The “do as I do, not as I say” approach to therapy supervision

The other week I participated in a training workshop for supervision in cognitive behavioural therapy, which was well-attended by the psychologists in my Trust. It was a useful workshop – with some theory in the morning, going through the (albeit limited) evidence for CBT supervision, and then the afternoon spent doing roleplays of supervision issues (such as scenarios where the supervisee departs from the cognitive model unnecessarily, or feels hopeless about progress in therapy, or dislikes their client).

The workshop got me thinking about a paper I had read soon after qualifying in the mid 90’s, that described a behaviour analysis account to therapy supervision. The main argument of the paper written by William Follette & Greg Callaghan (see reference below and available here) was that it is difficult to train therapists to do therapy well if you only rely on direct instruction (verbal descriptions of how to behave, in written form or face to face supervision). This type of supervision has the potential to produce rigid therapist behaviour, where the trainee carefully follows the supervisor’s instructions regardless of the client’s presentation or description of new problems. Follette and Callaghan describe that this in-session therapist behaviour, that is not necessarily sensitive to changes in the therapeutic relationship, is not necessarily the fault of the trainee but perhaps an unintended consequence of the training method.The supervision setting can inadvertantly strengthen this process if the focus is based solely upon retrospective descriptions of the content of the therapy sessions.

Follette and Callaghan describe this as the unfortunate effect of rule-governed behaviour, where the trainee is reinforced for following the verbal instructions of the supervisor, rather than reinforced for effectively “tracking” contingencies in the therapy relationship. Rule governed behaviour is useful when you want behaviour to be fairly immune to situational contingencies; however, in the case of therapy you want to develop trainees who effectively attend to changes in the client’s in-session behaviour. Follette and Callaghan describe the mathematical and practical limitations of providing “rules” to trainees, as effective therapy cannot be reduced to simple formulae to be slavishly followed.

The authors describe an alternative/associated training technology: using direct feedback to the trainee within the therapy session by the supervisor, giving moment-by-moment feedback through the use of a computer monitor in the room. The monitor shows graphically the supervisor’s rating of the quality of the therapy provided by the trainee.The aim of this method is to direct the trainee to be sensitive to the emerging contigencies in the therapeutic context, as inflexible application of techniques and focus will result in low ratings by the supervisor. This is contingency-shaped behaviour, where the trainee is reinforced for effective tracking in the therapy session. The article is interesting in discussing the advantages of this method, although I did think about the anxiety of the trainee in the process of moment-by-moment therapy ratings!

This approach makes sense if you think about the complex social behaviour that is required when doing psychological therapy. Beginning (and experienced!) therapists can become focused on “doing CBT right”, which can result in paying less attention to the client’s behaviour within the session. There may be many opportunities to strengthen the influence of the therapeutic relationship that are missed when therapists become overly focused on technique. Creating the context for change would seem as important as the methods used to make the change.

This may seem to be at odds with the view of CBT as technique-focused enterprise, with the traditional criticism that in CBT there is less interest in the dynamics of the therapeutic relationship. In contrast, I think it is reasonable to say that a CBT approach considers the therapeutic relationship to be a necessary but not sufficient condition for change to occur. Effective CBT involves therapists who are attentive to the “moment” AND use evidence-based methods to assist the client to change.

Reference

Follette, W. C., & Callaghan, G. M. (1995). Do as I do, not as I say: A behavior- analytic approach to supervision. Professional Psychology Research and Practice, 26, 413–421.

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Filed under CBT, Clinical Psychology, cognitive behavioural therapy, Psychology

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