Psychotherapy supervision: an ever‐evolving signature pedagogy
Authors: C. Edward Watkins
Journal: World Psychiatry (2020)

Psychotherapy supervision has been rightly recognized as one of the key signature pedagogies of psychiatry and other mental health disciplines1. Signature pedagogies refer to those characteristic forms of teaching and instruction that organize how future practitioners are educated with regard to three dimensions of professional work: to think, perform, and act with integrity2. Psychotherapy supervisors foster development of treatment-facilitative habits of head (knowledge), habits of hand (skills), and habits of heart (attitude/values). Much as clinical rounds serve as the signature pedagogy for medical education, psychotherapy supervision serves as the signature pedagogy for psychotherapy education. Since its formal inception nearly a century ago, supervision has been increasingly recognized as highly important for, even sine qua non to, the optimal learning of psychotherapy. Nagging, inhibiting myths about its practice (e.g., "If I have experienced supervision as a supervisee, then I am qualified to be a supervisor") have been exposed as erroneous, and a guiding ethos of supervision as a competency-based, evidence-based area of practice in its own right has emerged prominently3. Perhaps supervision's current status and future directions might best be captured by means of the following ten points. First, although a host of supervision definitions has been put forth, they all converge on some core features. Psychotherapy supervision typically involves senior, professionally approved supervisors formally providing relationship-based, treatment-focused psychotherapy education and training to junior colleagues/trainees about their ongoing therapeutic work4, 5. Second, supervision's primary purposes are: developing and enhancing supervisee conceptual/treatment skills; developing and crystallizing the supervisee's sense of identity as a psychotherapist; developing the supervisee's conviction about the meaningfulness of psychotherapy itself; and monitoring supervisee treatment efforts and safeguarding patient care1, 4, 5. Thus, supervision is fundamentally normative (assuring quality control), formative (facilitating supervisee development), and restorative (encouraging supervisee emotional processing and attending to supervisee well-being). Third, the primary perspectives of supervision practice are psychotherapy-focused, developmental, and social role/process1, 4, 5. Psychotherapy-focused supervision perspectives are oriented around a particular form of psychotherapy and its learning; the supervision process is uniquely stamped by the psychotherapy being learned. Developmental supervision perspectives give focus to the developmental stages and issues that define the growth experience of the evolving therapist and the supervisor's facilitative responsiveness to the developing supervisee. Social role/process perspectives place focus on supervisees' evolving learning needs and the supervisor roles that most responsively match those evolving needs. Fourth, the chain of change in psychotherapy supervision follows a logical progression. Through meeting and melding of their person/personhood, supervisor and supervisee build a constructive supervisory relationship, that makes supervisor intervention possible, that then contributes to supervisee development, that then accordingly contributes to patient development6, 7. Each var­iable in the chain builds on and is made a more likely reality by its predecessor's realization. Fifth, all supervision perspectives have come to increasingly grant primacy of place to the supervision relationship. This is now roundly recognized as a robust contributor to, and potential potentiator of, supervision's unfolding process and outcome7, 8. Sixth, the primary trans-theoretically applicable components of psychotherapy supervision are case conceptualization, teaching/instruction, modeling, providing feedback, asking reflection-purposed stimulus questions, and discussion8. Seventh, conceptual contributions and empirical study identify the earliest period of therapist development as being the most troubling, a time of particularly heightened supervisee vulnerability9. Beginning therapists tend to have limited skills, lack a sense of therapist identity, feel like an impostor, and can question their very fitness to serve. Heightened supervisor sensitivity to and support of the vulnerable supervisee may be most crucial at this pivotal juncture. According to the International Study of Development of Psychotherapists, a beginning supervision experience characterized by healing involvement is developmentally critical9. Eighth, supervision has increasingly become a multi-culturally minded endeavor. All supervision in some respects is a triadic multicultural relationship. Thus, such variables as gender, race/ethnicity, sexual orientation and religion/spirituality, readily affecting the treatment experience, also readily affect the supervision experience. Supervisors ideally strive to understand the myriad ways in which that is so and make the multicultural an integral part of the supervision process1, 4. Ninth, supervision research has advanced considerably since its inception in the late 1950s. Data across a host of studies indicate that supervision works, at least for supervisees, contributing to such positive outcomes as enhanced treatment knowledge, skill development/enhancement, and heightened self-awareness9. But supervision's impact on patients, referred to as the re­al effectiveness acid test, has yet to be definitively investigated and remains a most pressing accountability issue. Other identified limitations of supervision research (e.g., small sample sizes, over-reliance on self-report measures) also require redress going forward9. Tenth, psychotherapy supervision's significance as a vital educational practice is internationally recognized more so now than at any time in its 100 year history4. Supervision has gone global, a reality that seemingly will become even more heartily evident in the years and decades ahead. No longer viewed as an ancillary, expendable practice, psychotherapy supervision's time has come. It is now rightly recognized as one of the key signature pedagogies of the mental health disciplines, educational sine qua non for, and grand facilitator of the psychotherapist development process. Just as "there is nothing so practical as a good theory" , there is nothing so positively practice affecting as a good psychotherapy supervisor.