Cognitive behavioral supervisors influence new generations of clients and clinicians. Accordingly, the task is meaningful, rewarding, challenging, and critically important. This article describes traditional and unconventional approaches to supervising clinicians in cognitive behavioral therapy (CBT). Traditional methods such as the use of the Cognitive Therapy Rating Scale, videotape/audiotape review, live supervision, and cotherapy are reviewed. Further, inventive procedures for teaching supervisees cognitive flexibility, empathy, tolerance for ambiguity, and remaining steadfast when faced with negative emotional arousal are explained. Popular media, improvisation and acting exercises, and working with professional actors as teaching methods are explained.
Keywords: training; supervision; cognitive behavioral therapy; clinical education
In an early work on cognitive behavioral therapy (CBT) supervision, Perris (1993) defined supervision as "an interpersonal process in which two or more persons almost always with quite a different level of professional competence, participate actively" (p. 30). Supervision is more than an experienced clinician imparting wisdom to a relative novice. Rather, it is a comprehensive process that requires each person's full interpersonal engagement. Supervisory activity assumes many forms; supervisors work to improve supervisees' declarative knowledge, procedural understanding, technical skills, and self-reflection. In addition, supervisors review trainees' progress notes, assessment reports, case conceptualization write-ups, and other paperwork. Ledley, Marx, and Heimberg (2010) noted that supervisors not only teach trainees technical and conceptual skills but also coach them to become clinicians. In short, supervision is the way trainees' raw skills become refined (Newman, 2010). This article presents various conventional as well as uncommon methods for teaching beginning clinicians how to do cognitive therapy.
Bennett-Levy (2006) conceptualized clinical training along three interrelated dimensions: declarative, procedural, and self-reflective knowledge. According to Bennett-Levy, declarative knowledge refers to acquisition of factual knowledge. Procedural knowledge depends on factual knowledge but transcends this understanding by putting information into practice. Procedural knowledge incorporates actionable rules, strategies, and skills. Self-reflection is a "meta-cognitive skill that accompanies the observation, interpretation, and evaluation of one's own thoughts, emotions, actions, and outcomes" (Bennett-Levy, 2006, p. 60). Bennett-Levy stated that self-reflective knowledge builds clinical wisdom.
Binder (1999) noted that declarative knowledge that remains unapplied is essentially inert data. Boswell and Castonguay (2007) remarked that typically, trainees find applying cognitive interventions quite straight forward in a classroom setting. However, once they are confronted with a real client in a therapy office, they discover the genuine complexity associated with clinical care. Accordingly, Rosenbaum and Ronen (1998) argued that a complex skill such as psychotherapy must be taught experientially. They employed the analogy of learning to swim. Although a person could study the mechanics of swimming and the art of difficult strokes, their knowledge must be put into action in water. An abstract, intellectualized grasp of the process does not suffice. Similarly, cognitive behavioral psychotherapy must be practiced in order for supervisees to learn.
Ladany (2007) complained that criteria for admittance to graduate school are not linked to factors that predict competence in psychotherapy. Friedberg, Gorman, and Beidel (2009) argued that training in important but nonspecific factors such as genuineness, empathy, and warmth is misguided. Indeed, training a student in genuineness seems oxymoronic. Rather, training should focus on teachable knowledge, skills, and attitudes. Cognitive behavioral therapists should be wellschooled in learning theory fundamentals, cognitive behavioral theories of therapeutic change, and specific procedures. Newman (2010) delineated core foundational and functional competencies in CBT such as managing the therapeutic relationship, achieving cultural competence, seeking interdisciplinary consultation, as well as core functional techniques such as self-monitoring, cognitive restructuring via guided discovery, conducting behavioral experiments, pleasant activity scheduling, relaxation training, and assigning homework. Moreover, most cognitive behavioral therapists share core attitudes, such as scientific mindedness, collaborative empiricism, guided discovery, cultural alertness, and embracing negative emotional arousal (Friedberg & Tamas, in press).
Edwards (2010) urged that "supervision should provide a space for thinking, feeling, selfreflection, and learning" (p. 249). In the following sections, both traditional and unconventional supervision practices that help build this space for trainees' professional development are described.
