Supervision Essentials for

Cognitive–
Behavioral
Therapy
 Clinical Supervision
Essentials Series
Supervision Essentials for Psychodynamic Psychotherapies
Joan E. Sarnat
Supervision Essentials for the Integrative Developmental Model
Brian W. McNeill and Cal D. Stoltenberg
Supervision Essentials for the Feminist Psychotherapy Model of Supervision
Laura S. Brown
Supervision Essentials for a Systems Approach to Supervision
Elizabeth L. Holloway
Supervision Essentials for the Critical Events in Psychotherapy
Supervision Model
Nicholas Ladany, Myrna L. Friedlander, and Mary Lee Nelson
Supervision Essentials for Existential–Humanistic Therapy
Orah T. Krug and Kirk J. Schneider
Supervision Essentials for Cognitive–Behavioral Therapy
Cory F. Newman and Danielle A. Kaplan
Clinical Supervision Essentials
HANNA LEVENSON and ARPANA G. INMAN, Series Editors

Supervision Essentials for

Cognitive–
Behavioral
Therapy

Cory F. Newman and Danielle A. Kaplan

American Psychological Association • Washington, DC

Copyright © 2016 by the American Psychological Association. All rights reserved. Except
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Library of Congress Cataloging-in-Publication Data
Names: Newman, Cory Frank, author. | Kaplan, Danielle Alissa, author.
Title: Supervision essentials for cognitive–behavioral therapy /
Cory F. Newman and Danielle A. Kaplan.
Description: Washington, DC : American Psychological Association, 2016. |
Includes bibliographical references and index.
Identifiers: LCCN 2015050646 | ISBN 9781433822797 | ISBN 1433822792
Subjects: LCSH: Cognitive therapy—Study and teaching—Supervision. |
Psychotherapists—Supervision of.
Classification: LCC RC489.C63 N494 2016 | DDC 616.89/1425—dc23
LC record available at http://lccn.loc.gov/2015050646
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
http://dx.doi.org/10.1037/14950-000
To Norman and Phyllis Newman, my father and mother,
and my original “supervisors,” with love and gratitude.
—Cory F. Newman

To Alan, Jonathan, and Annalise,

with the happiest part of my heart.
—Danielle A. Kaplan
 Contents

Foreword to the Clinical Supervision Essentials Series ix

Acknowledgments xv
Introduction 3
Chapter 1. Essential Dimensions/Key Principles 15
Chapter 2. Supervisory Methods/Techniques 41
Chapter 3. Structure and Process of Supervision 61
Chapter 4. Handling Special Supervisory Issues 73
Chapter 5. Supervisor Development and Self-Care 109
Chapter 6. Research Support for the Supervisory Approach
and Future Directions 121
Suggested Readings 133
References 135
Index 149
About the Authors 157

vii
 Foreword to the Clinical
Supervision Essentials Series

W e are both clinical supervisors. We teach courses on supervision of

students who are in training to become therapists. We give work-
shops on supervision and consult with supervisors about their supervision
practices. We write and do research on the topic. To say we eat and breathe
supervision might be a little exaggerated, but only slightly. We are fully
invested in the field and in helping supervisors provide the most informed
and helpful guidance to those learning the profession. We also are commit-
ted to helping supervisees/consultees/trainees become better collaborators
in the supervisory endeavor by understanding their responsibilities in the
supervisory process.
What is supervision? Supervision is critical to the practice of therapy.
As stated by Edward Watkins1 in the Handbook of Psychotherapy Super­
vision, “Without the enterprise of psychotherapy supervision, . . . the prac-
tice of psychotherapy would become highly suspect and would or should
cease to exist” (p. 603).
Supervision has been defined as
an intervention provided by a more senior member of a profession to
a more junior colleague or colleagues who typically (but not always)
are members of that same profession. This relationship

77 is evaluative and hierarchical,

77 extends over time, and

1 Watkins, C. E., Jr. (Ed.). (1997). Handbook of psychotherapy supervision. New York, NY: Wiley.

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 FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

77 has the simultaneous purposes of enhancing the professional function-

ing of the more junior person(s); monitoring the quality of profes-
sional services offered to the clients that she, he, or they see; and serving
as a gatekeeper for the particular profession the supervisee seeks to
enter. (p. 9)2

It is now widely acknowledged in the literature that supervision is a

“distinct activity” in its own right.3 One cannot assume that being an excel-
lent therapist generalizes to being an outstanding supervisor. Nor can one
imagine that good supervisors can just be “instructed” in how to supervise
through purely academic, didactic means.
So how does one become a good supervisor?
Supervision is now recognized as a core competency domain for psy-
chologists4,5 and other mental health professionals. Guidelines have been
created to facilitate the provision of competent supervision across pro-
fessional groups and internationally (e.g., American Psychological Asso-
ciation,6 American Association of Marriage and Family Therapy,7 British
Psychological Society,8,9 Canadian Psychological Association10).

2 Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Boston, MA: Pearson.
3 Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Boston, MA: Pearson.
4 Fouad, N., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. S., Madson, M. B., . . . Crossman, R. E.
(2009). Competency benchmarks: A model for understanding and measuring competence in professional
psychology across training levels. Training and Education in Professional Psychology, 3(4 Suppl.), S5–S26.
http://dx.doi.org/10.1037/a0015832
5 Kaslow, N. J., Rubin, N. J., Bebeau, M. J., Leigh, I. W., Lichtenberg, J. W., Nelson, P. D., . . . Smith, I. L. (2007).
Guiding principles and recommendations for the assessment of competence. Professional Psychology:
Research and Practice, 38, 441–51. http://dx.doi.org/10.1037/0735-7028.38.5.441
6 American Psychological Association. (2014). Guidelines for clinical supervision in health service psychology.
Retrieved from http://www.apa.org/about/policy/guidelines-supervision.pdf
7 American Association of Marriage and Family Therapy. (2007). AAMFT approved supervisor designa­
tion standards and responsibilities handbook. Retrieved from http://www.aamft.org/imis15/Documents/
Approved_Supervisor_handbook.pdf
8 British Psychological Society. (2003). Policy guidelines on supervision in the practice of clinical psychology.
Retrieved from http://www.conatus.co.uk/assets/uploaded/downloads/policy_and_guidelines_on_
supervision.pdf
9 British Psychological Society. (2010). Professional supervision: Guidelines for practice for educational psychol­
ogists. Retrieved from http://www.ucl.ac.uk/educational-psychology/resources/DECP%20Supervision%20
report%20Nov%202010.pdf
10 Canadian Psychological Association. (2009). Ethical guidelines for supervision in psychology: Teach­
ing, research, practice and administration. Retrieved from http://www.cpa.ca/docs/File/Ethics/
EthicalGuidelinesSupervisionPsychologyMar2012.pdf

x
 FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

The Guidelines for Clinical Supervision in Health Service Psychology11

are built on several assumptions, specifically that supervision

77 requires formal education and training;

77 prioritizes the care of the client/patient and the protection of the public;
77 focuses on the acquisition of competence by and the professional
development of the supervisee;
77 requires supervisor competence in the foundational and functional
competency domains being supervised;
77 is anchored in the current evidence base related to supervision and the
competencies being supervised;
77 occurs within a respectful and collaborative supervisory relationship
that includes facilitative and evaluative components and is established,
maintained, and repaired as necessary;
77 entails responsibilities on the part of the supervisor and supervisee;
77 intentionally infuses and integrates the dimensions of diversity in all
aspects of professional practice;
77 is influenced by both professional and personal factors, including values,
attitudes, beliefs, and interpersonal biases;
77 is conducted in adherence to ethical and legal standards;
77 uses a developmental and strength-based approach;
77 requires reflective practice and self-assessment by the supervisor
and supervisee;
77 incorporates bidirectional feedback between the supervisor and
supervisee;
77 includes evaluation of the acquisition of expected competencies by the
supervisee;
77 serves a gatekeeping function for the profession; and
77 is distinct from consultation, personal psychotherapy, and mentoring.

The importance of supervision can be attested to by the increase in

state laws and regulations that certify supervisors and the required
multiple super­v isory practica and internships that graduate students
in all professional programs must complete. Furthermore, research has

American Psychological Association. (2014). Guidelines for clinical supervision in health service psychology.
11

Retrieved from http://www.apa.org/about/policy/guidelines-supervision.pdf

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 FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

confirmed12 the high prevalence of supervisory responsibilities among

practitioners—specifically that between 85% and 90% of all thera-
pists eventually become clinical supervisors within the first 15 years
of practice.
So now we see the critical importance of good supervision and its
high prevalence. We also have guidelines for its competent practice and an
impressive list of objectives. But is this enough to become a good super-
visor? Not quite. One of the best ways to learn is from highly regarded
supervisors—the experts in the field—those who have the procedural
knowledge13 to know what to do, when, and why.
Which leads us to our motivation for creating this series. As we looked
around for materials that would help us supervise, teach, and research clin-
ical supervision, we were struck by the lack of a coordinated effort to pre­
sent the essential models of supervision in both a didactic and experiential
form through the lens of expert supervisors. What seemed to be needed
was a forum where the experts in the field—those with the knowledge and
the practice—present the basics of their approaches in a readable, acces-
sible, concise fashion and demonstrate what they do in a real supervisory
session. The need, in essence, was for a showcase of best practices.
This series, then, is an attempt to do just that. We considered the major
approaches to supervisory practice—those that are based on theoretical
orientation and those that are meta-theoretical. We surveyed psycholo-
gists, teachers, clinical supervisors, and researchers domestically and inter­
nationally working in the area of supervision. We asked them to identify
specific models to include and who they would consider to be experts in
this area. We also asked this community of colleagues to identify key issues
that typically need to be addressed in supervision sessions. Through this
consensus building, we came up with a dream team of 11 supervision
experts who not only have developed a working model of supervision but
also have been in the trenches as clinical supervisors for years.

Rønnestad, M. H., Orlinsky, D. E., Parks, B. K., & Davis, J. D. (1997). Supervisors of psychotherapy:
12

Mapping experience level and supervisory confidence. European Psychologist, 2, 191–201.

13Schön, D. A. (1987). Educating the reflective practitioner: Toward a new design for teaching and learning in
the professions. San Francisco, CA: Jossey-Bass.

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 FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

We asked each expert to write a concise book elucidating her or

his approach to supervision. This included highlighting the essential
dimensions/key principles, methods/techniques, and structure/process
involved, the research evidence for the model, and how common super-
visory issues are handled. Furthermore, we asked each author to elucidate
the supervisory process by devoting a chapter describing a supervisory
session in detail, including transcripts of real sessions, so that the readers
could see how the model comes to life in the reality of the supervisory
encounter.
In addition to these books, each expert filmed an actual supervisory
session with a supervisee so that her or his approach could be demonstrated
in practice. APA Books has produced these videos as a series and they are
available as DVDs (http://www.apa.org/pubs/videos). Each of these books
and videos can be used together or independently, as part of the series or
alone, for the reader aspiring to learn how to supervise, for supervisors
wishing to deepen their knowledge, for trainees wanting to be better super-
visees, for teachers of courses on supervision, and for researchers investi-
gating this pedagogical process.

About This Book

In this book, Supervision Essentials for Cognitive–Behavioral Therapy, Cory
F. Newman and Danielle A. Kaplan present a scholarly, yet practical book
on cognitive–behavioral therapy (CBT) clinical supervision. In their sophis-
ticated theory-driven approach, these authors use multiple methods of
instruction—such as homework, role playing, audiovisual recordings, and
Socratic questioning—paralleling the techniques used in doing CBT ther-
apy. But this is not your father’s CBT! Drs. Newman and Kaplan challenge
our outdated assumptions of CBT principles by focusing, for example, on
the importance of the supervisory relationship, with the supervisor serving
as a role model of openness. In addition to nitty-gritty how-to’s on giving
feedback, conducting evaluations, and handling high-risk situations, they
also address up-to-date concerns about ethical and multicultural issues.
Drs. Newman and Kaplan bring their model alive through real-life super-
visory examples designed to demystify the supervisory process. These

xiii
 FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

illustrations describe a succinct and clearly laid out model that supervi-
sors can use to guide the goals and interventions of their supervisory ses-
sions. From setting an agenda and contracting for supervision to assessing
outcomes, the supervisor uses CBT techniques to help the supervisee learn
how to think like a CBT therapist.
This thoughtful book is an essential read for students and profession-
als alike; in these pages, there are nuggets of wisdom for novice and expe-
rienced supervisors who are committed to evidence-based approaches.
We thank you for your interest and hope the books in this series
enhance your work in a stimulating and relevant way.

Hanna Levenson and Arpana G. Inman

xiv
 Acknowledgments

W e would like to express our gratitude to a truly wonderful team

of professionals at the American Psychological Association (APA),
including Hanna Levenson, who invited us to write this book, and Arpana
Inman, Resarani Johnson, and Ed Meidenbauer, who shepherded us through
the process of developing the video portion of this project. In particular,
Hanna’s and Arpana’s support has been instrumental in bringing this book
to fruition. Additional thanks are due to Tyler Aune, Joanne Revak, and
Susan Reynolds for their editorial assistance and to Marla Koenigsknecht
for her marketing expertise. We are indebted to Andrew Carlquist, a stel-
lar doctoral student whose participation as the supervisee in the video is a
well-earned endorsement of his high level of competency as an early-career
cognitive–behavioral therapy (CBT) practitioner. Taking a meaningful look
back in time, we were fortunate to have had respective cadres of top-notch
clinical supervisors of our own who served as key professional role models.
We identify a number of them by name in the Introduction. Here, we collec-
tively wish to pay homage to our esteemed colleagues whose groundbreak-
ing work in the area of evidence-based clinical supervision inspired and
informed this book and who are cited liberally throughout the text.
Cory Newman would like to thank Aaron T. Beck and Judith Beck for
giving him the opportunity for over two decades to be part of their extra-
mural supervisory team at the Beck Institute for Cognitive Behavior Ther-
apy, which has allowed him to gain valuable cross-cultural experience as he
annually supervises their Beck Scholars, chosen from academic institutions

xv
 acknowledgmentS

throughout North America and around the world. Closer to home, at the
University of Pennsylvania, Cory has been privileged to supervise some of
the finest clinicians-in-training one will find anywhere and whose enthusi-
asm, knowledge, and dedication to learning have pushed him to be a better
supervisor.
Any skill that Danielle Kaplan has as a CBT supervisor is due in large
part to the skilled and dedicated supervision and mentorship she was given
during her own training. She is especially grateful to Drs. Donald Baucom
and Bernadette Gray-Little, and James O’Keefe, LCPC, JD, for their invest-
ment in her development as a clinician and as a professional. Her thanks,
too, to Dr. David Greenberg, who gave Danielle her first chance to super-
vise as a newly minted psychologist.
Danielle was deeply fortunate to have begun her career in New York
working for Dr. Robert Leahy at the American Institute for Cognitive Therapy.
Dr. Leahy and colleagues at AICT, including Drs. David Fazzari, Lisa Napoli-
tano, Laura Oliff, Jenny Taitz, Dennis Tirch, and Rene Zweig, deepened and
broadened her understanding of CBT and the affiliated therapies in ways
that continue to inform her own work and supervisory style. She is also
grateful to Dr. Leahy for organizing the dinner at which she chanced to sit
across from Dr. Cory Newman, without whom her participation in a project
like this undoubtedly would have remained an unrealized item on the bucket
list. It has been an honor and a pleasure to collaborate with Cory. Danielle’s
professional life has been greatly enriched by the opportunity to teach and
supervise at NYU-Bellevue Hospital Center, academic home to some of the
finest psychology externs and interns and psychiatry residents she has known.
Deepest thanks to them for continuing to teach and challenge her, and to
Drs. Carol Bernstein, Eve Caligor, Ilene Cohen, Alan Elliot, Lucy Hutner, Ze’ev
Levin, and Michele Rosenberg for giving her the opportunity to play a role in
the design and implementation of CBT training at Bellevue. It is also through
her time at Bellevue that Danielle has been given the gift of friendship with
Dr. Mark Evces, peer supervisor and business partner extraordinaire. She
could not have coauthored this book without the structural, logistical, and
unwavering emotional support of her husband, Alan Wolpert. She thanks
him for his steady belief in her, for being the mainstay of their family, and for
trusting that every wonderful thing they have together would come to be.

xvi
Supervision Essentials for
Cognitive–
Behavioral
Therapy
 Introduction

P icture the following three scenes, based on true stories from our pro-
fessional histories:

1. A postdoctoral fellow complains to one of her three supervisors that

she is not getting competent supervision. The fellow challenges the
supervisor to cite a book he has read on the topic. He goes to his book-
shelf and pulls his lone volume on the subject, whereupon the sur-
prised supervisee says, “You’re the first supervisor I’ve ever had who
had a book on supervision.”
2. The outpatient department of a major hospital-based psychotherapy
clinic arranges and holds a clinical supervisors’ meeting. The training
director explains the importance of formalizing and making such peer
supervision meetings routine, at least on a monthly basis. The following
month, many of the supervisors fail to attend. The month after that, the
meeting is postponed. The supervisors’ meetings are never rescheduled.

http://dx.doi.org/10.1037/14950-001
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

3
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

3. An experienced cognitive–behavioral therapy (CBT) supervisor receives

a voice mail message from a former supervisee who has just gotten his
first job as an assistant professor. He explains that one of his new
responsibilities is to provide clinical supervision to some of the grad-
uate students in his department. He asks his former mentor, “Could
I hire you to give me ‘supervision of supervision?’ I have never been
trained to do supervision, and frankly I’m very anxious.”

The delivery of competent clinical supervision is vital to the success-

ful training of therapists and lays the groundwork for the acquisition and
maintenance of therapists’ high professional standards throughout their
careers. Unfortunately, in the history of the field of psychotherapy, the
formalized training of new supervisors and the empirical study of super-
visory methods and their effectiveness were largely neglected. With regard
to the field of CBT in particular, the burgeoning database in support of the
efficacy of treatments for a wide range of clinical problems and popula-
tions was not matched by a corresponding knowledge base about the key
elements of cognitive–behavioral supervision (CBS). It is only in relatively
recent times in the field of psychotherapy in general and CBT in particu-
lar that the theory, techniques, and empirical bases for competent clinical
supervision have begun to be articulated (e.g., Bernard & Goodyear, 2014;
Campbell, 2005; Corrie & Lane, 2015; Falender & Shafranske, 2004, 2008;
Fleming & Steen, 2012; Hawkins & Shohet, 2012; Kaslow & Bell, 2008; Liese
& Beck, 1997; Milne, 2009; Milne, Reiser, Aylott, Dunkerley, Fitzpatrick, &
Wharton, 2010; Milne, Sheikh, Pattison, & Wilkinson, 2011; Padesky, 1996;
Roth & Pilling, 2008a, 2008b; Scaife, 2001; Sudak et al., 2015; Watkins, 1997,
2011; Watkins & Milne, 2014).
With these publications (and others) as a foundation, the current
volume combines the core features of CBT theory and practice with the
growing body of empirical findings on competent supervision to present
a pragmatically useful primer on how to be an effective CBT supervisor.
The tide in the field has turned, and although we are far from having all
the answers, we are confident that stories such as the three detailed at the
beginning of this introduction will fade into becoming rare exceptions
to the rule.

4
 Introduction

As the field of CBT developed via the empirical testing of treatment

packages specifically designed for discrete clinical problems, there was a
proliferation of corresponding treatment manuals. In addition to their
utility in guiding treatment, such manuals also served to instruct the
course of supervision, especially in clinical trials in which super­visors paid
particularly close attention to helping therapists adhere to the therapy
protocol (see Newman & Beck, 2008). There also has been a movement to
identify the commonalities across these separate CBT treatment manu-
als, selecting key processes that underlie numerous related disorders; this
streamlines the task of learning CBT methods that can be widely applied
and thus makes the task of conducting therapy and supervision more
manageable and less cumbersome (see Barlow et al., 2011; Dobson &
Dobson, 2009). Although it does not draw from a unified protocol per
se, this handbook adopts the spirit of an approach in which CBS can be
described in terms of its general, core principles. As such, it can be used
broadly in the oversight of a spectrum of clinical target areas, and super-
visees can be guided in their successful application of the most commonly
used CBT methods.

THEORETICAL UNDERPINNINGS
AND HISTORICAL BACKGROUND
This book owes much of its substance to the field of cognitive therapy as
originally developed by Aaron T. Beck (e.g., Beck, 1976; Beck, Rush, Shaw,
& Emery, 1979). In the early days of cognitive therapy, the approach was
considered distinct from the practice of behavior therapy and viewed
as being somewhat different from cognitive–behavioral therapy. Over
time, these therapeutic approaches have largely converged (under the
broad umbrella that is now CBT), owing in part to their shared theo-
retical sources and their valuing of measuring and testing the methods,
processes, and outcomes of treatment. Therefore, our intent is to repre-
sent the overarching principles of CBT and CBS, but our therapeutic lan-
guage will be most familiar to those who have been trained (and therefore
supervised) in a Beckian model.

5
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

In two widely cited publications on the topic of CBS (Liese & Beck,
1997; Padesky, 1996), the authors emphasized the strong parallels between
the structure and goal-orientation of CBT sessions and CBS meetings. A key
rationale is that a well-organized, well-focused clinical meeting—whether it
is between a therapist and client or a supervisor and supervisee—provides
fertile ground for learning, the efficient use of time, and the focusing of
attention and energy on high-priority topics and goals. The supervision
session provides a model for how supervisees can organize their CBT
sessions with their clients. When supervisors set an agenda, actively
ask open-ended questions, offer and solicit feedback, discuss the use
of CBT techniques, focus on the clients’ (and sometimes their own and
their supervisees’) key behaviors and cognitions, engage in experiential
methods such as role-playing, and assign and review homework, they
are implicitly teaching the supervisees how to get the most out of their
work with their clients.
Liese and Beck (1997) and Padesky (1996) also noted that CBT super-
visors help their supervisees to think like CBT practitioners, which involves
(among other things) conceptualizing clients’ problems in terms of their
belief systems, identifying the clients’ behavioral coping strategies (includ-
ing strengths and weaknesses therein), and determining which psychologi-
cal skill sets the clients would need to learn and practice most. Although
CBS was not equated with CBT practice, the two had much in common
conceptually, with the ultimate goal being to help the supervisees’ clients
acquire durable cognitive–behavioral self-help skills.
The next advancement in the field of CBS occurred in response to
an international trend toward competency-based conceptualizations of
clinical supervision (Reiser, 2014). The fact that CBT has emphasized
the importance of direct observation and objective standards and mea-
sures has given impetus to more writers’ attempts to delineate the key
components of CBS (e.g., Milne & Dunkerley, 2010; Reiser & Milne,
2012; Roth & Pilling, 2008a). This has gone hand in hand with the grow-
ing recognition that learning the skills, knowledge, and professional atti-
tudes to conduct competent supervision needs to be a formalized part
of a clinician’s training (Falender & Shafranske, 2004, 2007, in press;
Kaslow et al., 2004). Within a competencies framework, CBS now shares

6
 Introduction

many characteristics with supervision conducted from other theoretical

modalities by virtue of needing to include the essentials of documen-
tation and consultation, ethics mentoring, attention to cross-cultural
matters, trainee evaluation and professional gatekeeping, and other
pantheoretical elements of training novice therapists. Indeed, this text
presents the reader with both the core components of supervising CBT
per se and the broader aspects of clinical training and oversight. As such,
this text will be of interest to anyone who is active as a clinical supervisor
in the mental health care professions, particularly those whose primary
area is CBT or who are seeking to familiarize themselves with CBT, and/
or who bear the responsibility for training others at the graduate, post-
doctoral, or professional level.
As we touch upon in the last chapter on research and future directions,
the next evolutionary step (already under way) involves the objective and
reliable measurement of explicitly defined supervisory procedures, per-
haps in manualized formats, amenable to controlled research (Reiser &
Milne, 2012). These procedures center on CBT theory and practice but
also are derived from educational principles and research on theories of
learning (Reiser, 2014), emphasizing role-play, rehearsal, modeling, and
feedback. The chapters ahead are replete with comments on and examples
of these methods of supervision.

CBS AS DIFFERENTIATED FROM TREATMENT

Milne (2007) concisely defines supervision (particularly CBS) as “the
formal provision, by senior/qualified health practitioners, of an intensive,
relationship-based education and training that is case-focused and which
supports, directs and guides the work of colleagues” (p. 440). A cognitive–
behavioral approach makes a clear delineation between supervision and
treatment such that the supervisor does not take on a dual role as a thera-
pist for the supervisee. Having said that, when supervisees encounter dif-
ficulties in their work owing to personal experiences such as anxiety, low
self-confidence, and life events that lead to distress and distraction, the
CBT supervisor will not ignore the matter if it is affecting the supervisee’s
work. In such instances, the CBT supervisor will compassionately offer

7
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

general support, collaboratively discuss with the supervisee the degree to

which the latter’s personal matters are impinging on his or her work with
clients, offer constructive feedback to bolster the supervisee’s hopefulness,
and, if necessary, facilitate the trainee’s entering into therapy with a third-
party professional.
Pertinent to the matter of the distinction between supervision and
treatment in CBT, Newman (1998) summarized similarities and differ-
ences across several variables. For example, both the therapeutic relation-
ship (TR) and the supervisory relationship (SR) involve defined roles and
a power imbalance that are nonetheless facilitated by an atmosphere of
benevolent support, including promoting hopefulness and self-efficacy,
within safe, professionally appropriate interpersonal boundaries. In
both the TR and the SR, skills are taught, constructive feedback is regu-
larly offered, progress is measured, and there is a spirit of collaboration
in which the more “senior” person in the dyad assumes the lion’s share
of the professional responsibility for how the more “junior” person is
faring. On the other hand, the SR does not involve the treatment of the
supervisee, the time frame is often tied to an academic calendar (rather
than being based on clinical, financial, and/or research parameters), the
participants in the SR dyad have a shared responsibility for a third party
(the client), and the SR arguably has a more flexible evolutionary path
once the supervisee has completed training and is credentialed (e.g.,
super­visors and supervisees readily become colleagues and can establish
a more personal connection in the future, in contrast to therapists and
clients, who typically remain in their roles respective to each other long
after therapy is completed).

OUR PATH TO CBS EXPERTISE

The following brief sections are personal commentaries from each of the
authors, reviewing their respective pathways toward becoming experi-
enced CBT supervisors.
CN: I earned my license as a psychologist in 1989, but prior to that time
I had never received formal instruction on how to be a clinical supervisor.

8
 Introduction

My “how to be a supervisor” road map was composed of my experiences

as a trainee who received supervision for the better part of the 1980s, first
as a doctoral student at the State University of New York at Stony Brook,
then as a clinical psychology intern at the Veterans Administration Medi-
cal Center in Palo Alto, California, and finally as a postdoctoral fellow at
the Center for Cognitive Therapy at the University of Pennsylvania. I was
fortunate to receive supervision from top-notch professionals who were
experts in the field as well as genuine supporters of my development as
a therapist-in-training. I cannot possibly name all of my former super­
visors, but I would like to give special mention to such psychologists as
Marvin Goldfried, Tom D’Zurilla, Dan O’Leary, Steve Beach, Tom Burling,
James Moses, Bill Faustman, Fred Wright, Art Freeman, Bob Berchick,
and Ruth Greenberg. Of course, my chief mentor during my postdoctoral
years was a psychiatrist—Aaron T. Beck. Thus, although I never received
formal instruction in being a clinical supervisor, I was blessed with many
excellent role models from whom I learned by observation. Interestingly,
it is highly likely that my mentors never received formal training in super­
vision themselves.
Within weeks of obtaining my license to practice psychology, I became
part of the supervisory team at the Center for Cognitive Therapy and was
assigned my first supervisee—a first-year postdoctoral fellow—a position
I myself had assumed just 2 years previously. Before long I was assigned
additional postdoctoral supervisees as well as third-year and fourth-year
psychiatry residents going through CBT rotations at the University of Penn-
sylvania. Later, I purchased Dryden and Thorne’s 1991 handbook Train-
ing and Supervision for Counselling in Action, which became my primary
volume on the topic of clinical supervision for several years. Then, owing
to the leadership of Aaron T. Beck, the Center for Cognitive Therapy was
constantly running or taking part in clinical trials (on the treatment of panic
disorder, substance abuse, depression, bipolar disorder, personality dis­
orders, and other clinical problems), all of which required protocol super­
visors. I was assigned the task of supervising five licensed mental health
care professionals taking part in the CBT wing of a multisite National
Institute on Drug Abuse study on the treatment of cocaine dependence,

9
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

a trial that ran for several years. As a coauthor of the volume Cognitive
Therapy of Substance Abuse (Beck, Wright, Newman, & Liese, 1993), I was
in a good position to provide the training and supervision that were based
on this book.
When Aaron T. Beck and Judith Beck founded the Beck Institute for
Cognitive Therapy and Research (now named the Beck Institute for Cog-
nitive Behavior Therapy) in 1994, I was selected to be an adjunct clinical
supervisor for an international training program (although I remained
as a therapist and supervisor at the Center for Cognitive Therapy, on
the faculty at the University of Pennsylvania). Over the years that I have
been providing clinical supervision at Penn and via the Beck Institute,
I have supervised more than 300 predoctoral externs, postdoctoral fel-
lows, psychiatry residents, protocol cognitive–behavioral therapists in
clinical trials, and (via the Beck Institute) extramural fellows and “Beck
Scholars,” including therapists from five continents. During my sabbati-
cal in the Department of Psychology and Neurosciences at the University
of Colorado at Boulder in the fall of 2011 (having obtained my license
to practice psychology in Colorado), I provided group supervision to
three doctoral students and taught their graduate seminar on learning
to become a CBT supervisor.
During my years as a supervisor (still ongoing), I have endeavored to
keep up with the literature on supervision, contributing to it myself when
possible. As much as I learned from my venerable supervisors back in the
1980s, I must say that I have learned at least as much from my supervisees
collectively since that time. I look forward to learning ever more, year
after year.
DK: I received my doctorate in clinical psychology from the Univer-
sity of North Carolina at Chapel Hill in 2000. Although our graduate
training did not include formal course work in clinical supervision, we
were required to take courses in teaching and meet regularly for super-
vision of our work as undergraduate instructors. Many of the lessons I
learned from my program’s emphasis on teaching, and especially from
Drs. Donald Baucom and Joe Lowman, have been instrumental in laying
the foundation for my development as a CBT supervisor.

10
 Introduction

Upon obtaining my license to practice independently, I immediately

began supervising externs and interns at Advocate Illinois Masonic Medical
Center, where I had completed my own internship and postdoctoral work.
I supervised psychology trainees at all levels while I remained at Illinois
Masonic and continued to do so when I moved to New York in 2003 to
begin working at the American Institute for Cognitive Therapy (AICT).
It was at AICT, under the direction of Dr. Robert Leahy, that I began
to refine my supervisory approach to place more of an emphasis on
cognitive–behavioral case formulation and intervention. My time at AICT
was invaluable in my development as a supervisor, both because of the
opportunities I had to hone and enhance my CBS skills and because of the
supervision I received from Dr. Leahy and colleagues at the Institute. Dur-
ing my tenure at AICT, I also had the opportunity to run CBS groups
for clinical psychology doctoral students at Yeshiva University’s Ferkauf
Graduate School of Psychology.
In 2006, I accepted a position at Bellevue Hospital Center as “the
cognitive–behavioral therapist” in the outpatient psychiatry clinic. It is a
sign of how thoroughly the climate at Bellevue has changed since I began
working there that it was then considered notable that I was being hired
to work with clients within a cognitive–behavioral framework. My job
responsibilities at the time consisted of clinical work, supervising psy-
chology externs and interns, and running the CBT didactics and clinical
elective for the psychiatry residency. The residency training component
of my position required me to articulate my philosophy of CBS and com-
municate that philosophy to other supervisors in a way that encouraged
and assisted them in promulgating the core competencies of CBT to the
resident supervisees.
In 2010, I assumed the directorship of the NYU-Bellevue Predoctoral
Psychology Internship. With that position came the responsibility of set-
ting departmentwide policies for clinical supervision. During my time at
Bellevue, I have delved deeply into the literature on clinical supervision
in general and CBS in particular, including much that has been written
by Dr. Newman. I have also had ongoing opportunities to act as both a
participant in and a facilitator of discussion groups on supervision within

11
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

the context of the internship. In this capacity, I have been influenced by

many colleagues whose exceptional work has helped me to set a high bar
for my own supervisory efforts.
To date, I have been directly responsible for the CBS of more than
150 externs, interns, postdoctoral fellows, psychiatry residents, and licensed
professionals and have had ultimate supervisory oversight for the CBT
training of more than 100 additional psychology interns and psychiatry
residents. Thus, my development as a CBT supervisor also owes a good
deal to my many supervisees, who help me to become better at what I do
each time I am fortunate enough to share an hour with them.

