Becoming a Clinician: Supervision

Part II: Mixing it up with the experts

Posted Jan 23, 2021

Supervision 

Many of us were inspired to become a psychotherapist by our own experience in psychotherapy.

That first therapy—when it's helpful—may have changed how you think about yourself and your life. Therapy certainly had an impression on me, although coming from a psychoanalyst's family, I fought with it for several decades, before succumbing to the obvious, I was going to be a clinician. For most of us, the second round of mixing it up with clinicians, the next step towards becoming one yourself—is supervision.  

Supervision is the endeavor—the relationship—when someone with experience guides you as you begin working with people.  The supervisor is hired by your school or by the agency in which you’re working, seeing patients.  The supervisor is supposed to be watching you, helping you during the period of training. While on the face of it, the relationship is supposed to be for your benefit, to help you learn what to say and do in your new role as the therapist, it sometimes can be a double-edged sword.

The supervisor is supposed to herself be a well-trained expert on the population you’re seeing. Kids, parents, adolescents, families, people who have rather ordinary problems in living, or people with particular mental disorders—mood disorders, anxiety disorders, psychotic disorders. The thing is while this relationship is set up for you, it’s also set up to protect the school, the agency, or to some extent, to protect the clients you’re seeing from all the zillions of mistakes you’ll be likely to make.

While the supervisor is there to help you learn “how to be a clinician” she’s also there to spy on you. That may seem too harsh—even hyperbolic—because many supervisors are outstanding clinicians and educators and you’re lucky to be paired with them. Furthermore, how much you learn from your supervisor depends upon the nature, personality, training, and experience of the specific supervisor. But the mere fact that the supervisor is discussing your work elsewhere can be unnerving, and if you have a particularly anxious supervisor, you have to proceed with caution and think about her somewhat the way you think about a client..

The quality of supervision also rests on similar attributes of the student, and the match between the student and supervisor. Like all relationships, there’s a chemistry involved in what happens when two people meet and work together. Students learn in different ways, calling for different pedagogical methods. Some love it when the supervisor teaches them by way of offering up numerous examples from their own experience with clients. They eat up specific phrases they can use, word for word.

I had a wonderful supervisor...

I had a wonderful supervisor, an older man with an endless stream of useful phrases that I often used with my clients, and then some years later, I passed on to the students I was supervising.  When I was struggling, trying to help a client who was stubbornly sneering at all my efforts, he’d say “You’re working too hard” and then he’d gently remind me: “It’s not your job to fix her. I’d feel an immediate change in perspective, as the therapy picked up steam.  When a client constantly criticized me, hurting my feelings, he’d remind me “It’s passive into active testing." he'd day, pausing, then continuing on: "She’s doing to you what her mother did to her. This is testing. She’s doing this to you for a reason: She wants an example of how to be when she has that internalized mother criticizing her.” To the client who is upset over a guilt-inducing phone call with her mother, he’d say with a winkle, “tell her “send her a box of candy.”  It worked every time, the client would laugh, and honestly start to feel less guilty.

Other clinicians-in-training prefer a “hands-off” supervisor—one who listens and nods in approval at just about anything the student describes about her work with various clients, as long as it’s safe. “Do no harm” is the bottom-line rule for all health care providers, and although the supervisor may be hoping to play a role in the development of great clinicians, their primary job is to make sure the novice in training avoids errors that are harmful. The less forthcoming supervisor may be simply a quiet person, or she may herself had little guidance when she was in training, and therefore she has little real experience in knowing exactly what to do in different clinical situations. Or she may have, on reflection, decided you prefer to be mostly independent and learn mostly by experiences in each session, with few suggestions from the supervisor.

And then there's the lousy supervisor

Most students will have the disconcerting experience of spending at least one training year with a seriously bad supervisor. Usually, the problematic supervisor gets that way because of the supervision she got when she was in training—especially if it resembles the lousy parenting she received as a child. When your supervisor is imitating a harshly critical supervisor she herself endured in graduate school, you’re likely to have a bad year—at least in supervision.