TradiTional SuperviSion pracTiceS for cogniTive Behavioral Therapy WiThchildren and adoleScenTS
This section discusses six commonly used methods to supervise beginning cognitive-behavioral therapists. These methods are used by clinicians when working with various client populations meant to increase clinician efficacy, thereby resulting in better outcomes for clinical outcomes (Holloway & Neufeldt, 1995). Traditional CBT supervision methods take aim at several pedagogical targets such as developing an effective client-therapist working relationship, case conceptualization, as well as implementing cognitive-behavioral techniques (Lambert & Ogles, 1997).
Didactic instruction includes disseminating declarative knowledge and procedural skills through lectures, readings, and discussions. Bennett-Levy, McManus, Westling, and Fennell (2009) found didactic instruction may be one of the most useful methods for teaching declarative knowledge.
Typically, supervisors directly convey declarative and procedural information in informal mini lectures and demonstrations. Most supervisors adopt an interactive, conversational tone when instructing their trainees. The goal is for supervisees to acquire information and develop solid foundational knowledge. Didactic instruction is not a one shot static process but instead occurs repeatedly in a dynamic interpersonal interplay. Supervisees should be active consumers of information. They should chew over the material before they swallow and eventually digest the information. Moreover, supervisees should be invited to share their reservations about the information they see as distasteful. Questions, discussions, and even debate should be welcomed. Active processing helps propel progress from acquisition to skill application.
Role-play presents inactive procedures where supervisees practice their skills (Bennett-Levy et al., 2009). Simply, supervisees act on their acquired knowledge. Role-plays are effective, graduated means to practice multiple cognitive behavioral skills in a simulated context (Milne, Aylott, Fitzpatrick, & Ellis, 2008). Role-plays provide opportunities to experiment with acquired skills in a relatively safe environment. Trainees can test drive new approaches without fears of making massive errors. Role-plays enjoy the added asset of helping trainees understand and empathize with clients. Accordingly, trainees gain some self-reflective knowledge. Finally, role-plays allow supervisor modeling of clinical behaviors. Trainees observe and, ideally, subsequently imitate effective intervention strategies demonstrated by supervisors.
Experienced supervisors realize that clinical skills are not acquired through osmosis in roleplays. Accordingly, role-plays need to be systematically processed and punctuated with specific feedback. For instance, a common practice is for trainees to play the client and for supervisors to play the therapist. Following the role-play, the vignette is unpacked whereby the supervisor ensures that the supervisee is taking away proper lessons. After the role-play scene, trainees should summarize what they extracted from the experience. In addition, supervisors should direct trainees' attention to salient points they overlooked or neglected. Subsequently, the trainee and supervisor switch roles so the trainee gains practice with the work. Following this role-play, the supervisor gives the supervisee specific feedback on their skill performance.
Friedberg et al. (2009) offered several cautions about role-playing. When students and trainees portray clients, the scenarios fail to approximate real-life context. Skill generalization is less likely unless the analogue closely matches the actual clinical context. Friedberg et al. concluded that "if role-plays are too emotionally sanitized and dissimilar to genuine therapist-patient interactions they are merely abstract intellectualized activities rather than experiential learning exercises" (p. 119). The use of simulated patient role-plays, improvisational exercises, and characters from popular media are alternatives to traditional role-plays that are discussed later in the article.
Audiotape and Videotape Review
Reviewing audio recording or video recording sessions is another commonly used supervisory activity (DeRoma, Hickey, & Stanek, 2007; Macaskill, 1996). Video recording may be preferred more often in that the supervisor can observe nonverbal and verbal behaviors of both clients and trainees (Shepherd, Salkovskis, & Morris, 2009). Video recording may also enhance the supervisee's perceptions of their performance in session (Huhra, Yamokoski-Maynhart, & Prieto, 2008). While reviewing video or audiotapes, trainees can reflect on their decisions, which will bring about more self-awareness and more effective application of CBT principles (Shepherd et al., 2009).
The use of audiotaping or videotaping may come with a level of anxiety for both the trainee and the client (Alpert, 1996). Thus, clients, supervisors, and trainees should be involved in a discussion around use of this supervisory technique in order for agreement to occur prior to usage. However, even with a low level of anxiety, there may be helpful aspects of this process. Moreover, the presence of anxiety is likely from any form of evaluation coupled with the fact that many people do not enjoy seeing themselves on camera or hearing their own voices on an audio recording.