ROAD MAP TO THE CONTENTS OF THIS BOOK

Our chief goal in writing this book is to give the reader a concise hand-
book on the key components of effective CBS that can serve as a compan-
ion guide for a formal course, as well as a reference book for general use.
We draw from the best descriptive literature of years past (e.g., Liese &
Beck, 1997; Padesky, 1996), combining it with the ever-growing empiri-
cal literature on best practices in clinical supervision (e.g., Bennett-Levy,
McManus, Westling, & Fennell, 2009; Milne, Aylott, Fitzpatrick, & Ellis,
2008; Milne, Sheikh, Pattison, & Wilkinson, 2011; Reiser & Milne, 2012).
Along the way, we explicate both the clinical components and the admin-
istrative aspects of this supervisory model. Our intent is to communicate
in a tone that conveys the seriousness of the subject while also modeling
the sort of positive, congenial, empathic support that reflects a healthy
professional relationship.
The text goes beyond describing how CBT supervisors provide over-
sight to their trainees in delivering CBT techniques. It makes reference
to such important areas as cognitive–behavioral case conceptualization,
cross-cultural and ethical competencies in supervision, optimizing both
the supervisory relationship and the therapeutic relationship, managing
clinical crisis situations via supervision, and professionally administer-
ing the documentation and evaluative aspects of supervision. Further,
the current volume also touches on the use of group supervision and a

12
 Introduction

model for supervision of supervision (also known as metasupervision).

With liberal use of case material,1 this book clearly illustrates the essential
knowledge, skills, and attitudinal components of competent CBS. Readers
will learn how to use multiple methods of teaching in supervision, includ-
ing didactic instruction, experiential exercises, audiovisual recordings,
and homework assignments. From start to finish, this book demonstrates
how to conduct competent CBS with confidence and benevolence, com-
municating high motivation and enthusiasm for helping trainees develop
competency in CBT, and never straying from the primary goal of helping
the trainees’ clients.
As the title suggests, this book is written from the vantage points of
two authors with long professional histories of receiving and providing
training in CBT. Nonetheless, the skills, attitudes, and knowledge base that
make up competent clinical supervision of any theoretical orientation cover
a broad spectrum; consequently this book also describes best practices of
supervision that transcend CBT per se. Similarly, it is not our intent to
spell out all of the details of CBT-specific methods that super­visors teach,
review, model, and support because those methods would go well beyond
the scope of a convenient guidebook and are detailed in other CBT texts
(e.g., Beck, 2011). It also is not possible for us to give more than a brief
explication of the sort of supervision that is provided in clinical trials
that use specific CBT manuals for specific clinical problems. As noted,
we present CBS consistent with a cross-diagnostic approach (Barlow et al.,
2011). Thus, we consider this text to be principle driven more than
protocol driven.
Chapter 1 describes essential dimensions and key principles in CBS.
These include an explication of the supervisory relationship, the goals
that are pursued, the values that are conveyed, the types of CBT meth-
ods that supervisees need to learn, the process of contracting for super­
vision, and the process of evaluating supervisees. Chapter 2, on the topic

1 All case material and supervisory dialogues have been disguised to protect the confidentiality of
clients and supervisees, with the exception of Andrew (see Chapter 3), who has given permission
to have his session discussed in this book. His clients’ identities have been disguised to protect their
confidentiality.

13
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

of supervisory methods and techniques, takes into account the super-

visees’ level of development, their individualized training needs, their
professional setting, and the differences between individual and group
supervision. The importance of clinical documentation in supervision
also is noted. The remainder of the chapter focuses on supervision meth-
ods such as instruction, modeling, role-playing, and the use of audiovisual
recordings. Chapter 3 takes a brief look at what happens in a typical CBS
meeting, including a review of the highlights of the companion DVD to
this volume,2 which features one of us (CN) working with an advanced
doctoral student in clinical psychology. Chapter 4 provides a look at an
array of special issues in supervision, including handling supervisees who
pose challenges such as skills deficits or compromised professional func-
tioning that requires remediation. Other special issues include supervisors
being responsive to multicultural factors in supervision, promulgating
good ethical practices, and sometimes intervening directly with clients in
critical situations. Chapter 5 is devoted to the topics of supervisor devel-
opment, metasupervision, and supervisor self-care, from basic training to
continuing education. Chapter 6 provides an overview of the empirical
state of the field of CBS, along with a glance at the future of CBS, includ-
ing early instruction and training across the professional lifespan, global
cross-cultural advancements, and the ways that technology continually
influences the field. We also suggest sources that allow the reader to pursue
a host of relevant matters in greater depth than our convenient guidebook
can cover.
Along the way, the reader will notice some overlap of material from
one chapter to another. Given that different aspects of CBS are not always
readily compartmentalized, such overlap should be viewed as appropri-
ate cross-referencing. In any case, some degree of redundancy is good for
long-term retention, as we often see in our work with clients and super-
visees alike.
Welcome, and let’s continue!

2 Cognitive–Behavioral Therapy Supervision, available from APA Books at http://www.apa.org/pubs/

videos/4310957.aspx.

14
 1

Essential Dimensions/
Key Principles

THE IMPORTANCE OF THE

SUPERVISORY RELATIONSHIP
The centrality of the therapeutic relationship (TR) is widely acknowl-
edged and empirically supported in the field of psychotherapy (see
Norcross & Lambert, 2011). However, it may be argued that the salience of
the supervisory relationship (SR) is sometimes underestimated (Ladany,
2004). In fact, supervisors must be mindful of creating a safe environ-
ment for trainees—safe enough for them to speak freely about the dif-
ficulties they may encounter in treating certain clients. Such difficulties
may include supervisees’ gaps in knowledge about certain clinical prob-
lems and/or the proper corresponding interventions or their problematic
emotional reactions to clients, such as anger, fear, boredom, and sexual
attraction (Ladany, Friedlander, & Nelson, 2005; Ladany, Hill, Corbett, &
Nutt, 1996).

http://dx.doi.org/10.1037/14950-002
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

15
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

It is incumbent upon the supervisor to contribute to a climate in

supervision that encourages trainees to speak candidly and thoughtfully
about such matters without the fear of censure, condemnation, or harm
to their status in their training/credentialing programs. A key element in
formulating an objective evaluation of supervisees’ progress in training is
listening to or watching audiovisual recordings of therapy sessions con-
ducted by the supervisees. A collaborative, benevolent SR can go a long
way toward providing supervisees with both the implicit and the explicit
encouragement to submit recordings of their work that may not always
show them at their best but may allow the supervisors to give construc-
tive feedback that will assist both the supervisee’s and the client’s prog-
ress. Overall, there is evidence that a positive SR is related to the quality
of supervision and to the supervisees’ satisfaction with supervision (see
Livni, Crowe, & Gonsalvez, 2012).
How can supervisors create such a positive SR? It starts at the first
meeting, with the supervisor inviting a discussion about the goals of
supervision, and overtly saying things such as,

It is my responsibility to help you provide your clients with the best

care possible while simultaneously promoting your growth as a clini-
cal professional. I intend to give you a lot of constructive feedback
along the way so that you know where you stand, so that our work
together is a meaningful learning experience for you, and so that you
can make adjustments in your approach when necessary. I am very
invested in your success in this program, and I am highly motivated
to help you achieve your clinical learning goals.

During the course of supervision, it is useful for supervisors to positively

reinforce supervisees who take risks in making difficult disclosures about
their work with their clients. The following are examples of supervisors’
comments that serve this purpose:

77 “This new client on your caseload seems to have a history of exhibiting

high-risk behaviors, missing sessions, and sometimes making excessive
demands on his therapists that require limit setting. Moving forward,
we—as a clinical team—are going to give this client the benefit of the

16
 Essential Dimensions/Key Principles

doubt in terms of conceptualizing his problems objectively and provid-

ing him with interventions that may truly help him. I will be impressed
by anything that you do with this fellow that can help him break old pat-
terns and make progress in treatment. Similarly, I will be impressed if
you are willing to tell me about the inherent difficulties, including nega-
tive cognitive or emotional reactions, you may have at times in working
with this client. If you show that sort of courage it will give me the best
chance of working with you to come up with responses that will help
both you and your client.”
77 “When you submit recordings of your sessions with your clients, I will
listen to them in their entirety, and I intend to let you know where I
think you were on track and also where you may have gone off track,
but it will always be with the goal of helping you to help your client. If
you can listen to the recording as well and give yourself some correc-
tive feedback, that would be ideal, and I will respect your comments. I
will also look at your corresponding clinical note to get a better under-
standing of your views about the session and what you intended to
accomplish. In other words, I will greatly appreciate you sharing your
work samples with me, and I will welcome a constructive dialogue with
you about any sticking points you may have in a given session.”
77 (Upon seeing that the supervisee is somewhat distressed about a particular
client) “I give you credit for facing these problematic issues with this
client and for bringing them up in supervision. The easiest thing in
the world would be to omit this discussion, put this client last on our
agenda, and get a perfunctory signature from me on your note. Instead,
you are highlighting the difficulties you are having with this client, and
I commend you for that. Let’s do some problem solving, but first, how
are you feeling right now? What do you think about what I just said?”
77 (Chuckling in a good-natured way) “You don’t have to apologize for
using the word ‘countertransference.’ It’s not verboten in cognitive–
behavioral therapy, and in fact I could show you quite a bit of CBT
literature that explicitly uses this term, although maybe in different
ways than it was originally formulated. I am very open to hearing your
views on the matter. What sort of thoughts and feelings did you notice

17
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

in yourself in working with this client? I think it’s great if you can self-
reflect in this manner because it not only will provide us with useful data
in supervision but it also will help you to monitor yourself constructively
in session so that your behavior remains professional and clinically on
target.”

Whereas CBS is not free of occasional points of disagreement between

supervisors and their trainees, the supervisor attempts to be collaborative
in discussing and resolving the relevant issues. For example, a supervi-
sor may recommend a particular intervention, whereas the supervisee
may favor an alternative approach. Rather than getting into a “competi-
tion” about whose intervention is “right,” the supervisor can nicely ask
the supervisee to offer a rationale for his or her point of view and then
to summarize it thoughtfully. Many times, the issue is not a matter of
“either/or” as there may be ample reason to try more than one approach
such that both the supervisor’s and supervisee’s hypotheses can be tested
appropriately in the next session with the client. When supervisors have
reason to believe that their supervisees may be hesitant to offer contrast-
ing points of view, they (the supervisors) can nicely spell out that they
welcome supervisees’ comments that may not necessarily fall in lockstep
with what the supervisors believe. Supervisors can encourage an open
consideration of more than one hypothesis because the ultimate goal is to
help the clients by following the data rather than by being wedded to one
viewpoint or one method.

GOALS
There are two fundamental goals of clinical supervision in general and
several subgoals that are pertinent to CBS per se. The primary goal of
supervision is to provide clients with care that is properly and compe-
tently managed, in which both supervisor and supervisee measure the
clients’ progress and outcomes (Swift et al., 2015). The supervisor pro-
vides the trainee with ongoing feedback and direction so that treatment
stays on course and adheres to professional guidelines and mandates, thus
ensuring that clients receive at least a normative standard of care. The

18
 Essential Dimensions/Key Principles

secondary goal of supervision is to promote the professional development

of the supervisees themselves by affording them hands-on clinical expe-
rience combined with supportive and corrective instruction. Over time,
the supervisors take more of a backseat, asking more of the trainees (e.g.,
in terms of treatment planning and outcome evaluation), and moving
them toward goals such as licensure, independent practice, and specialty
areas. When trainees evince significant difficulties in meeting their clinical
obligations, perhaps owing to a poor acquisition of basic competencies
or perhaps because of compromised functioning, supervisors also have
the responsibility of serving as gatekeepers for the profession and for the
public. Rather than allowing such substandard trainees to have a perfunc-
tory pass toward graduation, supervisors need to facilitate their trainees’
receiving the remediation they need in order to earn the privilege of treat-
ing clients. We discuss this important issue again later in the volume.
Facilitating the supervisees’ professional development includes teach-
ing them and/or evaluating them on their foundational and functional
competencies in conducting psychotherapy in general. These are two of
the three categories (along with the developmental level) that make up
the Cube Model of psychotherapy competency (Rodolfa et al., 2005), a
conceptual framework with which we are most familiar and have found
particularly useful. Foundational competencies broadly include the quali-
ties we call “professionalism,” such as respecting and understanding the
scientific underpinnings of human functioning and mental health care;
adhering to ethical standards; being interpersonally effective; valuing
self-reflection and self-correction; being sensitive and responsive to cross-
cultural issues; diligently keeping clinical records; and knowing how and
when to appropriately consult with other professionals on matters perti-
nent to client care, among other variables.
Complementary to the foundational competencies are the functional
competencies that have to do with the specific skills and knowledge base
required to provide therapy to clients. In CBT, these include conduct-
ing a cognitive–behavioral (and perhaps a formal diagnostic) assessment;
collecting clinical data to formulate a cognitive–behavioral case concep-
tualization and measure clients’ progress; devising, implementing, and

19
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

evaluating the results of specific CBT interventions; and having the req-
uisite knowledge and skills to provide clients with valid, helpful psycho-
educational knowledge.
Of course, it is not solely the supervisor’s job to introduce the trainees
to the foundational and functional competencies of conducting therapy.
Extensive course work is part and parcel of trainees’ ascension to more
advanced levels of professional development and corresponding compe-
tence. However, supervisors are important promulgators of this knowl-
edge, by word and by deed. As an example, supervisors can make sure
that their therapists-in-training are conversant in the rules and excep-
tions pertinent to maintaining the confidentiality of client information.
Supervisor and trainee can do a role-play in which the supervisor plays the
part of the client while the trainee recites his or her monologue about the
limits of confidentiality. The supervisor can then offer feedback, perhaps
helping the trainee to improve his or her style of delivery of this information
so that it has more of a routine and benevolent feel and tone. Throughout
the course of the supervisory relationship, the supervisor then “walks the
walk” of preserving the client’s confidentiality by taking care not to dis-
close client information in unsecured ways and settings, thus serving as
an ethical role model.
The subgoals of CBS (consistent with enhancing functional compe-
tencies) include familiarizing the supervisees with the methods of CBT
per se, explicating how these methods differ across clinical areas of con-
cern and client populations. At times the clinical supervision is part of
a research project in which the supervisors are charged with the task of
guiding the therapists through a treatment protocol, making sure that the
CBT is delivered with fidelity, and with a minimum of “drift” (see Newman
& Beck, 2008; Waller, 2009). At other times the supervision is guided less
by circumscribed manuals and more by general CBT principles tailored
toward individually based case conceptualizations (e.g., Kuyken, Padesky,
& Dudley, 2009) and treatment plans (e.g., Leahy, Holland, & McGinn,
2011). In either instance, effective CBT supervisors help their supervisees
learn how to structure therapy sessions for time efficiency and become
familiar with delivering a number of specific techniques that are central
to CBT overall (e.g., self-monitoring, cognitive restructuring, behavioral

20
 Essential Dimensions/Key Principles

activity planning, exposures to avoided experiences, relaxation) as well as

methods that are associated with specialty areas within CBT (e.g., mind-
fulness, guided imagery, values-driven behavioral prescriptions, emo-
tional self-regulation, and self-soothing). In addition, supervisors work
with their supervisees to create homework assignments that will help
clients practice these methods in their everyday lives.
Thus, there is a pathway of teaching that leads from the supervisor
to the clinical trainee and then to the clients themselves. Ultimately, as
several studies have suggested, clients who learn and utilize the self-help
skills of CBT in a competent way tend to get more out of treatment as a
whole (Jarrett, Vittengl, Clark, & Thase, 2011; Strunk, DeRubeis, Chiu,
& Alvarez, 2007), just as clients who engage in CBT homework assign-
ments more regularly and with higher quality show better short-term and
long-term gains from their participation in CBT (Burns & Spangler, 2000;
Kazantzis, Whittington, & Dattilio, 2010; Rees, McEvoy, & Nathan, 2005).
Clearly, when CBT supervisors succeed in teaching their clinical trainees
to teach their clients—via the use of in-session methods and the use of
homework assignments—the all-important goals of promoting better
client outcomes and therapist competencies are facilitated.
Another important subgoal can be described as follows: supervisors
train their supervisees to learn to think like CBT practitioners, most
notably by studying and applying the principles of CBT case concep-
tualization (Beck, 2011; Eells, 2011; Kuyken et al., 2009; Needleman,
1999; Persons, 2008; Sturmey, 2009; Tarrier, 2006). This involves guid-
ing trainees to become data collectors and hypothesis generators who,
with care and interest, seek an increasingly better situational and phe-
nomenological understanding of their clients’ lives, taking into account
the clients’ biohistorical and familial-cultural contexts. It also involves
thinking across disciplines, such as when a medical problem may be
playing a role in the client’s difficulties. Here, supervisees need to give
consideration to the possibility that they may need to refer their clients
for a medical examination (e.g., an endocrinology work-up), neuro-
psychological testing, or other forms of assessment pertinent to their
health and overall functioning that may go beyond the scope of stan-
dard CBT.

21
 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

The following sample dialogue between a supervisor and clinical

trainee illustrates the process of teaching the trainee to think and concep-
tualize in CBT terms. The trainee at first states that the client’s behavior
“doesn’t make sense,” whereupon the supervisor encourages the trainee to
generate hypotheses that may help explain the client’s in-session reactions
and shed light on how to intervene in an accurately empathic way.

Trainee: My client spends a lot of time in session bitterly complaining

about not being appreciated, either in her personal life or at work. She
gives me example after example about her friends taking her for granted
and not giving back what she gives them. Almost every session she tells
me that nobody gives her credit for her contributions at work and that she
is constantly being overlooked despite her hard work. But here’s a funny
thing. A pattern has developed in our therapeutic relationship where I
give her positive feedback—such as telling her that I admire her sense of
responsibility at work or that I think she has been very resilient in the face
of disappointments—and then she doesn’t acknowledge what I’ve said at
all. She changes the subject or just keeps complaining. She comes across
as craving positive acknowledgment in her life, but when I try to give that
to her, she seems to ignore it. It makes no sense.
Supervisor: Well, it’s certainly a paradox. She purports to want something
from people, then you give it to her, and she appears not to notice it. It’s
incongruous. But maybe in a way it “makes sense” in her world. Can you
try to come up with a hypothesis or two that might explain this pattern?
Mind you, I’m not saying that you have to know for sure. We don’t have
enough clinical data for that sort of accuracy or certainty yet. But this is a
good opportunity for you to look for the “logic in the illogic.” How might
this all make sense?
Trainee: Well, the thought crossed my mind earlier that maybe she doesn’t
perceive the positive feedback for some reason. I was thinking that maybe
she has some sort of mental filter that for some reason does not allow her
to really hear or incorporate people’s positive comments toward her. That
might account for her really believing that nobody appreciates her and for
her not seeming to notice the support I’m giving her.

22
 Essential Dimensions/Key Principles

Supervisor: What sort of “filter” or schema might we be talking about here?

Trainee: I guess this could be an example of an “unlovability” or “social
exclusion” schema. I actually thought of that, but there’s another prob-
lem. I tried addressing this issue directly with her. I made a process com-
ment, which is something you and I have practiced through role-playing
in supervision. I told her that I noticed that every time I felt something
genuinely positive about her to the extent that I came out and told her
directly, she changed the subject and never engaged with me. And do you
know what she did? She changed the subject again! I couldn’t even make
a process comment with her. So I don’t think she couldn’t perceive the
positive regard I was giving her. It seemed like a deliberate avoidance on
her part. That’s why I couldn’t make sense of it.
Supervisor: Nice going with the process comment! That was one of the
things I was going to suggest, but you beat me to it. Good work. But since
she confounded your attempt to address the issue, we may have to come
up with additional hypotheses. What else could be going on here?
Trainee: Maybe she mistrusts the positive comments. Maybe she thinks
it’s all insincere and that it’s a way for people to manipulate her. But she
hasn’t said anything like that before, so I think this “mistrust” schema
hypothesis could be a bit of a stretch. It’s also possible that we’re talking
about a “vulnerability to harm” schema in that if she allows herself to
believe that someone has positive regard for her she might become too
attached, and she might be afraid of that. I’m just concerned that I’m get-
ting a little too wild with my hypotheses here.
Supervisor: Well, if you can perceive my positive feedback and can allow
yourself to trust it (chuckles), I have a lot of positive reactions to what
you’re saying. First of all, that’s excellent brainstorming you’re doing.
Rather than just feeling helpless in the face of client reactions that at first
glance seem not to make sense, you are indeed trying to understand the
“logic in the illogic,” and you are giving consideration to several hypoth-
eses. Second, I have to give you extra credit for recognizing that there is
a potential hazard in getting carried away with our armchair hypothesiz-
ing. We need to balance the benefits of brainstorming with the potential

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

drawbacks of straying too far from the data. So what can we do about that?
How can we stay closer to the data while still keeping an open mind?
Trainee: I can go back and look at previous documentation on the case. I
have an intake report from 3 months ago to which I can refer. I also have a
copy of a summary submitted by her previous therapist from a few years
ago and my own clinical notes from earlier in our work together. Maybe
there are clues there that might lend support—or not—to some of the
hypotheses about various schemas that we’re coming up with.
Supervisor: Bingo! Look at the client’s history. Part of this information
can be found in the clinical documentation. Another part could be . . .
Trainee: . . . talking directly with the client about her experiences in the
past when she was neglected, let down, or otherwise felt unappreciated.
Or maybe when she felt manipulated by someone’s sweet-talking her. Or
maybe when she believed she got too close to someone and then couldn’t
bear it when she lost them. Or whatever. It’s about looking at the history
and talking directly to the client about the issues.
Supervisor: Absolutely. You can tell her that you would greatly value her
input about her personal history and how it affects the present and that
you would welcome her viewpoints about your clinical hypotheses. That’s
another great way to stay close to the data. I know that you said that you
already tried to make a process comment with her to no avail, but maybe it
will take several times and several variations to reach her with your sincere
comments. How about if we try to role-play some ways that you could try
to make more of such process comments to her? Who do you want to be
first: the client or the therapist?

In the previous dialogue, the CBT supervisor encourages the trainee

to brainstorm schema-focused conceptual hypotheses while agreeing that
it is important to stay close to the facts of the case as known and as could
be gained through further inquiry. Note that the supervisor offers a good
deal of constructive, supportive feedback.
Another subgoal of supervision is helping trainees properly manage
and administrate the termination or transfer of their work with clients.

24
 Essential Dimensions/Key Principles

The importance of a client’s ending treatment on a constructive, posi-

tive note is analogous to the importance of someone’s successfully gradu-
ating from school with confidence, hope, and credentials. Similarly, the
necessity of smoothly transferring a graduating trainee’s clients to a new
therapist who can seamlessly continue to provide proper treatment is as
relevant as a hospital patient’s receiving consistent care from one shift of
nurses to the next. Supervisors help orchestrate the manner in which the
trainees accomplish the goal of a healthy termination or transfer first by
keeping track of the status of each client (including client absences from
treatment) and second by being aware of the supervisees’ target dates for
finishing their current period of training. The proper handling of therapy
terminations and transfers has major clinical and ethical implications
(Davis, 2008), so it is incumbent upon supervisors to make sure that no
client “falls through the cracks” in the system.
Supervisors serve as procedural advisors to their supervisees about
how to prepare clients for the end of their work together, both from a
practical, administrative standpoint and from a clinical standpoint (e.g.,
sensitively dealing with clients who feel a profound sense of anticipatory
loss, and/or anxiety, and/or anger). They also serve as ethical mentors,
helping supervisees understand how to steer clear of the two dysfunc-
tional extremes of termination—abrupt abandonment of the client on
the one extreme and seeing clients for extended periods of time with no
evidence of therapeutic benefit (or without attempting any adaptations to
the treatment plan) at the other extreme. In sum, supervisors play a vital
role in helping supervisees learn to create a positive resolution to their
work with their clients.
Supervisors, by their words and deeds, communicate a set of values
to their trainees (see Corrie & Lane, 2015; Falender & Shafranske, 2004),
which is an oft-overlooked subgoal of supervision. Although many of these
values are subsumed under the ethical principles that are formally codi-
fied and guide the field of mental health care, there are parallel values that
are not often explicitly articulated but that warrant mention in their own
right. The list that follows is neither exhaustive nor universal, and its con-
tents may be modifiable depending on cultural context. However, it is use-
ful to spell out the sorts of attitudes and beliefs that many CBT supervisors

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

try to inculcate in their trainees through modeling. The following items

are adapted from Newman (2012):

77 Time is precious. Therefore competent therapists strive to be time-

effective both in session and over a course of treatment.
77 Learning CBT well requires repetitions. If we apply the methods of
CBT to ourselves routinely, thus providing ourselves with more prac-
tice, it will benefit our professional development as well as our personal
well-being.
77 Stay close to the twin priorities of teaching clients solid, durable self-
help skills and boosting their morale and sense of hope.
77 Hypothesis generation and testing are far preferable to self-assured
dogmatism.
77 Embrace the role of being an ever-learning student for your entire
career.
77 To gain the trust and collaboration of a client is a privilege not a right.
77 To truly understand and empathize with clients, endeavor to see the
world through their eyes.
77 Words matter. They can hurt, and they can heal. Communicate with
kindness and clarity.

Other writers have included such values as the importance of tolerating

(indeed, embracing) ambiguity, rather than being disconcerted when real-
life clinical practice does not imitate the textbooks, and looking at high
affect in clients and oneself not as a distraction but as an opportunity for
better understanding (see Friedberg, Gorman, & Beidel, 2009; Safran &
Muran, 2001). Yes, supervisees need to have respect for the fundamentals
of CBT practice, but they can benefit from discovering the art of “flexibil-
ity within fidelity” (Kendall, Gosch, Furr, & Sood, 2008; Newman, 2015).

TEACHING CBT METHODS

Discussing the care of ongoing clients provides fertile ground for the
explication of any number of CBT practice methods. Although there are
many excellent books on the topic of learning and utilizing CBT tech-
niques that can be assigned to supervisees for homework (e.g., Beck, 2011;

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 Essential Dimensions/Key Principles

Kuyken et al., 2009; Leahy, 2003; Ledley, Marx, & Heimberg, 2010; New-
man, 2012; O’Donohue & Fisher, 2009), the supervisor is in an ideal posi-
tion to assist the supervisee in learning, applying, and practicing CBT
techniques. In other words, supervisors help instruct supervisees not only
about what to do but also how to do it (Bennett-Levy, 2006; Friedberg
et al., 2009), thus turning their supervisees’ raw skills into refined skills
(Newman, 2010).
Supervisors also play an important role in helping supervisees deal
with typical obstacles in implementing techniques, such as how to assign
homework and ask for feedback and yet end sessions on time, how to
balance a directive approach with guided discovery, and how to respond
when clients habitually say, “yes, but. . . .” As an illustration, the following
dialogue shows a supervisor providing a recommendation about how the
supervisee can improve the client’s use of thought records.

Supervisor: I’m glad you made copies of your client’s thought records so
we could take a closer look at them. I notice that most of the client’s com-
ments under the “automatic thoughts” column are in the form of ques-
tions. For example, she writes, “Why is this happening to me?” and “What
if I never figure out how to cope with my anxiety?”
Trainee: I noticed that, too. It makes it a little tricky to come up with
rational responses.
Supervisor: Here’s a suggestion. Ask the client to answer her own ques-
tions. For example, what are her hypotheses about “why these things always
happen” to her and about what is going to happen in the future in terms of
her skills in coping with anxiety? We want to draw out her implicit answers
to her questions because those are actually her automatic thoughts.
Trainee: My guess is that if we try to hypothesize answers to her questions,
we’ll find a lot of hopeless and self-reproachful thoughts, such as, “I’m so
weak and damaged I’ll never get better.”
Supervisor: Good guess! And you can see how important it would be to
start working on coming up with alternative responses to those sorts of
thoughts.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

Trainee: I think we’ll get a lot more mileage out of identifying auto-
matic thoughts this way. Next session, if my client asks a rhetorical
question that sounds distressed, I’m going to nicely ask her to try to
answer her own question and create her own hypotheses, and we’ll take
it from there.
Supervisor: While we’re talking about thought records, let me mention
another tip. Your client tends to think in “all or none” terms, and therefore
it would be great practice for her to generate some rational responses even
if she does not believe in them 100%. Can you think of a rationale you can
give her for this approach?
Trainee: I guess I could tell her that it’s good practice to consider view-
points other than her more customary depressive and anxious thoughts,
even if she doesn’t buy into them all the way.
Supervisor: Exactly right. Rational responding doesn’t require clients to
completely relinquish what they believe in favor of completely adopting
new ideas. This is CBT, not reprogramming! Good CBT just asks people
to stretch and flex their thinking—like “cognitive yoga”—to consider new
ideas that might work better for their mood and functioning.
Trainee: And that means being able to brainstorm, right?
Supervisor: Right. It’s about getting them out of their cognitive habits—
their tunnel vision. If your client can generate new ways of thinking, it will
be helpful, even if she only believes the rational responses at a low level at
first, such as 20%.
Trainee: I can see how that will give her evidence against her idea that you
either believe something or not, with nothing in between. This strategy
will encourage her to write down some rational responses that she might
have previously rejected because she didn’t totally buy them.
Supervision: So, in the next session, ask the client to answer her own
rhetorical questions to get at the actual automatic thoughts that are state-
ments, and then ask her to brainstorm some rational responses along with
listing the respective percentages that she believes them.

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 Essential Dimensions/Key Principles

The didactic part of being a clinical supervisor entails not only teach-
ing supervisees about how to implement the core methods of CBT but
also giving general instructions that will help the supervisees to stay on
task and be effective clinicians in general. The following is a nonexhaustive
sample list of 10 of such nuggets that good CBT supervisors may impart to
their trainees. Note that these comments may pertain to CBT in particular
but may just as easily reflect best practices regardless of theoretical model.

