Handbook of Training and Supervision in Cognitive Behavioral Therapy 3031337344, 9783031337345

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Mark D. Terjesen Tamara Del Vecchio   Editors

Handbook of Training and Supervision in Cognitive Behavioral Therapy

Handbook of Training and Supervision in Cognitive Behavioral Therapy

Mark D. Terjesen  •  Tamara Del Vecchio Editors

Handbook of Training and Supervision in Cognitive Behavioral Therapy

Editors Mark D. Terjesen St. John’s University Jamaica, NY, USA

Tamara Del Vecchio St. John’s University Jamaica, NY, USA

ISBN 978-3-031-33734-5    ISBN 978-3-031-33735-2 (eBook) https://doi.org/10.1007/978-3-031-33735-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Preface

Cognitive behavioral therapy (CBT) continues to be the dominant theoretical orientation among clinical, counseling, and school psychologists, social workers, and mental health counselors. Evidence-based training in and supervision of CBT is essential to effective clinical practice. While the American Psychological Association and the Association of State and Provincial Psychology Boards provide guidelines for competence in clinical supervision, there are missing gaps both in the training curricula as well as for those in the field providing clinical supervision. This book provides a scholarly and practical guide for training and supervision in Cognitive-Behavioral Therapy (CBT). This book fundamentals of clinical supervision books with a theory-driven approach backed by empirical support for training and supervising clinicians in the practice of cognitive-­behavioral therapy. This edited volume dispels the myth of “do it, teach it” as it relates to supervision and also addresses the importance of recognizing that one size does not fit all as it applies to CBT supervision. The book is a synthesis of the science and links it to practice in reviewing common areas as it relates to supervision that warrants consideration (supervisory alliance, ethics), specific setting (medical setting, schools), and client (individual, group, couples, and high-risk) components of supervision and addresses a neglected area of developing competency (career-­long development, measuring trainee and supervisor competency) in the provision of clinical supervision. This edited book also includes interviews with supervisees and supervisors as to lessons learned and future directions in the delivery of CBT supervision. The book is full of useful resources (sample contracts, policies, and rating forms) and practical suggestions about the practice of supervision. It is intended to give existing and future supervisors the skills and resources needed to supervise confidently and effectively address the mental health needs of their clients. 

Jamaica, NY, USA

Mark D. Terjesen Tamara Del Vecchio

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Acknowledgments

First and foremost, we would like to thank the many contributors without whom this edited book would not have been possible. We are indebted to our many supervisors over the years who provided the guidance and support needed to develop our cognitive behavior therapy skills. You are our models for evidence-based supervision, and we thank you.

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Contents

Part I Foundations Supervision in Cognitive Behavioral Therapy: Theory, Practice, Culture, and Ethics��������������������������������������������������������������������������    3 Mark Terjesen, Audrey J. Ford, Korrie Allen, Kristine Lin, Madalina Yellico, and Olivia A. Walsh  thics in Supervision ��������������������������������������������������������������������������������������   29 E Jeffrey E. Barnett  upervisory Alliance: Reflections and Illustrations��������������������������������������   47 S Lauren M. Lipner, J. Christopher Muran, Mark Terjesen, and Miriam Motechin  echnology in Cognitive Behavioral Supervision������������������������������������������   61 T Kristy K. Kelly, Haley M. Schultz, and Elizabeth Hagermoser-Bayley Part II Supervision Practices with Specific Populations  linical Supervision of CBT with Youth, Adolescents, and Families����������   87 C David Reitman and Maria Alejandra Sisniegas  upervising Work with Couples ��������������������������������������������������������������������  109 S Katherine J. W. Baucom, Brian R. W. Baucom, and Feea R. Leifker A CBT Model for Supervision in the Delivery of Care to Suicidal Individuals ������������������������������������������������������������������������������������  121 M. David Rudd, Craig J. Bryan, Gretchen J. Diefenbach, and Andrea Pérez-Muñoz  Trauma-Informed Approach to Supervision and Consultation��������������  141 A Elissa J. Brown, Colleen Lang, and Komal Sharma-Patel  upervising CBT with Youth in Schools: Keystones and Variations����������  157 S Robert D. Friedberg and Jessica M. McClure ix

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 eaching and Supervising in the Context of Behavioral Medicine��������������  179 T Livia Guadagnoli and Jason J. Washburn Supervisory Processes in the Context of Dissemination and Implementation Science ��������������������������������������������������������������������������  193 Rachel K. Zukerman, Annette J. Schieffelin, and Tamara Del Vecchio Part III Training and Competencies  eveloping and Implementing Supervisory Standards��������������������������������  209 D Meredith Boyd and Danielle Keenan-Miller  ompetency in Clinical Supervision in Cognitive Behavioral Therapy�����  227 C Rebecca Stock, Rachel Vaughn, and Mark Terjesen Evidence-Based Methods for Training CBT Supervisors: Recommendations for Career-Long Development����������������������������������������  243 Derek L. Milne and Robert P. Reiser The Use of Deliberate Practice in Cognitive Behavioral Therapy Supervision: From Declarative to Procedural Knowledge ����������  259 Dan Sacks and Alexandre Vaz Remediation Processes for Health Service Psychology Trainees with Problems of Professional Competence ����������������������������������  273 Stephanie L. Freitag, Erica D. Marshall-Lee, Shujing Zhang, Scot R. Seitz, and Nadine J. Kaslow Part IV Issues and Considerations  upervision from the Perspective of the Supervisee ������������������������������������  293 S Samuel T. Jackson and Amanda Faler Reflections on CBT Supervision and Training for Therapy and Consultation����������������������������������������������������������������������������������������������  307 Tamara Del Vecchio, Mark Terjesen, Keith S. Dobson, Amanda Fernandez, Martin Drapeau, Kristene A. Doyle, Marvin R. Goldfried, Brian McNeill, Ashley Scudder, Felipa Chavez, and Cheryl McNeil Index������������������������������������������������������������������������������������������������������������������  325

Editors and Contributors

Editors Mark D. Terjesen, Ph.D., is a Professor of Psychology and Assistant Chairperson of the Department of Psychology at St. John’s University in Queens, NY, USA. Dr. Terjesen has served as the program director of the School Psychology (PsyD and MS) programs and has trained and supervised doctoral students throughout his tenure, having mentored over 100 doctoral dissertation research projects. Dr. Terjesen has studied, published, and presented at a number of national and international conferences on topics related to assessment and clinical work with children, adolescents, and families. He has trained many professionals internationally in the use of Rational Emotive Behavior Therapy (REBT) and cognitive-behavioral practices with children and families. Dr. Terjesen has served as President of the School Division of the New  York State Psychological Association, the President of the Trainers of School Psychologists, and is Past President of Division 52 (International Psychology) of the American Psychological Association of which he is also a fellow. Dr. Terjesen is a Fellow of the Albert Ellis Institute and an approved supervisor. He serves as the Clinical Director at North Coast Psychological Services in Syosset, NY. Tamara Del Vecchio, Ph.D., is a Professor of Psychology and Chairperson of the Department of Psychology at St. John’s University in Queens, NY, USA. Dr. Del Vecchio currently leads the Child and Family Research Group at St. John’s University. Her primary areas of research relate to the development of early aggression and the role of cognitions and affect as predictors of poor parenting practices. She has published several papers and book chapters on this topic and other topics related to parenting, parent-child relationship, and the development of externalizing behavior problems. She also has extensive experience supervising therapists delivering parenting and family interventions to families with young children.