Several supervisory practices may mollify this performance anxiety. First, regular session taping makes the process commonplace and facilitates a matter-of-fact stance. Consequently, trainees' anxiety is more likely to habituate. Second, supervisees should elicit supervisees' automatic thoughts regarding their performance and evaluation via daily thought records. In this way, supervisees not only learn to cope with their own anxiogenic beliefs but also gain firsthand knowledge regarding capturing and testing automatic thoughts. Third, clear specific and balanced feedback about supervisees' performance reduces ambiguity as well as accompanying anxiety.
In Vivo Supervision
In vivo supervision or live supervision is another commonly used technique in CBT supervision. In vivo supervision is an intense form of supervision. Live supervision allows supervisors to directly influence trainees' behavior thereby resulting in increased self-awareness (Softas-Nall, Baldo, & Jackson, 1997). Traditional in vivo supervision involves immediate feedback from the supervisor to the supervisee through use of either "the bug in the ear," telephone contact, observation through a two-way mirror, and/or directly sitting in on the session. When examining the many ways to implement in vivo supervision, "the bug in the ear" may be the least intrusive method for clients in that the supervisee wears a device in their ear that allows them to hear the supervisor, but the client is not able to do so. Telephone or other in session interruptions may be less desirable because they may interrupt the flow of the session. However, the bug in the ear technology is costly.
Live supervision is ranked by many counselor and marriage and family programs as one of their most commonly used methods of supervision, behind audiotaping or videotaping sessions (Bubenzer, West, & Gold, 1991; Carlozzi, Romans, Boswell, Ferguson, & Whisenhunt, 1997). In vivo supervision not only involves assisting the supervisee with therapeutic techniques, case conceptualization, and various challenging client-therapist situations but also creates support for supervisees. Although in vivo supervision may be intimidating for trainees, many supervisees enjoy the safety net it provides (Wong, 1997).
Research is mixed regarding the impact of live supervision on client outcomes (Moorhouse & Carr, 2001). More specifically, Silverthorn, Bartle-Haring, Meyer, and Toviessi (2009) found that live supervision was beneficial to perceived clinical outcomes according to the supervisee, but clients did not have similar views. In their study, clients indicated lower levels of progress, which the authors indicate may have been because of the difficulty of their cases or a lack of confidence in the therapist. Overall, live supervision may impact only some client outcomes; the method remains widely used with various populations by various psychological disciplines (see Champe & Kleist, 2003 for a review).
For example, live supervision was used at the Penn State University (PSU) Milton Hershey Medical Center Cognitive Behavioral Therapy Clinic for Children and Adolescents to train child psychiatry fellows. A supervisor skilled in CBT would sit in on sessions to observe clinical care and directly teach child psychiatry fellows. Giving corrective feedback to fellows in here and now moments allowed clients to potentially gain maximum direct benefit from supervised care. Moreover, the supervisor gained firsthand knowledge regarding supervisees' clinical behavior and demeanor. Finally, anecdotal evidence suggested that clients valued the added presence of an expert in sessions with a novice therapist.
Cotherapy is another popular type of in vivo supervision. Cotherapy often involves the supervisor and supervisee working together with a client. Trainees learn from more experienced therapists in the moment (Storm, York, & Sheehy, 1990). Supervisees gain the opportunity to observe and imitate pivotal CT skills in real time. Further, the cotherapy supervision is helpful in certain cases when supervisees might need additional direct guidance in session. In addition, cotherapy supervision does not have to occur during every session. Instead, cotherapy supervision can be used in key points in treatment. For instance, when there is a critical issue or risk assessment (suicidal ideation/homicidal ideation, child abuse, psychosis, domestic violence, etc.) being discussed, cotherapy is a viable option.