1. “The sessions you conduct will automatically be better organized and

more instructive to the clients if you have good ‘bookends.’ In other
words, start and end your sessions in a strong way, which means that
you orient your client to be ready to get to work at the top of the
hour, and you summarize the work you have done at the end of
the hour so as to maximize what the client takes from the session.
For example, if we take a lesson from the Cognitive Therapy Rating
Scale (Young & Beck, 1980), a strong opening means that you check
on the client’s mood, set an agenda, and inquire about the previous
homework assignment. A strong finish means that you provide the
client with a summary statement about the session, ask the client for
feedback about the session, and collaboratively devise a new or con-
tinued homework assignment. If you can get into the positive habit
of providing these sturdy bookends to your sessions, it will make the
entire therapy session more time-effective, relevant, and memorable.
Similarly, it is helpful to have strong bookends for the entire course
of therapy. A strong first session introduces clients to the treatment
model and illustrates how it is relevant to their concerns, shows them
that you are a credible professional who is well-equipped and motivated
to help them, boosts their sense of hope, and immediately presents them
with some early skills and homework. A strong concluding session
summarizes your work together, reinforces a maintenance plan, and
promotes a sense of camaraderie in which you and your clients
contemplate your positive connection and a job well done.”
2. “As you begin to use your CBT conceptualization and intervention
methods, you may find that it’s difficult to relax and just be yourself.
After all, when you’re working so hard on method it’s not so easy to

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

focus on manner. But don’t worry because the more you practice, the
more you will find that you can weave your best personal qualities
into the interventions so that the therapeutic relationship is strong
and you can feel more natural in doing your work. Don’t feel that you
have to subjugate your personality to the model. I’m confident that
you will find that you can succeed in combining best practices in CBT
with the best of your personal style. The result will be that you will
enjoy the work more, and your clients will benefit greatly.”
3. “Clients vary in how much they are willing to engage in the homework
assignments. When they are not so keen to do the homework, don’t
give up. In other words, don’t let the clients’ lack of positive response
extinguish your appropriate homework-giving behavior! Instead,
hypothesize what might be getting in the way. Ask the client for feed-
back. Consider the possibility that the assignment needs to be more
specific to the needs of a particular client or that you can do more to
explain the assignment and demonstrate how it’s done. Maybe the
client harbors some negative beliefs about homework, owing to such
factors as low confidence, mistrust, sensitivity to interpersonal con-
trol, or other issues. Maybe clients will be more willing to take charge
and give themselves an assignment if you give them the chance to do
so. In other words, make the process more collaborative. In any event,
nicely and consistently show clients that you want to give them every
opportunity to succeed in therapy, and doing homework has been
shown to be one of the key ingredients in what makes CBT work. You
can tell clients that they can still benefit from CBT even if they don’t
do the homework, but add that you want to increase their chances
even more, and that’s why you’re willing to keep giving assignments,
in the hope that they will come around at some point and thus will
benefit more. Don’t let it be a power struggle. Homework should be
more of a benevolent offering.”
4. “When you give your clients a homework assignment, feel free to
announce to them that you are giving yourself a corresponding home-
work assignment. For example, your homework could be reading the
remainder of their journal writings that you didn’t have time to discuss

30
 Essential Dimensions/Key Principles

in the session, or it could be reading part of the same self-help book that
you are asking them to read, or taking their advice to read or view some-
thing that will teach you something about their culture, or any other
appropriate assignment that shows that you are willing to practice what
you preach. Obviously you don’t have to do this every session, and with
every client because that might be unwieldy. Nonetheless, for those times
when you overtly give yourself an assignment, it can be a nice finishing
touch to a session, like a demonstration of solidarity with the client.”
5. “We have to remember that we as clinicians are not the final judges
about what makes sense and what doesn’t make sense in the lives of
our clients. If we endeavor to ‘walk a mile in their shoes,’ then there
will be times when we can understand why clients do or believe things
that look ‘irrational’ to the naked eye. To be accurately empathic, and
to maximize collaboration, we as clinicians need to look for the ‘func-
tion in the dysfunction and the logic in the illogic.’ By doing so, clients
will be more apt to believe we ‘get it,’ and they may feel more accepted
and may become willing to consider making changes.”
6. “I know you’re trying to be vigilant about the client’s negative thoughts
and trying to effect change—and I applaud the fact that you are work-
ing so hard—but it may be better if you reduce the frequency and the
vehemence of your attempts to get the client to engage in rational
responding. First of all, it’s more efficient and it creates a better flow
of therapeutic dialogue if you listen and collect examples of the cli-
ent’s thinking style. Second, by having patience and occasionally sum-
marizing, not only will you be more relaxed but there also will be less
risk that the clients will feel like you’re micromanaging their thoughts.
Third, bear in mind that not all of your interventions will ‘take’ on the
spot. Sometimes the best you can do is to ‘plant seeds’—you know,
by providing a few key reframes of what the clients are thinking—
and then see if some of those seeds sprout over the coming weeks. I
used to be overzealous with some clients early in my career, totally
with good intentions, just like you. It was as if I had the dysfunctional
belief, ‘Nobody leaves this office until their cognitions are changed!’
We don’t have to have that belief.”

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

7. “Take the time to learn the finer details of your clients’ lives. Learn the
names of the significant people in their lives and their most important
dates on the calendar, such as birthdays and happy and sad anniversa-
ries. Remember where they went to school, what they do for a living,
where they have lived, and other details that will help you to know
them as individuals. If you invest the time to gather these sorts of
facts, you will be able to allude to them from time to time in the course
of your therapeutic dialogue, and this will solidify the therapeutic
relationship. Your clients will see that you know them as individuals
and not just as a name on your schedule.”
8. “Go the extra mile to write good clinical notes for each therapy ses-
sion, and please do this promptly while things are still fresh in your
mind. Then, before the next session, review the notes you wrote from
the previous session so that you are optimally oriented to the issues
on which you and your client are working. This will help you feel bet-
ter prepared and more organized, and it will greatly help you to set a
relevant agenda. In addition, you will be serving as a role model for
the client. After all, if you can remember the details of a given client’s
therapy session from last week, the client likely will see the merits in
remembering what happened in his or her own previous sessions.”
9. “Good therapy is a mutual education process. You are the expert in
CBT, but your clients are the experts on what it feels like to be them.
Exchange information. Sometimes clients will be more willing to
accept your assessment comments and proposed interventions if you
have been willing to let them educate you first. By the way, this is
not only a beneficial stance to take in treating a given client, but it is
also true with regard to your professional development. Clients have
a lot to teach us about all sorts of things. For example, they may have
gone through life-cycle events you have not yet reached but that you
could benefit from understanding a bit better. Similarly, your clients
can teach you a great deal about their culture. Be receptive to being a
student, even with your clients.”
10. “If you have diligently, earnestly applied a CBT case conceptualiza-
tion and its corresponding treatment approach to a given client, but

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the client is not improving, don’t despair and don’t assume that you
are being ineffective or that your client is just being ‘difficult.’ Con-
sider the possibility that the case may be more complex than you first
thought. Maybe the diagnosis needs to be revisited. Maybe there is
something going on in the client’s personal life outside the clinic that
is interfering with treatment. Maybe there is a medical condition that
needs to be considered. In other words, ask yourself, ‘What data are
we missing? Is there important clinical information that the client has
not yet disclosed for some reason?’ Please bear in mind how difficult
it must be to reveal things such as suicidal feelings, or to talk about a
trauma history, or to come out as a sexual minority, or to disclose an
addiction. Then think about how you can create an environment in
which it will be safe enough for clients to explore such weighty sub-
jects if they haven’t done so thus far. But don’t give up on clients or
yourself just because progress is slow to occur.”

Another important skill that the CBT supervisor would do well to

assess is the supervisee’s facility in answering a new client’s questions
about CBT. This is an anticipated interaction that can be role-played in
supervision so that the supervisor can gauge how clearly the supervisee
can explain the cognitive–behavioral model of treatment. Related to
this psychoeducational skill is the supervisee’s ability to address the cli-
ent’s concerns or questions about the official diagnosis (if one has been
proffered).
As noted, supervisors offer their supervisees didactic information
about CBT and opportunities to practice the skills that emanate from such
information. Therapists do the same for their clients. In terms of sup-
plemental didactics, supervisors and their supervisees can discuss which
CBT self-help books (or other relevant psychological literature for the
informed layperson) can be recommended to which clients. Well-known
CBT books such as Mind Over Mood (Greenberger & Padesky, 2015) and
The Feeling Good Handbook (Burns, 1999) are widely read by clients as
“take-home guides” that accompany their treatment, and many CBT
therapists-in-training are familiar with these seminal manuals. However,
there are any number of other high-quality CBT-related books on a wide

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range of topics (e.g., on overcoming problems associated with the full

range of diagnostic areas, utilizing mindfulness, coping with life stressors,
helping loved ones) that may be assigned to clients, and supervisors are
in a good position to endorse their use. In addition, there are important
texts that are not specific to CBT per se that are nonetheless potentially
helpful to clients, including such classics as Victor Frankl’s (1959) Man’s
Search for Meaning and Kay Redfield Jamison’s (1995) An Unquiet Mind.
Supervisors who are personally familiar with such writings may instruct
their supervisees to read one or more of these publications, both for gen-
eral professional growth and to be better informed about their potential
usefulness as homework assignments for their clients. An important point
about assigning readings is that it is advisable for the therapists and/or
their supervisors to have first-hand familiarity with the material before
asking clients to read it.
There are other characteristics of effectiveness as a therapist that are
somewhat difficult to quantify but that we hypothesize may enhance the
delivery and impact of therapy. Although not routinely mentioned in
therapy manuals, these characteristics are ripe for discussion and model-
ing in supervision. Such qualities have been described by some authors
as “meta-competencies” (see Corrie & Lane, 2015; Newman, 2012; Roth
& Pilling, 2007), and they include (but are not limited to): (a) clarity of
communication style; (b) good sense of timing in delivering interven-
tions (e.g., being fully prepared to discuss a highly sensitive and hereto-
fore sidestepped topic the moment the client alludes to it); (c) excellent
memory for the details of clients’ lives, their case conceptualizations, and
the contents of previous sessions; (d) a wide range of verbal repertoire,
tone of voice, and empathic nonverbals; (e) appropriate use of humor (in
which the client and therapist laugh together, lighten the mood, and bond
a bit more); (f) facility in being well organized so that clients are tended
to (and corresponding documentation and consultation managed) in a
thorough and prompt manner; and (g) the resiliency to impart an air
of hopefulness, encouragement, and steadfast commitment to help, even
when clients are entrenched in hopelessness and helplessness. These are
the sorts of qualities that help make therapy more memorable and inspi-
rational for clients, thus facilitating the clients’ retention and maintenance

34
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of important therapeutic principles and their motivation to participate

more fully in the process of treatment. Such meta-competencies begin
with the supervisor.

SETTING EXPECTATIONS FOR SUPERVISION

Supervisees benefit from learning early on what is expected of them and
what they can expect from their supervisors. From a practical standpoint,
supervisees should be given at least a rough estimate of the number of
clients they will need to treat, over what time frame, in what format of
supervision (e.g., individual and/or group), with how many supervisors,
and using which methods of documentation (e.g., written vs. electronic),
among other topics. Supervisors have a choice about how collaborative
they wish to be in establishing expectations about supervision. In some
settings, the institutional rules and culture may require supervisors to
impose set parameters of supervision. If the environment is more flex-
ible, supervisors can initiate a collaborative conversation with supervisees
about the sorts of expectations that may be most appropriate. This dis-
cussion may be in the form of a “needs assessment” (Corrie & Lane, 2015;
Milne, 2009), in which supervisors ask the supervisees directly about their
perceived strengths and weaknesses, their previous training experiences,
their sense of self-efficacy in and familiarity with certain types of clients
and clinical problems, and their opinions about what they need to work
on the most to become more competent overall. As such, a needs assess-
ment may allow for supervisors to tailor a course of clinical training to the
specific needs of each supervisee. At the same time, the supervisees will be
aware of what they have to work on to grow as professionals. This sort of
clarity is good for the entire supervision enterprise.
Likewise, supervisees benefit from knowing what they can expect
from their supervisors: for example, how often will they meet (once per
week?) and how long will each meeting last (a “50-minute hour?”). If the
super­visor is unavailable for any reason, will he or she provide a backup
or on-call supervisor for the trainee? Under what conditions should the
trainee consult with the supervisor between formal, scheduled supervision

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sessions? Should such extrasupervisory contacts occur only in a clinically

critical situation, or are routine questions okay? Under what conditions
will the supervisor directly meet with the supervisee’s client(s)? For exam-
ple, will the supervisor meet with the supervisee’s client(s) as a matter of
routine, or will this happen only in crisis situations? How often will the
supervisor provide formal, summative feedback? Indeed, setting expecta-
tions in supervision goes both ways.
These expectations can be spelled out in the form of a supervisory
contract. Exhibit 1.1 demonstrates a section of a sample contract, which
includes the supervisee’s required activities, the types of competencies the
supervisee is aiming to acquire, and the responsibilities of the supervisor.
As such, it is a document that is congruent with a collaborative profes-
sional relationship (Thomas, 2007).

EVALUATION OF THE SUPERVISEE

Supervisors necessarily keep track of the progress of the clients being
seen in treatment by their supervisees because their well-being is of para-
mount importance. At the same time, supervisors actively keep tabs on
the progress of their supervisees in learning the foundational and func-
tional competencies of delivering CBT. Supervisors evaluate their super-
visees regularly during the course of their work together by giving routine
feedback, also known as formative evaluation. This can be done at every
supervisory session by commenting on various aspects of the trainees’
management of their cases, including their handling of the therapeutic
relationship; their case conceptualizations; treatment plans; level of pro-
ficiency in the use of specific techniques and homework assignments;
clarity, accuracy, and thoroughness of their session notes; degree of pro-
fessionalism in their behaviors and attitudes; demonstrations of thought-
ful self-reflection; and responsiveness to supervisory feedback itself. This
is quite a substantial list of factors about which to be aware and on which
to comment. Although it would be easy to give short shrift to this part of
the supervisor’s job, perhaps to focus solely on how the clients are pro-
gressing in treatment, there is evidence that the quality of supervision is
significantly improved when supervisors make it a point to provide their

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 Essential Dimensions/Key Principles

Exhibit 1.1
Sample “Supervisory Contract” Document Items
I agree to . . .
1. Maintain a caseload of “n” clients for a period of approxi-
mately 12 months.
2. Write all therapy notes and reports promptly, and maintain
them in an organized fashion in the client’s chart so they may
be cosigned by the supervisor.
3. Protect my clients’ confidential information by keeping the
charts in a secure place, using disguised information in case
conferences, refraining from discussing cases outside of the
training sessions, and using password protection or encryp-
tion when sending digital transmissions of client data (e.g.,
session recordings).
I will learn to . . .
1. Create written cognitive–behavioral conceptualizations for
each case.
2. Structure sessions for good time management and good
organization of material.
3. Utilize a range of cognitive–behavioral interventions and
homework assignments.
4. Foster and maintain healthy, appropriate therapeutic relation-
ships with clients.
5. Learn to use self-reflection to assist my work.
I can expect that my supervisor will . . .
1. Give me constructive feedback in supervision.
2. Listen to at least four full-length recordings of my therapy
sessions over the course of 12 months and provide me with
ratings on the Cognitive Therapy Rating Scale (CTRS).
3. Provide me with four formal summaries of my progress as a
cognitive–behavioral therapist over the course of 12 months.
4. Take professional, ethical, and legal responsibility for the
welfare of the clients.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

trainees with ongoing feedback both positive and reflective of areas for
improvement (Milne, 2009; Milne, Sheikh, et al., 2011).
It is particularly useful if supervisors take the time and make the effort
to observe actual work samples, such as audiovisual recordings of their
trainees’ session(s) with clients. Although this activity is often time inten-
sive, it is the best way to assess the quality of the supervisees’ actual in-
session work. When time is limited, the supervisor may opt to watch only
a segment of a supervisee’s session, perhaps to give feedback or sugges-
tions on a discrete issue as it occurred. On the other hand, if the supervi-
sor intends to do a formal rating of the supervisee’s adherence to the CBT
model and/or competence in delivering the treatment, it is necessary to
observe the entire session. As noted, competent supervisors must create an
atmosphere of support so that the supervisees will be more likely to sub-
mit their recordings with a minimum of trepidation and with the positive
expectation that they will receive useful, constructive guidance. When the
supervisees make the extra effort to create these recordings, the supervi-
sors should review them as soon as possible both as a sign of respect for
the work of the supervisee (and thus to positively reinforce it) and to
provide timely clinical feedback.
In addition to providing routine, ongoing feedback, supervisors also
periodically provide their supervisees with summative evaluations, which
become a formal part of the supervisees’ record in their training program.
Official summative evaluations of trainees that are subpar may potentially
have a negative impact on the trainee’s future in the field and thus need
to be written in such a way that the critique is constructive and spells out
the supervisee’s ongoing training needs in as hopeful and respectful a way
as possible.
If routine feedback has been given properly, such that supervisees
know where they stand at any given time, the summative evaluations will
be a natural extension of the process, and the supervisees are likely to
perceive congruence and fairness in their evaluations. Summative evalua-
tions should not surprise or shock supervisees with unexpected critiques
that have not been discussed previously (see Davis, 2008). Instead, cor-
rective feedback should be given in such a way that the supervisees have
ample opportunity to work on shoring up their weaknesses. Summative

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 Essential Dimensions/Key Principles

evaluations ought to be based on a number of concrete factors, such as the

timeliness and contents of the supervisees’ clinical notes, the supervisees’
punctuality and attendance in supervision and meeting with their clients,
their case write-ups (e.g., formal case conceptualizations), their scores on
measures of their in-session adherence to and competence in delivering
CBT (e.g., on the Cognitive Therapy Rating Scale, Young & Beck, 1980;
Blackburn et al., 2001), and the objectively measured progress of the cli-
ents (e.g., reduction in suicidal ideation and gestures, stable improvements
on self-report inventories, corroborating indicators of improvement, such
as reports from clients’ family members and/or consulting professionals
on the same case). Using a combination of such measures lends cred-
ibility to the supervisors’ feedback, gives the supervisees a more accurate
and objective way to assess their own progress in training, and overtly
indicates areas in which the supervisees can strive to improve their work.
Whether the supervisors are providing formative or summative evalu-
ations, it is important that they do not fall prey to what has been dubbed in
the literature as “the tyranny of niceness” (Fleming, Gone, Diver, & Fowler,
2007), whereby supervisors fear being anything other than supportive of
their supervisees and thus avoid giving them the sort of direct, construc-
tively critical feedback that may be essential to their professional develop-
ment. We agree that it is vitally important for the supervisors to promote
a positive, hopeful atmosphere in supervision in which the trainee can
flourish, but we also believe that a measure of supervisors’ competence is
their ability to be supportive of and invested in the supervisees’ progress
as clinicians even as they are pointing out areas that need further work.
In doing so, supervisors serve as role models for their supervisees, who
themselves undoubtedly will need to balance genuine support with cor-
rective feedback in their work with clients. Giving supervisees construc-
tive feedback also helps ensure the proper treatment of the clients, which
is the top priority.
In contrast to the tyranny-of-niceness phenomenon is the problem of
supervisors who take a “no news is good news” approach in providing feed-
back. Such an approach can give supervisees the mistaken impression that
they are underperforming, when in fact the supervisor is silently thinking
that much of the work is “obviously” going well. A lack of feedback is often

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

cited by therapists-in-training as an example of a poor supervisory experi-

ence (Phelps, 2011). Indeed, the supervisor’s failure to provide supervisees
with adequate performance evaluations is a surprisingly frequent ethical
violation (see Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999).
It can also be useful to give supervisees the opportunity to evaluate
their supervisors in return given that supervisors potentially have much
to learn about how their trainees are perceiving and receiving their work
in supervision. Such feedback can help supervisors to make adjustments
in their approaches and help administrators who are in charge of an orga-
nization’s supervision infrastructure, policies, and assignments to address
any problems in their program of supervision. However, we must remem-
ber that supervisees are in a vulnerable position when it comes to giving
potentially critical feedback to their supervisors because they may fear
retaliation, with implications for their standing in a training program.
Thus, it is best if such feedback can be given anonymously. Clearly, this has
to be handled carefully as many training programs are sufficiently small
that it would be fairly easy to surmise which supervisee wrote what about
whom. A less formal method of eliciting feedback from supervisees can
take place as a routine occurrence in each supervision session, simply as a
way to “check in” and see how the meeting went that day. This procedure
can be viewed as part of the structure of a supervision session, analogous
to the therapist’s asking for feedback from clients in each therapy ses-
sion. The supervisor’s friendly and inviting demeanor can reassure the
trainee that the purpose of such feedback is to improve the supervisory
experience. A running theme throughout this text is that supervisors have
authority and power, but they must use this authority and power wisely
and benevolently. Nowhere is this more evident and important than in the
area of providing and receiving evaluative feedback.

40
 2

Supervisory Methods/Techniques

T his chapter takes a look at some of the methods that are used in
cognitive–behavioral supervision (CBS) to help supervisees learn to
become competent (and ultimately proficient) in cognitive–behavioral
therapy (CBT) and to be vigilant in tracking and documenting what tran-
spires in their sessions with clients. First, we consider how the supervisee’s
level of professional development and the clinical setting in which the
supervisee trains affect the supervisor’s expectations.

http://dx.doi.org/10.1037/14950-003
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

EXPECTATIONS DEPENDING UPON

THE SUPERVISEE’S DEVELOPMENT
AND THE CLINICAL SETTING
Therapists who are about to commence receiving clinical supervision do so
from a wide range of developmental starting points. For example, a super­
visee may be one of the following:

77 A new graduate student who is about to treat clients for the first time.
77 An advanced graduate student who has been accepted to a competitive
practicum.
77 A predoctoral intern who now is responsible for his/her largest case­
load to date.
77 A postdoctoral fellow who is seeing clients to accumulate hours for
licensure.
77 A newly licensed mental health professional who is legally and pro-
fessionally permitted to treat clients in independent practice but who
nonetheless seeks ongoing consultation until he or she gains more
clinical experience.
77 A seasoned clinician who initiates and undergoes a course of clini-
cal consultation to respecialize in a particular clinical population or
modality of treatment.
77 A senior, full-time academician who spends part of his or her sabbatical
seeing clients and receiving consultation to stay connected to clinical
work.

As one might surmise, the supervision of this spectrum of clinicians

is not a case of “one size fits all.” The supervisor would have to take into
account the supervisee’s developmental level (McNeill & Stoltenberg,
2016; see also the Cube Model of competence, Rodolfa et al., 2005) in
making the proper assignment of cases (if that is one of the supervisor’s
functions), deciding the level and intensity of clinical oversight to provide,
and evaluating the supervisee’s performance and progress. For example,
a supervisor may recommend against assigning a high-risk client to
a novice therapist in his or her first clinical practicum. If the supervisor
does not have administrative input into such case assignments, he or she

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 Supervisory Methods/Techniques

may then opt to give the inexperienced practicum student extra time and
attention in managing the high-risk case. Similarly, the supervisor may be
more apt to evaluate the trainee on his or her general level of professional-
ism in trying to keep the client stable and safe, rather than expecting the
supervisee to master advanced techniques, such as guided imagery, in the
context of trauma work.
Another example of an adjustment that supervisors may make to eval-
uate the novice therapist more fairly would be to use the Cognitive Therapy
Rating Scale (CTRS; see Chapter 6 for more information) as a checklist
of adherence to the treatment model rather than grading each item on its
0–6 competence scale. In this scenario, the inexperienced therapist would
only have to incorporate the key elements of CBT into a session (e.g., scor-
ing “yes” or “no” for such items as agenda-setting, collaboration, feedback,
homework) rather than perform them at high levels. The CTRS tradition-
ally has not been used in this manner, and we are unaware of any studies
that have employed the CTRS without using the scoring system per se, but
as a training tool it may be quite useful to introduce the CTRS as an adher-
ence checklist before using it as a scorable competency measure.
As noted, doing a needs assessment addresses the supervisees’ devel-
opmental level and immediately communicates two positive messages:
first, supervisees are respected, involved participants in this partnership
called “supervision,” and second, the supervisor cares about providing
something that is tailor-made. Some of the comments we have heard from
supervisees when asked about their training needs include the following:

“I would like to learn to use some of the specific techniques of CBT,

such as thought records, so I can become comfortable with assigning
them to clients.”
“I have to admit that I’m a little unsure of myself with the CBT
model because I have typically taken a less directive, more Rogerian
approach with clients. I want to be able to be more structured and
focused but not at the expense of being warm and a good listener. I’m
not saying that CBT therapists are not warm and are not good listen-
ers, but I’m not sure how I’m going to combine everything. I could
use some guidance and feedback in this area.”

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“I know that this clinic uses video recording a lot, so I’m very
interested in getting feedback on my complete sessions and to have
the opportunity to see myself on video so I can get a better idea about
what I’m doing right and what I need to work on more.”
“I really enjoyed my exposure to CBT during residency and think
I have a good sense of the theory and basic techniques, but I never
did a full course of CBT from start to finish. I’d like to learn how to
do that now.”

When a trainee is a novice therapist, supervision likely will require sig-

nificant attention to foundational and functional competencies (Newman,
2010) and thus may include many or all of the following:

77 Discussing and practicing rapport-building, listening, and reflection skills.

77 Assigning the supervisee basic readings in CBT.
77 Psychoeducation (and additional readings) about specific disorders
and clinical problems.
77 Reviewing the essentials of ethical practice, including discussion of the
American Psychological Association (APA) Ethical Principles of Psy-
chologists and Code of Conduct (APA, 2002; 2010).
77 Presenting an overview of the professional practice of clinical note keep-
ing and the proper use of clinical phone (and other media) contacts.
77 Practicing ways to socialize clients into the CBT model.
77 Modeling multidisciplinary collaboration and consultation (e.g., con-
tacting and consulting with the client’s psychiatrist after receiving
authorization from the client).
77 Skills practice (e.g., cognitive restructuring, Socratic questioning,
graded-task hierarchies, diaphragmatic breathing, guided imagery).
77 Beginning a dialogue about cross-cultural factors in doing competent
CBT.
77 Compiling a list of common CBT homework assignments and their
applications.

As trainees advance in their level of understanding of and comfort with

cognitive–behavioral theory and techniques, the emphasis in supervision can
shift to higher-level therapy competencies, such as case conceptualization,

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complex techniques with high-risk clients, and recognizing and repairing

strains in the therapeutic relationship.
The American Psychological Association (Fouad et al., 2009) has
developed functional competency benchmarks that may serve as a useful
aid for the supervisor to evaluate his or her trainees’ skill set relative to
their level of training and professional development. Although not spe-
cific to development as a cognitive–behavioral therapist, the benchmarks
identify 16 key domains (including professionalism, scientific knowledge
and methods, and evidence-based practice) across which trainees’ prog-
ress toward independent practice can be evaluated. Each domain com-
prises behavioral anchors suggesting a trainee’s readiness for practicum,
internship, and entry to practice, respectively. The benchmarks may serve
as a useful aid to the supervisor in setting goals for a training year that are
appropriate to a trainee’s developmental level and evaluating psychology
trainees’ progress toward the goals as the year progresses. Benchmarks
pertinent to the behaviors of the supervisors themselves also have been
developed (Falender & Shafranske, in press).
Supervisors working with psychiatry residents may wish to familiarize
themselves with the Psychiatry Milestone Project, an initiative that was
jointly developed through the Accreditation Council for Graduate Medical
Education (ACGME) and the American Board of Psychiatry and Neurol-
ogy (2014). Similar to the benchmarks described, the psychiatry mile-
stones identify key areas of competency across inpatient and outpatient
psychiatry, consultation, and psychotherapy supervision. For supervisors
interested in CBT-specific measures of competency to aid in goal setting
and evaluation, the ACGME (2001) also has developed guidelines for
psychiatry resident competency in CBT. These include the ability to for-
mulate clients’ diagnoses according to a CBT model, structuring sessions
for maximal effectiveness, helping clients identify and modify unhelpful
cognitions, and developing a strong and active therapeutic alliance (also
see Friedberg, Mahr, & Mahr, 2010; Kamholz, Liverant, Black, Aaronson,
& Hill, 2014; Sudak, 2009; Sudak, Beck, & Wright, 2003).
Now let us examine the issue of how the methods of clinical super­
vision are influenced by the particular training setting. In settings such as

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a university-based clinic, in which the therapist-in-training is an advanced-

degree candidate and the supervisor is one of the faculty, the super­visor’s
jurisdiction over the course of a client’s treatment and the nature of super-
vision are generally clear. In other contexts, the role of the clinical super-
visor and the course of treatment may be dependent in part on factors
outside the context of the supervisory relationship. The following examples
(adapted from Belar, 2008) highlight some of the factors that may influ-
ence a supervisor’s role, responsibilities, and structuring of supervision:

77 The supervisor would prefer that the trainee audiotape or videotape

sessions, but the setting in which the trainee is working does not allow
the recording of sessions owing to concerns about confidentiality.
77 Agency charting and documentation requirements compel trainees to
file a client contact note within 24 hours of the corresponding therapy
session, which does not allow sufficient time for the supervisor to review
or edit the note before its official entry.
77 A practicum student on a psycho-oncology service sees her client for
individual therapy sessions at bedside and accompanies him to a chemo­
therapy session multiple times within the course of a week; thus, several
treatment contacts occur between supervision sessions, which the super-
visor may find potentially problematic.
77 A trainee working as part of a multidisciplinary team on a psychiatric
inpatient unit is given direction and input regarding the course of treat-
ment by team members and providers other than the primary super­
visor, some of whom share legal responsibility for the client’s welfare.
77 A psychologist serves as the CBT supervisor for a psychiatry resident
who also discusses her clients regularly with a psychopharmacology
supervisor and the medical director of the outpatient clinic in which
the clients are seen.

In situations such as those outlined, the familiar model of weekly super-

vision in the supervisor’s office may not match the demands of the agency
or the client population. The concept of “flexibility within fidelity” (Kendall
et al., 2008), generally used to refer to the dissemination and implemen-
tation of evidence-based therapy in real-world clinical settings, may be a

46
 Supervisory Methods/Techniques

helpful model for conceptualizing the selection and application of best

practices in supervision across a variety of settings and client populations.
For example, a supervisor who is accustomed to reviewing audiotapes of
therapy sessions may be unable to do so if a trainee is providing services
on an inpatient unit that does not allow client recordings. In such cases,
the supervisor may request to observe a session from behind a one-way
mirror with the client’s consent or sit in on an entire therapy session (i.e.,
supervision cotherapy) to obtain the firsthand information that ordinarily
would be gleaned through audiotape or video review. When the supervisor
does not go to the training site and therefore cannot directly observe the
supervisee’s work, the supervisee can be encouraged to take copious notes
(including direct quotes from both the client and the supervisee) during
and immediately after a session. Although not as comprehensive and veridi-
cal as a recording or a live observation, such extradetailed note taking may
be enough to provide transcriptionlike material for review in supervision.

DOCUMENTATION
Supervisors are responsible for impressing upon their trainees the neces-
sity of keeping good, thorough clinical notes on each case. Whether the
notes are written in a physical chart or in a formal, protected electronic
system, the supervisor also must review and cosign the trainee’s notes.
Both the notes themselves and the supervisor’s cosignatures must be done
in a timely fashion. Such documentation is vital for medical–legal pur-
poses, serves a training function, and provides the supervisor with a mea-
sure of the trainee’s clinical thinking style.
The contents of clinical notes ideally contain the following information:

77 Personal identifiers, including the name and date of birth (and perhaps
medical record number) of the client and the name of the therapist and
supervisor.
77 The client’s diagnosis and/or other concrete description of the clinical
problem(s).
77 Data from client self-report measures (e.g., the Beck Depression
Inventory II, Beck, Steer, & Brown, 1996; the Outcome Questionnaire,

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

Lambert, Lunnen, Umphress, Hansen, & Burlingame, 1994; The Patient

Health Questionnaire-9, Kroenke, Spitzer, & Williams, 2001), or from
interview-based or observational measures (e.g., the Beck Scale for
Suicide Ideation, Beck, Kovacs, & Weissman, 1979).
77 A brief mental status checklist.
77 A risk-assessment checklist (e.g., presence or absence of suicidal ideation,
intent, plan).
77 An agenda for the session, as well as a list of ongoing goals.
77 The body of the note itself, including problems that were identified
and addressed, the interventions that were used, the main “teaching
points” of the session for the client, homework that was reviewed and/
or assigned, important quotes from the client and/or the therapist, and
the client’s level of responsiveness and progress in the session.
77 Signatures (or e-signatures) of the therapist and supervisor, the date of
today’s session, and the date of the next appointment (if applicable).