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Contributors

Korrie  Allen, Psy.D., is a licensed psychologist and works in private practice at Birch Psychology in Denver, Colorado. She received an undergraduate degree in psychology from the University of Notre Dame and doctorate in psychology from St. John’s University. Her recent studies have focused on reducing disruptive and violent behavior in the school setting and parent child interaction training. She has successfully completed several research projects funded by agencies such as the U.S. Department of Education, Governor’s Office of Substance Abuse Prevention, Commonwealth Health Research Board, and the Society for School Psychology Research. Jeffrey E. Barnett, Psy.D., ABPP, is a Professor of Psychology at Loyola University Maryland. He is a licensed psychologist with over 35 years of experience in assessment, treatment, and clinical supervision and is a distinguished practitioner of the National Academies of Practice. His areas of expertise and scholarship fall within ethics, legal, and professional practice issues for mental health professionals. Brian R. W. Baucom, Ph.D., is Co-Director of the Behavioral Health Innovation and Dissemination Center and an Associate Professor of Clinical and Quantitative Psychology at the University of Utah. Clinically, Dr. Baucom specializes in cognitive behavioral and integrative therapies for individuals and couples. He has clinical experience in academic, Veterans Affairs, and private practice settings. Katherine J. W. Baucom, Ph.D., is a licensed psychologist and Assistant Professor of Psychology at the University of Utah. Dr. Baucom has served in leadership roles in national CBT-focused organizations, including on the Board of Directors of the Society for the Science Clinical Psychology and the Association for Behavioral and Cognitive Therapies. She has been delivering, supervising, and training others in individual and couple-based cognitive-behavioral therapies for over 10 years. Meredith  Boyd is a clinical psychology doctoral student at the University of California, Los Angeles. Her research centers on investigating strategies for supporting mental organizations and their workforce in improving client outcomes, with a focus on optimizing clinical supervision. As a clinical trainee, Meredith has experience providing clinical supervision to more junior doctoral students and undergraduate peer counselors. Elissa J. Brown, Ph.D., is Professor of Psychology and Executive Director of the Child HELP (Heal, Empower, Learn, Prevent) Partnership at St. John’s University. She has participated in research on the assessment and treatment of sexual assault, child physical abuse, domestic violence, and bereavement related to traumatic circumstances (such as September 11, 2001). She is the Director of a Category II site

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of the National Child Traumatic Stress Network. She is co-­developer of Alternatives for Families: A Cognitive-Behavioral Therapy, a treatment for family conflict and physical abuse, and a certified trainer of Trauma-Focused Cognitive-Behavioral Therapy, a treatment for traumatized youth and their non-offending caregivers. Craig  J.  Bryan, Psy.D., ABPP, is a psychologist and the Stress, Trauma, and Resilience Professor of Psychiatry and Behavioral Health at The Ohio State University. He has published hundreds of scientific articles and multiple books, including Rethinking Suicide and Brief Cognitive Behavioral Therapy for Suicide Prevention. He has trained and provided clinical supervision to hundreds of clinicians in evidence-based suicide risk management. Felipa Chavez, Ph.D., is an Assistant Professor of Clinical Psychology at Florida Institute of Technology. Currently, Dr. Chavez is the Director of Building Blocks, which disseminates Parent Child Interaction Therapy (PCIT) to local families through the Community Psychological Services (CPS) center at Florida Tech’s Scott Center for Autism. Her clinical and research interests are focused on how improvements in disruptive classroom behaviors can improve classroom manageability, student academic performance, and teacher stress, with rippling effects for reduced child abuse potential in the home, among lower-income, at-risk predominantly African American youth. Dr. Chavez is a PCIT International-certified within agency trainer and has trained over 60 clinical psychology graduate students in the dissemination of PCIT treatment services. Gretchen J. Diefenbach, Ph.D., completed her graduate training in clinical psychology at Louisiana State University and postdoctoral fellowship at the University of Texas-Houston Health Science Center. She is currently a Senior Scientist and Coordinator of Research Programs at the Anxiety Disorders Center at the Institute of Living\Hartford Hospital where she has also provided clinical and supervisory services for over 20 years. Dr. Diefenbach specializes in cognitive-­behavioral therapy (CBT) and her research aims to improve CBT access and outcomes for individuals with anxiety and related problems including suicidality. Keith  S.  Dobson, Ph.D., is a Professor Emeritus of Clinical Psychology at the University of Calgary, and a Consultant for the Mental Health Commission of Canada. His research focuses on models and treatments of depression, as well as stigma related to mental health problems. He is a Past- President of the Canadian Psychological Association, the Canadian Association of Cognitive and Behavioural Therapies and the World Confederation of Cognitive and Behavioural Therapies. Kristene A. Doyle, Ph.D., Sc.D., is the Director of the Albert Ellis Institute (AEI) and founding Director of the Eating Disorders Treatment and Research Center. She is also a Diplomate in Rational Emotive Behavior Therapy (REBT) and serves on the Diplomate Board. In addition to training and supervising AEI’s fellows and staff therapists, Dr. Doyle conducts numerous workshops and professional trainings

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throughout the world. Dr. Doyle is co-author of A Practitioner’s Guide to RationalEmotive Behavior Therapy, 3rd edition. She is also the co-editor of Cognitive Behavior Therapies: A Guidebook for Practitioners and the Journal of RationalEmotive & Cognitive-Behavior Therapy. In addition to her work at AEI, Dr. Doyle is an Adjunct Full Professor at St. John’s University and Teachers College, Columbia University. Martin Drapeau, M.Ps., Ph.D., is a clinical psychologist and professor of counselling psychology and psychiatry at McGill University, as well as adjunct faculty in clinical psychology at the University of Sherbrooke. His research is in the area of best practices in psychology, clinical practice guidelines, and psychotherapy process and outcome. He has served as vice president of the Quebec College of Psychologists and has also served as editor of Canadian Psychology, the Canadian Journal of Behavioral Science, and Science & Practice. Amanda  Faler, Ph.D., is a graduate of the University of Cincinnati School Psychology program and is currently a clinical fellow at Cincinnati Children’s Hospital Medical Center. As an early career psychologist, she hopes to keep research on supervisee perspectives in supervision at the forefront of her own work as a supervisor. She specializes in the treatment of moderate-to-severe problem behavior in children with neurodevelopmental disabilities. Amanda  Fernandez, Ph.D.,  is a registered clinical psychologist in Calgary, Alberta, Canada. Her research focuses on cognition and depression. She is a member of the Psychological Association of Alberta and the Canadian Association of Cognitive and Behavioural Therapies. Audrey  J.  Ford, M.A., is a Ph.D.  Candidate in the Child, Family, and School Psychology program at the University of Denver. She currently is completing her internship year at the University of Wisconsin School of Medicine and Public Health. Her research focuses on promoting equitable access to specialized services for students with disabilities including the creation of the “Gender and Race Intersectional Disproportionality Tool.” Clinically, her interests include the intersection between externalizing and internalizing disorders. Stephanie  L.  Freitag, Ph.D., is a postdoctoral resident at the Emory University School of Medicine. She graduated from Binghamton University with a PhD in clinical psychology in 2021 with a focus on severe psychopathology. She hopes to have a clinical career that combines her interest in trauma-informed care with evidence-based practice, while engaging in social justice advocacy to address disparities in mental healthcare. Robert  D.  Friedberg, Ph.D., ABPP, is a Full Professor, Head of the Pediatric Behavioral Health Care Emphasis, Director of the Center for the Study and Treatment of Anxious Youth at Palo Alto University, and a licensed clinical

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psychologist for over 30 years. Friedberg is the author of 11 books as well as numerous journal articles and national/international presentations. Marvin  R.  Goldfried, Ph.D., Distinguished Professor of Psychology at Stony Brook University, is the author of numerous articles and books, cofounder of the Society for the Exploration of Psychotherapy Integration (SEPI), and founder of In Session: Psychotherapy in Practice and AFFIRM: Psychologists Affirming Their Lesbian, Gay, Bisexual and Transgender Family. Livia Guadagnoli, Ph.D., received her PhD in Clinical Psychology with an emphasis in Behavioral Medicine from Northwestern University Feinberg School of Medicine. She is currently a postdoctoral research fellow in the Laboratory for Brain-Gut Axis Studies (LaBGAS) at KU Leuven in Leuven, Belgium, where she received a Postdoctoral Research Fellowship from the Research Foundation Flanders (FWO). Livia has unique clinical and research experience in the field of psychogastroenterology, and her work involves studying the impact of psychological processes on visceral symptom perception in an effort to develop targets for behavioral intervention. Elizabeth  Hagermoser-Bayley, Ph.D., is a licensed psychologist and Assistant Clinical Professor at the University of Wisconsin–Madison. Prior to joining academia, she practiced as an outpatient psychologist. Elizabeth currently trains and supervises school psychology graduate students in Educational Specialist and PhD programs. Samuel T. Jackson, M.A., is a clinical psychology doctoral student at St. John’s University in Queens, New York. As a clinical supervisee himself, he is interested in bringing student perspectives to research on clinical supervision processes and outcomes. Additionally, his research explores associations between mental health literacy and help-seeking behavior among caregivers and emerging adults. Nadine J. Kaslow, Ph.D., is at Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, where she is a Professor; Vice Chair for Faculty Development, Diversity, Equity, and Inclusion; and Director of Postdoctoral Residency Training in Health Service Psychology. She received her PhD in clinical psychology from the University of Houston in 1983. Past president/chair of the American Psychological Association, Association of Psychology Postdoctoral and Internship Centers, and the American Board of Professional Psychology, her major interests are in a competency-capability approach to psychology education and training, culturally responsive interventions for African Americans, and suicide and interpersonal violence. Danielle Keenan-Miller, Ph.D., is an associate adjunct professor at the University of California Los Angeles, and director of the UCLA Psychology Clinic, where she teaches and trains graduate students in evidence-based psychotherapy. She has