A difficult problem for students early in training—especially if they’ve had little experience with therapists before graduate school—is believing “the supervisor is always right.” This belief, heavily endorsed by most graduate programs, can lead to hair-raising confusion in the novice. Students attracted to professional psychology or counseling are usually socially active people who were always helping their family members along with their friends in high school and college, and arrive at graduate school with good social skills and a profoundly empathic nature; that’s why they’re attracted to the field in the first place. They know intuitively what is likely to help other people, they’re sensitive to nuances in personality and compassionately responsive—they arrive with the right foundation to be good clinicians.

When a supervisor conveys a basically negative attitude towards the student’s clients as well as towards the graduate student herself, the supervisor may keep suggesting unfriendly interventions and get insistent in demands that the student uses them.  The naturally talented student finds herself in a bind; pleasing the supervisor means harming the client.  The lousy supervisor, like all supervisors, carries the awesome burden of making sure novice clinicians “Do no harm”  while unconsciously, she ends up pushing the novice to be harmful. Students go through hell trying to negotiate a year with this kind of supervision, and when they believe the supervisor must be right, it can take another year with a really good supervisor and/or therapist to undo the damage done to the clinician-in-training

The structure of training is what makes supervision so important and yet so potentially difficult—the student isn’t the one paying the supervisor, the supervisor isn’t working for the student. The supervisor’s working for the people responsible for the student’s training. Nevertheless, the supervisor is supposed to be someone with whom the student identifies. The student is expected to imitate the supervisor. As for the supervisor, you have the difficult—even hair-raising at moments—job of attracting your students, hoping they’ll want to “be like you” while you need to make sure the clients are receiving good, and always safe, care. Sometimes it’s painful to watch an insecure anxious clinician-in-training; the anxious novice is awkward, feeling insecure about whatever she’s saying or doing. The supervision requires support and patience, allowing the new clinician to learn by trial and error as long as nothing is dangerous.

While I’ve not seen this empirically studied, I suspect most clinicians, after learning numerous theories and models of therapy in graduate training, end up imitating most closely the beloved therapist with whom they’ve had a transformative experience. The transformation that happens in successful therapy is powerful. When you’ve been lucky enough to have had that experience with a clinician who really understood and loved you-- it’s likely you’ll return to using the theory or model of therapy she made most use of.

Sometimes there’s another role model in the picture. He or she can be a teacher or a supervisor whose been particularly helpful.

Imitation is the secret of learning to be a clinician

As highly social mammals, as primates, we learn by imitation. In fact, our species appears to imitate more than any other; in experimental studies, it’s been demonstrated that homo sapiens imitates meaningless gestures we witness—actions that serve absolutely no purpose. Other primates imitate, but only when learning to do something functional, never just for the hell of it. We imitate in the absence of functionality.

Stick out your tongue at a newborn infant and watch her try to stick her tongue out, back at you, it’s a social instinct. Babies, then children and onward, imitate their elders—their siblings, parents, and everyone older in the community. The complexity of our social and cognitive organization demands years and years of learning, taking longer to grow from infancy into adulthood than any other species. Much of the learning allowing us to transform into functional adult humans, happens by way of imitation.

The idea that we mainly learn through formal education is a fallacy. Monkey see, monkey do. The role of imitation is well understood; in many occupations, we’re apprentices. In the building trades, carpentry, plumbing, you’re expected to learn by imitation. In some occupations, you may learn a ton of information by way of books, videos, and lectures, but in terms of what you actually do, you’re learning how to do it by watching others and then imitating their actions.  Witness the years of what’s commonly known as “Internship.” That’s apprenticing, learning by imitation. The same holds true in business. You learn how to make deals, how to negotiate with others, by way of watching the experts, and self-consciously imitating them until it becomes automatic. Surgery and nursing, you’re imitating. In law, you’re learning how to behave in court, how to talk to the judge, how to interrogate a witness, by watching the experts and then imitating their actions.

While clinical training often begins with that first appointment in a therapist’s office, what about ongoing life-long professional development? In comes the third relationship-dependent intimate connection that helps promote good and even great psychotherapy by supporting the ongoing learning and confidence-promoting experience for the clinician. Enter consultation.

In part III we continue, discussing the most fun of all, consultation