As one can see, writing notes that are this thorough requires the trainee
to be efficient, industrious, conscientious, professionally accountable, and
clinically astute. As such, trainees’ notes are an excellent barometer of their
ascending competence.
Effective supervisors routinely read the trainees’ written accounts of
their interactions with clients (e.g., assessments, therapy sessions, clinically
relevant telephone contacts) to offer feedback, suggest changes, and sign the
notes. Supervisors can be role models for good record keeping by keeping
their own supervision notes and adding commentaries to the trainees’ charts
when they (the supervisors) have contact with the clients, such as when they
sit in for part or all of a session, speak with the client directly by phone, or
intervene in the care of the client in a crisis situation (as described later).
When supervisors carefully evaluate the contents of their supervisees’
clinical notes, valuable teaching points may emerge. The following are
sample comments from supervisors, in which they give feedback to the
supervisees about their documentation of their work with clients:

“I’m glad to hear that you called your client the day after your previ-
ous session to see how he was doing and to get an update on his level
of suicidal thinking. Please create a note for that in the chart. Writing a

48
 Supervisory Methods/Techniques

note will show that you are following through with the treatment plan
of giving this client extra safety monitoring on an outpatient basis.”
“Did your client fill out her mood inventories last session? The
note didn’t contain her scores. If she declined to do them, insert a
comment to that effect. If possible, ask her to come a little bit early to
sessions so she can complete these questionnaires. It would be great
to keep a running tabulation of her scores as one of the measures of
her progress.”
“I think you have a good rationale for postponing the exposure
intervention with this client. He seems to be ambivalent about being
in CBT, and if you push this intervention it may lead to his leaving
therapy before you really get a chance to help him. Add a comment
about this rationale in the clinical note. We want the chart to reflect
your clinical thinking behind the decision to include or not include
a particular intervention.”
“It’s a pleasure to review your session notes! They’re well-written,
clear, thorough, and really give a sense that you have conceptualized
your clients well. Excellent! I know it’s time-intensive to do this, but
I hope you’ll keep up this great work.”

INSTRUCTION, MODELING, ROLE-PLAYING,

AND REVIEWING RECORDINGS
Effective CBS, similar to effective CBT, involves collaboration between the
participants such that both parties are actively working. In supervision,
the “work” often involves the supervisors offering instructions and dem-
onstrations about how to properly interact with clients in various clinical
situations, using a range of CBT methods, whereas the supervisees answer
questions, explain their treatment plans, generate hypotheses, and practice
procedures (e.g., via role-playing with the supervisor). Competent super-
visors strive for this sort of balance of effort, such that the trainees gradu-
ally learn to think independently, and the supervisors guide and shape
them with well-crafted questions, comments, instructions, and examples
of “how to do x.” Clearly, an important part of gaining and maintain-
ing such supervisory skills includes being (and staying) competent in

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

delivering CBT as a therapist. In the following sample dialogue, a CBT

super­visor guides her supervisee to elicit more specific information from a
client whose communication style is vague and avoidant.

Trainee: I’ve found that it’s very hard work to try to understand my client.
I try to ask the right questions, but he’s very slippery, if that’s an appropri-
ate term to use. He talks a lot, but I really have trouble following him, and
then I don’t quite know what to do when he looks at me and asks, “Do you
understand?” because a lot of the time I really don’t know what he’s talking
about, and I’m hesitant to say that.
Supervisor: Tell me about your hesitation, if you don’t mind. What do you
think it would mean, and what do you think would happen if you told
him that you would like to understand him better, but that sometimes it’s
difficult to follow him?
Trainee: I guess I have two concerns. One is that I don’t want to seem like
I’m not listening, and the other concern is that I don’t want to imply that
he’s not making sense.
Supervisor: Fair enough. How can you tell him in a way that mitigates
those concerns?
Trainee: I could just be honest and say, “I’m sorry, but I don’t understand,
and I really want to understand, so could you clarify that for me again?”
Supervisor: Absolutely. Keep it simple, humble, and honest. Sometimes
you just have to give the clients some differential reinforcement so they
know where they stand. If they’re communicating clearly, and you respond
in a way that shows that you’re ‘getting it,’ then your response reinforces
their clear communication. Conversely, if you tell the clients that you need
them to clarify further, then that gives them feedback that they need to
modify how they’re explaining things. If you do this in a polite, caring,
manner—as I know that you can—this might be all you need to do.
Trainee: That makes sense, but I often worry that this client is going to be
annoyed at me if I say this, or maybe he won’t be capable of explaining
things better, and he will just get frustrated.

50
 Supervisory Methods/Techniques

Supervisor: That could happen. If the client did respond to your polite,
caring request with annoyance and frustration, what clinical data would
that provide you?
Trainee: I would hypothesize that he is very sensitive to being mis­
understood, perhaps because that happens a lot in his life. Another related
hypothesis might be that he is misinterpreting my comment as being an
accusation or an insult. That could be reflective of a “mistrust” schema, or
maybe it could be an “incompetency” schema if he’s upset with himself for
struggling to make himself understood.
Supervisor: All of those are useful hypotheses. Well done! I hope that
he will respond well to your entreaties, but if he gets flustered in the way
that you anticipate he will, you will gain valuable material for hypothesis
generation and hypothesis testing.

A week later, this same supervisor–trainee dyad reviewed an audio

recording that the trainee made of one of her sessions with the client dis-
cussed previously. Their dialogue about the case continues here:

Supervisor: In listening to this session, I can see why it’s difficult to commu-
nicate with this client. I notice that he uses a lot of pronouns, but he rarely
spells out what the corresponding noun is. He says things like, “This isn’t
what I want,” “That doesn’t work for me,” and, “Can I ever make it better?”
Maybe you can ask him for the nouns that go with “this,” “that,” and “it.”
Trainee: Asking him for more nouns might be a little awkward, but I’ll try.
Supervisor: Well, it’s “awkward” if we’re talking about a conversation in
everyday life, but this is therapy, where “awkward” is part of the territory!
I don’t mean to make light of this, mind you. You can be very nice about
it, saying, “When you tell me that ‘This is not what I want,’ what exactly are
you referring to by ‘this?’”
Trainee: Okay, I’ll try to ask him for the nouns.
Supervisor: I also noticed something else about the client’s style and
yours, too.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

Trainee: Oh? I’m curious.

Supervisor: You asked the client some really good open-ended questions.
Very thought-provoking questions indeed. As I listened to the record-
ing, I eagerly awaited the client’s answers, but they never came. He skated
right around your questions. It’s quite a consistent pattern. It’s almost
like you’re not having a dialogue. You ask a question, and he talks about
something else. You follow him and ask another good question that relates
to what he’s talking about now, and he replies about something else yet
again. It goes on and on like that. He’s a moving target.
Trainee: I hadn’t thought about it like that before, but I think you’re right.
His style of avoiding my questions is part of the reason I’m not connect-
ing with him, and why I’m not “getting” him. Do you think that’s deliberate
on his part? Is he purposely avoiding my questions?
Supervisor: That could be part of his overall avoidant style. Or maybe
he’s not really hearing you. Or maybe he hears you all too well and doesn’t
want to answer. You can explore this by returning to your original ques-
tion, rather than letting the client take you on a wild goose chase.
Trainee: You mean, just say to him, “Could we get back to the earlier ques-
tion? I am interested in hearing your thoughts.”
Supervisor: Exactly. Try asking him again. Bring him back to the question
you asked.
Trainee: I might get more useful information from the client that way,
and maybe I will understand him better. On the other hand, I might find
that he doesn’t take kindly to my probing. Either way, we’ll go beyond our
current stuck point.
Supervisor: Well put! I agree. Let’s see what happens next session.

If the trainee records the following session and the supervisor listens
to it, the supervisor will be able to hear the extent to which the trainee was
able to follow through with the plan to nicely ask the client to be more
specific about what he means and to return to the original questions that
seemed to get lost in the shuffle. Indeed, this is one of the many advantages

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 Supervisory Methods/Techniques

of making recordings—the supervisor can ascertain how much “transfer”

there is from the supervision session to the therapy session and to what
degree this facilitated a productive response from the client.
When reviewing recordings of supervisees’ sessions with clients, super­
visors can offer feedback on a moment-to-moment basis (such as when
segments of the session are played and then paused for discussion) or
more global feedback with regard to the entirety of the session. Both of
these approaches have utility, although they each pose their own chal-
lenges. For example, moment-to-moment feedback can be helpful in elu-
cidating clinical choice points, such as when the supervisees are asked why
they responded to their clients in one way versus another and how they
interpreted their clients’ comments and other behaviors at the moments
they occurred. On the downside, an overzealous supervisor can micro-
manage a supervisee, suggesting too many options and offering too much
critical feedback without first seeing how the session progressed. Such an
approach is to be avoided if possible because it can foment trainee self-
doubt and increase trainee self-consciousness (when, instead, they need to
be most conscious of the client!). An effective CBT supervisor understands
and communicates that there often are many “correct” ways to run a ses-
sion and that the trainee does not necessarily have to mimic exactly what
the supervisor thinks he or she might have done at that precise moment
on the recording. Given that metaphors can be quite helpful in the process
of learning for clients and supervisees alike (Edwards, 2010; Stott, Mansell,
Salkovskis, Lavender, & Cartwright-Hatton, 2010), the supervisor’s com-
ment that follows includes a metaphor to make this point:

Supervisor: Conducting an effective CBT session is like climbing a tree.

The goal is to get to the top, and although it clearly takes the right set of
skills and mental “mapping” to get there, it is probably true that there are
many different “branch combinations” that one could take to achieve the
goal. I might take one particular route to climb the tree, and you might
take another, and we may both wind up succeeding and meeting at the top.
The key is in having a plan and being flexible enough to alter the plan if
one route seems too risky or if the originally chosen path seems unlikely

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to take you to the top. The more you know about CBT conceptualization
and interventions, the more branches you will have to choose from, and
the stronger the therapeutic relationship is, the sturdier the branches will
be, allowing you more leeway to find your way safely, even with a mistake
or two along the way. So when I tell you that I might say or do something
different than what you said or did in the recording, I’m not saying that
you were incorrect or that my way is better. I’m just encouraging you to
see how there may be more than one way to accomplish your goals and
that you don’t have to be overly worried and self-conscious about doing
everything right at all times or only in a particular way.

On the other hand, there may be discrete sections in a supervisee’s

recorded session on which a supervisor would like to focus to provide a
valuable teaching moment. For example, the supervisor may wish to sug-
gest a particular intervention at a particular point in time, such as by advis-
ing the supervisee to nicely ask the client what is going through her mind
when she demonstrates a marked shift in affect (e.g., she stops talking
in midsentence and looks away) or suggesting that the supervisee ask the
client, “What constructive action can you take to begin to deal with this prob-
lem?” when the client needs some practice in implementing problem-solving
methods. In the following example, the supervisor hones in on a specific
comment the supervisee made to his client. The goal is to help the supervisee
to be more empathic and effective with a client whose expressions of anger
were interfering with the therapeutic dialogue in session.

Trainee: I know I didn’t handle this session well. I felt a bit helpless in
the face of my client’s anger. She was bitterly complaining about so many
things, and she seemed to be escalating, to the point where I couldn’t com-
plete a sentence without her interrupting me. I remember thinking that
this was an example of a “therapy-interfering behavior,” but I wasn’t sure
how to address it.
Supervisor: I’ve been there myself, so I understand what you mean by
saying that you felt “helpless.” I appreciate the fact that you’re willing to
talk about what didn’t go very well in your session. That takes a lot of

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courage and trust in the supervision process. It also shows me that you’re
interested in learning, even when it hurts!
Trainee: Thanks. I definitely want to figure out what I can do differently
when a client is so emotionally dysregulated like that.
Supervisor: I can offer two points right away. One is a general comment.
The other is very specific, having to do with something you said to your
client that I think you can change in the future. The general comment
is that a client’s therapy-interfering behaviors provide you with valuable
information that can be conceptualized. Therefore, rather than just feeling
“helpless,” you can be thinking that you will use this adverse incident in
session to understand your client a little better. You may not be able to say
an entire sentence without being interrupted, but you can silently concep-
tualize and hypothesize what is going on, and this is not being “helpless.”
Trainee: That’s very helpful. If I think about conceptualizing, I might not
feel so at a loss about what to do, and it might help me to know what to say
at a different time, when the client is not so emotionally activated. What
was the specific comment I said that I should change?
Supervisor: First, I want to say that you’re making a good point about
how conceptualizing helps you to know what to say—whether it’s now or
later—in order to have the best chance of intervening empathically and
constructively. That’s great that you’re getting that point. We’ll talk much
more about that later. But here’s the comment that you made that I think
you can change. There was a moment when you said to your client, “I need
you to calm down right now.”
Trainee: Oh, that was terrible! It’s not about what I need. After I said that
she just got worse.
Supervisor: Nice catch. You already get it. Good self-observation.
Trainee: I think I said it out of desperation. I was thinking that if I just
sat there passively she would continue to escalate, and that wouldn’t be
helpful. But I didn’t necessarily know what to say either. So I blurted out
the comment, “I need you to calm down right now,” which I regret.

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Supervisor: Even though there’s no magic formula for getting a client to

de-escalate on the spot, there is a middle ground between being passive and
helpless on the one extreme, and saying something potentially unempathic
or confrontational on the other extreme. For example, rather than saying
that you need for her to calm down right now, you can behave in such a
way that it will gradually help her to feel understood, and perhaps that will
help her “calm down” gradually.
Trainee: That’s what I wanted to do. I tried to be a good listener, but that
seemed so inadequate.
Supervisor: Well, being a good listener is a pretty good start. Also, you can
physically lean in a bit, showing that you are very attentive, with a som-
ber, sympathetic facial expression, and you can add simple, soft-spoken
phrases that might not get interrupted, such as, “I’m listening,” or “I hear
you,” or “That’s so hard,” or “I’m with you,” and other comments like that.
Then you’re less likely to be perceived by your client as demanding that
she be quiet, or that she’s bothering you, or that you’re telling her she
doesn’t have a right to her feelings, and you’re more likely to be perceived
as someone who is trying to be there. That might assist the process of her
de-escalating, and later—when the timing is better—you can talk more
about what she was perceiving at that moment, and how she could regu-
late her emotions more effectively.

In the example given, the supervisor used a specific moment in a

session recording to give the supervisee some corrective feedback. This
included suggesting methods that potentially could be used effectively
across similar situations in the future in which a client is emotionally
dysregulated and the therapist wants to find a happy medium between
being passive and engaging in a power struggle. The supervisor also gives
positive reinforcement for the supervisee’s ability to self-reflect and self-
correct, which in turn positively reinforces the supervisory relationship
and promotes supervisee learning.
With regard to giving feedback on an entire session, perhaps includ-
ing the use of a measure such as the original or revised version of the
CTRS (Blackburn et al., 2001; Young & Beck, 1980), the benefits include

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being able to see how the supervisee plans, organizes, and constructs a
full session. The supervisor can see how well the supervisee stays on task
and yet shifts gears if unexpected, relevant clinical information comes to
light. Similarly, the supervisor can ascertain whether the supervisee cre-
ates a therapeutic atmosphere in which the client feels both supported and
encouraged to work toward change. The supervisor can also determine
if the homework assignment grows out of what has been discussed in
the session and if the supervisee is providing the client with opportuni-
ties to practice skills and provide feedback. On the downside, it is often
impractical to review previously unseen recordings of entire therapy ses-
sions within the scope of a single supervision session. More often, the
supervisor needs to take the extra time to review (and perhaps rate) the
recording on his or her own time and then use part of the next supervision
session to offer feedback and encourage discussion.
The CTRS can also serve as an inter­rater reliability check of sorts. This
is when the supervisor asks the supervisee to choose one of the latter’s
recorded sessions, and then they both rate the session independently. They
then compare their respective ratings, which can be an extremely instruc-
tive exercise. Supervisors can gain a glimpse at how the supervisees assess
their own skills, and both parties can share their rationales about why they
rated each item of the CTRS the way they did. Admittedly, our suggested
reliability check in this instance is more for clinical training than for sta-
tistical or psychometric purposes.
It should be acknowledged that recording supervisees’ sessions
and observing them—similar to engaging in role-playing exercises in
supervision—has the potential to provoke anxiety in supervisees. Super-
visors need to be mindful of this and be suitably empathic. In our expe-
rience, the pros of recording supervisees’ sessions for evaluation far
outweigh the cons. In citing the literature on this subject, Nelson (2014)
states that the evidence suggests that few therapists-in-training actually
have problems with making recordings and that those who experience
some anxiety at first typically succeed in adapting with repetition (as
one might expect based on the principles of habituation). Supervisors
themselves can serve as effective coping models by showing the record-
ings of their own unedited CBT sessions with clients. Supervisors who

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are willing to display their own imperfect work, perhaps offering self-
supervisory advice along the way (e.g., “If I could go back and do this
session again, I would have said . . .”) contribute to a sense of collabora-
tion and congruence in supervision.

SUPERVISION INDIVIDUALLY OR IN A GROUP

At times the CBT supervisor may have a choice between structuring super-
vision individually or in a small-group format. Individual supervision
allows for more in-depth discussion of fewer clients and a supervisory
experience that may be more tailored to the individual supervisee’s learn-
ing needs. When supervisees are working with clients who are at high risk
or have complex needs, individual supervision may be necessary to devote
sufficient time to case conceptualization and thorough treatment plan-
ning. Individual supervision may also be preferable when supervisees are in
need of remediation of foundational competencies or additional training
in a specific area of CBT. The time required to help supervisees achieve the
desired level of competence combined with the supervisee’s right to dis­
cretion about the need for remediation together suggest that supervision in
these instances might best be conducted on a one-to-one basis. Similarly,
any significant areas of conflict between supervisor and supervisee generally
are best addressed within the context of individual supervision.
Small-group supervision (sessions of which may need to be lon-
ger than an hour, if feasible) can provide increased opportunities to
learn cognitive–behavioral theory and technique through exposure to
cohorts’ case presentations. With more than one supervisee present, there
are ample opportunities to enhance supervision with role-playing, skills
practice in a group format, and modeling of CBT techniques. The decision
to provide CBS in a group format requires the supervisor to be especially
mindful of triaging and agenda setting. A formal agenda for supervision
set at the beginning of each session is necessary to ensure that risk levels
are adequately assessed for each client under supervision, that the most
critical issues are addressed, and that each trainee gets sufficient time for
discussion and feedback.

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Particularly for more advanced supervisees, group or dyadic super-

vision may be a useful arena for fostering their own development as clini-
cal supervisors. Over the course of a supervisory hour, the participants can
be encouraged to share their own insights and suggestions on each other’s
cases, thereby honing their “supervisory ear” and their therapeutic one.
Small-group and dyadic supervision also provides an opportunity for more
formalized practice of supervisory skills. For example, trainees can alternate
in taking on the role of a supervisor, in which they facilitate agenda setting
for the session, help each other to work through stuck points in a recent
therapy session, and set goals for the next session. In such a situation the
clinical supervisor effectively plays the role of metasupervisor (Newman,
2013), providing feedback to the trainees not only on their work as thera-
pists but also on their effectiveness and areas for development as a future
supervisor.
Practice in the supervisory role can at times be introduced even with
trainees who are less experienced with the CBT model. For example, one of
us (DK) teaches an introductory CBT course for third-year psychiatry resi-
dents. New course material frequently is introduced by having the residents
divide into groups of three, with each group member having the chance
to play the role of client, therapist, or observer at different times. As each
new skill—for example, agenda setting or completing a thought record—is
introduced, the triad has the opportunity to practice it in vivo, with the
observer providing feedback to the therapist on his or her ability to explain
concepts clearly and apply them effectively in working with the client.
Regardless of the level of CBT-specific experience of the trainees in a
group supervision format, it is important for the supervisor to summarize
overtly and reinforce the most important teaching points of their meetings.
In this way, the supervisor serves as an editor-in-chief of sorts so that the les-
sons learned can be distilled into their most valid components and instilled
in the group’s supervisees via repetition and the supervisor’s confirmatory
comments.

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 3

Structure and
Process of Supervision

T he purpose of this chapter is to describe a typical routine that a

cognitive–behavioral therapy (CBT) supervisor and supervisee gen-
erally will follow for time efficiency, breadth of coverage of relevant clini-
cal material, and optimization of learning. As will become apparent in the
case illustration provided (taken from Cognitive–Behavioral Therapy
Supervision, the companion DVD to this volume),1 the evidence-based
supervisor takes a multimodal approach (see Milne, 2009). Using meth-
ods such as didactics, Socratic questions, measures of progress (both the
clients’ and the supervisee’s), audiovisual recordings, modeling, role-
playing, and other methods, the supervisor instills and enhances learning
through multiple channels of perception and enactment.

1 Cognitive–Behavioral Therapy Supervision, available from APA Books at http://www.apa.org/pubs/

videos/4310957.aspx.
http://dx.doi.org/10.1037/14950-004
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

WHAT HAPPENS IN THE SUPERVISION SESSIONS?

The CBT supervisor sets an agenda at the start of a supervision meeting,
similar to the way a therapist structures a therapy session. The well-being
of the supervisee’s clients is the top priority; therefore, a review of each
of the cases generally takes top billing. The specific order of review of
the cases depends on the number of clients who need to be covered and
their respective levels of severity and/or urgency. A well-managed agenda
allows the supervisor–supervisee dyad to give the proper amount of atten-
tion to each case.
Aside from review of each case (and corresponding clinical notes), the
supervision meeting agenda may include general topics pertinent to the
delivery of CBT, such as properly applying certain techniques (e.g., thought
records, exposure hierarchies, relaxation inductions, imagery work,
modifying core beliefs), constructing a case conceptualization, designing
homework in ways that will be most helpful for the clients (and most likely
to earn their collaboration), and managing strains in the therapeutic rela-
tionship. Similarly (time permitting), the supervision meeting may involve
informative discussions about such topics as the common characteristics of
clients with particular diagnoses (e.g., eating disorders, posttraumatic stress
disorder, personality disorders), or about issues pertinent to phase of treat-
ment (e.g., the proper handling of termination and transfer). Additional
important topics that may find their way onto the agenda include ethical
questions and cross-cultural matters in treatment. Ideally, these would be
brought up in the context of one or more of the cases being supervised,
but they may be discussed as freestanding topics.
As noted, supervision sessions may include experiential exercises
(e.g., role-playing) and/or listening to (or viewing) recordings of the
supervisee’s recent work with a given client. Of course, the supervisor will
have confirmed that the client has given consent to the recording, under-
stands that the recording will be used in clinical supervision, and knows
the parameters for its further use in training or prompt deletion. Super­
visors make sure that the supervisees tell their clients that the latter are free
to say “no” to being recorded and that the clients continue to receive the level
of attention and treatment they expect. At the same time, some initially

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 Structure and Process of Supervision

reluctant clients eventually give consent when they are told that by being
recorded for supervision they are receiving an extra high level of consulta-
tion on their case and that it is their therapist who is being evaluated, not
them (the clients). The agenda of a cognitive–behavioral supervision (CBS)
meeting may also include didactic instruction (e.g., discussing assigned read-
ings, reviewing different methods for teaching clients self-help techniques),
handling clinical dilemmas, and working on treatment plans. Supervisors
and their supervisees collaboratively decide how to apportion the time
that will be devoted to these myriad topics, and the supervisor models
being a good manager of time.
There may be times when there is little new clinical material to review
in a supervision session (e.g., following a time of the year when therapists
and clients alike have been on vacation and sessions have been temporarily
put on hold). Rather than canceling a supervision session at such times, it
may be better to take advantage of the situation by doing alternative training
activities, such as the supervisor showing an old video of his or her own work
with a client, or engaging in role-play exercises to provide the supervisee
with valuable practice. Far from just filling time when there are no clients to
discuss, doing experiential exercises is indispensable when teaching trainees
the complexities of conducting CBT (Ronen & Rosenbaum, 1998).

CASE ILLUSTRATION
Let us talk a bit about “what happens in a supervision session,” as depicted
in the video of the supervision session of one of us (CN) with his super-
visee, an advanced graduate student (Andrew). We will start with a general
overview, followed by a section on the supervisor’s thoughts at specific
moments.

General Overview of the Four Agenda Items

The supervision session was roughly divided into a four-part agenda that
was collaboratively set up during the first few minutes of the meeting.
Most of the contents and structure of this supervision session were typical
of such meetings, although the reviewing of Andrew’s recorded session

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

with his client “G” and its scoring with the Cognitive Therapy Rating
Scale (CTRS; Young & Beck, 1980) represented a “special” occurrence;
such reviews were done three times during the semester. Given that there
were no emergent issues involving a high-risk client in immediate need,
this recorded session (and its rating) was placed at the top of the agenda.
After that was another “special” topic, the reviewing of Andrew’s final ses-
sion with his client “S,” including the way the termination note provided
an overview of the work that had been done in S’s course of treatment, his
current condition, and his maintenance plan for continuing to use his CBT
self-skills going forward. The next agenda item focused on an African-
American client, but rather than reviewing a recent therapy session per se
the supervisor and supervisee addressed the way the client’s ethnic/cultural
background played an important role with regard to the therapeutic rela-
tionship and the treatment plan. Finally, the fourth agenda item centered
on an ethical issue Andrew needed to confront in response to a client’s
strong request that he become her sister’s individual therapist. The super-
visor helped Andrew to frame the ethical dilemma, to freely express his
discomfort, and to try to see more than one side to the issue so as not to
allow his discomfort be the only consideration in making a decision about
how best to handle the matter. Finally, the supervisor engaged Andrew in
a role-play to help him work on a repertoire for nicely saying “no” to the
client, being able to manage any sort of alliance strain that might occur as
a result of saying no, and doing some constructive problem solving with
the client rather than just letting the matter come to a screeching halt
when Andrew said “no.”
The supervision session was densely packed with useful clinical
material, which is one of the benefits of structuring the meeting by using
an agenda at the start. Case material was reviewed, not merely to check
on the current status of the clients (although that is important) but also
to plan strategy for upcoming sessions. The supervisor offered several
hypotheses and suggestions but also occasionally asked the supervisee
what he thought he could do next in his treatment of a given client, thus
encouraging Andrew to do some independent problem solving rather
than simply instructing him on what to do (see Cummings, Ballantyne,

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& Scallion, 2015). The supervisor offered positive feedback and construc-
tive criticism within the context of a congenial, collaborative supervisory
relationship, as summarized in Exhibit 3.1.
The supervision session was also noteworthy for its use of a role-play
exercise to help the supervisee practice benevolently setting a limit with
a client, a valuable skill for a trainee who needs to learn the delicate bal-
ance between asserting professional authority and maintaining a sense of
respectful collaboration. The supervision meeting also addressed a sensi-
tive cross-cultural issue, in that a client had experienced racial discrimi-
nation that the supervisor and Andrew (as “two white guys”) needed to

Exhibit 3.1
Positive Feedback and Constructive Criticism
in the Supervision Session
Positive feedback: The supervisor noted that the supervisee . . .
77 Conducted a session with G that was scored at well above the
acknowledged level of competency as indicated on the CTRS.
77 Had a particularly strong therapeutic relationship with G and
that his strategy for change—involving multiple methods such
as cognitive restructuring, current behavioral exposures to
avoided situations, processing of past trauma, and client skill-
building (e.g., communication with her son)—was on target
and had the potential to effect significant therapeutic change.
77 Helped his client S attain remarkable changes over the course of
treatment, far more than the supervisor had expected in light of
the deficits that the client showed at intake.
77 Wrote very good clinical notes and the supervisor (in his role as
cosigner) appreciated this.
77 Used methods from dialectical behavior therapy and acceptance
and commitment therapy that the supervisor found educational,
and therefore was grateful for learning from the supervisee.

(continued)

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

Exhibit 3.1
Positive Feedback and Constructive Criticism
in the Supervision Session (Continued)
77 Had shown excellent self-awareness in recognizing that his
client G had “pushed his buttons” with regard to how she
interacted with her son. Notably, instead of simply acting on
this feeling and telling the client not to treat her son that way,
Andrew recognized that he had to process his reaction silently
while staying focused on the client’s needs.
77 Did the right thing in deferring giving an answer to the client
who wanted him to become the individual therapist for her
sister, instead saying that he would have to consult with his
supervisor. The supervisor stated that this is good practice when
confronted with an ethical gray zone.

Constructive criticism: The supervisor added that the supervisee . . .

77 Had uncharacteristically chosen not to give client G an overt
homework assignment. However, the supervisor stated that
Andrew had been giving the client “implied,” ongoing assign-
ments, such as showing up at work despite her being anxious.
Therefore, homework was not being neglected entirely. Never-
theless, the supervisor advised Andrew to make the homework
assignments more explicit, so that there would be no misunder-
standing going forward.
77 Could broaden the scope of his clinical thinking by giving con-
sideration to the “devil’s advocate” position of saying “yes” to his
client’s request to provide therapy to her sister. In other words,
instead of simply allowing the state of “feeling uncomfortable”
with the client’s request to dictate his answer, Andrew could
more thoroughly consider the pros, the cons, and the contextual
factors relevant to this ethical gray-zone situation.

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 Structure and Process of Supervision

acknowledge humbly that they might not adequately be able to compre-

hend at a personal level (see Falender, Shafranske, & Falicov, 2014).
Another important moment occurred when the supervisor advised
Andrew that it was not necessary for him to disclose too much of his own
personal information in supervision to deal effectively with an emotional
reaction to a client. This is an example of the boundary between provid-
ing supervision and providing therapy. The supervisor stated that it was
important for Andrew to use his personal reactions as a “cue” that he
needed to stay focused on the client and not let his own feelings unduly
guide his choice of intervention. In this particular supervisory session, the
supervisor was satisfied that Andrew was able to process his own reactions
appropriately. If there had been evidence to the contrary, the supervisor
might have asked Andrew to do some self-help assignments to improve
his self-reflection and self-practice, perhaps by using the Bennett-Levy,
Thwaites, Haarhoff, and Perry (2015) workbook. For example, Andrew
could do the exercise that asks therapists to write about a personal pattern
that may be impinging on their work with a particular client (p. 118) and
then to write about what they learned about themselves as a result of work-
ing on a problem-solving diagram (p. 135).

Specific Moments/The Supervisor’s Thoughts

In setting the agenda, I (CN) wanted to devote much of the time to the
case of G given that I had listened to an entire session recording. However,
I first checked in with Andrew to make sure that there were no pressing
matters (e.g., high-risk situations with other clients) that would require a
lot of time. I also wanted to leave sufficient time to discuss other agenda
items of import. Once we reached a collaborative agreement (within the
first 5 minutes of the supervision session), I summarized the four items
on our agenda and we proceeded.