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served for multiple terms on the executive board of the Association of Psychology Training Clinics. She is also the co-author of The Binge Eating Prevention Workbook and maintains a private practice in Los Angeles bringing together the art and science of psychotherapy. Kristy K. Kelly, Ph.D., is an Associate Clinical Professor of Educational Psychology at the University of Wisconsin–Madison. Kristy is the co-director of a university training clinic and coordinates clinical training within the School Psychology Program. Her scholarship focuses on clinical and practicum supervision, pre-service training, and issues of professional practice. Kristy engages in scholarship that promotes the training of pre-service psychologists and integrates research and practice. Colleen  Lang, Ph.D., is a clinical psychologist and the Founder and Director of Behavioral Wellness of NYC, a group private practice specializing in the practice of CBT and DBT. She is also a clinical supervisor at Teacher’s College of Columbia University and has served as a Clinical Supervisor at St. John’s University and Ferkauf University of Albert Einstein School of Medicine. Feea R. Leifker, Ph.D., is a licensed psychologist, Co-Director of the Behavioral Health Innovation and Dissemination Center and a Research Assistant Professor of Psychology at the University of Utah. Dr. Leifker’s practice focuses on work with individuals and couples struggling with posttraumatic stress, anxiety disorders, and relationship distress. She has several years of experience supervising trainees in CBT-based individual and couple therapies. Kristine  Lin, Psy.D., is a licensed clinical psychologist and Nationally Certified School Psychologist. She is an assistant professor and International Program Coordinator in the Department of Psychology at Asia University in Taichung, Taiwan. She received her Bachelor of Science degrees in psychology and family and human development from Arizona State University and doctorate in school psychology from St. John’s University. Her research has focused on adapting measures of psychological functioning for use in other countries as well as utilizing artificial intelligence for social and emotional learning. She is currently conducting research funded by the National Science and Technology Council in Taiwan. Lauren M. Lipner, Ph.D., is Assistant Professor at Long Island University – Post campus. She is also Co-Investigator at the Brief Psychotherapy Research Program and on faculty at the Icahn School of Medicine at Mount Sinai Beth Israel. With funding from Society for Psychotherapy Research, her research focuses on the identification and measurement of alliance rupture and resolution and understanding the implications of these events for psychotherapy outcome and premature termination. Erica  D.  Marshall-Lee, Ph.D., is an Assistant Professor, Emory Department of Psychiatry and Behavioral Sciences, and Clinical Director and the primary supervisor for the Adult Outpatient Program, Psychosocial Rehabilitation Clinic at Grady

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Health System. She received her PhD in 2001 from the University of Mississippi. Her major interests are in the areas of serious and persistent mental health concerns, personality disorders, marginalized community mental and physical health disparities, education and training, and social justice advocacy informed mental and physical health. Jessica  M.  McClure, Psy.D., is a clinical psychologist and Medical Director of Behavioral Health, HealthVine, at Cincinnati Children’s Hospital Medical Center. She is the coauthor of several books on CBT with youth (CBT Express: Simple 15-min techniques for treating children and adolescents in any setting; Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts; Cognitive therapy techniques for children and adolescents: Tools for enhancing practice) and has been providing clinical care, training, program development, and supervision in the area of pediatric mental and behavioral health for over 20 years. Cheryl McNeil, Ph.D., is a Professor of Psychology in the Clinical Child program at West Virginia University. Dr. McNeil has coauthored several books (e.g., ParentChild Interaction Therapy, Second Edition, Short-Term Play Therapy for Disruptive Children, Parent-Child Interaction Therapy with Toddlers: Improving Attachment and Emotion Regulation), a continuing education package (Working with Oppositional Defiant Disorder in Children), a classroom management program (The Tough Class Discipline Kit) and a psychotherapy DVD for the American Psychological Association (Parent-Child Interaction Therapy). Dr. McNeil is a global trainer for PCIT International and has disseminated PCIT to agencies and therapists in many states and countries, including Norway, New Zealand, Australia, Taiwan, Hong Kong, and South Korea. Brian McNeill, Ph.D., received his Ph.D. in 1984 from Texas Tech University in Counseling Psychology and is currently a Professor and Director of Training for the Counseling Psychology Program at Washington State University. He is the co-editor of The Handbook of Chicana and Chicano Psychology and Mental Health (2004), Latina/o Healing Practices: Mestizo and Indigenous Perspectives (2008), and Intersections of Multiple Identities (2009). He is also the Co-Author of IDM Supervision (2010) and Supervision Essentials for the Integrated Developmental Model (2016). Dr. McNeill is a licensed Psychologist in the states of Washington and Idaho where he practices and consults. Derek  L.  Milne, Ph.D., is a clinical psychologist and a Fellow of the British Psychological Society, with extensive experience as a clinical supervisor, supervisor trainer, and supervision researcher. Starting in 1996, he led the first ever systematic R&D programme on evidence-based clinical supervision, developing our understanding and seeking to enhance practice within the field of mental health (esp. CBT supervision). Collaboration has been extensive within the National Health Service in England, with Dr. Robert Reiser in California, and latterly with the BABCP (British Association for Behavioural & Cognitive Psychotherapy). In

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2011, he retired as Director of The Doctorate in Clinical Psychology at Newcastle University, but he continues to teach and research supervision. Miriam Motechin, M.S., is a certified school psychologist and a doctoral candidate in the St. John’s University’s PsyD program in school psychology. Miriam’s research interests have involved meta-analytic analyses of therapeutic programs and development of programs to support educational evaluations. She is currently a clinical extern at the Icahn School of Medicine at Mount Sinai in the Division of ADHD, Learning Disorders, and Other Related Disorders. J. Christopher Muran, Ph.D., is Associate Dean and Full Professor at the Gordon F. Derner School of Psychology, Adelphi University. He is also Principal Investigator of the Mount Sinai Beth Israel Psychotherapy Research Program and on faculty at Icahn School of Medicine at Mount Sinai. His scholarship (supported by grants from NIMH) has focused on practice and training in alliance building and rupture repair. He is an APA fellow and has been honored by distinguished research career awards from the Society for Psychotherapy Research and the National Register. Andrea  Pérez-Muñoz, M.S., is a doctoral student in clinical psychology at The University of Memphis, Department of Psychology. Robert P. Reiser, Ph.D., a licensed clinical psychologist in California and Adjunct Faculty at the Beck Institute, has been an active clinical supervisor over the past 20 years with 8 years’ experience in running a training clinic for an APA-approved doctoral program; as a consulting supervisor providing CBT training to Veterans Administration clinicians within the CBT-D national training program; and, currently, he trains psychiatric residents in the Department of Psychiatry at the University of California, San Francisco. He has written and co-authored several journal articles, has contributed book chapters on evidence-based approaches to clinical supervision, and has co-­authored with Derek A Manual for Evidence-Based CBT Supervision and, most recently, a book on supportive clinical supervision. David  Reitman, Ph.D., is a psychologist and professor at Nova Southeastern University in Fort Lauderdale, Florida. He has published broadly on the assessment and treatment of child behavior problems and parenting practices. He has served on the editorial boards of Behavior Therapy, Cognitive and Behavioral Practice, and Child and Family Behavior Therapy; as an Associate Editor of Education and Treatment of Children; and as the Editor of the Behavior Therapist. He has provided clinical supervision to over 150 students over the past 25 years. M. David Rudd, Ph.D., ABPP, is the 12th President of the University of Memphis and a Distinguished University Professor of Psychology. He has several hundred publications and over 15,000 citations of his work on suicidality, including two prominent books on treatment, Treating Suicidal Behavior and Cognitive Behavioral Therapy for Suicide Prevention. Along with others, he helped develop the core competencies in suicide risk assessment and treatment.

