A Unifying Vision of Psychotherapy Supervision:
Pan-Theoretical Markers and Modules for Supervision Practice and Supervisor Education
C. Edward Watkins
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As a complement to the article last month, in which I propose a unifying vision of psychotherapy supervision, I take up two additional questions in this article: Are there pan-theoretical markers of supervision concern that require pan-theoretical supervisor response? Is it possible to work toward a supervisor-informing unified educational/supervision science? I first examine how a context-responsive psychotherapy integration framework (Constantino, Boswell, Bernecker, & Castonguay, 2013) might accordingly inform a context-responsive psychotherapy supervision, where markers of pan-theoretical supervision concern are identified for pan-theoretical supervision response. Extrapolating from Constantino et al. (2013), four such supervision markers are described: Low outcome expectations, change ambivalence, problematic self-strivings, and alliance ruptures. I conclude by raising the possibility of creating an ever-informed and ever-informing unified educational/supervision science that can heuristically provoke supervision scholarship in the decades ahead. What follows can be thought of as yet another starting point — a way to think substantively about supervision unification and the eventual evolution of a unified educational/supervision science.
In what follows, I complement this Contextual Supervision Relationship Model (CSRM; my previous article) presentation by (a) identifying potentially problematic model-consistent supervision markers (e.g., low expectations) and (b) considering what might be done to profitably address them across supervision systems. My proposals involve reasoning by analogy from the highly useful unification framework of Constantino, Boswell, Bernecker, and Castonguay (2013). Reasoning by analogy refers to critically reflecting upon what is known in one area to inform or stretch our thinking in another area (Milne, 2006). Such psychotherapy to supervision analogizing can prove particularly valuable “because the models and methods of the more sophisticated psychotherapy literature may help to formulate and illuminate supervision in some key, common areas” (Milne, 2006, p. 220).
Constantino et al. (2013) proposed a unifying, context-responsive psychotherapy integration framework, defined by utilization of nomothetic and idiographic principles, incorporation of common and specific treatment factors, valuing empirical testing and evidence-based strategies, and privileging methodological pluralism and clinical relevance. Their approach accentuates the preeminent significance of contextual meaning, provided via a host of intertwined contributing factors (e.g., a coherent treatment rationale and rationale-consistent therapist behaviors, the person and personality of the patient, the patient’s culture, and the patient’s presenting pathology): “…unification derives from drawing on the complex interconnections among treatment processes and participants” (Constantino et al., 2013, p. 3).
Constantinoetal. (2013) identified five pan-theoretical treatment markers—low outcome expectations, change ambivalence, self-strivings, alliance ruptures, and outcomes monitoring—that in turn call for pan-theoretical psychotherapist action. Their data-informed approach rests on the foundational reality that there may well be frequent and repeated problematic scenarios occurring across systems of psychotherapy that require cross-system therapist responsiveness:
Our approach highlights some of these scenarios, the person of the patient, and evidence-based ways to respond as a form of psychotherapy integration and a potential model for innovative clinical training. This framework reflects more than assimilating different therapies and their theories; it embodies responding to markers drawn from multiple domains of clinical science (Constantino et al., 2013, p.3).
Constantino et al. (2013) proposed modular, marker-specific training as one way to help therapists in better addressing those five treatment concerns—preparatory instruction that is foremost therapist readying in purpose (cf. Boswell & Castonguay, 2007).
Reasoning by analogy, I propose that a context-responsive psychotherapy integration (Constantino et al., 2013) can be fruitfully used to inform a context-responsive psychotherapy supervision integration. Such a framework—highly consistent with the CSRM and reflective of the material in my first article—would similarly be characterized by: utilization of nomothetic and idiographic principles (e.g., Norcross & Popple, 2017), incorporation of common and specific supervision factors (Watkins, 2016b; Watkins, Budge, & Callahan, 2015), valuing empirical testing and evidence-based supervision strategies (Milne, 2009, 2014), privileging of methodological pluralism and educational relevance (Watkins, 2014a, 2014b), being forever guided by our evolving understanding of the person and personality of the supervisee, the supervisee’s culture, and the supervisee’s developmental learning needs (Hardy & Bobes, 2016; Stoltenberg et al., 2014), and tailoring or customizing the supervision experience in according fashion (cf. Lambie & Blount, 2016; Norcross & Halgin, 1997).