1. Client G: I thanked Andrew for providing me with a CD of his audio-

recorded session with G. This meant that the session was not trans-
mitted to me online, and therefore confidential material easily could
be contained and disposed. I told Andrew that he performed well on

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

the CTRS, and I summarized some of the activities I had heard that
signified a competently conducted CBT session. Although I did not
spend time reviewing the scoring code item by item, I told Andrew
that his score was well above the acknowledged competency cutoff
score of 40 (for a more complete discussion of the history and param-
eters of CTRS scoring, see McManus, Rakovshik, Kennerley, Fennell,
& Westbrook, 2012; Muse & McManus, 2013). I advised Andrew to
be more explicit about assigning G a homework assignment (which
would give Andrew a higher CTRS score), although I acknowledged
that G’s success in going to work every day was itself an extension of
previous homework assignments involving between-session exposure
to feared and avoided situations. Andrew and I talked about G’s fear
of talking to her son about his suicidal ideation combined with her
intrusive “helicopter parent” behaviors. Andrew used the case con-
ceptualization to explain that G lamented that she had not been able
to “save” her mother from suicide many years ago, and now she was
trying to protect her son from the threat of suicide by hovering and
trying to manage his mood. Unfortunately, she also maintained a
problematic belief that bringing up the subject of suicide with the son
could actually precipitate his making an attempt. Thus, Andrew and
I concluded that it would be useful for him to discuss this belief with
G and to use role-playing to help her practice how she could commu-
nicate her concerns effectively and safely to her son. At the same time,
I noted that G was understandably frightened by her son’s suicidality
and that we would have to respect her right to say “no” if she could not
be persuaded about the potential benefits of talking openly with her
son. In a good example of the division between “teaching and treat-
ing,” I applauded Andrew’s citing his personal reaction to G’s behavior
toward her son so that he could remain as objective as possible in giv-
ing her feedback that fit her life situation. In other words, he spotted his
“countertransference” reaction, and in being self-aware he was able
to stay on task. As befits the behavior of a CBT supervisor, I did not
pursue the matter further because I was satisfied that Andrew’s self-
awareness was a sufficient safeguard in this situation. I made it clear

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to Andrew that he did not need to tell me more of the details of his
personal history that would account for his internal reaction. If I had
believed that he was not sufficiently self-aware, I might have given
him an assignment to self-explore on his own time and ask him for
his conclusions about how best to proceed with the client, keeping his
personal response to the side.
2. The termination session and written summary on client S: We reflected
on Andrew’s successful treatment of S, who began therapy as a highly
avoidant young man with significant deficits in social functioning.
Now, at termination, S not only had low scores on his Beck invento-
ries (signifying few mood symptoms), he was actively dating, and he
was more willing to recognize and acknowledge the full spectrum of
his emotions. I was pleased that Andrew had promptly completed the
written termination summary for this case, an important aspect of
case documentation. I also gave Andrew kudos for his idea of having
S hold CBT self-help sessions (after therapy) at home as a way of prac-
ticing his skills and therefore improving the chances of maintaining
his gains. Andrew and I briefly summarized the case conceptualiza-
tion and related techniques as a way to remind ourselves of the route
that had been taken to help this client overcome his fears of his own
thoughts and feelings (based on being frightened of the thoughts and
feelings of his estranged father, who was severely mentally ill). With
Andrew’s support of S and effective management of his treatment
plan, S exceeded my expectations of what he would gain from therapy,
and I let Andrew know how praiseworthy this was.
3. The special cross-cultural issue with the “I.T. Guy”: Before talking about
our third agenda item, I did a clock check with Andrew as a way of con-
firming that we had sufficient time to devote to the remaining items
on our supervision list for today. We then focused on the “I.T. Guy,” an
African-American male client who seemed to be living the American
dream of a high-level job and financial success but who was chronically
angry, in part as a result of his personal experiences with racial injus-
tice. Andrew astutely noted that the client had suffered grievously from
his father’s incarceration, adding that the client believed that a white

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person would not have been imprisoned for a similar offense. Andrew
and I had to ponder our conundrum of trying to help the client man-
age his anger without implying that his anger was without just cause,
especially as we (“two white guys”) were not in a position to know
how he felt. I hit upon the idea of asking Andrew to give the client
a homework assignment in which he would research historic quotes
from famous people of color (male and female) who wrote about deal-
ing with racial injustice in part through strength of mind-set. In this
way, we could suggest that the client had a right to rail against the
system that jailed his father and still could use his personal skills to
be the master of his moods. I added that perhaps Andrew and I could
offer to learn from the client by being willing to read something (that
the client would recommend to us for our own homework) so that
we could be his “students” on this cross-cultural topic. To his credit,
Andrew was tactful and careful about taking my suggestion, saying that
he would “run it by the client first.” This was exactly the right thing to
do since it might be presumptuous of me to ask the client to be our
teacher when he is expecting us to help him; he might not want to be
put in the position of having to educate us. The client should make the
call on this one. We just want to communicate that we are open to the
idea that he could teach us something valuable.
4. The special ethical decision about whether or not to treat a client’s sister:
Our final agenda item in this supervision session was quite rich because
it involved discussing an ethical issue, using guided-discovery ques-
tioning to help Andrew think through the problem, employing a role-
play to practice how he might diplomatically say “no” to the client’s
request, and advanced problem-solving to help decide how to manage
confidentiality if Andrew opted to say “yes” to providing therapy to
his client’s sister. I noted that by asking Andrew to treat her sister, the
client was giving him a vote of confidence and that he could feel good
about this. At the same time, Andrew was uncomfortable about poten-
tially being in a confidentiality bind if he treated both sisters, particu-
larly if either one had clinically significant issues involving the other.
I agreed that this could be a problem, but I wanted Andrew to think

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things through more carefully rather than just avoiding what he found
uncomfortable. Yes, a therapist’s feelings of discomfort in response to a
client’s request can be an important cue that the request is profession-
ally ill-advised. On the other hand, it could just be a case of Andrew’s
giving up too quickly and avoiding trying to solve the problem! Thus,
I asked him if he could play devil’s advocate and argue in favor of see-
ing the sister. Under what conditions might this be doable? In talking
about this, we hit upon the concept of availability of treatment. Did
the client’s sister have other treatment options? Would she avail herself
of any other therapists? We also noted that Andrew could talk explic-
itly with his client about confidentiality—for example, that he could
treat the sister only if both clients agreed that confidentiality would be
maintained within the dyad but that Andrew would be free to use his
clinical judgment to share things with one client about the other. We
did a role-play so that Andrew could practice nicely saying “no” to his
client while giving her a solid rationale. This led to some problem solv-
ing, in which we came upon the idea that Andrew could talk to the sis-
ter by phone, thus making personal contact and perhaps encouraging
her to get the help she needed, but he would give her a referral and try
to boost her confidence in following through. I was happy that Andrew
brought up this topic in supervision given that it is an ethical gray zone
and thus requires some serious thought and advance troubleshooting
before definitive action is taken with the client(s).

As we can see, this CBS meeting included points of focus that were not
solely the province of CBT per se. Good mental health care supervision,
regardless of the treatment modality, often helps supervisees to bolster
their foundational competencies, such as cross-cultural responsiveness
and ethical decision making. This well-structured supervision session was
identifiable as CBT by virtue of its use of the conceptual language and
techniques of this theoretical orientation, including the use of the CTRS
as a way to rate Andrew’s recorded session with G, with support and guid-
ance offered in a congenial tone.

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 4

Handling Special
Supervisory Issues

I n this chapter we address issues and situations in supervision that are

not the customary, routine aspects of training and clinical oversight
that first come to mind when we think of clinical supervision. However,
an important part of competency in supervision involves managing
problems with supervisees, demonstrating a working knowledge of cross-
cultural issues (Falender, Shafranske, & Falicov, 2014), having a strong
foundation in clinical ethics (Pope & Vasquez, 2011; Thomas, 2014), and
being willing and able to step up and deal with difficult clinical situa-
tions so that trainees get the extra help they need and clients are assured a
reasonable standard of care. The following pages provide some guidance
to cognitive–behavioral therapy (CBT) supervisors called upon to apply
such knowledge and handle a sample of problematic scenarios.

http://dx.doi.org/10.1037/14950-005
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

DEALING WITH SUPERVISEES WHO POSE

CHALLENGES (ANXIETY, SHAME, DEFENSIVENESS)
For many supervisors, the time they spend with their supervisees is a
uniquely rewarding part of their professional experience. However, it is
inevitable that some supervisory relationships will be more challenging
than others. Although each supervisor–supervisee dyad is unique, there are
some common issues that may arise in the course of cognitive–behavioral
supervision (CBS) that add a layer of difficulty to the experience.

Anxiety/Shame
Perhaps the most common area of difficulty in the supervisory relation-
ship is trainee anxiety. Particularly for supervisees in the early stages of
their training or those who have been trained in other modalities but are
new to CBT, some anxiety is to be expected. Novice supervisees are in
the position of having their fledgling CBT skills observed by a supervisor
who may also be providing evaluative feedback to their home program,
might later serve as a reference for a predoctoral internship or job, and
ultimately have a say in whether they proceed through their training to
become a licensed member of the profession. Under these circumstances,
it would be surprising if trainees did not experience some anxiety in
supervision. However, there are times when a supervisee’s level of anxiety
is high enough to interfere with the supervisory process and the super-
visee’s professional development. A highly anxious supervisee may have
difficulty articulating the contents of a session with a client, identifying
productive next steps in the therapeutic process, or encoding and utilizing
supervisory feedback.
The CBT supervisor can do a good deal to mitigate supervisees’ anxi-
ety, beginning in the early phases of supervision. Supervisors would do
well to communicate to their trainees early in supervision that mistakes
are an expected part of the learning process and corrective feedback is
routine. It is important for the CBT supervisor to make sure that sugges-
tions for change are combined with feedback on things the supervisee
has done well or areas in which he or she has shown growth. Just as it is

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unhelpful to point out and challenge every automatic thought a client

mentions in session, overloading a supervisee only with feedback on
areas for change can be bewildering or even demoralizing.
Supervisors can help to reduce their trainees’ anxiety through model-
ing openness in supervision: for example, through judicious self-disclosure
of the supervisor’s imperfections as a therapist. Much as a therapist’s brief,
well-timed reflection on challenges that he or she has overcome can help
normalize clients’ experience of struggle or imperfection, the CBT super-
visor can reference his or her own challenges as a beginning (or seasoned!)
therapist to help supervisees feel more comfortable with their own learning
curve. Supporting this approach is a study by Nelson, Barnes, Evans, and
Triggiano (2008), which described how experienced, “wise” supervisors
in their sample normalized difficulties as part of professional learning
and development. In addition, such supervisors also used a modicum of
humor in their humble self-disclosures of the foibles of their own work,
as is seen in the following supervisor comment.

Supervisor: The first time I did progressive muscle relaxation interven-

tion with a client, I was so nervous I think I probably made her more tense
than before we started. To make matters worse, I started to have the hic-
cups! It was really a comedy of errors, I must admit. Later, I had to practice
the technique a bunch of times outside of session before I really felt ready
to use it with clients. I wonder if the same thing is happening when you try
to use the exposure narrative that we talked about in here. Would it help
if we practiced this some more, here in supervision?

Similarly, the supervisor can help decrease a supervisee’s anxiety

about “not knowing” by seeking consultation when appropriate. The fol-
lowing supervisor’s comment is illustrative:

Supervisor: You know, I have some ideas about how to help your client
through this impasse, but the things we’ve been talking about haven’t been
working as well as either of us would like. I know that Dr. E. just dealt with
something very similar with one of her clients. Let’s run this by her and see
if she has any thoughts to share with us.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

A suggestion such as this can serve as a useful reminder to supervisees

at all levels of training that it is appropriate to consult with others when
help is needed.
At times, supervisees’ cognitions about the supervisory process itself
or their own skill set might fuel the anxiety they experience in supervision.
Thoughts and assumptions such as, “I have to act like I know what I’m
doing, even when I don’t” or “I should know how to do all this by now”
might diminish supervisees’ comfort in asking for help or admitting to gaps
in knowledge. The CBT supervisor can, when appropriate, encourage a con-
versation about the supervisory process or the supervisee’s self-evaluative
thoughts. CBT techniques may be used to assess such cognitions and per-
haps modify them in ways that facilitate the trainee’s ability to participate
more constructively in the supervisory process. The supervisor can steer
clear of the pitfall of turning such an approach into therapy for the super-
visee by staying squarely focused on the supervisee’s anxiety and related
thoughts about the work he or she is doing, as follows.

Supervisor: I’ve found that a lot of the techniques that are helpful for my
clients—such as asking guided discovery questions in order to respond
rationally to automatic thoughts—are also helpful for me when I’m hav-
ing doubts about my work. It’s also a great way for me to practice the
techniques themselves. Would you be okay with our trying that for you
right now? For example, I noticed that you sighed and looked a little dis-
concerted when I asked you how things went when you reviewed Mr. Ws
case conceptualization with him. What went through your mind just now?
Trainee: Well, I was thinking that he didn’t agree with some of the things
we talked about in here. I didn’t know how to respond to that or where to
go from there.
Supervisor: Thanks for telling me. That’s important to know. Here’s a
typical guided discovery question you can ask yourself. “What did it mean
to you” that he disagreed?
Trainee: Well, I guess that I got it wrong. And that you would probably be
really disappointed in me because we spent so much time on it in here—
like maybe if I had explained it better it would have gone over better.

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Supervisor: Thanks for sharing that with me. I wonder if we can take
a few minutes and look at some other possibilities for what might have
happened with Mr. W, and also try to look at this situation in a way other
than that you’re doing something wrong or risking disappointing me. Is
that OK with you?
Trainee: That would be a big help, actually.
Supervisor: OK, great. So one possibility is that I might have been dis-
appointed in you. Any other ones?
Trainee: Well, you might have been wondering what you got wrong, too.
Supervisor: Absolutely. We did work on this together. I could just as easily
think that I disappointed you! But I don’t know that “getting it wrong” is nec-
essarily a bad thing. Sometimes we can get as much information out of what
doesn’t go well with a client as we can out of what does go well. Maybe we can
spend some time thinking about what we can learn from Mr. Ws reactions.
Based on that idea, what’s another rational response we can apply here?
Trainee: Maybe we can actually improve the case conceptualization, based
on Mr. Ws comments, or maybe incorporate his reactions into our con-
ceptualization of his response style when someone tries to give him well-
meaning feedback.
Supervisor: Exactly. That would be very constructive. Notice how you can
rationally respond to this situation without having to feel badly about it.
Learning doesn’t always have to be painful!

Although the technique illustrated does not differ substantially from

that which might be used in therapy, the aim is to explore the trainee’s
thoughts as they relate to his or her work at present and does not necessitate
delving into the trainee’s personal history or relationships with others. This
highly circumscribed use of the technique maintains the important bound-
ary between teaching and treating. When supervisees spontaneously stray
into the area of revealing too much about themselves (as they may do in their
personal therapy), the supervisor has to find a nonshaming way of asking
them to refrain from doing so. The following supervisor sample comment
provides an illustration.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

Supervisor: I appreciate your trust in me, but it’s not necessary for you to
disclose so much about your personal life and challenges in supervision. I
want to be understanding about any stressors that might be affecting you
in your work here, but I also want to draw a line between supervision and
therapy. That way we’ll keep our supervisory relationship in the proper
zone, and frankly, it’s better for you if we do that. I hope that doesn’t sound
dismissive or uncaring in any way. It definitely matters to me how you feel
and how positive your experience in supervision is.

Resistance/Defensiveness
Supervisees’ anxiety may at times present as defensiveness or resistance
to incorporating the supervisor’s suggestions on how to proceed in treat-
ment. The simple cognitive restructuring technique discussed in the pre-
vious section for addressing anxiety also sometimes proves useful when
a trainee appears resistant to supervision. However, there are times when
supervisees’ resistance to feedback involves something more than anxiety.
Not all trainees seek supervision in CBT voluntarily. Some may engage
in CBT training and supervision as a requirement of their program but
have a strong preference for another model of case conceptualization and
intervention. In such cases, a supervisee may be reluctant to employ CBT
techniques suggested by the supervisor or believe that being asked to do
so is an unwelcome challenge to his or her own preferred way of thinking.
An apparently resistant supervisee may also have misconceptions
about CBT. Consider, for example, the following interaction between one
of the authors (DK) and an advanced psychiatry resident who had been
trained primarily in psychodynamic psychotherapies.

Supervisor: It sounds like the client was really in a lot of pain when she
was talking about her mother’s leaving her at home alone for the weekend
when she was a teenager.
Trainee: Yes, she was crying until she had a hard time catching her breath. She
was very distressed. At that point, it just seemed cruel to do what you were
asking me to do—to ask about her thinking while she was in so much pain.

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Supervisor: Let’s imagine for the moment that this weren’t your “CBT
client.” What might you have done if you were working with her in a dif-
ferent modality?
Trainee: Well, I would have empathized with her.
Supervisor: Absolutely. Empathy and validation are very appropriate and
helpful in that moment. Were you thinking that a CBT approach would
instruct you not to do this?
Trainee: Well, you keep telling me that we’re supposed to be evaluating
her thoughts.
Supervisor: In the right context, with the right tone, that’s true, but I can
tell you straight out that in CBT it would be extremely important for you
to provide the client with empathy at such a moment. We could role-play
that situation if you wish. You could be the client, and I can illustrate how
a CBT clinician might respond, perhaps trying to understand the client’s
thinking in the process, but always with warmth, support, and caring.

Note in the example how the supervisor does not bristle at the super-
visee’s suggestion that assessing a vulnerable client’s thoughts would be
“cruel” but rather takes an approach that is more exploratory and instruc-
tive. The supervisor recognizes that the supervisee maintains a faulty
belief about CBT itself, and the supervisor is in a position to modify this
belief, in a nondefensive, noncruel way! The supervisor remains collab-
orative with this therapist-in-training, looking for common ground, and
not getting into a power struggle (see Sudak et al., 2015).
In their overview of CBS, Liese and Beck (1997) discuss some of the
common misconceptions about CBT that might interfere with a produc-
tive supervisory relationship. Among them are the beliefs that CBT is
unconcerned with the role of the client’s historical, developmental expe-
riences; that CBT views the therapeutic relationship as being relatively
unimportant; and that those who practice CBT are unconcerned with the
client’s emotions, choosing instead to focus exclusively on the client’s “dis-
torted” thinking. A supervisee who has been exposed only to the myths or
stereotypes of CBT might well be resistant to attempting to treat a client

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from a cognitive–behavioral perspective. Thus, it is important for a super-

visor who is experiencing his or her supervisee as resistant to explore the
degree to which the supervisee maintains some of these inaccurate view-
points of CBT.
It is important to distinguish between a supervisee who is resistant to
working with clients within a CBT framework and one who is resistant to
being supervised in general, the latter of which may indicate a more seri-
ous problem. Periodic consultation among supervisors who are working
with the same supervisee or, when relevant, consulting with a supervisee’s
training program can be helpful in allowing the CBT supervisor to con-
textualize defensiveness and resistance and identify appropriate strategies
for addressing them. When possible, these strategies should be discussed
with the supervisee in a way that clearly lays out the nature of the problem
and specifies targets for change. The following are examples of ways that
supervisors might identify and operationalize problems that might arise
in working with resistant supervisees:

“I’m required to cosign your notes, but you haven’t been bringing the
charts to our meetings. Can we talk about what’s getting in the way
and come up with a plan to remedy this?”
“We have been talking for a few weeks now about working with
your client to develop strategies for coping with her intense anger. I
notice that you have spent a lot of time talking with her about the
historical origins of her anger but not as much time discussing her
current behavior when she gets angry. This concerns me because I
haven’t heard that there’s been much change in her behavior, and she
is on probation at work due to her anger outbursts there. Let’s talk
about how you’re viewing the problem and what you think about the
problem-solving interventions I’ve been suggesting.”
“I’m hoping we can talk a little bit today about our interactions
in supervision. I’ve noticed that we have disagreed quite frequently
on numerous clinical and operational issues. I would like for us to
find a way to become more collaborative because the clients’ well-
being and your training goals are better served if we can find points
of agreement.”

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“I wanted to let you know that in our quarterly supervisors

meeting it came up that none of your supervisors has ever received
a recorded session from you. This is one of the requirements of the
training program, so we need to find a way to solve this problem.
What are your views on this matter?”

These comments represent an approach that is appropriately assertive—

after all, the supervisors are in a position of authority, and they need to
exercise that authority when necessary—while also expressing hopeful-
ness about coming to a positive resolution. The overarching message from
the supervisor is, “We have a specific problem we need to deal with as a
team. Here is the problem as I see it. I also welcome your views about
the problem. Let us promptly find a collaborative way to solve the prob-
lem, for the clients’ benefit, and yours.” The supervisees’ response to this
entreaty is informative. If supervisees seize the opportunity to try to
improve their clinical work and interactions with the supervisor, it pro-
vides evidence of their commitment to learning, capacity for good com-
munication and problem-solving skills, and prioritization of constructive
conflict resolution over doubling down on the problematic status quo.
On the other hand, if they respond unfavorably and with negative affect,
this may provide evidence of a more serious issue that may need to be
addressed at the institutional level. If the supervisor approaches the prob-
lem in a composed, thoughtful, hopeful, and constructive way, the super-
visee’s response will provide useful information that is mostly reflective of
the supervisee’s attitudes and affect.

The Supervisor’s “Contribution” to the Problem

At times, a supervisor’s own assumptions, attitudes, and behaviors might
impede the supervisory process and increase trainees’ anxiety, defensive-
ness, or resistance to supervision. For example, a supervisor who focuses
exclusively on supervisees’ areas that need to be improved and consis-
tently fails to highlight their strengths and successes might leave his or her
supervisees with the impression that they can do nothing right. Similarly,
a supervisor who presumes that he or she is the sole expert and that his or

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her supervisees have nothing to contribute to the supervisory dialogue may

find that supervision comes to resemble a monologue in which the super-
visor is lecturing to an increasingly frustrated supervisee. Supervisors
who recognize, validate, and incorporate the unique skill sets that their
supervisees bring to the table, some of which may differ from the super-
visor’s own, may find that their supervisees are more receptive to learning
from the supervisor’s way of thinking and areas of expertise. This may be
particularly true for CBT supervisors who are working with supervisees
who are new to CBT but have been trained extensively in other modali-
ties and theoretical orientations. A supervisor who fails to recognize and
acknowledge the skills that his or her supervisee has already developed
loses an opportunity for a productive and collaborative exchange of ideas
and for the supervisor’s own learning.
In light of the role that supervisors’ own behaviors can play in their
supervisees’ openness or resistance to supervision, it is important for
feedback about supervision to be bidirectional. The more readily a super-
visee can share information about what is helpful and not helpful in the
supervisor’s approach to supervision, the more fruitful the supervisory
relationship can become. Given the inherent power imbalance in the
supervisory relationship, feedback from the supervisee is more likely to be
obtained when the supervisor asks for it proactively. This helps to create
an environment in which the supervisee’s observations and requests for
change are met with acceptance and nondefensiveness. Metasupervision,
to be discussed in Chapter 5, may be a useful aid to supervisors in examin-
ing their own role in the ups and downs of the supervisory relationship.
It is extremely important for supervisors to exhibit a high level of moti-
vation to resolve any strains in their working relationship with supervisees
in a positive way. In the same way that a therapist’s successfully resolving
an alliance strain with a client can result in significant therapeutic gains
(Strauss et al., 2006), a supervisor’s interpersonally adept handling of ten-
sion with a supervisee can present the latter with an excellent model for
conflict resolution (Safran & Muran, 2001). The supervisee can then bring
that same skill and spirit to his or her work with clients. For a supervisor
to achieve the goal of reaching a positive accord with a supervisee after a
disagreement, the supervisor has to be self-aware, empathic, and mindful

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of the big picture (helping clients and clinical trainees), rather than being
focused on winning an argument or asserting authority.
Part of being self-aware is being willing to be a healthy skeptic of one’s
own thoughts and to reflect on one’s own emotions without simply
acting on them. In supervision, this means the supervisor is willing to
reassess his or her own ideas about how to properly manage the super-
visees’ training and the clients’ care. As an example of this process, many
years ago one of us (CN) supervised a visiting professor who was spending
her sabbatical getting more clinical training in CBT. Given that her license
to practice psychology was in a different state, she required full-fledged
supervision (i.e., not just consultation) from a practitioner licensed in
Pennsylvania (the home state of the Center for Cognitive Therapy). Our
working relationship proceeded smoothly until we disagreed about the
treatment of a young man who had an anxiety disorder manifested by clin-
ically significant avoidance. I watched a video of one of the supervisee’s
sessions with this client and noticed that although she was very empathic
toward the client (and it was clear that the therapeutic relationship was
strong), the client easily was able to talk his way out of doing any expo-
sure exercises and behavioral experiments. In the supervision session, I
expressed my concern, saying that the supervisee needed to be more direc-
tive; otherwise, the client would simply use therapy for emotional support
and nothing more. I suggested that she give him explicit feedback about his
avoidance patterns. In response, the supervisee called my attention to the
case conceptualization, highlighting a learning history in which the cli-
ent’s father used to routinely deride him for his failings, making demands
for change that served mainly to poison their relationship and undermine
the client’s self-confidence. She stated that she did not want to risk repli-
cating that sort of relationship, which she feared she would do if she were
to lower her degree of unconditional acceptance and increase the level of
confrontation in session. She added that she did not want to reinforce the
client’s “incompetency” schema and associated shame by pointing out his
failure to participate in exposure exercises and behavioral experiments.
At first, my supervisee and I had difficulty hearing each other as we
continued to make our own points, and we progressively became more
frustrated. At last, I made a process comment on our difference of opinion

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and wondered aloud if we could find a middle ground on which we could

agree and build a foundation for ongoing interventions for the client. I
took the lead, saying that I was going to take stock of my staunch “anti­
avoidance” position and try to moderate it. I invited the supervisee to do
the same with regard to her “unconditional acceptance” model. I acknowl-
edged that I felt frustrated when I watched the video, thinking that the
client was “taking the path of least resistance” in treatment, that the super-
visee was positively reinforcing this, and consequently the client was not
getting an adequate “dose” of CBT.
However, I acknowledged that I did not always feel optimally empathic
toward certain avoidant clients, and I recalled aloud that some years ear-
lier my own CBT supervisor observed that my male clients with anxiety
disorders tended to leave treatment prematurely, whereas my female cli-
ents with anxiety disorders stayed and did well. Upon further reflection,
I had to admit that I was “tougher” on my male clients than my female
clients, a bit of implicit sexism that I was not proud to reveal. My super­
visor had hypothesized that I was calmer and more understanding of the
women clients’ feelings of stress but more apt to be “an aggressive sports
coach” with the male clients (as if to say, “Get back on that field and show
what you’re made of!”). I worked on this problem over the years, including
examining my personal history of being uncompassionate and intolerant
of my own anxiety, but perhaps I still had more work to do!
In the here and now of my supervision session, I stated that there was
evidence from my previous clinical work that I needed to be a little more
understanding (and less demanding) of male clients with anxiety. Follow-
ing my cue, my supervisee told me about her tendency to be an all-doing
“caretaker” of vulnerable people in her life, and how she could probably
benefit from expanding her repertoire so as to ask more of others, includ-
ing her clients, not to mention certain people in her life.
At first glance, this vignette may seem like an example of turning super-
vision into therapy, but the fact that the process was shared, with super­visor
and supervisee equally partaking in a process of self-evaluation to help a
client, meant that the boundary into treatment was not crossed. This is
better understood as an example of interpersonal process in CBS (Safran
& Muran, 2001), in which I needed to find a balance between seeing (and

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acknowledging) the merits of what the supervisee was doing and assertively
and directly asking her to do more. As Milne and Reiser (2014) noted, “man-
aging this tension between support and challenge is at the core of effective
supervision” (p. 412). In our mutual exercise of self-reflection, my supervisee
and I felt more at ease with each other, understood each other’s position a
little better, and came to the revolutionary conclusion that it was possible to
be empathic toward a client and be more assertive in promoting difficult but
powerful evidence-based interventions! Empathy and directiveness are not
mutually exclusive therapeutic activities in CBT! Who knew?

TRAINEE IMPAIRMENT/SKILL DEFICIT

(REMEDIATION AND GATEKEEPING)
The close working relationship between supervisor and trainee may at
times result in the trainee’s spontaneous disclosure of his or her cur-
rent challenges in life. For example, supervisors may become aware of
trainees’ difficulty adjusting to a training site or a new geographic loca-
tion, personal or familial illness, relationship breakups, and trainees’ own
struggles with depression, anxiety, or conditions that may mirror those of
the clients they treat. Concerned as the supervisor might be about his or
her trainee’s personal well-being in such circumstances, it is important to
ascertain if challenges such as those mentioned affect a trainee’s ability to
meet expected levels of performance. When a trainee’s difficulties clearly
affect his or her ability to conduct therapy safely, ethically, and with an
appropriate level of skill, a trainee may be considered impaired. Impair-
ment has been formally defined as, “A condition that interferes with pro-
fessional functioning to the extent it negatively impacts clients/patients or
makes effective service delivery impossible” (Kaslow et al., 2007, p. 481).
It should be noted that the concept of impairment as it applies to the safe
practice of therapy does not refer to the presence of physical or men-
tal disabilities requiring a modification in nonessential job functions as
mandated by the Americans With Disabilities Act (DeLeire, 2000). Neither
does it refer to transient, contextual factors affecting a therapist’s work,
such as in the case of a supervisee who is not at his or her best as a result
of going through a process of grieving a loss.

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It is when dealing with an impaired supervisee that the supervisor’s tri-

partite role as overseer of client safety, facilitator of the supervisee’s profes-
sional development, and gatekeeper to the profession comes to the fore. The
supervisor working with an impaired trainee must be mindful of all aspects
of this role simultaneously and work to address each one appropriately.

Client Safety
The well-being of clients being treated by a trainee for whom questions
of impairment have arisen requires significant attention and scaffold-
ing on the part of the supervisor. A possible starting point in determin-
ing whether the difficulties the trainee is experiencing rise to the level of
impairment—or conversely, can improve with additional assistance—is
more frequent supervision and more direct observation of the supervis-
ee’s work, such as via videotaped sessions. Supervisors might also be called
upon to sit in on sessions with the supervisee and the client or conduct
an independent assessment to evaluate clients’ safety. In cases in which
it is determined that the supervisee is unable to continue to treat a par-
ticular client, the supervisor facilitates the transfer of the client’s care in as
smooth and undisruptive a manner as possible. This may include having
the supervisor directly assume responsibility for treating the client until
the supervisee is able to resume work or until another supervisee can take
over for the duration of treatment.

Supervisee Development
Although supervisee impairment generally is thought of as being distinct
from the supervisee’s having skills deficits, there may be times when these
two factors interact. For example, a supervisee who is actively struggling
with panic disorder may be less willing or able to facilitate an interoceptive
exposure exercise with a client who has a similar problem. Although the
CBT supervisor is not (and does not function as) the supervisee’s thera-
pist, there are instances in which clinical supervision can help to address
the issues interfering with the trainee’s professional functioning, as illus-
trated here.

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Supervisor: I’m noticing that although we’ve discussed using overbreath-

ing exercises with Ms. X to address her panic symptoms, you seem worried
about trying it out in session. Can you tell me a little bit about what you
imagine might happen if you tried it?
Trainee: Well, I know that feeling where your heart starts pounding and
you can’t catch your breath, and it’s really awful. I just don’t want to put
anyone else through that for no reason.
Supervisor: It’s true that the sensation you describe can feel really fright-
ening at first. If I hear you right, it sounds like you think that if you try
some of these strategies with Ms. X, it will just result in her feeling really
awful, and nothing good will come of it. Does that sound right?
Trainee: Well, when you put it that way, it sounds a little extreme. I know
that interoceptive exposures can be very helpful in the long run. But in the
short term, it’s really hard on the client, and the therapist has to be super
confident in order to make this work, and frankly I’m not sure I’m super
confident. So I guess I’m looking for alternative ways to help this client
and to bypass the exposures if possible.
Supervisor: I appreciate your candor about how you feel, and I’m glad
that at some level you can make an objective evaluation about the efficacy
of exposure exercises so that you don’t view them as being unhelpful. Even
though you’re not very confident right now, are you open to the possibility
that with some graded practice of your own—maybe in some role-playing
in supervision—that you can gradually gain some confidence so that you
will be able to implement interoceptive exposure exercises into your work
with clients who have panic disorder?
Trainee: (Hesitant). I would like to say yes. What would the graded prac-
tice look like?