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Dan Sacks, M.A., is a Clinical Psychologist and certified Deliberate Practice (DP) coach. He is secretary of the board for the International Deliberate Practice Society. Dan teaches DP and CBT in numerous psychotherapy schools and provides workshops and supervision to professionals globally. He is also the founder of the Israeli Center for Deliberate Practice. Annette J. Schieffelin is a clinical psychology doctoral student in the Child and Adolescent track at St. John’s University in Queens, New York. Within the field of clinical supervision, Annette is generally interested in research that examines the role of supervision in the dissemination and implementation of evidence-based treatments. Additionally, her current research explores the impact of parenting on child functioning. Haley M. Schultz, Ph.D., earned her doctoral degree in Educational Psychology from the University of Wisconsin–Madison. She is a clinical child psychology fellow at Nationwide Children’s Hospital. Ashley  Scudder, Ph.D., is a Scientist at the Partnerships for Prevention Science Institute at Iowa State University. Dr. Scudder is a PCIT International-certified regional trainer. Her clinical and research interests are focused on ways in which evidence-based treatments are tailored or adapted to potentially improve their impact or reach, including 1) understanding community-based service systems, 2) developing and testing implementation models, and 3) adapting and testing existing evidence-based treatments to novel populations or community settings (e.g., domestic violence shelters, prisons, autism). She has been providing clinical consultation to community-based PCIT clinicians for the past 10 years and has now trained more than 300 professionals across 7 states in Parent-Child Interaction Therapy. Scot  R.  Seitz, Ph.D., is a postdoctoral resident in health service psychology at Emory University School of Medicine. He graduated from Georgia State University with a PhD in clinical and community psychology in 2021. His professional interests include social justice advocacy, serious and persistent mental disorders, and program development and evaluation. Komal Sharma-Patel, Ph.D., is a psychologist in the Mood and Trauma Clinic at Children’s National Hospital in DC. She has an expertise in trauma and has been providing clinical and supervisory services to individuals across the lifespan for more than 10 years. Maria  Alejandra  Sisniegas, M.S., is a fourth-year PsyD student at Nova Southeastern University’s Clinical Psychology graduate program. Her clinical interests include working with children, adolescents, and families impacted by behavioral disorders, predominantly ADHD and ODD, and co-morbid mood and anxiety disorders. Her research interests include issues related to immigration and acculturative stress.

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Rebecca  Stock, M.S., is a certified school psychologist who is completing her Psy.D. in the School Psychology Doctoral program at St. John’s University. Her research focuses on clinical and supervision competency and childhood bereavement. Rachel Vaughn, PsyD, is a LCSW and NYS Certified School Psychologist who earned her doctorare in School Psychology at St. John’s University. Her research focuses on clinical supervision in professional psychology and creating a multimodal training program that will increase clinical supervisory competency and selfefficacy prior to graduate students entering into the field. Alexandre  Vaz, Ph.D., is cofounder and Chief Academic Officer of Sentio University. He provides workshops and advanced clinical training and supervision to clinicians around the world. Dr. Vaz is the author/co-editor of five books on deliberate practice and psychotherapy training and two series of clinical training books: The Essentials of Deliberate Practice (APA Press) and Advanced Therapeutics, Clinical and Interpersonal Skills (Elsevier). He has held multiple committee roles for the Society for the Exploration of Psychotherapy Integration (SEPI) and the Society for Psychotherapy Research (SPR). Olivia A. Walsh, M.S., is a certified school psychologist and a doctoral candidate at St. John’s University’s PsyD’s program. Olivia’s research interests include looking at differences in children’s behaviors, thoughts, sleep and parenting behaviors across cultures, as well as behavioral parent training and the use of deliberate practice in psychotherapy. She is currently a clinical extern at Northwell’s Zucker Hillside Hospital in the Child and Adolescent Outpatient Psychiatry Department. Jason J. Washburn, Ph.D., is a clinical psychologist and professor at Northwestern University Feinberg School of Medicine. He is the Director of Graduate Studies for the MA and PhD programs in Clinical Psychology. He is the 2020–2022 Chair of the Council of University Directors of Clinical Psychology. His interests include education and training in health service psychology, integrating outcomes into routine practice, nonsuicidal self-injury, and suicide assessment and prevention. Madalina  Yellico, Ph.D., is a licensed psychologist in private practice at North Coast Psychological Services (Syosset, NY). She completed her doctorate in clinical psychology at St. John’s University with a focus in the study of anger, rumination, and impulsivity in relationships. Dr. Yellico specializes in working with children, adolescents, and their families, frequently with a parent-training component. She is trained in evidence-based practices, including Cognitive-­Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT), and Parent-Child Interaction Therapy (PCIT).

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Shujing Zhang, Ph.D., is a postdoctoral resident at the Emory School of Medicine. She graduated from the University of Georgia with a Ph.D. in counseling psychology in 2021. Her professional interests include culturally informed clinical work for individuals with serious mental disorders and trauma and global health prevention and intervention research. Rachel K. Zukerman, M.A., is a clinical psychology doctoral student at St. John’s University in Queens, New York. She is interested in the field of dissemination and implementation science, and her research explores the cognitive and affective processes of partner conflict.

Part I

Foundations

Supervision in Cognitive Behavioral Therapy: Theory, Practice, Culture, and Ethics Mark Terjesen, Audrey J. Ford, Korrie Allen, Kristine Lin, Madalina Yellico, and Olivia A. Walsh

Clinical supervision plays a key role in developing clinical skills and knowledge for psychotherapists in training (Milne, 2009). Clinical supervision is a primary mechanism by which trainees attain and maintain competency (Bernard & Goodyear, 2013). While clinical supervision plays a key role in trainees’ development, there is no comprehensive definition of clinical supervision in psychotherapy (Bernard & Goodyear, 2013). Instead, clinicians have often conceptualized supervision in psychotherapy as instruction for trainees to gather guidance in forming case conceptualizations, theoretical knowledge, therapeutic competency, and clinical skills (Bernard & Goodyear, 2013). The American Psychological Association (APA) released guidelines for Clinical Supervision in Health Service Psychology in 2015 to promote the quality of supervision in health service psychology. While these guidelines are informative, the definition is based on a number of assumptions made by the members of the task force. One of these assumptions is that the supervisor is competent not only as a professional psychologist but also as a clinical supervisor (Fouad et  al., 2009). However, this assumption may not be accurate as little research has focused on M. Terjesen (*) · O. A. Walsh Department of Psychology, St. John’s University, Queens, NY, USA e-mail: [email protected] A. J. Ford University of Denver-Colorado, Denver, CO, USA K. Allen Birch Psychology, Denver, CO, USA K. Lin Asia University, Taichung, Taiwan M. Yellico North Coast Psychological Services, Syosset, NY, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. D. Terjesen, T. Del Vecchio (eds.), Handbook of Training and Supervision in Cognitive Behavioral Therapy, https://doi.org/10.1007/978-3-031-33735-2_1

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evaluating the competency of supervisors (Bernard & Goodyear, 2013). In addition, the guidelines’ authors acknowledged that guidelines are not mandated to be followed nor are they all-inclusive; in fact, supervisors’ judgments should take precedence over the guidelines (APA, 2015). This may be problematic if a supervisor is incompetent and judgments may harm both the client and the supervisees. While these guidelines are a step in the right direction of providing a more uniform definition of clinical supervision, it still does not standardize the supervision process in any way. There is also a gap in how supervision is delivered, which warrants further consideration. Further, the practice of supervision may vary by supervisor, supervisee, training context, and the theoretical orientation of the supervision of clinical skills. Falender and Shafranske (2021) offer a comprehensive text on clinical supervisory competency that nicely merges the science and the practice and should be considered an essential read for any supervisors at any stage of their supervisory career. This chapter focuses on the practice of supervision in cognitive behavior therapy (CBT).