Cognitive Therapy Scale
Regardless of whether supervision is in vivo or characterized by audiotape/videotape review, the Cognitive Therapy Scale (CTS; Young & Beck, 1980) represents a useful tool for supervisors. The CTS was initially developed to assess therapist adherence to Beck, Rush, Shaw, and Emery's (1979) cognitive therapy protocol. This rating scale is focused on the assessment of therapeutic skills related to CBT through viewing of audiotapes/videotapes or via live supervision. More specifically, this tool assesses 11 dimensions of therapist strengths and weaknesses based on a 7-point scale ranging from 0 (poor) to 6 (excellent). These 11 dimensions are broken down into two categories: general therapeutic skills/conceptualization and strategy/technique. The general therapeutic skills category encompasses ratings on agenda setting, feedback, understanding, interpersonal effectiveness, collaboration, and pacing/efficient use of time. The second category based on conceptualization, strategy, and technique comprises guided discovery, focusing on key cognitions and behaviors, strategy for change, application of cognitive-behavioral techniques, and homework dimensions. The CTS also includes a section which addresses whether the session was characterized by typical or unusual circumstances. The CTS concludes with a global overall rating of the clinician.
The CTS enjoys moderate-to-high interrater reliability for total scores and moderate-to-high ratings on each item (Dobson, Shaw, & Vallis, 1985; Vallis, Shaw, & Dobson, 1986). Morever, numerous studies focused on assessment of therapist skills and competence included the CTS as a measure (Hollon et al., 1992; Lau, Dubord, & Parikh, 2004; Ng, 2005; Shaw et al., 1999). Although the CTS is widely used, caution is recommended regarding the sole use of rating scales to make decisions regarding therapist competency. Rater error may occur if different raters focus on different behaviors when making judgments (Vallis et al., 1986).
Unconventional Cognitive Behavioral Therapy Supervision Practices
Ronen and Rosenbaum (1998) asserted that experiential exercises are valuable in CBT supervision when they wrote, "Clinical supervision often requires techniques to increase opportunities for practicing and experiencing, to foster openness to new experiences, and to direct sessions toward new channels of communication" (p. 22). In the following section, several uncommon training methods including improvisational theater, fictional characters as simulated clients, and simulated role-plays by trained actors are described. The common thread between the methods is an emphasis on enhancing experiential learning within supervision.
Improvisational Theater Exercises in Training and Supervision. Both Kraemer (2006) and Zeig (2009) noted that in psychotherapy, clients share the drama of their lives. Zeig advocated that psychotherapists should train themselves in dramaturgy to propel change and make the therapy experience memorable. Friedberg, McClure, and Garcia (2009) concluded, "At their most inspiring, both theater and therapy form an experiential bond between audience (therapist) and performer (patient) forged in an emotional furnace sparked by genuine expression, sound reflection, and true creative action" (p. 8). Further, Mahoney (1991) argued that psychodrama techniques add meaningfully to psychotherapy supervision.
CBT is an inherently creative enterprise (Kuehlwein, 2000) where clients and therapists collaborate to craftproductive change where there was once paralyzing stasis and/or maladaptive actions. Kuehlwein noted that cognitive therapists need to "develop techniques by which we break out of normal methods of construing our world" (p. 178). Training in improvisational theater is a way to facilitate this creativity.
A concrete key initial task for beginning supervisees is remaining alert to what is happening in front of them in therapy and then responding with an appropriate intervention. Improvisational theater improves trainees' observational skill as well as increasing spontaneity, empathy, and interpersonal relatedness (Weiner, 1994). In addition, most CBT clinicians encourage their patients to stay present. Modifying clients' painful self-recriminations about the past and catastrophic predictions about the future are common goals. Exposure and behavior experiments require attention to the here and now. Training in improvisational theater can improve clinicians' skill levels in keeping their clients emotionally present.
Immediacy in session is a virtue in CT. Effective cognitive therapists test beliefs and shiftmaladaptive behavior patterns in the urgent, emotionally loaded here and now context. A reasonable assumption is that training in improvisational theater techniques would prime beginning cognitive therapists for this experiential work. Ringstrom (2010) explained, "An improvisational scene results from one party unpredictably setting something in motion while the other takes what is given and moves it one step further" (p. 239). Certainly, this process could also describe the psychotherapeutic encounter. Trainees are quick to become perplexed when clients act in quirky, unpredictable ways that are not discussed in texts and manuals. Some trainees become shocked and frozen because of these surprising exchanges. Training in improvisational theater could increase their flexibility and responsiveness to these unscripted moments in CBT. Accordingly, Kindler and Gray (2010) advocated that experience in improvisation enhances psychotherapists' responsiveness in treatment. Because cognitive therapy is action oriented, theater exercises are a nice fit in supervision. Writing about the congenial nature of CBT and psychodrama, Fisher (2007) noted that " . . . action is an excellent medium for rehearsing and engraining new thoughts and behaviors as well as detecting old ones" (p. 241).