The supervisor could then use supervision time to review the rationale
and the expected outcome for interoceptive exposure and to role-play as
a client so that the supervisee can practice an intervention such as over-
breathing without fear of making a real client “feel worse.” This sort of

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role-playing can be done multiple times, with the supervisor enacting dif-
ferent challenges, such as a client who stops taking part or who reacts with
distress. The supervisee will then have the opportunity to practice repara-
tive interventions in a safe environment and see that even a less-than-ideal
outcome at the moment of the intervention may still have psycho­
educational and therapeutic effects on a client if it is processed properly
and empathically. If the supervisee benefits from the supervisory role-play,
the supervisor can then raise the bar and ask if the supervisee is willing to
take the role of the client who will be doing the interoceptive exposure. If the
supervisee agrees, the supervisor will be able to model how to effectively and
sensitively handle a client who has misgivings about a procedure. If the
supervisee declines to do the exercise in the role of the client, the super-
visor does not then press the matter or otherwise risk turning the inter-
action into something akin to doing therapy with the supervisee. Rather,
the supervisor can suggest that the supervisee continue to practice the
procedure as a therapist but also consider seeking outside therapeutic help
to learn to decatastrophize the physical sensations of anxiety and panic.
The following is a sample comment from a supervisor in such a situation.
Note the hopeful, helpful tone used to motivate (rather than risk shaming)
the supervisee.

Supervisor: I think you’re in a position where you can continue to practice

implementing the interoceptive exposure exercises so you can ultimately
do them with an actual client. But I can promise you that if you practice
the method on yourself—in other words, if you can do the overbreath-
ing yourself, maybe in the presence of your own CBT therapist—you will
benefit doubly. You will find that you can manage your own fight-or-flight
symptoms better, which is important in its own right for your quality of
life. But even more, you will feel that measure of “super confidence” that
has been eluding you. I can tell you from my own experience as a therapist
that when you deal with your own biggest issues, you feel so much better
about asking your clients to deal with their biggest issues. You will feel that
your therapeutic messages to yourself and your clients are congruent, and
this is valuable. What do you think about that?

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Gatekeeper Function
At times, concerns about the level of a supervisee’s impairment may lead
the supervisor to question the advisability of the supervisee’s continuing
his or her training. When clinical supervision takes place in the context
of a private arrangement between the supervisor and supervisee, well-
articulated guidelines for the termination of supervision ideally should be
stated in the supervisory contract put in place at the beginning of super-
vision. The supervisor may also benefit from consulting with regional and
national ethics committees and licensing boards to determine an appro-
priate course of action (Kaslow et al., 2007).
The ethical and legal issues involved in dealing with an impaired
trainee become more complex when supervision is provided within an
agency or institutional setting. In such cases, clinical supervisors should
be certain to consult with their own administrative supervisors regarding
any existing policies and procedures involved in the modification or ter-
mination of the supervisory relationship. This may also involve consulting
with the organization’s human resources or legal departments, particu-
larly when taking any action that involves a trainee’s suspension, mandat-
ing of mental health or substance abuse treatment, or terminating the
supervisee from a training position. When a supervisee is a matriculated
student at another training institution or from another discipline, the
supervisor or an appropriate representative from the supervisor’s adjunct
training site should also be in contact with the supervisee’s home institu-
tion or training program.

POWER AND EVALUATION

Inherent in all supervisory relationships, no matter how collaborative and
no matter how much the supervisor may value an egalitarian teaching
style, is an imbalance of power between supervisor and supervisee (see
Murphy & Wright, 2005; Patel, 2004). Most supervisory relationships are
between an unlicensed therapist and a supervisor who holds ultimate legal
and ethical responsibility for the well-being of the clients under the super-
visee’s care (Campbell, 2005). In addition, the clinical supervisor often is

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responsible for supervisees’ formal evaluations, thus influencing the lat-

ter’s progression to higher levels of training and their eventual eligibility
to enter into the profession fully credentialed. One way in which super-
visors can empower their supervisees is by recommending resources that
inform them about what to expect in supervision and how best to navigate
the process (e.g., Falender & Shafranske, 2012, in press).
As noted, the attuned supervisor will bring up the question of evalua-
tion proactively and early in supervision, stating that evaluative feedback
is an integral and expected part of supervision. Supervisees ideally should
be aware of the objective criteria on which they will be evaluated and, if a
formal evaluation form will be used, given a template of the form at the
start of supervision. Although training may take place in a setting that
uses its own evaluation form, supervisees who are specifically interested
in improving their CBT skills might also be given the option of having
their progress assessed with a CBT-specific instrument, such as the CTRS
(Young & Beck, 1980). It is fitting and proper for supervisors to commu-
nicate with their supervisees face to face about the formal, written evalu-
ations. This process allows the supervisees to provide feedback about how
their perceptions of their own progress compare with the supervisors’
assessment and similarly allows supervisors to explain their rationales
for their evaluations. When supervisors handle this process competently,
and when supervisees are reasonably receptive, it can serve as a positive
learning experience, and any unfortunate miscommunications or mis-
understandings can be addressed and perhaps resolved in a mutually
satisfactory way.
It is to be expected that supervisees will have areas of strength as
well as areas for further growth and development, most of which can be
addressed in the context of routine supervision meetings. However, at
times the magnitude of a supervisee’s skills deficit requires a more formal
and concrete plan of remediation. As stated, when this is the case, it is
important that the supervisor follow all policies and procedures devel-
oped by the institution under whose auspices he or she is supervising.
Thus, a supervisor who is considering implementing a formal remedia-
tion plan for a supervisee should incorporate input from the supervisee’s

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other immediate supervisors, his or her program or department chair,

and the director of training at the site at which the supervisee is training.
All formal feedback concerning the need for remediation should be
put in writing and discussed in terms of measurable and operationalizable
outcomes and objectives (e.g., “Supervisee will complete charting within
48 hours of seeing a client”). For feedback to be educational rather than
punitive, it should also include a plan for helping the supervisee address
areas of weakness. This may include additional supervision sessions, pro-
viding the supervisee with suitably instructive readings, and/or helping the
supervisee develop a plan for improving his or her time management skills.
Finally, a remediation plan should include a specific date at which progress
toward goals will be reevaluated and additional steps will be suggested—
including, if necessary, termination from the practicum site or program—
if deficits are not remediated.

AWARENESS OF AND SENSITIVITY TO

MULTICULTURAL/DIVERSITY ISSUES
Supervisors play an important role in helping supervisees to appreciate
the relevance of cultural issues in the application of CBT to diverse popu-
lations. Castro, Barrera, and Holleran Steiker (2010) noted that “culture
consists of the worldviews and lifeways of a group of people . . . transmit-
ted from elders to children, and [conferring] members . . . with a sense of
peoplehood, unity, and belonging . . .” (p. 216). Culture is associated with
such factors as language, food, social structure and customs, symbols and
rituals, beliefs, and a striving for survival and continuation. The authors
cite evidence that when clinicians adapt therapy to be more comprehen-
sible to and respectful of a client who identifies strongly with a given cul-
ture, it improves the client’s engagement in the process of treatment.
When a client is of a nonmainstream cultural group (i.e., outside the
majority or plurality in a given societal milieu), it is particularly important
for the supervisor to bring the potential importance of this topic to the
supervisee’s attention. Similarly, when the supervisee self-identifies as part
of a nonmainstream cultural group, the supervisor needs to be sensitive

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to this and proactive in discussing the ways in which the supervisee’s

cultural identity affects his or her experience in his or her work as a clini-
cian (see Iwamasa, Pai, & Sorocco, 2006). Self-knowledge is an important
part of cultural competence. As an exercise, supervisors and supervisees
alike can ask themselves the question, “Who am I as a cultural being?”
(Falender & Shafranske, 2012), giving consideration to how their self-
perceptions interact with their perceptions of the cultural characteristics
of those for whom they are clinically responsible. Regardless of whether
it is the supervisor, the supervisee, the client, or some combination of
them who represent a minority population in society, it is incumbent
upon the supervisor to be proactive in creating a positive atmosphere for
discussing the role of culture in therapy and supervision. Supervisors and
supervisees may have a great deal to learn from each other with regard
to cultural issues and their effect on therapy and supervision, which not
only benefits the clients but also helps supervisors to grow and super-
visees to feel more positively about supervision (Ancis & Ladany, 2010;
Inman, 2006).
One of the challenges in being culturally sensitive is being accurately
empathic with clients whose life experiences as cultural minorities are
dramatically different from those of the therapist and/or supervisor, and
arguably “unknowable” (as in the case of Andrew and his supervisor try-
ing to understand the racial discrimination experienced by the African-
American client in Chapter 3). Rather than falling prey to “all or none”
thinking, in which one feels helpless to understand the client at one
extreme or insists that “I know exactly how the client feels” at the other
extreme, there is a middle ground approach. This moderate tack involves
actively trying to imagine what it must be like to be this particular client
(similar to a “method actor” researching a role to be the character), while
simultaneously acknowledging that this approach does not replicate the
actual experience of the client. Supervisors can help their trainees prac-
tice this technique via the use of hypothetical questions, a method that is
consistent with “guided discovery,” one of the core features of a well-run
CBT session (therapy or supervision). For example, supervisors can ask
their supervisees, “How would you feel if you were . . .

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77 a sexual minority who has never ‘come out’ to his family and feels all
alone?
77 someone struggling to speak English as a second language and often
dealing with being derided by people who speak only English?
77 new to this country, but you had close family members ‘stuck’ else-
where in the world?
77 a young person who is acculturated here but living with parents who are
‘old country’ in their lifestyle and attitudes, so you were torn between
two worlds?
77 judged by others at first glance all your life (e.g., because your skin was
a different color or because you were permanently in a wheelchair)?”

Entertaining such hypothetical questions in supervision often stimu-

lates meaningful conversations that can help trainees increase their cul-
turally related empathic capacity. This is a good starting point in fostering
“cultural humility” (Falender & Shafranske, 2012). Another important
step is conceptualizing clients’ behaviors in light of their cultural back-
ground and adapting one’s clinical responses accordingly. For example, in
the following sample transcript, the supervisor and supervisee talk about
the potential significance of the client’s repeated, deliberate skipping of
a self-report inventory item. The client is a never-married, devoutly reli-
gious woman of color who was born and raised in Africa.

Trainee: I have been keeping track of the client’s Beck Depression Inven-
tory (BDI-II) scores, and the client has been very consistent in filling
out the form before every session. But I should tell you that there is one
item that she always skips, which is the one that asks about any diminishing
of sexual interest. Should I ask her to fill that one out? Should I just let it go?
Supervisor: That’s a good question. Usually, I would just advise you to ask
her in a sensitive way about her reasons for skipping that item. Ordinarily,
I would think that maybe we’re talking about a client’s run-of-the-mill
embarrassment about answering a question about sex.
Trainee: Or maybe there could be a history of sexual trauma that makes
her choose to avoid anything that reminds her about sex. You know, she

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also gave sparse answers at intake when she was asked about posttraumatic
stress symptoms.
Supervisor: And that would be a very good reason not to ignore her omis-
sion of the item that asks about sex because it could be a highly clinically
relevant topic that might never get addressed if we passively allow her to
avoid the issue. On the other hand, we want to be respectful of the client’s
boundaries, and this may be one way in which she is setting a boundary—
by skipping the question. And then there’s the matter of her cultural back-
ground to consider.
Trainee: I was thinking about that. Maybe as a single woman who strongly
identifies with her cultural origins, she is supposed to think that sex is irrele-
vant for her, and perhaps it would be an affront if I asked her to give consid-
eration to questions about her libido, even though that’s relevant to clients
with depression like her and relevant to most of the clients I work with.
Supervisor: I wonder who we can consult on this matter. Maybe we can
put out a message on the listserv of the Association for Behavioral and
Cognitive Therapy and discreetly ask for a confidential back-channel con-
sultation from a clinician who has had firsthand experience with this cli-
ent’s cultural background.
Trainee: I’m relieved to hear this. I thought I was doing something wrong
by not collecting the BDI-II data properly, but I was very hesitant to bring
up this topic with this particular client, knowing her cultural origins and
identity.
Supervisor: Not to worry. You did exactly the right thing. The client’s
well-being always comes first. Data collection is important but not as
important as respecting the client’s boundaries, and clients like this one
may have stricter boundaries than others. Still, on the chance that she has
a history of sexual trauma, we don’t want to avoid the topic of sex entirely
without first consulting on the matter and maybe thinking of other ways
that we can approach the issue of past trauma. For now, until we can get
more information, continue to allow her to skip the last question on the
BDI-II. But please keep your antennae up for any comments your client

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may make that signal that she has something to say either about sex or
trauma, or both. That would be the time to be quiet and let her talk while
you listen intently and maybe only give her some gentle guidance.

As Castro et al. (2010) point out, the effort to incorporate multicul-

tural perspectives into empirically supported treatments represents a
balance between nomothetic formulations of diagnoses and distress that
emphasize treatment fidelity and idiographic understandings of a client’s
presentation that call for individualization and flexibility. The evidence
that cultural adaptations result in better treatment outcomes for ethnic
minority clients is mixed and inconsistent (e.g., Griner & Smith, 2006;
Huey & Polo, 2008) and may depend in part on the specific cultural group
for which the intervention is adapted, the degree to which core concepts
of the original evidence-based treatment are preserved in the modified
format, and the degree of acculturation of the client population.
There are many non-CBT–specific resources that may be of help to the
culturally attuned supervisor. For example, the American Psychological
Association and Commission on Accreditation (2009), in collaboration
with the Council of National Psychological Associations for the Advance-
ment of Ethnic Minority Interests (2009), generated a series of culture-
specific recommendations for psychology education and training. Along
the same lines, there are informative readings outside the field of mental
health care per se that can be extraordinarily elucidating regarding the dif-
ficulties involved in balancing professional protocol with cultural beliefs
and rituals. An excellent example is the nonfiction book The Spirit Catches
You and You Fall Down (Fadiman, 1997). This book chronicles the painful
and ultimately tragic story of a young refugee girl’s odyssey through an
American medical establishment that struggled to understand the girl’s
serious neurological symptoms in their own right, much less through the
lens of her Hmong culture. This volume provides no simple answers to a
complex matter; it does not point fingers of blame toward medical per-
sonnel or the girl’s family but rather enlightens the reader regarding the
many ways that vital communication and understanding between practi-
tioners and clients/patients (and their families) can be derailed owing to

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a clash of cultures. CBT supervisors who read this book will be enriched,
and if they choose to assign this text to supervisees (and/or students in
a supervision course), the result will be meaningful discussions that will
improve the supervisees’ cultural competency.

AWARENESS OF AND RESPONSIVENESS

TO LEGAL/ETHICAL ISSUES
A comprehensive discussion of the myriad specific ethical and legal issues
that may arise in the course of clinical or supervisory work is beyond
the scope of this book (for a comprehensive summary of some of the
more common of these issues see Koocher, Shafranske, & Falender, 2008).
However, some central features of ethical supervision warrant mention
and description here. The supervisory relationship itself provides an
opportunity for the supervisor to model the ethical principles at the core
of the profession. Through weekly interactions with the supervisee, the
supervisor demonstrates adherence to key principles such as beneficence,
integrity, justice, and respect for all persons (American Psychological
Association, 2002, 2010). The ethical clinical supervisor also avoids any
actions within the supervisory relationship that violate the ethics code,
such as exploitative dual relationships.
The ethically adept supervisor is aware of the more subtle ways in
which ethical issues may arise in supervision. For example, the supervisor
recognizes when the clinical material a supervisee presents falls outside
of the supervisor’s area of competence and models ethical conduct by
consulting with colleagues and/or additional educational materials. More
broadly, when supervisors are struggling with life crises or other serious
problems, they must wisely self-monitor (and/or seek peer consultation)
to ensure that their personal issues do not interfere with their ability to
provide adequate, unbiased, and effective supervision. Pursuant to this
matter, supervisors need to be prepared to make arrangements for both
appropriate self-care and adequate supervision coverage for their train-
ees to ensure the quality of the supervisees’ training experience and the
appropriate monitoring of the clients under their care.

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Clinical supervisors would do well to be aware of any legal statutes

relevant to the clients under their supervision and make their super-
visees aware of them as well. For example, in the United States, supervisors
make it a point to familiarize themselves with the guidelines for reporting
child or elder abuse or neglect in their states and discuss these in detail
with their supervisees early in supervision and again when such matters
become clinically relevant.
Perhaps the legal principle most relevant to clinical supervision is that
of respondeat superior—literally, “let the master answer.” The term refers
to the principle that employers—or, in this case, clinical supervisors—are
legally responsible for the conduct of employees under their supervision.
Given the additional possibility that clients may pose a danger to them-
selves or others, it is important for supervisors to be aware of the ways in
which this doctrine informs their supervisory responsibility. On a basic
administrative level, supervisors are prepared to endorse the contents of
any therapy notes they countersign. Clinically, it means that supervisors
attest to the fact that the treatment that they are overseeing is one they
believe to be relevant, appropriately delivered, and reflective of the best
interests of the client.
Although some legal and ethical issues may be clear-cut (e.g., obtaining
a signed release before using a video of a client for educational training),
there inevitably will be times when supervisees bring up ethical gray areas
(as described in Chapter 3). The ideal supervisory climate for managing
such matters is one in which active discussion of ethical and legal issues is
woven throughout supervision. The supervisor should be proactive in high-
lighting these ethical gray areas as they arise and make space for trainees to
engage in reflection about how best to address them. This involves differen-
tiating areas of ambiguity from areas that are frankly nonnegotiable under
the laws and ethics code under which the supervisee operates.
The following clinical dilemma arose in the course of a supervisee’s
work with a client who was highly ambivalent about continuing in therapy
and whose core schema was mistrust, especially regarding authority fig-
ures. Note how the supervisor helps guide a discussion of the relevant
ethical considerations.

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Trainee: Something happened this week in a session with a client that

has really bothered me. Ms. X asked me to write a letter for her verifying
that she uses her dog as an emotional support animal and that she should
be allowed to take him on the plane with her when she goes to visit her
mother. I know she loves this dog, and it’s going to be a really stressful
trip for her, given the complicated relationship she has with her mother.
But she’s asking me to write a letter saying that the dog serves a formal
therapeutic purpose, and I think that’s stretching the truth. On the other
hand, we have spent so much time talking about whether she can trust me.
I’m worried that if I give her a flat-out “no,” it will damage our therapeu-
tic relationship. I wound up telling her that I needed to consult with my
supervisor about this because I didn’t know what to say.
Supervisor: I understand why this situation causes you some consterna-
tion. Requests like this one are hard to respond to when you’re put on the
spot, especially when dealing with a client with trust issues. I’m glad that
you were able to communicate to the client that you couldn’t give her a
firm answer until you had the chance to think about it and talk it over in
supervision. Deferring an answer so that you can consult first is often an
appropriate strategy.
Trainee: Is there a hard-and-fast rule or policy about these sorts of letters?
Supervisor: I don’t believe there is anything specific in the ethics code
about writing letters on behalf of clients per se, but I think we can look at
some general ethical principles for guidance. There are a few issues at play
here—let’s go through them and see if things become clearer.
Trainee: I really want her to see me as someone she can trust and who has
her best interests at heart. At the same time, I don’t want her to get the idea
that she is entitled to whatever she wants and that I’m her unconditional
advocate. She needs some gentle limit-setting, too.
Supervisor: Thinking conceptually in terms of schemas, you don’t want
to reinforce her mistrust schema by saying “no,” but you also don’t want to
reinforce her entitlement schema by just saying “Yes, whatever you want.”
Let’s see what we can derive from the ethical guidelines as well. [Pausing

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to reflect] It would seem that we have to consider the ethical principles of

beneficence and nonmaleficence, fidelity and responsibility, and integrity. In
other words, you want to help your client within reasonable limits, earn
her trust, and not cause her any harm. On the other hand, you want to be
truthful—in this case, it means not writing a letter you think misrepre-
sents the facts, especially if it creates negative consequence for others and
for society. What are your thoughts on that?
Trainee: Well, it’s not as though my client taking her dog on the flight is
going to harm anybody else, at least I don’t think so. I know these things
are done and that airlines supposedly have guidelines and safeguards. I
just don’t want to send the wrong message that I will automatically sign
on to whatever my client wants, even if my viewpoint differs somewhat.
Supervisor: Okay, is there a way to support her without giving this message
of entitlement and without being untruthful?
Trainee: I guess I could write a letter on her behalf but be very careful to
stick to the facts. I could truthfully state that she is in therapy, that she has
official diagnoses of major depression and panic disorder, that she is mak-
ing a stressful trip, that she lives alone except for her one companion—
which is her dog—and that she would benefit from the companionship
of her pet. But I’m not saying that she has to have her dog with her or she
can’t fly.
Supervisor: That makes sense. You would be acting consistently with the
ethical principles we mentioned. You’re supporting her, being honest, and
not causing harm to her or to society.
Trainee: But maybe I’m subtly causing her harm by reinforcing the idea that
she cannot make this trip on her own and by showing her that I’ll do what-
ever she wants so she won’t have to deal with the difficult issues in therapy.
Supervisor: Good point. What can you do to minimize the likelihood of
this sort of harm, other than simply refusing to write a factual letter?
Trainee: Well, I can write the letter, but I can explain the limits of what I
can say, pointing out that we need to be accurate and truthful. I can tell

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her that I want to be helpful to her but that might also mean suggesting
that she is capable of a higher level of functioning than she thinks, which
might trigger her anxiety and mistrust at times.
Supervisor: Excellent. What else?
Trainee: I could tell her that there will undoubtedly be times when she
and I won’t see eye to eye, but that doesn’t mean we can’t work together
benevolently or that we can’t resolve our differences constructively.
Supervisor: Correct. Writing a factual letter this time does not mean that
she has license to expect you to do whatever she wants, from now on, all the
time! This situation can lead to an overt discussion about how she trusts or
mistrusts others, how she views her level of self-efficacy, and how one can
have a mature disagreement with someone else and not be harmed.
Trainee: It makes sense. This whole situation is an ethical issue as well as
a therapeutic issue, and with a little problem-solving we can find a way to
take constructive actions in both areas.

In this case, the supervisor leaves room for the supervisee to iden-
tify her own reactions and areas of discomfort with the situation before
proposing a solution and uses the supervisee’s own thought process as a
framework for highlighting the ethical and therapeutic issues involved.
Discussions such as this one can be a valuable method of facilitating
supervisees’ attunement to ethical issues and boosting their confidence in
weighing such issues. Supervisors need to be able to recognize ethical issues
when they occur in their supervisees’ work; communicate their observa-
tions in a thoughtful, knowledgeable, nonsanctimonious way; engage in
prompt problem solving when the need arises; and teach the supervisees
how to prevent ethical problems from occurring or worsening. It is vitally
important to create an atmosphere in supervision that is receptive to the
open discussion of ethical issues, risks, and errors. Ideally, therapists-in-
training should feel free to ask questions such as the following:

“My client invited me to her wedding. I would hate to let her down
by not going, but I’m not sure if it’s appropriate. What should I do?”

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“My client gave me a very nice gift; I tried to turn him down, but
he insisted. Now I’m thinking that I need to return it to him, but I’m
afraid of making him feel rejected, which is one of his vulnerabilities.
Did I make a mistake in accepting the gift? Should I return it?”
“My client wants me to write him a letter that will explain that he
missed some midterms owing to being ‘too depressed’ and asking for
special accommodations for him to take them late. I’m uncomfort-
able doing this because the client never mentioned his exams until
today, and frankly I doubt the legitimacy of my client’s claims. I’m
torn because I think it may be inappropriate for me to write this let-
ter when it goes against my clinical opinion, but on the other hand
my client is going to suffer some serious academic consequences if I
decline. How should I handle this?”
“My client made an off-hand comment today that when her
14-year-old daughter came home after midnight, she was so angry that
she ‘throttled her.’ I didn’t ask what she meant by that, and now I’m
thinking that I should have. Is this child abuse, and should I report it?”
“I think I made a big mistake, and I’m really worried about it. My
client told me a lot of horror stories about her past hospitalizations,
and then she made me promise that I would never hospitalize her
again. I tried to empathize with her without really answering her, but
I think I might have given her the impression that I wouldn’t ever
hospitalize her. How do I backpedal on this without totally losing
her trust? Should I just keep the promise now that I think I made it,
or would that endanger good clinical care in an emergency? Should I
let this pass, and then just use my best judgment later if she needs to
be hospitalized, even if she feels betrayed by me? I’m very confused.
I’m really sorry about this. I know I should have handled this better.”

These are but a small sample of the sorts of ethical questions that may
arise in supervision. Our intent here is not to provide definitive answers
to these questions because that often is not possible in the absence of con-
text. Our message is that competent supervisors readily, humbly accept
that they will need to help their supervisees flesh out issues such as these,
weigh pros and cons, consider the case conceptualization and treatment
plan in each instance, and perhaps consult further with outside parties

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(e.g., trusted colleagues, the director of the institutional program, mem-

bers of state or provincial boards in the relevant mental health care field,
the attorneys from one’s liability insurance company). It is good practice
to positively reinforce supervisees for bringing these matters to the super-
visor’s attention so that supervisees will be encouraged to face and address
ethical dilemmas rather than overlook, underestimate, avoid, or (in a
worst case scenario) simply disregard them. A particularly useful mes-
sage to give supervisees about dealing with an ethical conundrum is that
they rarely have to solve the problem immediately on the spot. It often is
okay to defer responding and seek additional input from appropriate par-
ties before reaching a conclusion with a definitive course of action. This
approach reduces the risk of making impulsive or misinformed mistakes.
It should be noted that sometimes it is quite appropriate for supervisors
to consult with others as well.

INTERVENING DIRECTLY WITH THE CLIENT

Although it is important for supervisees to learn to handle independently
a wide spectrum of clinical situations, there are times when it is appro-
priate and even necessary for supervisors to intervene directly with a
supervisee’s client (Newman, 2013). As the supervisor bears the ultimate
clinical and legal responsibility for the client’s care and as some clients
pose a level of risk or high challenge that may exceed the supervisee’s level
of experience and/or competence, it is incumbent upon supervisors to get
into the trenches and deal head-on with difficult clinical matters (Hipple
& Beamish, 2007; Ladany, Friedlander, & Nelson, 2005). The benefits are
many. Clients at risk gain additional clinical care, supervisees who are
feeling alone and out of their depth gain the support of a trusted and
experienced mentor, and the supervisor gains the chance to model impor-
tant therapeutic and professional competencies. The following are several
such direct intervention situations that we have faced, some of which were
planned in advance following consultation with the supervisee and some
of which occurred on the spur of the moment in an emergent crisis. In
all cases, we met with the supervisees to process what had just occurred,

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toward the dual goals of ensuring proper follow-up with the clients and
emphasizing what the supervisees learned from these situations. In each
of the following illustrations, we use first-person pronouns without iden-
tifying which of us was involved, and client information is vague enough
to preserve client anonymity.

Situation 1
A female practicum student therapist came to my office, saying that she
had a male client who refused to leave her office until she gave him a hug
(he was still there). We already knew from our previous supervision ses-
sions that this client had a romantic attraction to the student therapist and
a history of crossing boundaries inappropriately in many life situations, so
his demand for a hug was not merely an innocent request for support at a
difficult time. The student told me that she had another client waiting to
be seen and didn’t know what to do because her office was still occupied
by the hug-demanding client who wouldn’t leave. I told her to use my
office to see her next client and that I would go into the office with the
hug-demanding client to set firm limits with him and to reestablish the
ground rules of the clinic to which he would have to adhere to continue as
a client with us. Later, in a debriefing meeting with the practicum student,
I inquired as to how she felt about continuing to work with this client,
and she stated that she was willing to do so, confident in her ability to set
limits. I gave her positive feedback for conceptualizing the situation well,
not reinforcing the client’s inappropriate behavior, consulting with me
promptly, and having the fortitude to try working with the client anew.

Situation 2
A postdoctoral supervisee called me on my personal line after work hours,
stating that one of her clients (in a clinical trial involving high-risk clients)
had just called to leave a message that she was going to kill herself tonight.
The postdoctoral therapist first called the client immediately, tried to assess
if the client had already taken any self-harming actions, and (upon learning

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that she had not) instructed her to go to the emergency department of

a nearby hospital or disclose her location so that the therapist could call
the police to find her and transport her to the hospital. The client refused
on both counts and hung up. She would not answer her phone when the
postdoctoral therapist tried several times to call back. Upon learning of
this situation, I instructed the postdoctoral therapist to refer to the client’s
intake information sheet, on which the client had listed her home address
and emergency contact numbers, and call both a contact person and the
police, letting both parties know that there was reasonable cause for imme-
diate concern, stating that it was not clear if the client was at home; I also
told the therapist to make herself available as the clinical contact person to
continue to talk with the police as the situation developed. In the mean-
time, I called the client directly, in the hope that she would not recognize
the incoming phone number and would answer out of curiosity, which she
did. I identified myself to the client as her therapist’s supervisor, engaged
her in a discussion about how she was feeling and why she wanted to die,
reaffirmed that her therapist (my supervisee) was concerned and wanted
to do everything possible to help her and keep her safe, and said we were
glad she had let us know about her suicidal intentions rather than simply
acting on them. I kept her on the line until her good friend (the emergency
contact person) and then the police arrived. I took full responsibility for
this maneuver, apologized to the client for making the judgment call not to
tell her that the police were on the way, and added that her therapist would
be ready to resume outpatient treatment with her upon her safe and proper
discharge from the hospital. In the debriefing with the postdoctoral thera-
pist, we reestablished and updated a clinical treatment plan and prepared
ourselves to meet together with the client (with my being there for only one
session) upon her return to outpatient care.

Situation 3
My supervisee informed me that she had only just then learned from a
medical school official who had previously referred a (now-ongoing) cli-
ent that the client had a history of violence. This client often misused

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therapy sessions to rail against third parties for their acts of “injustice” and
to make disparaging remarks toward women, including the therapist. He
tended to dominate sessions with his angry complaints, and now he was
demanding an official letter from the therapist “confirming” that he was
well enough to return to medical school, which clearly he was not. The
supervisee was concerned that if she told him that she could not write the
letter, he might become violent toward her. I agreed to meet with this cli-
ent along with the supervisee, and I called the client in advance to let him
know that I (in my role as clinical supervisor) would be attending. I also
called the police, explaining the situation (but without naming the client)
and asking for an officer to be in the waiting room in plain clothes at the
time of the scheduled session. The supervisee and I made a plan for how to
run the session, in which I would confirm to the client that our clinic was
committed to helping him with his psychological problems, but because
he had not apprised us of his history of violence, we were not in a position
to make any endorsements on his behalf until this issue had been dealt
with thoroughly in therapy, which had not yet occurred. In planning for
the session, I told the supervisee that if I thought the situation with the cli-
ent was becoming potentially dangerous (e.g., if he were to become hostile
in response to our comments), I would instruct her to leave the room so
that I could talk to the client “in private,” which would be her cue to alert
the plainclothes policeman to come to the office at once. Thankfully, the
situation never reached this level of crisis. Although the policeman was at
the ready, the client simply balked at further therapy, stating that he would
find somebody “more competent.” He left, and we never heard from him
again. We called him to follow up, and we left messages asking that he con-
firm that he was in treatment with someone else, but he never responded.