Cognitive Behavior Therapy Supervision While CBT is the primary theoretical orientation of most mental health providers (Wolitzky-Taylor et  al., 2018), inconsistencies in CBT supervision training have been reported (Milne, 2016). Clinical supervision in CBT theoretically was intended to be a systematic and direct extension of CBT (Beck, 1997; Padesky, 1996). More specifically, the model for clinical supervision specifically for CBT was proposed to mimic the structure and form of CBT sessions, such as using agendas, setting goals, assigning homework, providing feedback, and incorporating problem-solving (Cummings et al., 2015). However, this format is not presented in a formal supervisory model; therefore, it may be challenging for supervisors to engage in a CBT format systematically and consistently. In addition, while CBT supervision following this format may have high face validity, little empirical evidence supports these specific components as recommended (Milne et al., 2010). In addition, the extension of clinical practice to supervision is not always consistent with some supervisors not following these CBT principles as they relate to supervision (Milne, 2008). Additionally, little empirical evidence exists supporting the causal mechanism between supervision and treatment quality (Milne et al., 2008), that is, understanding to what degree supervision improves service provision and clinical outcomes. Findings are mixed as to whether clinical supervision directly impacts client outcomes (Watkins, 2020). Despite some of the gaps in knowledge and practice of CBT supervision, it is also important to recognize that some progress is being made to address some of these issues, through the creation of manuals such as Milne and Reiser’s Manual for Evidence-Based CBT Supervision (2017). While a standardized manual for CBT supervision may help create a more uniform method, it is not used by all. According to APA (2015), there is no specific guideline that a supervisor needs to follow. As

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stated earlier, APA’s guidelines are suggestions, and the supervisor is ultimately responsible for what structure they follow. Therefore, it is critical to discuss and acknowledge the specific issues surrounding supervision in CBT due to the potential that negative experiences during supervision may have on clinical trainees. The practice of supervision in CBT would benefit from further empirical support and dissemination of “best” supervisory practices. This may help prevent inadequate or improper supervision, the seventh most commonly reported reason for disciplinary actions by licensing boards (Greenberg et al., 2010). Moreover, in a survey of 363 supervisees, 35% reported having a harmful supervision experience (Ellis et al., 2014). Reiser and Milne (2017) found that “lack of recognition of the importance of power, privilege, and cultural differences; poor supervisory boundaries; accounts of unresolved and unrecognized difficulties in the supervisory alliance; lack of consistent formative feedback; and inadequate, inconsistent documentation of problems in supervision” (p. 102) were among the fundamental problems supervisees reported in their supervision. Similarly, Ellis et al. (2017) found unethical supervision to include issues related to boundaries during supervision, inconsistent feedback, and inadequate documentation of problems that occurred during supervision. Ethical considerations for the provision of CBT supervision are briefly offered later in this chapter. To prevent harmful or unethical supervision moving forward, Milne and Reiser (2016) argued for a broader systems-contextual view of supervision to guide and develop clinical supervisors. In addition, it may be beneficial for supervisors to participate in professional development and have a certain level of competency, which will be discussed later in this chapter. With the training of CBT clinicians not conforming to a one-size-fits-all model, we think it is important to start with a section on understanding the supervisee’s training level and how a CBT supervisor may wish to modify their supervisory approach as a result.

Developmental Model for Supervision in CBT Developmental models of supervision have been used in a plethora of iterations, including in the application of CBT supervision (Mason & Mullen, 2022; Simon et al., 2014; Stoltenberg & McNeil, 1997). Anecdotally, many supervisors claim they hold to a developmental supervision model; however, few clearly define how to meet supervisees at their current skill level. Roscoe and others (2022) have suggested that a lack of uniformity between CBT supervisors indicates the need for more guidance and clarity within the field about the activities, processes, and development of CBT supervision. For example, the inconsistent use of well-­ established CBT supervision practices, such as formal evaluation of video review and opportunities for role-play in supervision, could be addressed by more clearly outlining the process of the supervisee’s development and available support (Roscoe et al., 2022). Therefore, it is important to address how CBT supervisors view the developmental processes and how that is applied to the supervision and training of clinicians.

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To begin, Johnston and Milne (2012) position the concept of supervision in the context of learning. When discussing supervision activities, the term zone of proximal development references Vygotsky’s theory of sociocultural development (Johnston & Milne, 2012; Nye, 2007). The language used to describe the supervision process suggests that the supervisor is responsible for providing the structure that promotes the supervisee’s learning of how to be an independent clinician. In this way, on the tandem bicycle metaphor that Milne and James (2005) used to describe the roles of CBT supervision, the supervisor is in the role of creating clear learning objectives and methods to facilitate learning. While many have detailed the process of what CBT supervisors can do to promote their supervisee’s growth (i.e., directly teach, role-play, and homework, Mason & Mullen, 2022; goal setting, guided discovery, and video recordings, Johnston & Milne, 2012), how supervisors communicate the supervisee’s current level of performance and their next step toward growth have been ill-defined. Roscoe and others (2022) found that providing trainees with a workshop about CBT supervision before they engage in a supervision relationship allowed them to better advocate for interpersonal and self-reflective issues. The following describes a developmental model of CBT supervision that emphasizes the need to systematically determine the requirements for independence, the support available for growth, and where the supervisee currently stands developmentally. A developmental approach allows the CBT supervisor to embed education about the supervision process into the relationship. Not only does this equip the CBT supervisor to better meet the supervisee’s needs but it also empowers the supervisee to know how they can advocate for more support or more independence in the development process.

Brief Sequence of Supervision Supervision starts before the first supervision meeting; it begins with a clear understanding of what a certain activity looks like as an independent practitioner and requires reflection on the supervisor’s part. In addition to CBT concepts such as goal setting and reflectivity (Johnston & Milne, 2012), applying educational concepts such as backwards planning (Graff, 2011) and scaffolding (Vygotsky, 1978) will help fill the gap of how the CBT supervisor can promote the growth of their supervisee. A true developmental supervision model provides structures such as pre-­ assessment, explicit instruction, and progress monitoring (Simon et al., 2014). In most contexts, pre-assessments are based on the supervisor’s impression or a list of competencies put in place by the university-based program or an accrediting body such as the APA. However, many of the competencies do not apply to the specific activities within the training site, or they are so broad and general that it is difficult to ascertain an individual’s competence. In this case, the onus for specific goal development falls on the supervisee. However, the supervisee has never been at the training site before and might not know the existing structures (Proctor & Rogers,

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2013). Therefore, the pre-assessment is best informed by the supervisor’s reflection on what the training site offers.

Backwards Planning (Pre-Assessment) Backwards planning refers to explicitly mapping out the expectations for a certain activity in independent practice before structuring the activities for supervision. Beginning with the end in mind in CBT supervision requires the supervisor to take an inventory of their role and current independent practices. For example, in a clinical practicum, it is first necessary to detail your expectations for an independent psychologist at each part of the clinical process. The process can be done within a myriad of contexts, including contexts in which therapy and consultation are the main activities (see Appendix A: What Does Independence Look Like?). The reflective practice of the CBT supervisor’s own work then allows them to determine what they can offer the supervisee in terms of learning. The first step is to answer the questions: • What behaviors do someone who is independently practicing this skill exhibit? –– What preparation or knowledge is needed before the activity in independent practice? –– What self-monitoring strategies are needed throughout the activity in independent practice? –– What does competence look like during the activity in independent practice? –– What would reflection look like after the activity in independent practice?