Hoffman, Utley, and Ciccarone (2008) argued that training in improvisational theater fosters efficient critical thinking. They developed an elective course featuring exercises such as playing various social statuses, improving and directing attention, telling stories, and team building. Hoffman et al. reported that medical students completing the course said the improvisational course "helped them with active listening and appreciating other people's train of thought" and that the elective taught them to be "more human" (p. 538).
Improvisational theater discourages debilitating perfectionism. Mistakes are undeniably part of the process and represent opportunities for future learning (Weiner, 1994). When trainees are trapped by their perfectionism, flexibility is truncated. Rosenbaum and Ronen (1998) wrote, "The more encouragement given to supervisees to think and act in innovative ways and creative ways (within the general theoretical boundaries of CBT), the better the supervisees are able to apply the basic features of CBT" (p. 228). Indeed, flexibility within fidelity is rapidly becoming the clarion call for CBT clinicians (Kendall, Gosch, Furr, & Sood, 2008). Good CBT clinicians are rooted by faithfulness to the model, but flexibility allows psychotherapy to take flight.
In the last several years, I (RDF) have experimented with this approach in supervision. Trainees often seem frightened and perplexed when treatment does not proceed as scripted in texts. As most clinical supervisors know, the unexpected is frequently the rule rather than the exception in treatment. For instance, at PSU Milton Hershey Medical Center Child Psychiatry Fellowship Training Program, improvisational theater exercises were used in both the didactic training series in CBT and during clinical supervision in the CBT Clinic for Children and Adolescents. Child Psychiatry fellows often came to the CBT didactic training with rigid, stereotyped views of CBT based on limited reading of the literature and clinical experience. Consequently, their view of the approach was more of a caricature rather than a true portrait of the approach. To facilitate broader thinking and conceptualization during didactic presentation, seminars began with improvisational theater games (Bedore, 2004; Weiner, 1994). Improvisational theater exercises also preceded role-plays demonstrating different therapeutic processes and methods. Child Psychiatry fellows learned to respond to the unexpected and react in the moment to what was happening in front of them.
Use of Popular Culture Characters in Clinical Supervision and Training. Schwitzer, MacDonald, and Dickinson (2008) advocated for using popular culture characters in clinical supervision. Simply, popular culture figures become simulated clients. Schwitzer et al. explained that including popular characters in supervision offers experience for novice clinicians in a safe environment while avoiding ethical problems. Pop culture clients are "fun" clients and decrease supervisees' discomfort. Moreover, these characters are an excellent teaching tool because they potentially provide a wide range of diverse clients. Schwitzer et al. explained that using cases drawn from historical figures, fictional literature, fairy tales, movies, television, cartoons, and virtual sources present unique training opportunities.
I (RDF) employed various popular fictional characters in didactic and clinical training, Clockers (Lee, 1995), Girl Interrupted (Mangold, 1999), and It's Kind of a Funny Story (Boden & Fleck, 2010) are several films I showed to psychologists and psychiatrists in training. Trainees watch the movie and then complete several tasks. Initially, they use the information presented to complete case conceptualizations. Subsequently, certain emotionally provocative scenes are selected, the film is paused, and trainees are asked to respond as if they were in session with the characters.
Simulated Role-Plays with Trained Actors. An ugly didactic truth is role-plays between supervisees are rarely effective. In general, psychotherapy trainees are lousy actors! Melluish, Crossley, and Tweed (2007) wrote that "when trainees role-play patients, the demonstration lacks authenticity" (p. 104). Pomerantz (2003) noted that role-playing with trainees is made difficult because the trainees are primarily interested in learning the clinician role.