Situation 4
An advanced psychiatry resident in his CBT rotation explained in a
supervision session that his client often tried to turn the therapeutic rela-
tionship into a “friendship” and that he was becoming hesitant to meet
with her. He explained that she had made “flirtatious threats,” saying that

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the rules for professional boundaries were “stupid,” and that if he did not
become her friend (e.g., including scheduling her for appointments after
hours), she would in fact tell her friends and family that she was being
“abandoned” in her treatment. The supervisee was at a loss as he wanted
to maintain proper boundaries with this client, but he did not want his
appropriate actions to result in his being accused of causing harm to a
client. He also noted that he felt increasingly uncomfortable seeing this
client but did not want to end treatment as that might in fact become
a case of abandoning the client, thus adding credence to her threatened
complaint. After discussing various options, all in the context of review-
ing the case conceptualization for clues as to how to respond, we opted
for a model in which we would provide this client with dual provider
care, with the twist being that we would be in the room at the same time
for every session. The goal was to provide this client with the treatment
she needed (i.e., not abandoning her) while greatly reducing the sense
of intimacy she was trying to create while meeting one on one with the
male resident. In addition, I explained to the client that it was my deci-
sion (as the supervisor) to change the parameters of treatment, and I
gave her a thorough rationale, all the while taking great pains not to
scold or shame her. At first, the client was unhappy with this cotherapy
arrangement, but she adapted, and treatment proceeded until the end
of the resident’s rotation. I then transferred the client’s care to a female
resident.
One of the not-so-obvious challenges for supervisors in scenarios
of the sort described is how to be empathic with clients with whom they
have never worked (or bonded) directly, all while setting limits, usually
under some duress. We as supervisors may consider ourselves to be fully
capable of being empathic on demand, but it couldn’t hurt to go the
extra mile by preparing ourselves mentally and emotionally for such
situations, just to make sure that we bring our best interpersonal skills to
bear on the matter. This may take the form of being self-reflective about
any negative automatic thoughts we may be having at those times when
we have to intervene and responding rationally in advance of making

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contact with the supervisee’s client. Examples of such rational responses

could be the following:

“My supervisee has worked hard to create a good connection with

this client, and I want to preserve that.”
“This may be extra work for me, but it’s also a great opportunity
to be a positive role model for my trainee about acting professionally
in a difficult situation.”
“My supervisee needs my support at a time like this, and I intend
to come through.”
“I intend to set limits with my supervisee’s client, but the first
thing I’m going to ask the client is how he’s feeling, and I’m going
to listen.”

Supervisors would do well to remember that their supervisees typi-

cally are working hard to establish and maintain their positive therapeutic
relationship with their clients, so the supervisors’ direct interactions with
the clients need to be congruent with the goal of supporting their super-
visees in this important endeavor.
As one may easily ascertain from the length and breadth of this chap-
ter, special issues in supervision are many and varied, driving home the
point that supervision is not just about teaching CBT. The job of a com-
petent CBT supervisor is demanding and often complicated, requiring
ongoing self-monitoring and continuing education throughout one’s
career.

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 5

Supervisor Development
and Self-Care

TRAINING AND DEVELOPMENT OF THE SUPERVISOR

Unlike days of yore, when learning the nuts and bolts of doing clinical
supervision was an on-the-job training scenario (see Newman, 2013), it
is now acknowledged that the training of supervisors needs to be formal­
ized, and it needs to start before supervisors actually work with super­
visees. Ideally, such training would take place during the advanced years
of graduate school, perhaps after the trainees have successfully completed
a couple of years of practicum work as a cognitive–behavioral therapy
(CBT) practitioner-in-training. At that point, these students would have
enough familiarity with the CBT approach to know what constitutes
competency in this model in particular and how to measure client prog­
ress and outcomes in general. At the same time, these students would not
yet be sufficiently credentialed to provide “real” supervision (with all its
attendant responsibilities and medical–legal mandates), so they would

http://dx.doi.org/10.1037/14950-006
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

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need to take part in simulated supervision scenarios, such as role-playing

(perhaps as a structured part of a graduate seminar on supervision),
and group supervision, in which the students would be encouraged
by the group leader (i.e., the professional who is licensed or the meta­
supervisor of the group) to give each other feedback on their manage­
ment of their cases.
Several models for the training of supervisors have been developed (see
Milne, Sheikh, Pattison, & Wilkinson, 2011), a thorough review of which
would go well beyond the scope of this concise text. Nevertheless, let
us take a brief look at two such models. One model, geared toward estab­
lished professionals seeking continuing education, holds that a combina­
tion of interactive workshops (involving video clips and role-playing),
written materials (e.g., handouts, scoring codes, and/or a manual), plus
ongoing metasupervision (perhaps via phone or computer) is a robust
method for helping professionals practice and maintain their new com­
petencies in conducting supervision (Beidas & Kendall, 2010). Workshops
alone are a good starting point, but without supplemental learning mate­
rials, ongoing mentoring, and planned self-reflection (see Bennett-Levy
& Padesky, 2014), there is a tendency for the workshop participants to
revert quickly back to their customary practices (Miller, Yahne, Moyers,
Martinez, & Pirritano, 2004; Rakovshik & McManus, 2010; Sholomskas
et al., 2005). One such comprehensive program of supervisor develop­
ment is the Advanced Cognitive Therapy Studies program at the Oxford
Cognitive Therapy Centre (https://www.octc.co.uk) offered in five, spaced
workshops. Among these short courses are those that focus on learning
to be a CBT supervisor and trainer; the classes involve between-course
assignments and evaluations by the senior psychologists of the Centre.
A second model, aimed at advanced graduate students who are still
learning to be therapists and are not yet credentialed, involves formal
course work (as part of the requirement for the terminal degree) over a
semester or a year. A formal course as part of graduate training allows for
ample repetitions of multimodal teaching methods, including a reading
list, classroom discussion of such readings, classroom viewing of audio­
visual recordings of CBT sessions with participatory color commentary

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supervision (e.g., where both the therapist featured on the recording and
the others in the class weigh in on their views about what is transpiring
on the video), learning to use established scales to rate such recordings
(e.g., the Cognitive Therapy Rating Scale [CTRS], Young & Beck, 1980),
and role-playing. Regarding this latter element of training, the role-playing
may occur in triads, in which one of the students provides supervision of
a dyadic therapy role-play, or with the course instructor being the fourth
person who serves as a metasupervisor who then gives feedback to the
supervisor after the triadic exercise is complete.
One of us instructed a supervision training seminar for advanced stu­
dents in a CBT-oriented clinical psychology doctoral program (Newman,
2013) that was divided into training modules (involving respective sets
of readings and assignments), as follows:

1. Overview of the chief responsibilities and competencies of being a

clinical supervisor.
2. The supervisory relationship.
3. Being conversant in and sensitive to ethical and cross-cultural issues
in supervision.
4. Maximizing trainee competency in CBT (and doing CTRS ratings).
5. Documentation, feedback-giving, and the evaluative role of the
supervisor.
6. Managing supervisees’ work with high-risk clients and crises.

The seminar included live practice sessions involving instructor

modeling, role-playing, and feedback from both the class and the course
instructor. Note that many of the foundational (i.e., professionwide) com­
petencies of supervision were taught first, before the teaching of func­
tional competencies (i.e., specific to the methods of CBT) in the fourth
module, the latter of which required considerable time and attention.
Aside from the readings, course assignments often involved the grad­
uate students creating audiovisual recordings of their CBT sessions with
real clients and viewing, rating, and discussing them later in class. In other
words, the students would rate their own work as CBT therapists as if
they were their own supervisors, giving themselves constructive feedback

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on such variables as their structuring of sessions, use of homework, the

quality of their alliance-building skills, using a case formulation to devise
a strategy for change, focusing on key client behaviors and cognitions,
using CBT techniques and guided discovery questioning, eliciting feed­
back, and the like. The instructor also showed audiovisual recordings of
his own work with CBT clients and encouraged the class to critique and
rate those sessions, too! In this manner, the course instructor was act­
ing as a “coping model,” a highly effective way to model personal devel­
opment and the learning of skills (Bandura, 1986), destigmatize the
idea of making mistakes, and encourage students to self-assess and self-
improve in the same way (see Calhoun, Moras, Pilkonis, & Rehm, 1998).
With a little encouragement and not too much cajoling, the students
soon began to practice their supervisory skills on the course instructor
without undue inhibition. The atmosphere was one of collegiality, in
which feedback was offered to help whoever was being evaluated as a CBT
practitioner.
It is important to state that the course modules on cross-cultural and
ethical issues in supervision, as well as supervising the care of high-risk
clients, were not meant to provide any sort of definitive word on the sub­
jects. These important areas of concern often involve significant gray zones,
generally requiring an understanding of situational context and customar­
ily benefiting from additional consultation. Thus, lively class discussions
were held about numerous hypothetical supervisory situations, under the
heading, “If you were the supervisor, how would you handle this?” A few
examples included the following:

77 Your supervisee asks you if it’s okay for him to accept a gift from a
client.
77 Your supervisee is of Hispanic descent. You receive a direct call from
her client, stating that he wants his care to be transferred “to a therapist
who is white.”
77 Your supervisee states, “I’m trying to help my client modify her all-or-
none dysfunctional belief that her family will disown her if she tells them
that she is seriously dating a boyfriend who is of a different religion, but
she’s not changing.”

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77 Your supervisee says, “Working with my client Mr. X feels creepy and
unsafe.”
77 You have a supervisee who is South Asian, and you wish to assign her a
new client who also happens to be South Asian. You assume that they
will be a good match, but is that necessarily so?
77 You are meeting with your supervisee when it suddenly occurs to you
that you have not discussed one of her chronically suicidal clients in
some time. You ask the supervisee about this, and she replies that the
client “dropped out of treatment.”

Classroom discussions on these (and other) hypothetical supervisory

situations help trainees learn to think like supervisors, which involves being
willing to take responsibility for providing competent professional guid­
ance to trainees and knowing when it is wise to consult with others. This
sort of supervision training course also helps the students to be more aware
of the important topics they need to be discussing with their own current
clinical supervisors, including preventing and/or dealing with high-risk
situations, hashing out ethical dilemmas, and tuning in to cultural biases
that may be subtly influencing therapy and/or supervision. When this
happens, all parties involved in the training of the students (and the stu­
dents themselves) have to raise the bar for themselves, which ultimately
benefits clients.

ONGOING LEARNING AND CONSULTATION

FOR THE SUPERVISOR AND METASUPERVISION
Becoming a supervisor in CBT is not an outcome but rather the start of a
career-long process. To continue to develop and grow as professionals—
and to transcend from competence to true expertise—supervisors need to
self-monitor their work and occasionally seek consultation from qualified
others. Consultation may take the form of a periodic meeting of super­
visors within an organization or clinic, serving the dual functions of peer
supervision (e.g., keeping each other from drifting off their supervisory
protocol) and administrative problem solving (e.g., how best to address
one of their graduate students who is struggling in practicum work). More

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formally, consultation may involve supervision of supervision, also known

as metasupervision (Newman, 2013), in which a highly experienced CBT
supervisor provides oversight and feedback to a more junior supervisor
(or to a supervisor less experienced in CBT per se). The junior supervisor
bears the clinical and legal responsibility for the therapist’s training and
the well-being of the clients, whereas the metasupervisor facilitates the
junior supervisor’s self-reflection rather than issuing orders. As Barton
(2015) aptly stated, “A learning community is not a chain of command.”
The metasupervisor endeavors to help the supervisor trainees to improve
their supervision skills in general, expand and deepen their CBT super­
vision repertoire in particular, receive formal evaluations for credentialing
purposes (e.g., being designated as an expert supervisor in the Academy
of Cognitive Therapy [http://www.academyofct.org]), and receive addi­
tional guidance in managing the cases that are being seen under the
supervisor trainees’ umbrella of clinical responsibility.
Metasupervision can also help improve the working relationship
between supervisors and their supervisees, helping them to collaborate
more effectively and thus helping everyone, most importantly the clients.
An excellent illustration is provided by Armstrong and Freeston (2006),
who described a case in which the supervisor and supervisee clashed over
their different approaches to the handling of a case. The supervisor val­
ued case conceptualization and thus wanted the supervisee to be more
thoughtful and mindful about matching interventions to the specific,
unique needs of the client. The supervisee, by contrast, felt institutional
pressure to help clients make progress quickly to facilitate client turnover
in the clinic and thus wanted to focus on teaching the client some general
coping skills right away. As the authors noted, a metasupervisor observ­
ing this problem in supervision would be in an excellent position to give
the supervisor helpful feedback, perhaps highlighting the need for better
goal congruence and advising the supervisor to recognize and empathize
with the supervisee’s sense of performance pressure. The metasupervisor
might then initiate a role-play exercise so that the supervisor could practice
a congenial way of addressing the need to combine the teaching of CBT
skills with attention to conceptualization issues in therapy. The supervisor

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may then be well-prepared to repair the strain in the supervisory relation­

ship, improve communication in the supervision session, and facilitate an
improved sense of shared purpose in helping the clients.
Another example of the utility of metasupervision doubles as a reminder
of the importance of striving toward cultural competency in conducting
cognitive–behavioral supervision (CBS), as described in Newman (2013).
The metasupervisor was a male, U.S.-based psychologist providing formal
oversight for a male, Asian psychiatrist who was training in CBS as part of
an international training program (the Beck Institute for Cognitive Behavior
Therapy, http://www.beckinstitute.org). The U.S.-based metasupervisor
observed a video of the Asian psychiatrist (held in the latter’s home office in
the Far East) meeting with a female supervisee (a psychiatry resident).
The two Asian professionals held their supervision session in English for the
benefit of the U.S.-based metasupervisor. They discussed the case of a client
who exhibited significant levels of anxiety and avoidance and whose treat­
ment plan included planned exposure exercises, a well-established, empiri­
cally supported intervention. Unfortunately, as the supervising psychiatrist
and his resident explained on the video, the client did not wish to do the ima­
ginal exposures that had been proposed as a homework assignment, and the
resident decided to honor his request to sidestep the assignment, at least
temporarily. The supervising psychiatrist skillfully helped the resident to
conceptualize the client’s problematic avoidance, express empathy for the
client, and yet find a way to motivate the client to take graded steps toward
doing the exposures. The resident quietly, politely agreed to do this in the
next session.
The U.S.-based metasupervisor gave high marks to the supervising
psychiatrist for his professionalism and competence in managing the
supervision session with his resident, but added a culturally based ques­
tion. He noted that the resident had spoken slowly, quietly, and politely in
the supervision session as she agreed with the supervisor to press on with
helping the client to face the imaginal exposure exercises. The U.S.-based
metasupervisor then wondered aloud if the resident was in a bit of a bind in
that she might be trying to be deferential and respectful toward her older,
male client (who did not wish to take part in the planned intervention)

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and now was trying to be deferential and respectful toward her older,
male supervisor who was encouraging her to go ahead with the expo­
sure interventions. The U.S.-based metasupervisor interpreted the female
supervisee’s quiet, demure manner as being supportive of this hypothesis.
The metasupervisor also respectfully added that he was not implying that
a young Asian woman (especially a highly credentialed one) would neces­
sarily be passive and deferential to older Asian men, but at the same time he
did not want to miss a potentially culturally related phenomenon. Thus,
the metasupervisor brought up this topic tentatively, eager to obtain the
psychiatrist supervisor’s opinion on this issue.
The Asian supervisor nicely corrected the U.S.-based metasuper­
visor on this matter, saying that there was ample evidence that the resi­
dent supervisee had been quite capable of managing the client in terms
of setting limits and organizing the sessions and that she had at times
been able to express opinions in supervision that differed somewhat from
those offered by the supervisor. Thus, the supervisor was confident that the
supervisee was not in a culturally based double bind of the sort that the
U.S.-based metasupervisor hypothesized.
Later, the U.S.-based metasupervisor described this situation as part
of a lecture to mental health professionals in another Asian locale. These
Asian clinicians offered an additional hypothesis that the metasuper­visor
had not considered. They hypothesized that the resident supervisee may
have been considerably more animated and vocal if she had been speak­
ing in her native language, as she was accustomed to doing in super­
vision. The fact that she was going out of her way to take part in that
particular supervision session in English may have been a significant fac­
tor in making her look quiet and passive. This idea had never occurred
to the metasuper­visor, and he realized (once again) how difficult it can
be to be culturally sensitive in doing international training and how easy
it is to fall back on Anglo-centric assumptions about language. None­
theless, the course of metasupervision between the U.S.-based psycholo­
gist and the Asian psychiatrist was productive, and the latter stated that
the guidance and validation he received had been beneficial to his work
with his resident.

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 Supervisor Development and Self-Care

SUPERVISOR WELLNESS
As meaningful and rewarding as the work of a CBT clinician can be, the
responsibilities of being a therapist and/or supervisor can be daunting
and stressful. To be healthy role models for supervises and clients and to
be functioning properly in our professional roles, we need to make our
own wellness a priority, perhaps by utilizing the coping skills we teach oth­
ers. When therapists actively self-apply CBT methods, they gain valuable
technical practice and promote a better sense of empathy for their clients
regarding the trial-and-error process of learning to make cognitive–
behavioral changes. They also improve their own morale and sense of
self-efficacy in the process. Therapists who use CBT skills for them­
selves may also be more adept at remaining empathic when at first their
thoughts may otherwise lead them to be angry with their clients as they
are able to recognize and moderate their own emotional reactions in the
moment (see Newman, 2012). This sort of self-reflective practice is an
essential part of developing expertise in conducting CBT (Bennett-Levy
et al., 2015).
The process of therapist self-application of CBT techniques begins
with clinical supervisors fostering the development of their trainees’ self-
reflection skills. Supervisors can do this best by creating a safe, accept­
ing environment in which their trainees can share their own automatic
thoughts (e.g., about their own work or how they feel about their clients)
without fear of disapproval (Newman, 2013). With practice, the CBT
trainees then become that much more adept at encouraging their clients
to self-reflect in a similar way, thus leading to more productive therapy
sessions and a better transfer of skills to the clients.
Supervisor wellness is closely related to wellness as a therapist. Both
positions involve a high level of responsibility, exposures to many clini­
cal stories that can be heartrending, being a potential lightning rod for
the negative feelings of those you are sincerely trying to help, and having
your work exposed and scrutinized firsthand as the norm. Maintaining
wellness as a clinician—whether as a supervisor or a supervisee—involves
being able to self-apply the methods of CBT to keep things in perspective
(rather than catastrophize), stay in problem-solving mode (rather than

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feeling helpless and avoiding), learn and grow from negative experiences
(i.e., come to accept, tolerate, and even embrace discomfort in the service
of the great value of becoming a better clinician), be mindful of the mean­
ingful moments that so frequently occur in the course of one’s work (i.e.,
feeling honored and privileged to be trusted and held in high regard and
to bear witness to others’ pathways to personal growth), and balance all of
these aspects with personal pursuits that allow one to recharge one’s per­
sonal battery, feel nurtured and refreshed, and immerse oneself in a wide
range of life experiences. Aside from that, there’s nothing to it!
There are methods that CBT practitioners and supervisors can practice
during a busy, stressful day that can help promote wellness and enhance
clinical performance. For example, a brief mindfulness exercise before a
therapy or supervision session can be a boon to the clinician’s alertness and
effectiveness. In a randomized trial, Dunn, Callahan, Swift, and Ivanovic
(2013) showed that therapists who engaged in a 5-minute “centering exer­
cise” (from Acceptance and Commitment Therapy: An Experiential Approach
to Behavior Change [Hayes, Strosahl, & Wilson, 1999]) before meeting with
a client rated themselves as being more present in the subsequent session,
and the clients also rated the sessions more favorably. Anecdotally, we have
recommended that our trainees generate and think of self-statements that
promote hope and self-support, particularly in the context of treating high-
risk, high-maintenance clients who test our mettle, patience, and the limits
of our professional coping. Such self-statements, which can be practiced
before sessions as well as during sessions (silently, to oneself), include

77 “My client may not accept my expressions of goodwill or collaborate

with my best efforts to provide helpful interventions, but I will offer
them just the same.”
77 “Don’t take [the client’s negative comments] personally. It’s all data.
Conceptualize the problem, and respond in a professional manner that
exceeds the client’s expectations.”
77 “My worth as a therapist does not hinge on this one client’s response
to treatment. I will continue to make a good faith effort to provide the
best CBT I can. I have helped others, and I must not forget that. Perhaps
I can still help this client, too.”

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 Supervisor Development and Self-Care

Similarly, supervisors can catch their own automatic thoughts, and respond
to them therapeutically, as illustrated by the following examples:

Automatic Thought: I hate having to give my supervisee critical feedback

for his struggles in doing CBT and keeping up with the notes. This
meeting is going to be so painful today.
Rational Response: I can be thoughtful and respectful when I share my con­
cerns with him. I can ask for feedback. I can show that his progress in
this program is a priority. I can model how to be collaborative when
talking about uncomfortable topics, which is something he needs to
learn in working with his clients anyway. I can feel proud of myself for
not postponing this meeting and for actively practicing antiavoidance.
Automatic Thought: I have too many supervisees and too many clients for
whom I am responsible, and I’m just too tired to do it all. But that won’t
matter at all, and nobody will care about how I feel if there is an adverse
incident. It will still be my failure.
Rational Response: You’re tired, that’s true, but not too tired to still be a
skilled, caring professional who takes your work as a supervisor and
therapist seriously. Rather than catastrophizing about possible adverse
incidents, do some problem solving first. At least two of your col­
leagues have asked you if they can help in some way, and you always say
no. Talk to them, and see what can be worked out in terms of reducing
your supervisory load.

Such self-application of rational responding, problem solving, and reaching

out to helpful others is good practice and good role-modeling. It reduces
stress, and allows one’s perception of the considerable upside of being a
CBT supervisor to shine through more clearly.

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 6

Research Support for the

Supervisory Approach and
Future Directions

T he status of cognitive–behavioral supervision (CBS) has advanced

significantly during the last 20 years such that

There is now a series of compelling and empirically supported rec-

ommendations as to best practices in [cognitive–behavioral therapy]
CBT supervision that can be gleaned from competency sets, system-
atic reviews of supervision, and reviews of training and supervision
in clinical trials that have demonstrated effectiveness. (Reiser, 2014,
pp. 502–503)

Some of these best practices include making use of experiential methods

such as role-playing that enhance procedural learning, direct observa-
tion of the behaviors of both supervisees (with clients) and supervisors
(with their supervisees), the use of homework to enhance the transfer and
maintenance of skills, and the measurement of progress and outcomes (of

http://dx.doi.org/10.1037/14950-007
Supervision Essentials for Cognitive–Behavioral Therapy, by C. F. Newman and D. A. Kaplan
Copyright © 2016 by the American Psychological Association. All rights reserved.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

both the trainees and their clients), among others (e.g., structuring ses-
sions, using guided discovery questions, conceptualizing clinical prob-
lems). Part of this advancement has stemmed from the emphasis on
developing psycho­metrically sound instruments with which to measure
the mentoring behaviors of supervisors and the clinical behaviors of
supervisees in their sessions with clients. A key goal is to determine which
supervisor behaviors are most efficacious in training supervisees in CBT,
then codifying these behaviors into manuals and studying the best ways
to train super­visors in the use of such manuals for better dissemination
(Reiser & Milne, 2012). These are challenging tasks, and although the cur-
rent state of the field is promising, much work remains to be done.

MEASURES AND OUTCOMES

As noted, the field’s ability to evaluate the efficacy of supervisory practices
depends in part on there being reliable and valid ways of measuring the
process. Similar to the codification and measurement of treatment adher-
ence and competency, the assessment of the efficacy of CBS may utilize
circumscribed manuals (perhaps in conjunction with treatment programs
that use therapy manuals), or perhaps CBS will take a more principle-
based approach, without necessarily specifying which discrete supervisory
actions need to occur in which meetings.
The literature includes several excellent reviews of (and sources per-
taining to) the empirical status of measures of therapist competence in
delivering CBT (e.g., Muse & McManus, 2013) and of supervisor compe-
tence in mentoring trainees in becoming effective CBT practitioners (e.g.,
Milne & Reiser, 2011; Watkins & Milne, 2014). In addition, the Corrie and
Lane (2015) book includes a copy of an additional promising measure (The
Supervisor Evaluation Scale; Corrie & Worrell, 2012), and the Oxford Cog-
nitive Therapy Centre has developed and tested an easy-to-use inventory
for routinely rating supervisors’ behaviors (The Supervisor Competency
Scale; see Rakovshik, 2015). The reader is directed to these publications for
a more complete overview of the state of the field. For the sake of brevity,
we focus here on a widely used measure of CBT competence to which we

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have referred many times (the Cognitive Therapy Rating Scale [CTRS])
and a comprehensive, well-researched measure of supervisor competence
called “SAGE” (Supervision: Adherence and Guidance Evaluation; Milne,
Reiser, Cliffe, & Raine, 2011).

The Cognitive Therapy Rating Scale

Originally designed by Young and Beck (1980) to measure therapists’ fidel-
ity and competency in conducting cognitive therapy for depression, the
CTRS, as well as its revised version (Blackburn et al., 2001), have been used
to evaluate the delivery of Beckian CBT for a full spectrum of clinical prob-
lems. Clinically and administratively, the CTRS has also been used to evalu-
ate supervisors’ adherence to the CBT model and as a measure of readiness
to conduct CBS at a proficient level. For example, although CTRS scores of
36, 39, and 40 (on a scale of 0–66) have been used respectively in various
settings and protocols as threshold scores for competency as a CBT practi-
tioner (see McManus, Rakovshik, Kennerley, Fennell, & Westbrook, 2012),
the Beck Institute for Cognitive Behavior Therapy requires two ratings at a
score of 50 or greater as a criterion for admission into its extramural train-
ing program for supervisors. Although we have already noted that treat-
ment and supervision in CBT have much in common, and indeed there are
items on the CTRS that are directly applicable to best practices in CBS (e.g.,
setting an agenda, collaboration, pacing, interpersonal effectiveness, focus-
ing on key cognitions and behaviors, having a conceptualization-based
strategy for change, eliciting feedback, assigning homework), the CTRS
does not explicitly rate some items that have been identified as being part of
evidence-based supervision (e.g., using multimodal methods of teaching,
using video observations and ratings); thus, the CTRS does not map onto
supervision optimally. On the other hand, there is evidence that when the
CTRS is used regularly in supervision, the supervisees’ clients have better
outcomes (Simons et al., 2010), an example of the benefits of ongoing mea-
surement of supervisees’ progress.
Although the CTRS is widely used and frequently studied (Trepka,
Rees, Shapiro, Hardy, & Barkham, 2004), both versions have had mixed

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results in terms of interrater reliability (Muse & McManus, 2013). Thus,

one of the future directions in the study of measuring practitioner com-
petency in CBT (one of the central responsibilities of supervisors) will be
further refinement and study of the CTRS and similar measures, without
which the links among supervisor competency, therapist competency, and
client outcome will be difficult to ascertain clearly (see Webb, DeRubeis,
& Barber, 2010).

Supervision: Adherence and Guidance Evaluation (SAGE)

The SAGE scale for rating supervisor competence in CBT has a lengthy
history of conceptual and methodological development (see Milne &
Reiser, 2014). SAGE includes 22 items on which a supervisor is quantita-
tively evaluated on a scale of 0–6 (from absent to expertly done, much like
the CTRS) across three larger domains. One of these domains is dubbed
“common factors” and includes items such as interpersonal relating and
collaborating. A second domain is called the “supervision cycle” and fea-
tures items such as agenda setting, feedback (giving and receiving), evalu-
ating, questioning, listening, and teaching. The third domain is known as
the “supervisee cycle,” with scoring items such as conceptualizing and plan-
ning. Notably, the rater (who essentially serves as a metasupervisor) also
can offer qualitative written feedback to provide a rationale for a rating,
give specific suggestions for improvement, or offer positive comments.
SAGE includes a scoring manual, according to which, “[T]he instrument
can be used to evaluate the competence of supervisors; to audit adher-
ence to standards for supervision (especially CBS); to develop practice,
by enabling detailed feedback to be provided to supervisors; and to pro-
file different styles of supervision” (Milne & Reiser, 2014, p. 410). SAGE
is actively being used in numerous ongoing studies. In terms of future
directions, this scoring system undoubtedly will play an important role
in the further empirical development of guidelines for competent CBS, as
well as in studies on the impact of CBS on supervisees and their clients.
Milne (2014) has developed, as a companion to SAGE, a complementary
11-item questionnaire called REACT (Rating of Experiential Learning and

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Components of Teaching & Supervision) that solicits supervisees’ feed-

back. Similar to SAGE, REACT allows for the collection of quantitative
and qualitative data. The psychometric data on REACT have been good,
making this another promising measure for ongoing and future research.
Recent literature reviews of the research on clinical supervision have
shown that much of the extant work has focused on the process of super-
vision more than the outcomes (e.g., Pilling & Roth, 2014; Roth & Pilling,
2008b). The link between supervisor competency and favorable client out-
comes has been a challenge to demonstrate systematically (see Bambling,
King, Raue, Schweitzer, & Lambert, 2006), although there is more evidence
for each link in the chain, in that competent supervision improves the
supervisees’ clinical competencies (e.g., enhancing their alliance-building,
interviewing, and technical skills, see Beinart, 2014; Inman et al., 2014;
Mannix et al., 2006; Reiser, 2014; Roth & Pilling, 2008b), and there is evi-
dence that therapists who demonstrate better CBT competencies produce
better outcomes for clients receiving CBT (e.g., Brown et al., 2013; Ginzburg
et al., 2012; Kuyken & Tsivrikos, 2009; Strunk, Brotman, DeRubeis, & Hollon,
2010; Trepka et al., 2004). In fact, the Mannix et al. (2006) randomized,
controlled trial showed that competent CBS could be used effectively in a
cross-disciplinary fashion. In this landmark study involving the training
and supervision of palliative care nurses in delivering CBT coping tech-
niques to patients with cancer, the authors found that continuation of
supervision of one group of nurses resulted in significantly better perfor-
mance of their core CBT skills and maintenance of self-confidence as CBT
clinicians when compared to the nurses assigned to the group whose super-
vision discontinued after 6 months. All of the nurses in the study earlier
had shown significant skill attainment in the first 6 months of the project,
in which everyone received the equivalent of 12 days of CBT instruction
and skills-building supervision. From these findings, the authors con-
cluded that in this cohort of nurses, supervision was necessary to ensure
maintenance of their CBT skills and the confidence to use them.
As challenging as it has been to find causal links from supervisor behav-
ior to client outcomes, some data exist that give us reason to be optimistic
about our ability to identify the key elements of supervisor competency

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and determine the impact of supervisory behaviors on trainee perfor-

mance and client progress. For example, in a quantitative and qualitative
content analysis of the transfer of impact from CBS to CBT practice, 20 audio
recordings of 10 alternating supervision and therapy sessions suggested
that “[S]upervision clearly and repeatedly improved patient care, albeit
within an uncontrolled n = 1 design” (Milne, Pilkington, Gracie, & James,
2003, cited in Milne, 2014, pp. 52–53). Milne (2014) reviewed numerous
randomized controlled trials conducted in the United Kingdom and Australia
and found supervision was associated with improved client care and out-
comes, but he urged caution in determining a causal link, in that supervisor
behaviors were not sufficiently measured and fidelity to a CBT approach
could not be confirmed. Milne suggested that future studies on the efficacy
of CBS would do well to place more emphasis on its design, delivery, and
impact on supervisee learning and enactment than on client outcomes per
se, arguing that client variables add considerable statistical noise in trying to
evaluate the level of competency of the supervision originating at the start
of the causal chain (also see Reiser & Milne, 2014).
The phenomena of measures that are not yet as psychometrically sound
as they could be combined with the high variability of client functioning
and engagement make it difficult to firmly link therapist competency with
client outcome when evaluating one clinician at a time. This problem has
been remedied somewhat through larger sample sizes, such as in evaluat-
ing an entire training program or interpreting the results of a large-scale
outcome study (Muse & McManus, 2013; Webb et al., 2010). The use of
larger samples would be helpful in allowing the field to state more con-
fidently that when supervisors adhere to evidence-based practices, their
super­visees consequently adhere more closely to the treatment protocol
(Inman et al., 2014) and that positively rated supervisory relationships are
related to better supervisee development and learning (Beinart, 2014).
Let us now turn our attention to some current developments in the
field that are informing us about future directions, including (a) the routine,
formalized early training of supervisors; (b) dissemination and evaluation
of supervision methods that are global in scope; (c) expanded oversight
of supervision practices across the professional lifespan; and (d) more

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comprehensive and secure use of technology (with clear, corresponding

professional guidelines).