Explicitly Defining Development The next step of supervision requires the supervisor to construct the developmental process. To accurately assess the supervisee’s current skill level and whether a particular activity is within their zone of proximal development, the CBT supervisor needs to explicitly define the steps that might be taken to reach independence in the skill or activity that is the focus of the training. For example, in CBT clinical work, it makes more sense for supervisees to develop competency in some of the standard practices within CBT (e.g., psychoeducation, cognitive restructuring/reframing, activity scheduling/behavioral activation, and progressive relaxation) before work with more challenging/resistant clients (e.g., personality disorders, suicidal clients, and dual diagnoses). In therapy, developing the skill of psychoeducation comes before the more advanced skills of acting opposite or thought logs. Clearly defining the skills necessary for each level moves the CBT supervisor from thinking about their skill level to the trainee’s skill level in a systematic way. While Mason and Mullen (2022) provide a description of the levels of trainees based on emotional qualities (i.e., anxious), the focus in this practice is to address the skills that might

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be developed step-by-step and to connect the supervisor’s experience to the supervisee’s. The questions that need to be answered in this stage are as follows: • “What behaviors would a supervisee who is emerging as an independent practitioner with this skill exhibit?” –– What is one step down from independence in this skill? –– How might preparation be different for a supervisee who is not quite ready for independence? –– What type of reflection would be appropriate and most helpful for a student who is moving toward independence? • What behaviors would a supervisee who is developing this skill exhibit? –– What technical skills am I expecting the supervisee to have at the start of the training year? –– What soft skills am I expecting the supervisee to have at the beginning of the training year? –– What are the necessary expectations for the supervisee in their role at the beginning of the year? For example, within the context of CBT clinical work, the expectation for a developing supervisee simply is to practice reflection about their CBT skill performance in their clinical work, whereas an emerging supervisee is expected to produce actionable reflections after a session to develop continued clinical competency. Defining the development of specific skills that the supervisee will develop throughout the training experience will provide a clear ladder of progression for the supervisee and supervisor. This ladder can be utilized to set shared goals and communicate the supervisee’s progress. In essence, the prework of detailing the skills of a developing, emerging, and independent practitioner will aid the CBT supervisor in crafting the needs assessment, clear learning objectives, and evaluation, allowing the supervisor to better meet the supervisee’s needs (Milne & James, 2005). It is important to note that these steps are not set in stone. Parallel to the process of CBT, supervision too can skip steps and recursively find its way back to working on the same skill. The important piece to defining the steps is not the linear progression, but it is instead shedding light on the mysterious act of skill acquisition. Sharing the knowledge of the steps toward independence with trainees not only demystifies the process but also empowers the supervisee to create strong, shared goals (Johnston & Milne, 2012).

Goal Directed Many have observed the similarities between effective CBT and effective CBT supervision (Corrie & Lane, 2015; Prasko et al., 2011; Pretorius, 2006). The overlap includes goal directedness. Johnston and Milne (2012) found that shared goals in

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CBT supervision help to establish the supervisory relationship. When the supervisor has taken time to detail the developmental trajectory at a certain training site, the supervisor’s reflection provides a scaffold that allows supervisees to craft specific and attainable goals. In fact, Milne and Dunkerley (2010) found that the goal-­ directed principle of supervision is strengthened when taking a developmental approach. In a way, providing this scaffold also moves the needs assessment and evaluation activities, initially owned by the CBT supervisor, to the middle of the tandem bicycle model, allowing the supervisee to utilize the developmental trajectory as a means of self-evaluation (Milne & James, 2005). The action of self-­ evaluation then also empowers the supervisee in the process of goal setting because they have a model of language for the potential activities in which they could engage (Vygotsky, 1978). The shared ownership of formative evaluation throughout the learning process also allows the evaluation stage to be recursive instead of stand-alone.

Planning Levels of Support After the pre-assessment phase is the explicit instruction phase (Simon et al., 2014). Once the supervisor has constructed a developmental skills progression for that specific training site and the supervisee has crafted goals for their training year, the supervisor must construct methods to facilitate learning (Milne & James, 2005). In the context of learning sciences, this could be considered the actual activities that CBT supervisors practice (e.g., role-play and video review), or this could also detail self-study and supervisor-supported activities that will help the supervisee develop a particular skill. Borrowing again from the field of education, the level support system introduced by Walker and others (1996) is a model of three tiers of support for students in the classroom (e.g., universal, targeted, and intensive). Although used heavily in education, this model has also expanded to other realms, such as pediatric psychology, to communicate the level of patient need to a consultation and liaison team (Carter et al., 2020). Therefore, based on the shared language that the developmental trajectory provides, the CBT supervisor and supervisee can conjointly decide on how to facilitate the growth from a developing practitioner to an independent practitioner through intentional scaffolds. The three tiers allow the supervisee to see what is usually invisible, what do all supervisees receive in terms of supervision compared to what might be necessary in a particularly complex case (Proctor & Rogers, 2013). To limit shame or challenging cognitions in the supervisee such as “My supervisor is providing me with higher levels of support because I am failing,” it is important to normalize that there are times that the supervisor might choose a higher level of support through consultation for complex cases. Along with normalization, it is also important to share that both the CBT supervisor and the supervisee can ask to move to a certain level of support for a case. These conversations should always be completed in a way that

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also elicits the cognitions and emotions that the supervisee feels about receiving support. If a supervisee struggles with a particular skill (e.g., motivational interviewing), the tiers of support can be useful along with walking through the same process as the developmental trajectory.

Supervisor-Supervisee Relational Issues Within clinical supervision, regardless of the definition, guidelines, or manuals used, it is important to understand the potential issues that may arise in the supervisor-­supervisee relationship. This edited volume has another chapter specifically written about the supervisory working alliance (see Chapter “Supervisory Alliance: Reflections and Illustrations”) and a section below that addresses the relationship from an ethical perspective. However, we thought it necessary to briefly address some aspects of the relationship between supervisor and supervisee that may be important for the supervisor to consider. There are certain assumptions that are made about clinical supervision that do not always readily translate into behavior. The supervisor is the licensed professional who is assumed to be competent (Bernard & Goodyear, 2013). It is the supervisor’s goal to not only assist in providing the trainee knowledge and clinical skills but also provide clients with quality care (Swift et  al., 2015). To do so, ongoing feedback is critical (Newman & Kaplan, 2016). It may also be beneficial for supervisors to evaluate their competencies prior to being a supervisor to understand where they may need to further their training and utilize professional development in these lacking areas. The supervisee is the training clinician who learns from the supervisor with a goal of developing competency in order to advance to the next level or to licensure (APA, 2015). Supervisees are not responsible for regulating the quality of supervision they receive; it is the supervisor’s responsibility, along with the training programs, to ensure they are competent to provide supervision (Reiser & Milne, 2017). The supervisory relationship’s saliency is often underestimated (Ladany, 2004). An issue a supervisor may come across is how much to challenge the supervisee without compromising their supervisory relationship. While it is critical for the supervisee to feel supported in developing their skills and knowledge, it is also critical for the supervisor to push the supervisee out of their comfort zone and challenge them. This is a delicate balance. Supervisors are encouraged to be aware not only of how they are delivering the criticism but also of the supervisee’s personality and body language so that they can tailor how to challenge each trainee individually. The supervisor-supervisee relationship is hierarchical in nature as the supervisor holds more power; this suggests that supervisees are required to comply with their supervisors (Goodyear & Rousmaniere, 2017). This raises the issue of what happens when a supervisee does not follow the supervisor’s guidance. As stated earlier, part of supervision is providing clients with quality treatment; therefore, it is essential to address this situation. It is critical for the supervisor to add these issues to the

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agenda for supervision, problem-solve, and provide direct, formative feedback to the supervisee (Cummings et al., 2015). The hierarchical nature of the supervisor-­ supervisee relationship may also contribute to supervisees distorting and withholding information during supervision (Goodyear & Rousmaniere, 2017), highlighting the importance of direct observation. It is the supervisors’ responsibility to proactively prepare for these challenges (Cummings et al., 2015).

The Role of Culture in Clinical Supervision in CBT With an increasing number of culturally diverse individuals seeking psychotherapy and counseling services (Inman & Ladany, 2014) and an increase in the number of culturally diverse providers, there is more diversity within clinical care and supervision (Tohidian & Quek, 2017). With this rise, there has been more attention toward culture-related and diversity-related issues in both clinical practice and supervision. Although lengths have been taken to address multicultural competency training in graduate school programs through the American Psychological Association’s accreditation standards (American Psychological Association Committee on Accreditation, 2018) as well as guidelines for practice and supervision, there are still some multicultural domains in which supervisors are lacking (American Psychological Association, 2005, 2015; Kune & Rodolfa, 2013). The role of culture in clinical supervision in CBT as it relates to current issues and strategies for supervisory practice will be reviewed, and strategies to address the practice of supervision will be offered.