"Simulated Role Plays (SRP) refer to role-play situations where trained actors portray clients in clinical vignettes (Melluish et al., 2007). SRP is a longtime staple of medical education (Barrows, 1968) and are commonly used to teach physicians' communication skills (Hanna & Fins, 2006). Hanna and Fins (2006) outlined several advantages of simulated patients. First, simulations are lowrisk situations which enable practice by novices. Second, scenarios can be tailored to specific training issues in particular curricula. Third, simulations demonstrate empirical success in improving instructional outcomes. Lewis (2002) concluded that standardized actors help in the clinical training process by facilitating reliable evaluations and in propelling new learning. The use of actors rather than peer students in role-plays makes sense since "actors are more familiar than non-actors with the technique of moving in and out of roles" (McNaughton, Tiberius, & Hodges, 1999, p. 139).
Videotaping interventions with trained actors provides pedagogical and supervisory value. Gilliland (1982) described a procedure where she employed drama students to simulate several case studies in a psychopathology course. The actors were filmed completing a simulated session with either the instructor or another trained clinician. Course ratings showed high student satisfaction. Moreover, a video library for subsequent use was developed.
An ongoing project begun at PSU Milton Hershey Medical Center and continuing at Palo Alto University that incorporates improvisation, fictional characters, and filmed trained actors in clinical vignettes is illustrative. The project integrates the use of popular characters and simulated actors. Similarly to the Pomerantz's (2003) recommendations, collegial relationships with local university theater departments were established and acting students were recruited to play compelling literary figures with psychological impairments. For instance, in one completed vignette, an actor portrayed Holden Caulfield from Salinger's (1951) Catcher in the Rye.
Trainees prepare for the video demonstration by reading the novel. Reading the novel allows trainees the opportunity to learn case background and other contextual information. Holden was interviewed by an experienced clinician and the video was shown to trainees. Students then completed cognitive behavioral case conceptualizations based on the interview and material from the novel. Second, the vignette was paused at salient points to illustrate central CBT tenets. Similar to Gilliland's (1982) suggestion, a video library will be built with various characters.
Supervising CBT trainees and fellows is a dynamic process that entails both traditional and unconventional methods of training. The use of traditional methods, which includes videotaping, in vivo supervision, didactic training, role-plays, and measures of clinical effectiveness, remains the foundation of many supervisor-supervisee experiences. However, integration of foundational techniques and more innovative training methods such as simulated role-plays and improvisational theater techniques are necessary to facilitate a clearer understanding of how CBT works for supervisees for a multitude of professional and personal backgrounds. Further, being able to supervise trainees and fellows with various tools increases the chances that one of these techniques will be more effective than others in imbuing a sense of competence in budding psychologists and psychiatrists. Moreover, the use of innovative supervisory techniques will continue to expand as CBT supervisors embrace the dynamic aspects of the supervisory process. Through immediacy in the supervision session, the use of the here and now process facilitated by review of tapes or improvisational techniques may be the most effective way to enhance supervisor-trainee trust and encourage clinical growth and competence in supervisees.
The process of supervising trainees and fellows can be challenging yet rewarding. A new generation of psychologists and psychiatrists will rely on the skills, ingenuity, and guidance of their supervisors to put their foundational knowledge into action during real clinical sessions. Thus, as supervisors supplement conventional methods of supervision, of which they may be more comfortable, with more unconventional tactics, the more likely that the supervisory process will unfold in a positive direction. Essentially, when a supervisor is open to expanding their repertoire of supervisory methods, possibly even one's suggested by the trainee, they are more likely to be met with success in conveying supervisory messages and clinical skills. As supervisors know, supervision frequently mirrors clinical sessions in which the unexpected is likely to occur. Thus, if supervisors expect the unexpected to occur, they can cope more readily with a toolkit of both innovative and traditional techniques.
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Robert D. Friedberg, PhD, ABPP
Palo Alto University/Pacific Graduate School of Psychology, California
Gina M. Brelsford, PhD
Penn State University, Harrisburg
Correspondence regarding this article should be directed to Robert D. Friedberg, PhD, ABPP Pacific Graduate School of Psychology, Palo Alto University, 1791 Arastradero Rd., Palo Alto, CA 94304. E-mail: email@example.com…