular case. I wonder whether it would be helpful to sit in on the next session to provide support and “in vivo” training? Or if a separate supervisory conversation, supplemented by video review of a recent session, role play of handling the difficulty, and the like, might provide the needed input?

This question comes up with some regularity in my setting focused on “difficult” patients with chronic and comorbid problems characterized by personality disorder, trauma history, suicidality. A survey of training directors recommends cotherapy (i.e., supervisor and trainee acting as cotherapists for a given session) as the strongest supervisory method (Romans, Boswell, Carlozzi, & Ferguson, 1995) but noted that it used less often than other modes of training, mainly due to logistical concerns. I typically do not provide co-therapy, except for limited circumstances when I feel the need to “sit in” based on some discernment about (a) the client’s case formulation and current needs, (b) the existing skill-set and needed learning of a given trainee, and (c) the nature and history of their therapeutic relationship. Typical times to insert myself in the process may be after there has been some apparent breach in the therapeutic alliance, or to help manage an emergent crisis. While the client’s welfare is the highest priority, I believe it is also crucial that I be collaborative, open to input, and transparent with trainee therapists about my thought process and decisions as a supervising therapist. I consider it my duty to help advance trainee skill sets and model the kind of relational stances that I want to see them also employ, second only to my duty as supervisor to the clients themselves.

But is what I do “evidence-based”? Is there evidence of the effectiveness of co-therapy generally on therapist skill-acquisition or client outcomes in individual therapy? A recent article by Tanner, Gray, and Haaga (2012) from American University provide what I believe is useful input on the topic. Their brief answer is that cotherapy doesn’t seem to make much difference one way or another. Null hypotheses are retained in each of a variety of analyses conducted by Tanner et al, all focused on individual CBT therapies conducted in a university training clinic with several cohorts involved. The research methods used are reasonable for the questions asked, and the results are relentlessly clear. Tanner et al note the most important implication:

“Cognitive-behavioral therapy supervisors can choose to review tapes and discuss cases with trainees, or they can add live cotherapy supervision to the mix, according to their own preferences, realizing that the choice most likely will not make a systematic difference in the trainee’s ability to retain clients in treatment or help them reduce symptom levels” (p. 1251).

Reframing this summary a bit to focus on individuals, rather than aggregates, it appears that judgment is permitted, even required, when it comes to co-therapy with particular cases, trainees, and moments in time. This paper, precisely because it shows null results, reminds us as a field to press toward deeper questions about how change occurs and skills are aquired for clients and psychotherapy trainees alike. Simple “sitting in” in cotherapy (or even more extended versions of co-therapy) does not itself guarantee that any particular mechanism of change will be activated, or that any specific learning will be scaffolded for a trainee. Presence of a co-therapist may or may not result in an increase in adherence to any particular principle associated with change. This article serves as a reminder to me as a supervisor that mindful judgment is required from me about what is to be done, when, how, and why. Now I’ve still got to decide what to do about that trainee and the difficult case I’ve got in my clinic!

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Kenneth L. Critchfield, Ph.D.

Ken Critchfield received his doctoral degree (Ph.D., 2002) in Clinical Psychology from the University of Utah where he used interpersonal models to study psychotherapy processes and case formulation. From 2004-2014, Dr. Critchfield was director of research, and eventually become co-director of the Interpersonal Reconstructive Therapy (IRT) clinic at the University of Utah Neuropsychiatric Institute. There, he worked closely with Dr. Lorna Smith Benjamin, creator of IRT, to operationalize and test efficacy and process of change of IRT as applied with adults having severe and chronic psychiatric problems often involving comorbid personality disorder and suicidality. He joined the faculty of the Department of Graduate Psychology at James Madison University in August, 2014 and continues to work in close collaboration with Dr. Benjamin. He is a licensed clinical psychologist and now co-directs JMU’s Combined-Integrated Doctoral Program in Clinical and School Psychology.