Cultural Competency Issues in Supervision One of the challenges in competency and supervision in health service psychology (school, clinical, and counseling) doctoral-level training is that supervisors are not consistently exemplifying essential components of supervisory practice, such as demonstrating multicultural competence (Falender, 2018; Furr & Brown-Rice, 2016; Kakavand, 2014; Ladany, 2014). Inconsistencies such as this can be dangerous as they not only affect the supervisees’ clients but also do not adhere to the standards of competent and ethical supervision (Falender, 2018). Further, just because supervisors think they are competent in supervising multicultural issues may not reflect that they actually are. Differences have been seen between self-assessed multicultural competency and actual practice among self-­ identified multiculturally competent psychologists. One supervisory area that may be impacted upon by supervisors’ lack of multicultural competency in supervision may be that of the supervisory relationship. This may be seen when supervisors demonstrate difficulties with “understanding or empathizing with diverse and multiple cultural aspects of supervisees and clients (e.g., race, ethnicity, gender, and

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gender identity)” (Falender et al., 2013, p. 16). Additionally, although scales have been developed, such as the Supervision Outcome Scale, which provides the supervisee’s perspective on the supervisor’s competence in addressing multicultural issues and has highlighted a need for improvement in supervisory training, it is difficult to understand or assess the effectiveness of multicultural supervision (Falender et al., 2013; Hansen et al., 2006; Sehgal et al., 2011; Tsong & Goodyear, 2014). Examples of negative impacts of a lack of multicultural competence directly experienced by supervisees include self-doubt and feelings of powerlessness (Jernigan et al., 2010; Singh & Chun, 2010). Thus, understanding both the supervisor’s and supervisee’s worldview and frames of reference can positively affect the effectiveness of multicultural supervision. This increased understanding can be facilitated through supervisors attending to and initiating conversations about the intersecting identities of themselves, their supervisees, and the clients. Multicultural competence may also be impacted by the methods through which supervision is delivered. For example, with the increasing occurrence of group supervision, overlooking or avoiding discussing multicultural events or misapplying multicultural theory can hinder culturally effective supervision (Falender et al., 2013; Kaduvettoor et al., 2009; Riva & Cornish, 2008). A competent supervisor is able to address issues of diversity in his/her relationship with the supervisee as well as the supervisee’s relationship with the client (Bernard & Goodyear, 2013; Falender et  al., 2013; Kune & Rodolfa, 2013). Attention to diversity in supervision often focuses on a single factor, such as gender, race, or ethnicity. In contrast, the intersectionality of these factors with other facets of diversity, such as sexual orientation, age, immigration station, gender identity, and socioeconomic status, is often overlooked (Falender & Shafranske, 2021).

 he Importance of Cultural Competence in CBT Supervision T and Strategies for Supervisors Culturally responsive supervisors work to address the clinical needs of their clients to make professional practice effective. As a result, supervisees report more satisfaction with supervision when their supervisors attend to diversity-related problems (Falender & Shafranske, 2004; Tohidian & Quek, 2017). Attending to issues of culture and diversity is important, but doing them in a culturally competent way is essential. We like the cultural competency in clinical definition provided by Tsui et  al. (2014), “cultural competence in clinical supervision refers to the ability of supervisees and supervisors to related to each other in order to achieve the objectives of clinical supervision, regardless of any diversity issues or contextual differences” (p. 240). Supervisors can be effective in acquiring cultural competence by providing positive supervision experiences, such as allowing supervisees to discuss cultural issues with their supervisors, which, in turn, help supervisees to feel more sensitized to the importance of cultural issues as they affect the therapeutic process (Pope-Davis &

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Coleman, 1997; Sue & Sue, 2008; Burkard et al., 2006). Thus, it is important for supervisors to become culturally competent by enhancing their awareness and knowledge of multicultural issues in supervision (Tsui et al., 2014). The term “ecological niche” is used to represent the intersection of various identities, which include but are not limited to religion, sexual orientation, gender, disability, education level, race, socioeconomic status, race, immigration history, religion, indigenous heritage, etc. We recommend that the supervisor consider their own ecological niche as well as those of the supervisee and their client. Although the supervisee is not required to do so, a supervisor may self-disclose their identity and discuss how it may influence the lens through which the client is viewed and will be discussed throughout supervision. In so doing, the supervisor is modeling, supporting, and discussing multicultural perspectives (Falendar & Shafranske, 2021; Jernigan et al., 2010). It is also important for the supervisors and supervisees to have an emic understanding, meaning that conceptions are seen through the eye of the members of a specific culture (as opposed to etic, which refers to universal conceptions across cultures; Falendar & Shafranske, 2021). This allows for interventions to be decontextualized to determine their cultural basis and then recontextualized in line with relevant cultural aspects of the client’s particular group (Quintana & Atkinson, 2002), thus making the treatment informed by multicultural thought. It is important for supervisors to understand ethnic identity development as a factor operating within the clinical relationship (Falendar & Shafranske, 2021). Having supervisors be proactive in initiating discussions with supervisees regarding diversity variables, such as race, gender, socioeconomic status, and sexual orientation, as they relate to clients’ worldviews and case conceptualization can be beneficial. Conversations such as these can foster and develop supervisees’ multicultural knowledge. Not only should supervisors initiate these kinds of conversations but they should also demonstrate acceptance of cultural differences between themselves, the clients, and their supervisees. Supervisors’ awareness of their biases, beliefs, and values and their influence on intercultural encounters are also important to consider (Tohidian & Quek, 2017). Increased awareness regarding both similarities and differences between the supervisor and supervisee can be facilitated by viewing diversity as normative rather than as something unique or unusual (American Psychological Association, 2015). Further, helping improve their supervisees’ self-awareness, considering client cultural background when conducting case conceptualization and intervention planning, and improving supervisees’ multicultural competency are beneficial for developing a cultural mindset to supervision (Ancis & Ladany, 2010; Soheilian et al., 2014). When interventions intentionally focus on cultural issues, such as discussing culturally appropriate therapeutic interventions, supervisees’ self-awareness, professional growth, and self-efficacy increase, and their perception of their supervisor’s competence is improved (Cashwell et  al., 1997; Gatmon et  al., 2001; Inman, 2006; Mori et  al., 2009; Soheilian et al., 2014). Supervisors should be aware of any of these multicultural processes in supervision and evaluate the multicultural competencies of the supervisees (Ancis & Ladany, 2010; Soheilian et al., 2014).

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It is also important for supervisors to be supportive by fostering a collateral alliance, creating relational safety, managing power, and communicating to the supervisees that they care about their views and opinions, in turn helping the supervisees to feel validated. Examples of such behavior include managing discomfort experienced by supervisees while discussing multicultural issues; modeling self-­ disclosure, respect for diverse perspectives, and openness; and encouraging professional growth in their supervisees. Timely and consistent feedback regarding multicultural strengths and weaknesses from supervisors to supervisees help with the supervisees’ professional development in influencing their understanding and perceptions of clients in multicultural contexts. Failure to do so may result in negative consequences for supervisees (Tohidian & Quek, 2017). We like the multicultural orientation model proposed by Watkins et al. (2019) that is applied to psychotherapy supervision: the Multicultural Orientation-­ Supervision (MCO-S). This model primarily focuses on the supervisor in recognition of their power position in the supervisory relationship. Three components of MCO-S may be helpful for supervisors to consider. The first is cultural humility, which posits that supervisors must be open and willing to reflect upon themselves in understanding the supervisees’ and their clients’ cultural backgrounds and identities. Having supervisors display both respect and curiosity in understanding their cultural identities and avoid making assumptions about them is important. Supervisors who demonstrate cultural humility are less likely to engage in supervisory microaggressions and are better able to detect and repair any possible conflicts in the supervisory relationship. The second component is cultural comfort, which indicates that supervisors should aspire to feel comfortable, non-defensive, and relaxed before, during, and after holding culturally relevant conversations with their supervisees. To successfully do so, they will need to work through their own cultural anxiety and discomfort, possibly by consulting with others to better understand the cultural issue to be discussed. The final component of the model is cultural opportunities, which is when supervisors take advantage of an opportunity to discuss culture rather than avoid or miss it. There are multiple ways in which a client’s presenting problem can be approached, of which the possibility of the impact of culture is present. Supervisors should recognize the importance of discussing culture as it is an important aspect of both supervision and therapy. Supervisors who demonstrate both cultural humility and cultural comfort are better able to detect and utilize opportunities to address cultural issues as they arise in supervision as well as have more successful discussions about culture (Watkins et al., 2019). Further, the field of psychology has begun to address issues related to clients who are queer people of color; however, the field has been slow to focus on issues unique to queer people of color as they relate to supervisees or supervisors (Singh & Chun, 2010). The Queer People of Color (QPOC) Resilience-Based Model of Supervision, developed by Singh and Chun (2010), focuses on supporting both supervisee and supervisor development to provide culturally competent and affirmative supervision that addresses the intersections of race and sexual orientation. Similar to recommendations offered by Tohidian and Quek (2017) and Watkins et al. (2019), this framework requires supervisors to engage in ongoing self-reflection regarding their