Further reasoning by analogy from Constantino et al. (2013), I propose that markers and modules may also be equally important for psychotherapy supervision. Akin to psychotherapy, there may well be frequent and repeated concerning scenarios occurring across systems of supervision that require cross-system supervisor responsiveness. Supervision scholarship down through the decades, particularly that which is developmentally informed (e.g., McNeill & Stoltenberg, 2016; Ronnestad & Skovholt, 2013; Watkins, 2016a), suggests the presence of at least four such potentially problematic, pan-theoretical supervision markers: low outcome expectations, change ambivalence, negative self-strivings, and alliance ruptures (after Constantino et al., 2013). (Securing supervisee feedback is eminently important, but supervision—because of its evaluative nature—does not readily parallel psychotherapy with regard to outcome monitoring [the fifth marker in Constantino et al., 2013]; therefore, it is not included here as a fifth supervision marker.) Although these four troubling issues have typically been recognized in the supervision literature, I am not aware that they have been specifically designated and described as pan-theoretical markers in need of pan-theoretical response. Furthermore, I am not aware of any attention given to the idea of pan-theoretically-driven modular training for these four concerns. In what follows; (a) I describe those four supervision markers and consider some possible responsive, marker-specific supervisor actions and, (b) raise the possibility of using marker-specific modules for supervisor trainees (i.e., trainees who are in the process of learning to be psychotherapy supervisors).
Context-Responsive Psychotherapy Supervision Integration:
Candidate Starting Points
In introducing their model, Constantino et al. (2013) stated: “…models need to begin some- where, and we offer here a starting point…” (p. 4). I do likewise with regard to this supervisory extrapolation, offering what might best be thought of as a supervision marker-module starting point. Because supervision re- search lags far behind psychotherapy research (Hill & Knox, 2013; Milne et al., 2012), this discussion of the four candidate starting points is based on available research (e.g., Ronnestad & Skovholt, 2013) and the accumulated wisdom of supervision scholars down through the decades (e.g., expert panel consensus; converging practice-based opinions). Table 1, modeled after Constantino et al. (2013), provides a summary snapshot of each marker with possible accompanying supervisor responses.
Low outcome expectations. This can be defined as: Limited belief in supervision’s efficacy. It typically involves doubt about the planned program of supervision. Expectations are clearly associated with psychotherapy process and outcome (Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011; Wampold & Imel, 2015), and there is every reason to believe that would also be the case for psychotherapy supervision process and outcome (Watkins, 2016b). Low expectations can result from such reasons as: a disorganized supervision beginning (Bernard & Goodyear, 2014); role conflict and role ambiguity (Friedlander, 2015); and mismatched therapeutic orientations (cf. Mcaleavey, Castonguay, & Xiao, 2014).
I have certainly seen the effect of mismatched therapeutic orientations happen where a supervisee (e.g., first developing a sense of oneself as either being psychodynamic or cognitive-behavioral): (a) gets paired with a supervisor who shares a seemingly opposing theoretical perspective; (b) feels hesitant about entering into such a supervision relationship; and (c) may even balk at the mismatch. In preventing or counteracting mismatch-induced low expectations, supervisor sensitivity to, understanding about, and open discussion of such hesitations and reservations (e.g., due to the supervisee’s desire to protect an embryonic practice self) would seem most critical to any possibility of supervisory relationship development. Failure to respect the supervisee’s evolving therapeutic orientation can lead to relationship rupture (e.g., Burke, Goodyear, & Guzzard, 1998; Gray, Ladany, Walker, & Ancis, 2001).
In preventing or counteracting a disorganized beginning, role conflict, and role ambiguity, supervisors appear best served by fully clarifying expectations, making any and all supervisory matters as clear as possible, and then engaging in collaborative discussion with supervisees about those very matters (Ellis, Hutman, & Chapin, 2015; Nelson, Barnes, Evans, & Triggiano, 2008). Role conflict, where supervisor and supervisee have opposing expectations about supervision, may be the most common reason for alliance ruptures (Friedlander, 2015). We can improve supervision by working to collaboratively define and align our expectations from the outset.
Change ambivalence. This can be defined as an approach-ambivalence conflict, wanting and being threatened by the possibility of change via therapist development. Therapist identity development has long been recognized as a challenging, oftentimes painful process of creating and putting in place a practice self, where predominating questions tend to be “Who am I as a therapist?” and “How do I therapeutically define myself?” (Ecklar-Hart, 1987; Ford, 1963; Leszcz, 2011; Watkins, 2012b). Anxiety, self-doubt, and internal struggle are developmentally normative, as can be supervisee resistance behaviors (e.g., Nelson et al., 2008). What can make this identity definition process so difficult is that the blueprint for therapist development only truly takes form in the very process of being in process (i.e., doing and trying out therapy and gaining a sense of who one is in that role over time; Watkins, 2012b). Wahesh (2016, p. 49) nicely captures the essence of change ambivalence as follows
… supervisee resistance caused by anxiety can be understood as ambivalence to change….internal struggle within the supervisee between sustaining the status quo and changing. In other words, supervisees may engage in resistant behaviors because their status quo is threatened…. Even though they might understand the benefits of change (i.e., improved clinical skills, client outcomes), they also recognize the benefits of maintaining their current beliefs or behaviors (i.e., these beliefs or behaviors function well in other relational contexts) and the potential disadvantages of change (i.e., having to try a behavioral strategy or skill that feels uncomfortable).