ROUTINE, FORMALIZED, EARLY TRAINING

OF SUPERVISORS
The field of clinical supervision has come a long way since the days when
new supervisors had their first exposure to “training” when they began
working with their first supervisees. The field has recognized that formal
instruction is a necessary prerequisite for optimally conducting super­
vision (American Psychological Association and Commission on Accredi-
tation, 2009) and that the contents of such instruction need to be derived
from evidence-based practices in the modality of therapy being super-
vised. Research on best practices in supervision is an area that is only now
starting to grow, but over time there will be an ever-growing database on
which to construct supervision programs that are efficacious in shaping
the clinical skills of therapists-in-training. Ultimately, the aim is to show
that early, systematic training in supervision will produce better super­
visors, which in turn will lead to more competent therapists, which will
result in healthier, more durable therapeutic outcomes for clients.
As the future brings more studies on supervision, the result will be a
broader evidence base on which to construct training courses on best prac-
tices. In the years to come, graduate level training in supervision will no
longer feel like a new frontier but will become more firmly embedded in the
normative early-career curriculum. Therapists-in-training will simultane-
ously be supervisors-in-training, and through this more demanding appren-
ticeship, they will become more knowledgeable about the key ingredients
of the supervision they receive. The bar will naturally be set higher for all
parties because long-time supervisors will need to keep up with advance-
ments in the field to satisfy their more aware trainees, and the trainees will
be better positioned to accept and adapt to the professional demands of
being fully licensed and credentialed. All of this should result in improve-
ments in the delivery of CBT to the clients, which we anticipate will be
confirmed by the data in the years ahead.

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 SUPERVISION ESSENTIALS FOR COGNITIVE–BEHAVIORAL THERAPY

DISSEMINATION AND EVALUATION OF SUPERVISION

METHODS THAT ARE GLOBAL IN SCOPE
Cognitive–behavioral therapy, as a modality originally rooted in cultures in
which English was the primary language, requires modifications appropri-
ate to nonanglophone and non-Western cultures if it is to be used world-
wide. Over the past few decades, the promulgation of promising data from
a plethora of CBT clinical trials, coupled with sociological, political, and
technological changes that have rapidly changed the world, have resulted
in the widespread establishment of academic and clinical centers for CBT
around the globe. Indeed, hubs of CBT exist on six continents (and it is not
out of the question that there will someday be a CBT center in Antarctica
for lonely, worried scientists and environmentalists).
As the field continues to be more aware of cultural adaptations that
need to be made to CBT conceptualization and intervention (see Hays &
Iwamasa, 2006; Tsui, O’Donoghue, & Ng, 2014), there is an ever-growing
need to train and credential supervisors whose practice largely will not be
in English. Organizations such as the Academy of Cognitive Therapy (ACT,
http://www.academyofct.org), in part through their international listserv,
have begun to involve a more multicultural, multilingual cohort of experi-
enced clinicians around the world to serve as supervisors and metasuper-
visors when therapy sessions are conducted across the linguistic spectrum.
For example, when an applicant includes a recording of a CBT session as
part of his or her submission for credentialing by the ACT, it is becoming
more likely that it can be evaluated and formally rated by a senior clinician
who will be able to understand the language directly, without having to risk
skewing the meanings via an attempted translation into English.
As noted, the acquisition of cross-cultural knowledge and related clini-
cal competency is a lifelong endeavor. Thus, at any given point in time, both
supervisors and their supervisees will be in the process of learning about
the normative belief systems and behavioral practices of clients from a wide
range of heritages and locales, as well as gaining awareness of variations
in international codes of ethics (Thomas, 2014). The on­going increase in
international training opportunities (coupled with the technology to enact

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Research Support for the Supervisory Approach and Future Directions

secure supervision from a distance) will necessitate that supervisors learn

from their supervisees when it comes to adapting CBT for use with the
latters’ clients. Far from viewing this as a complication in the process of
training, competent CBT supervisors will embrace this opportunity for
bidirectional, synergistic learning.
Cross-cultural issues also play a role in international collaborative
research projects, in which coinvestigators need to take into account the
effects of using measures (both self-report and observational ratings of
others) that have been adapted for use in different languages and contrast-
ing societies. As a humorous anecdote, Milne and Reiser (2014) describe
the culture gap that can exist even when both researchers share a com-
mon mother tongue. When Milne (from the United Kingdom) used SAGE
to rate the supervision sessions of Reiser (from the United States), the
former found the latter’s upbeat, can-do attitude a bit at odds with the
common British style of understatement, and it could well have adversely
affected the ratings if Milne had not been alert to this cultural difference.
Notably, in the spirit of the notion that “everybody is a student,” Milne hum-
bly added that he learned in the process of doing the qualitative ratings
of Reiser’s super­vision sessions “to try and be a notch or two more posi-
tive” (p. 411).

IMPROVED AND EXPANDED OVERSIGHT

OF SUPERVISION PRACTICES ACROSS
THE PROFESSIONAL LIFESPAN
As the field further responds to the need for more training, practice, and
research on supervision, accrediting and licensing boards will routinely
mandate supervisors to demonstrate their periodic participation in con-
tinuing education on this subject. In addition, more professionals will have
the opportunity to take part in research trials of supervision, thus offering
them greater exposure to training along with metasupervision. Gradu-
ate training programs will prioritize the regular convening of supervisors’
meetings, the collection of students’ evaluations of supervisors, and the

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recording of supervision sessions for oversight and future training pur-

poses. Over time, this will become the norm.
Training in CBS now is being offered sooner in one’s career than it had
been in earlier epochs. Therefore, accreditation bodies evaluating gradu-
ate programs in mental health fields will evaluate such programs’ adher-
ence to high standards in introducing students to the basics of being a
supervisor. At the other end of the timeline, maintaining one’s license to
practice will necessitate confirmation of ongoing, updated training in best
practices in supervision.

MORE ROUTINE AND SECURE USE OF

TECHNOLOGY WITH CONSENSUS GUIDELINES
As described in detail by Rousmaniere (2014), “The past two decades
has [sic] witnessed an explosion in the number of technologies being
used to deliver and enhance supervision and training, such as Web-
based video­conference . . . Web-based software for tracking clinical
outcomes, and software to code psychotherapy session videos” (p. 204).
As a result, super­v ision and training from great distances is rapidly
becoming commonplace, and this trend will only become more pro-
nounced, especially as a way to reduce travel costs, reach clinicians in
remote areas, and improve assessment of outcomes (e.g., in terms of
therapist-acquired competencies and client wellness). Rousmaniere
(2014) also noted that these advancements bring with them a host of
questions and challenges of the practical and legal–ethical variety that
are nowhere close to being resolved at present. For example, how can
supervisors maintain the confidentiality of client records if they have
access to them via mobile devices and/or “the cloud”? To what degree
will technological competency be a necessary supervisory competency
for the proper use of new devices and methods for safely receiving,
transmitting, storing, and deleting sensitive clinical material? How will
distance super­vision affect the supervisory relationship and related cli-
ent outcomes? How can clients best be given accurate, comprehensible,
and perhaps frequent updates about how their personal information

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Research Support for the Supervisory Approach and Future Directions

will be communicated and protected so that the clients’ consent can

truly be “informed?”
These are the sorts of questions that will receive more attention over
time, not only in academic discussions but also in terms of new policies
and mandates that will need periodic updating.
These and other questions are being tackled to some extent, and
Rousmaniere (2014) offers useful suggestions on choosing cloud-based
file storage and transfer services—as well as telepsychology programs—
that are compliant with the Health Insurance Portability and Account-
ability Act (HIPAA) in the United States. He also highlights the hazards
of assuming that such services, devices, and programs are discrete,
single-purpose, only turned on when used, and “private” (as opposed
to public) as the default mode. He proposes that supervisors will need
to assume quite the opposite—that sensitive client information is part
of a technology ecosystem unless steps are actively taken to isolate such
information (e.g., via strong passwords, encryption, privacy settings
deliberately set to “private”). In the United States, the American
Psychological Association (APA) has published the “Guidelines for
the Practice of Telepsychology” (APA, 2013), in which clinical super-
visors are urged to continue in-person supervision when possible, be
reasonably proficient in the technologies they are using, and consult
with knowledgeable others to reduce the risks that come with ongoing
technological advancements. These are daunting but necessary steps,
and they will more routinely become a part of the supervisor’s mandate
going forward.
On the more personal level, supervisors and their trainees will
need to reach agreements about how they will communicate in cases
of emergent clinical situations outside the supervisory hour (e.g., Will
they use text messaging?). There is also the question of how distance
supervision will affect the quality of the trainee’s learning experience
in supervision. Fortunately, the data on this issue are promising in that
several studies have suggested that cybersupervision is as effective as
individual face-to-face supervision and that both supervisors and super-
visees have perceived no significant differences in their perceptions of

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the quality of the super­visory relationship (see Inman et al., 2014, for
an overview).

FINAL REMARKS
In conclusion, whether CBS is conducted long distance or in person, indi-
vidually or in groups, within a homogeneous cultural milieu or cross cul-
turally, as part of clinical trials or routine clinical training, in the context
of early professional development or continuing education, or between
supervisor and supervisee or metasupervisor and supervisor, the field
clearly has turned a corner. Long gone are the days when CBS was an after-
thought in training, taken for granted as a naturally acquired competency,
unmeasured and untested in research, and generally underrepresented
in the literature. Now there is a growing body of empirical research on
CBS to go along with the welcome appearance of professional standards,
manuals, books, and scoring codes with which to understand and further
develop this critical area of our profession.
We hope that this concise handbook has served as a convenient, elu-
cidating reference for anyone who wishes to conduct CBS. As clinical psy-
chologists who have spent (and continue to spend) a significant part of
our careers involved in the direct training and supervision of CBT thera-
pists, we know firsthand how rewarding it is to play a role in the develop-
ment of our supervisees as they learn to bring the power and promise of
evidenced-based CBT methods to their clients, present and future. We wish
you all the best in your careers as you do the same.

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 Suggested Readings

Bennett-Levy, J., Thwaites, R., Haarhoff, B., & Perry, H. (2015). Experiencing CBT
from the inside out: A self-practice/self-reflection workbook for therapists. New
York, NY: Guilford.
Provides an excellent program of self-application of cognitive–behavioral
therapy (CBT) for practitioners. A great resource for the learning of self-
reflection, and the practicing of clinician self-care.
Corrie, S., & Lane, D. A. (2015). CBT supervision. London, United Kingdom: Sage.
Allows readers from the United States to get a sense of the delivery of CBT
supervision and treatment from the British socio-political-economic system,
thus bringing the issue of context to the fore.
Milne, D. (2009). Evidence-based clinical supervision: Principles and practice.
Oxford, United Kingdom: Wiley-Blackwell.
From one of the leaders in empirical modeling and testing of mental health
supervision, this text helps the reader appreciate how supervision is being
advanced via rigorous research.
Newman, C. F. (2012). Core competencies in cognitive–behavioral therapy: Becom-
ing a highly effective and competent cognitive–behavioral therapist. New York,
NY: Routledge.
Spells out the knowledge, attitudes, and skills required to deliver top-quality
CBT, including many supervision principles and illustrative vignettes in
imparting these competencies to trainees in CBT.

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Newman, C. F. (2013). Training cognitive behavioral therapy supervisors: Didac-

tics, simulated practice, and “meta-supervision.” Journal of Cognitive Psycho-
therapy, 27, 5–18.
Describes a graduate-level seminar in CBT supervision, as well as an extended
vignette of cross-cultural metasupervision, which supplements the summaries
of these topics within the body of the Newman and Kaplan text.
Sudak, D. M., Codd, R. T., Ludgate, J., Sokol, L., Fox, M. G., Reiser, R., & Milne,
D. L. (2015). Teaching and supervising cognitive–behavioral therapy. Hoboken,
NJ: Wiley.
The lead author is one of the top CBT psychiatrists in the world, thus giving
the reader a prime example of how CBT supervision is applied in an inter-
disciplinary way.
Watkins, C. E., & Milne, D. L. (Eds.). (2014). The Wiley international handbook of
clinical supervision. Chichester, West Sussex, United Kingdom: Wiley Blackwell.
Encyclopedic in its coverage, this magnum opus covers almost every conceiv-
able special angle on the topic of clinical supervision across theoretical orien-
tations. A comprehensive reference, with writings by top contributors from
around the globe.

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Academy of Cognitive Therapy Barrera, M., Jr., 91

(ACT), 1, 114, 128 Barton, S., 114
Accreditation Council for Graduate Beck, Aaron T., xv, 1, 5, 6, 9, 10, 79, 123
Medical Education (ACGME), Beck Depression Inventory II, 47, 69,
45 93
ACT. See Academy of Cognitive Beck, Judith S., xv, 6, 10
Therapy Beck Institute for Cognitive Behavior
Advanced Cognitive Therapy Studies, Therapy, xv, 1, 10, 115, 123
110 Beck Scale for Suicide Ideation, 48
American Institute for Cognitive Behavior therapy, 5
Therapy (AICT), 11 Bellevue Hospital Center, xvi, 2, 11
American Psychological Association
(APA), 131 Case reviews, 62
Commission on Accreditation, 127 Castro, F. G., 91, 95
culture-specific recommendations, CBS. See Cognitive–behavioral
95 supervision
Ethical Principles of Psychologists CBS goals
and Code of Conduct, 44, 96 CBT case conceptualization, 12,
functional competency 19–24, 29, 32–33, 36–37, 39,
benchmarks, 45 45, 54, 58, 62, 68–69, 76–78,
telepsychology guidelines, 131 83, 101, 106, 114, 123, 128
Americans With Disabilities Act, 85 client confidentiality maintenance,
An Unquiet Mind, 34 20
Anxiety. See Supervisee anxiety client termination or transfer
APA. See American Psychological management, 24–25
Association competently managed client care,
Armstrong, P. V., 114 18
Automatic thoughts, 27, 28, 75, 106, promotion of supervisee
107, 119 development, 19–20

149
 INDEX

CBS goals (continued) CBT methods, teaching

teaching psychotherapy answering client’s CBT questions, 33
competencies, 19–20 best practices, 29–32
values communication, 25–26 improving client’s use of thought
CBS measures and outcomes records, 27–28
cross-cultural issues and, 129 meta-competencies, 34–35
CTRS, 123–124 overview, 20–21, 26–27
literature on, 122–126 reading recommendations, 33–34
SAGE, 123, 124–125 Center for Cognitive Therapy, 1, 9,
about supervision competency, 10, 83
125–126 Clinical notes. See also
CBS supervisory methods/techniques Documentation
based on clinical setting, 45–47 conceptualization, as an aid, 24
based on supervisee’s contents, 47–49
development, 42–45 supervisor comments on
documentation, 47–49 supervisee, 48–49
instruction, modeling, role-playing supervisee performance, as an
and reviewing recordings, indicator, 39
49–58 taking, 32, 47–49
sample dialogue with trainee, Clinical setting, supervisor
22–24, 27–28, 50–52, 54–56, expectations based on, 45–47
75–77, 87, 93–95, 98–100 Cognitive–behavioral supervision
supervision individually or in (CBS). See also CBS subtopics
group, 58–59 CBT and, 4–6
CBT (cognitive–behavioral therapy) directiveness in, 85
best practices, 121–122 empathy in, 85
being yourself, 29–30 essential dimensions and key
client homework assignments, principles, 13
30–31 future of, 14
effective client change, 31 path to expertise in, 8–12
empathy, 31 status, 121–122
good clinical note taking, 32 theoretical underpinnings and
information exchange, 32 historical background, 5–7
learning finer details of clients’ treatment as differentiated from,
lives, 32 7–8
starting and ending sessions Cognitive Therapy Rating Scale
strongly, 29 (CTRS), 37, 43, 56–57, 64–65,
summarizing, 31 68, 71, 90, 111, 123–124
with slow client progress, 32–33 Competency. See Psychotherapy
CBT case conceptualization training, competencies; Supervisee
12, 19–24, 29, 32–33, 36–37, 39, competency; Supervisor
45, 54, 58, 62, 68–69, 76–78, 83, competency
101, 106, 114, 123, 128. See also Constructive criticism, in supervision
CBS goals session, 65–66

150
 INDEX

Corrie, S., 122 legal/ethical supervisory issues, 40,

Cross-cultural issues 96–102
CBS measures, outcomes and, 129 sample supervision session dealing
of clients, 64, 65, 69–70 with, 97–100
CTRS. See Cognitive Therapy Rating supervisee questions about,
Scale 100–102
Cube Model of psychotherapy supervision session case
competency, 19, 42 illustration, 64, 66, 70–71
Cultural issues, xiii, xv, 7, 12, 14, 19, and technology, 130
21, 25, 44 terminations and transfers, 25
awareness of and sensitivity to, trainee impairment, 85, 89
91–96 Ethical Principles of Psychologists and
client, 64, 65, 69–70, 91 Code of Conduct, 44
cross-cultural, 64, 65, 69–70, 129 Evaluation. See Feedback; Supervisee
metasupervision and cultural evaluation
competency, 115–116 Experiential exercises, 6, 13, 61–63, 121
multicultural/diversity issues,
91–96 Fadiman, A., 95–96
self-knowledge and, 92 Feedback., xi, xiii, 6–8, 16–18, 20,
supervisee, 91–92 22–24, 27, 29–30, 36–40, 43–44,
Cyber-supervision, 131–132 48, 50, 59, 65–66, 68, 103,
110–112, 114, 119, 123–125.
Defensiveness, of supervisee. See also Supervisee evaluation
See Supervisee resistance/ positive feedback and constructive
defensiveness criticism in supervision
Directiveness session, 65–66
in CBT, 85 supervisee anxiety about
in supervisory relationship, 83–85 supervisor, 74–75
Documentation, 47–49. See also supervisee feedback about
Clinical notes supervisors, 40, 82
client termination written from supervisees about their
summary, 69 progress, 90
Dryden, W., 9 on supervisee session recordings,
52–58
Empathy, 22, 26, 31, 34, 54–56, 79, supervisor moment-to-moment,
101, 106, 115 53
and supervisor wellness, 117 Feeling Good Handbook, 33
cross-cultural, 92–93 Formative evaluation, 36, 39
in supervisory relationship, 12, 57, Foundational competencies, xi, 19, 20,
82–85, 88, 114 36, 44–45, 111
Ethical issues, xi, xiii, 7, 12, 14, 19–20, Frankl, V., 34
25, 37, 44, 62, 73, 96 Freeston, M. H., 114
in a course on supervision, 111–113 Functional competencies, 19–20, 44
international codes, 128 benchmarks, 45

151
 INDEX

Gatekeeping, xi, 7, 85–89 Multicultural/diversity issues, xiii,

Group supervision, 10–12, 14, 35, 14, 128
58–59, 110 awareness of and sensitivity to, 91–96
Guidelines for Clinical Supervision in client, 91
Health Service Psychology, xi culture-specific recommendations
and readings, 95–96
Handbook of Psychotherapy empathy technique for, 92–93
Supervision (Watkins), ix sample transcript of supervision
Holleran Steiker, L. K., 91 session on, 93–95
Homework, xiii, 6, 13, 21, 26–27, 29, self-knowledge and, 92
30–31, 34, 36–37, 43–44, 48, supervisee, 91–92
57, 62, 66–68, 70, 112, 115, supervisory, 91–96
121, 123
Nelson, M. L., 57
Impairment, 85–86, 89. See also Newman, C. F., xiii, xv, xvi, 1–2, 8, 11,
Trainee impairment/skill 26, 67
deficit Notes. See Clinical notes;
Intervention with supervisee’s Documentation
clients Novice supervisors, 74
preparation for, 106–107 Novice therapists, xiv, 7, 42.
sample situations, 102–106 competencies and, 43–44

Jamison, K. R., 34 Overbreathing exercise, 87–88

Oxford Cognitive Therapy Centre,
Lane, D. A., 122 110, 122
Leahy, Robert, 11
Legal issues Padesky, C. A., 6
supervisory, 37, 47, 89, 96–102 Positive feedback, in supervision
trainee impairment, 89 session, 23, 65–66, 103, 124
Liese, B. S., 6, 79 Power, in supervisory relationships, 8,
40, 79, 82, 89–91
Man’s Search for Meaning, 34 struggle with client, 30, 56
Metacompetencies, 34–35 Psychiatry Milestone Project, 45
Metasupervision, 13, 14, 82, 110, 113 Psychotherapy competencies. See
consultation as, 114 also Supervisee competency;
cultural competency in, 115–117 Supervisor competency
supervisory relationship APA functional competency
improvements through, benchmarks, xi, 45
114–115 Cube Model of, 19, 42
Metasupervisor, 59, 110, 111, foundational, xi, 19–20, 36, 44,
114–116 71, 111
Milne, D. L., 7, 85, 126, 129 functional, 19–20, 36, 44, 45
Mind Over Mood, 33 metacompetencies, 34–35

152
 INDEX

novice therapists and, 44–45 Shame, supervisee, 74–78. See also

teaching, 19–20, 44 Supervisee anxiety
trainees and, 44–45 Skills. See Supervisee skills
The Spirit Catches You and You Fall
Rating of Experiential Learning Down (Fadiman), 95–96
and Components of Teaching SR. See Supervisory relationship
& Supervision (REACT), Summative evaluations, 36, 38–39
124–125 Supervisee anxiety. 74. See also
Rational response, 27–28, 77, 107, 119 Supervisee resistance/
REACT. See Rating of Experiential defensiveness
Learning and Components of as impediment to supervisee
Teaching & Supervision development
Reading recommendations, 30–34 about skill set, 76–77
Recordings. See Supervisee session as special supervisory issue, 74–78
recordings; Supervisor session about supervisee session
recordings recordings, 57
Reiser, R. P., 85, 129 about supervisor feedback, 74–75
Remediation, for skill deficits, 14, 19, supervisor openness and, 75–76
58, 85–86, 90–91 supervisor’s contribution to, 81–85
Resistance, of supervisee. See supervisor seeking consultation
Supervisee resistance/ and, 75–76
defensiveness about supervisory process, 76–77
Role-playing, 6–7, 14, 20, 23–24, 33, Supervisee competency. See also
49, 57–58, 62–63, 79, 110–111, Psychotherapy competencies
114, 121 client outcomes and, 126
in supervision session case supervisor competency and,
illustration, 64, 65, 68, 71 125–26
trainee impairment and Supervisee development, xi, 14
supervisory, 87–88 anxiety as impediment to, 74
Rousmaniere, T., 130, 131 impairment/skill deficit and,
86–88, 90
SAGE. See Supervision: Adherence needs assessment, 35, 43
and Guidance Evaluation promotion of, 19–20
Self-assessment, supervisee, xi, 56–57 supervisor expectations based on,
Self-help assignments, 6, 31, 33, 63, 42–45
67, 69 supervisory relationship, and, 126
Self-knowledge, and cultural issues, 92 Supervisee evaluation. See also
Self-reflection, 19, 36–37, 67, 110, 114, Cognitive Therapy Rating
117 Scale; Feedback
in supervisory relationship, 83–85 APA competency benchmarks, 45
Session recordings. See Supervisee feedback from supervisees
session recordings; Supervisor about, 90
session recordings need for remediation, 91

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 INDEX

Supervisee evaluation (continued) Supervision: Adherence and Guidance

needs assessment, 43 Evaluation (SAGE), 123,
overview, 36, 38 124–125
power in supervisory relationships Supervision, future directions
and, 89–91 expanded oversight of supervision
summative evaluations, 36, practices across professional
38–39 lifespan, 129–130
supervisee feedback about global supervision methods
supervisor in, 40 dissemination and
“tyranny-of-niceness,” 39 evaluation, 128–129
work sample observations, 38 overview, 126–127
Supervisee personal information routine, formalized, early
disclosures supervisor training, 127
in supervision session case routine and secure use of
illustration, 67, 68–69 technology with consensus
supervisor restraint of, 77–78 guidelines, 130–132
Supervisee resistance/defensiveness Supervision goals, 16. See also CBS goals
examples of supervisor approach setting expectations for, 35–36, 37
to, 78–79, 80–81 Supervision of supervision. See
supervisee misconceptions about Metasupervision
CBT and, 78–80 Supervision session, case illustration
about supervision in general, client homework assignments in,
80–81 66, 68
supervisor’s contribution to, client’s cross-cultural issues in, 64,
81–85 65, 69–70
to supervisor suggestions, 78–81 client termination in, 64, 69
Supervisee session recordings, 16, CTRS scoring in, 68
17, 38 ethical issue in, 64, 70–71
client permission for, 62–63 four-part agenda, 63–71
contract for supervision, part of, overview, 63, 71
37 positive feedback and constructive
supervisee anxiety about, 57 criticism in, 65–66
supervisee self-assessment of, 57 role-playing in, 64, 65
supervisor reviews of, 51–58, specific moments and supervisor’s
63–64, 67–68, 71 thoughts, 67–71
Supervisee skill deficits supervisee personal information
impairment and, 85–89 disclosures, 67, 68–69
remediation for, 90–91 supervisee session recording
Supervisee skills review in, 63–64, 67–68, 71
anxiety about, 76–77 supervisor session recording used
supervisor recognition of, 82 in, 63
Supervision. See Cognitive–behavioral Supervisor competency, x, xi, 6, 73.
supervision; CBS goals See also Psychotherapy
subtopics competencies

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 INDEX

client outcomes and, 125–126 trainee impairment/skill deficit,

supervisee competency and, 85–89
125–126 Supervisory methods and techniques,
The Supervisor Competency Scale, 14. See also CBS supervisory
122 methods/techniques; CBT
Supervisor development, 14 methods, teaching
ongoing learning, consultation and global dissemination and
metasupervision, 113–116 evaluation of, 128–129
training and, 109–113 Supervisory problems
Supervisor session recordings, 57–58 example of dealing with, 83–85
Supervisor training “no news is good news” approach
class discussions on hypothetical problem, 39
situations, 112–113 self-reflection in supervisory
course modules, 111, 112 relationship, 83–85
models for, 110–111 supervisor’s contribution to, 81–85
overview, 109–110 supervisor’s high motivation in
routine, formalized, early, 127 approaching, 82–83
seminar, 111–113 Supervisory process
simulated supervision scenarios overview, 61–71
in, 110 supervisee anxiety about, 76–77
supervisor session recordings, Supervisory relationship (SR), 8.
57–58 boundaries, 8, 96
Supervisor wellness and self-care, creating positive, 15–16
117–119 course module, 111
Supervisory contract, 36, 37 distance supervision, in, 130–132
Supervisory issues, special empathy and directiveness in, 83–85
anxiety/shame of supervisee, feedback, 65–66
74–78 importance of, xiii, 15–18
client safety, 86 improvements through
gatekeeping for the field, 89 metasupervision, 114–115
intervention with supervisee’s problems, general, 74–75
client, 102–107 problems with the setting, 46–47
legal/ethical issues, 96–102 self-reflection in, 83–85
multicultural/diversity issues, 91–96 supervisee development, and, 126
overview, 73, 107 supervisee misconceptions about
power and evaluation, 89–91 CBT and, 78–80
remediation for skill deficits, 90–91 termination, 89
resistance/defensiveness of
supervisee, 78–81 Technologies, for supervision, 14,
supervisee development, 86–88 127–128, 130–132
supervisees with challenges, 74–85 Termination
supervisor’s contribution to as CBS goal, 24–25
problems with supervisee, review in supervision session,
81–85 64, 69

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 INDEX

Termination (continued) supervisee development and,

supervisee failure, 91 86–88
written summary of, 69, 89 supervisory role-playing approach
Therapeutic relationship (TR), 8, 12, to, 87–88
15, 22, 30, 36–37, 45, 54, 62, Training and Supervision for
64–65, 79, 83, 105, 107 Counselling in Action (Dryden
Therapy sessions. See also Supervisee and Thorne), 9
session recordings Treatment
supervisee personal information CBS as differentiated from, 7–8
disclosures in, 67, 68–69 CBT manuals, 5
Thorne, B., 9
Thought records, 27–28, 43, 59, 62. See Values, communication of, 25–26
also Automatic thoughts
TR. See Therapeutic relationship Watkins, Edward, ix
Trainee impairment/skill deficit Wellness
client safety and, 86 methods, 118–119
ethical and legal issues, 89 of supervisors, 117–119
example of supervisor approach of therapists, 117–118
to, 86–88 Work sample observations, 17, 38
gatekeeping, 89
overview, 85–86 Young, J., 123

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 About the Authors

Cory F. Newman, PhD, ABPP, is director of the Center for Cognitive

Therapy, professor of psychology in psychiatry at the University of Penn-
sylvania Perelman School of Medicine, and adjunct faculty at the Beck
Institute for Cognitive Behavior Therapy. He is a diplomate of the
American Board of Professional Psychology, and a founding fellow of
the Academy of Cognitive Therapy. He earned his doctorate in clini-
cal psychology from the State University of New York at Stony Brook
in 1987 and subsequently completed a postdoctoral fellowship at the
Center for Cognitive Therapy under the mentorship of Dr. Aaron T. Beck.
Since then, Dr. Newman has maintained a full caseload of clients and has
supervised more than 300 postdoctoral fellows, psychiatry residents,
predoctoral students, international Beck Scholars, and other mental
healthcare practitioners. He has served as a protocol cognitive-behavioral
therapist and supervisor on numerous large-scale psychotherapy outcome
studies, including the Penn-Vanderbilt-Rush Treatment of Depression
Projects and the NIDA Multisite Collaborative Study on Treatments for
Cocaine Abuse. While on sabbatical at the University of Colorado at
Boulder in fall 2011, Dr. Newman taught the graduate seminar on the
fundamentals of cognitive–behavioral supervision.
Dr. Newman is an international lecturer, having presented more
than 200 cognitive–behavioral therapy (CBT) workshops and seminars

157
 About the Authors

throughout the U.S., as well as in 18 other countries. He is the lead author

of dozens of articles and chapters of CBT for a range of clinical problems
and has authored or coauthored six books, including Bipolar Disorder: A
Cognitive Therapy Approach and Core Competencies in Cognitive–Behavioral
Therapy: Becoming a Highly Effective and Competent Cognitive–Behavioral
Therapist. On the side, Dr. Newman is an avid hockey player and a trained
classical pianist.

Danielle A. Kaplan, PhD, is the director of the Predoctoral Psychology

Internship at New York University (NYU)-Bellevue Hospital Center,
where she is a clinical assistant professor in the NYU School of Medi-
cine’s Department of Psychiatry. She also coordinates CBT training and
supervision for the NYU psychiatry residency. Dr. Kaplan received her
doctorate in clinical psychology from the University of North Carolina
at Chapel Hill. Since then, she has practiced CBT in community men-
tal health, hospital-based, and private-practice settings and has taught
and supervised CBT at Northwestern University and Yeshiva Univer-
sity’s Ferkauf Graduate School of Psychology. Dr. Kaplan is the author of
numerous book chapters and conference presentations on topics, includ-
ing diversity training, cross-cultural mental health issues, and vicarious
traumatization. In addition to her teaching and supervisory responsibili-
ties, she maintains a private psychotherapy practice where she special-
izes in CBT for depression and anxiety disorders and reproductive and
perinatal mental health. Dr. Kaplan is an enthusiastic traveler, dancer, and
student of other languages.

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