In addressing change ambivalence, motivational interviewing has been identified as potentially helpful.
Wahesh (2016) provides a useful description and example of how that intervention can be effectively employed for that purpose.
Education can also be helpful as a way of resolving change ambivalence. Just as being educated about the change process in psychotherapy can benefit patients (Swift & Greenberg, 2015), educating supervisees about the therapist development process and its ambiguous, challenging, yet ever-evolving nature can accordingly be beneficial for supervisees (Pica, 1998; Watkins, 2012b). Such education provides supervisees with an informing framework, normalizes the reality of internal struggle, and frames struggle as growth inducing. Though no panacea, having that developmental understanding in mind can ease supervisee anxiety and ambivalence.
Problematic self-strivings. This can be defined as competing supervisee needs for both self-enhancement and self-consistency being conflictually operative in the supervision situation. Drawing on Constantino et al.’s (2013) use of social psychology theory and research, supervisees can be thought of as having two fundamental self-strivings: (a) a need for positivity or self-enhancement, where evaluations and interactions are desired that contribute to maintaining a favorable sense of self; and (b) a need for verification or self-enhancement, where evaluations and interactions are desired that contribute to maintaining a favorable sense of self-coherence and psychological control. Change ambivalence is still present, but tends to be overlaid by a predominating and complicating negative self-view. Where these positivity/verification self-strivings conflict, the need for verification, self-confirmation, may well come to the forefront (cf. Constantino et al., 2013). Intense anxiety, self-doubt, and/or resistance (compared to Change ambivalence above) may be experienced by the supervisee, with protective (e.g., hyperactivating or deactivating) strategies being employed to protect the self from the possibility of threatening feedback (cf. Fitch, Pistole, & Gunn, 2010; Pistole & Fitch, 2008; Watkins & Riggs, 2012).
Psychotherapy supervision is a feedback-laden experience. Where problematic supervisee self-strivings exist, supervisors ideally take measure of that reality and adjust supervision accordingly. Developing a supervisory secure base, creating an epistemically safe supervision space and place (Bennett & Saks, 2006) would seemingly be a priority. Providing verifying feedback may be most crucial early on. Being attentive to relation-inferred self-efficacy beliefs (i.e., what supervisees think the supervisor believes about their therapeutic efficacy) could also be highly important, disabusing supervisees of any projected misattributions they might make about the supervisor (Lent & Lopez, 2002).
Alliance ruptures. An alliance rupture can be defined as: A tear or relational strain in the supervisor-supervisee alliance, where the quality of the supervisory working interaction is adversely affected (Ladany, Friedlander, & Nelson, 2016; Scaife, 2009). Ruptures possess fester capacity (i.e., if left unaddressed, they can prove corrosive) and derail, even destroy, the supervision relationship. All supervisees may well experience a supervision rupture at some point during training (Creaner, 2014). Primary sources of supervision rupture are: (a) mismatched expectations and miscommunications; (b) developmentally normative conflicts; and (c) problems of interpersonal dynamics (Bernard & Goodyear, 2014). Because conflict and negative experiences can occur in any supervision relationship, alliance rupture appears to be a trans-theoretically and cross-culturally relevant concept (e.g., Bang & Goodyear, 2014; Son & Ellis, 2013; Tsui, O’Donoghue, & Ng, 2014; Wong, Wong, & Ishiyama, 2013). Some examples of rupture events include the following: Supervisees reacting negatively when they feel that their thoughts or input are ignored; supervisees being offended when they experience the supervisor as being racially or culturally insensitive; or supervisees feeling overwhelmed and stifled by the supervisor’s “I teach, I tell, you listen, you do” approach.
Rupture repair refers to corrective efforts that are made to resolve the rupture-inducing conflict or event. Two fundamental action steps have been identified as increasing the likelihood of repair: (a) opening up the matter of possible rupture for discussion; and (b) providing opportunity for processing of the rupture event in as full a manner as possible with the supervisee (cf. Grant, Schofield, & Crawford, 2012; Ladany, Friedlander, & Nelson, 2005; Nelson et al., 2008). Critical features that also increase repair likelihood include: openness, disclosure, safety, non-defensiveness, and humility (Watkins, Hook, Ramaeker, & Ramos, 2016; Watkins, Reyna, Ramos, & Hook, 2015). Such action steps and features make ever possible the restoration of the supervision alliance to good working order.
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