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own diversity and awareness of privilege and oppression. The authors propose suggestions to further the field as it relates to supervision of queer people of color: (1) psychologists can include that they value queer trainees of color when recruiting supervisees, (2) psychologists can provide training on working with queer people of color and exploring the intersection of race and sexual orientation, (3) psychologists can discuss how the multiple identities of queer people of color trainees may influence case conceptualization of clients, and (4) counseling centers can employ queer people of color staff psychologists. Finally, in order to guide effective supervision in multicultural and international contexts, we agree with Falender’s argument that there is a need to “develop an empirically derived knowledge base to expand supervisor knowledge, skills, and attitudes regarding the implementation of Competency Benchmarks as a metric for supervisee competency development” (Falender et al., 2013, p. 19). That being said, supervisors should continue to educate and familiarize themselves with effective multicultural supervisory practices by pursuing ongoing training, such as attending continuing development workshops and reading relevant literature, especially as it relates to helping supervisees navigate conflicts or tension between professional and personal values (American Psychological Association, 2015). Research that addresses cultural, diversity, and social justice issues in the supervisory relationship will help guide supervision as well as in the training of competent CBT supervisors. Additionally, having supervisors attend to and initiate conversations about marginalized identities will assist in training multiculturally competent clinicians (Falender et al., 2013). Although there have been strides in addressing multicultural issues in supervision, there is a clear need to further research in this area and train supervisors to become more culturally competent, thus influencing the supervisor-supervisee relationship, quality of supervisee training, and intervention outcomes.

Ethical Practice and the Provision of Supervision Supervision is a key tool in supporting a beginning clinician in becoming an independent practitioner. As in other clinical practice areas, challenges and issues may hinder the process if not adequately anticipated, reviewed, and managed. Presented here is a summary of main ethical concerns, their possible impact on therapeutic practices and learning, and suggestions for how they can be handled. It is important to note that these are ethical concerns that apply to the overall field of psychology and clinical supervision and are not specific to CBT supervision, but where appropriate, we provide specific CBT examples of the application of these principles. Further, we discuss ethical guidelines across professions where CBT supervision may occur and the reader is encouraged to consult their specific ethical guidelines for their professional domain of practice. For a more comprehensive review of ethical considerations in CBT supervision, the reader is referred to Chapter “Ethics in Supervision” in this edited volume. This section focuses primarily on the consideration of ethics as it impacts supervisory and therapeutic practices.

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Competence in Supervision Competence is a vital element in satisfying the ethical obligation toward the best interest of the client (Milne & Dunkerley, 2010). Not only could clinical care be compromised if the supervisor struggles in an area of psychological proficiency, but there is an added risk of harming the learning and professional trajectory of the trainee. A strategy to address concerns of supervisor competency would involve a self-assessment of competency for the supervisor, which Barnett and Molzon (2014) propose can be broken down into two areas. First, a supervisor should evaluate their ability to supervise adequately, incorporating the capacity for didactic instruction, assessment, guidance, and Socratic questioning. The second area is the determination of competence in the clinical areas being supervised, such as the presenting concern of the client and the client population (Barnett & Molzon, 2014). If a supervisor recognizes a need for more expertise in one of these areas, referring supervisees to a colleague with the necessary experience is best. As it relates to this chapter and this handbook, this would involve being aware of one’s CBT competence in a clinical and supervisory capacity for the area of concern. For example, while a supervisor may have strong CBT clinical and supervisory experience in working with clients with an anxious symptom presentation, that does not mean they would be competent to supervise a clinician working with a client with an eating disorder. This possibility should be discussed at the commencement of supervision and be stated as part of the supervisory contract (Barnett & Molzon, 2014). A supervisor further has the goal of assessing the competence of the supervisee (Johnson, et al., 2008). Concerns with competency can relate to a lack of experience and training but also incorporate concerns with moral character and psychological stability (Kaslow et al., 2007). In our experience, feedback about concerns in these areas is one that a supervisor may shy away from, as clear expectations may not be as clearly delineated as they are for clinical skill development. That being said, it is important for supervisors to address any concerns in these areas for the well-being of the client as well as for the professionalism and well-being of the supervisee. Regular assessment and timely feedback are practical tools to ensure continued competence and clinical development in the application of CBT. That is, providing more frequent feedback, not just at the midway and end of the supervisee experience, offers a learning opportunity for supervisees to develop competency. As an example, if a supervisee demonstrates strong clinical skills in collaboratively identifying automatic thoughts and irrational beliefs of the client as well as in challenging the helpfulness of these beliefs as well as the accuracy of them but neglects to clarify that the client understands the role that these thoughts/beliefs play in their unhealthy negative emotions and problematic behaviors, feedback about this skill would better be provided earlier and more frequently in supervision to develop the skills of the clinician as well as benefit the client. Such evaluation should establish clear criteria for assessing clinical skills and understanding how often this process will occur (Wise & Cellucci, 2014). There are a number of measures of competency in skills in CBT that are reviewed within

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another chapter in this edited handbook (see Chapter “Competency in Clinical Supervision in Cognitive Behavioral Therapy”). However, we encourage supervisors to be clear in advance as to all areas that will be assessed as part of the training experience. To increase the likelihood of accuracy, it is important for supervisors to avoid making assumptions about competency and instead view it as a fluctuating area. To elaborate, the field of psychotherapy is both diverse and progressing. Therefore, it is important to recognize that professional proficiency needs to be regularly assessed and developed to stay adequate. Some resources supportive in assessing competence can be found at http://www.cfalender.com/clinical-­ supervision-­resources.html. Once a formal assessment is made of a supervisee, a supervisor should be aware of their own desire to misrepresent their actual assessment of the supervisee due to the likeability of the student or the desire to support their future endeavors. Supervisors are sometimes called on to present their evaluations of a trainee to other professionals, such as for a job, another training position, or to continue in the academic setting. As in any human relationship, there may be an urge to present the supervisee in a positive light. Supervisors should strive to be accurate in recommendations and other written documents regarding the supervisee’s ability (Johnson et al., 2008). If there is a concern, limiting interaction with clients or possible cessation of the provision of clinical services and preventing forward movement in an academic program may be warranted.

 thically Personalizing Supervision to Best Meet Supervisee E Strengths and Weaknesses Similar to issues of competence, another challenge in providing supervision is having the flexibility to personalize supervision while maintaining its structure. Due to the divergent level of training and experience for each supervisee as well as the ethical obligation to provide appropriate care for each client, it is essential that the supervisor accurately assess the supervisee’s strengths and weaknesses and customize supervision as a result. This customization promotes the most growth for each trainee. A suggestion for assessing the individual levels of need is to review past coursework and clinical experience (Barnett & Molzon, 2014) and, if available, past reviews of trainee competency. Additionally, a conversation at the onset of the supervision should be had around relevant trainings, knowledge, and skills, and the supervisee’s perspective of clinical strengths and weaknesses. Awareness of supervisee skills and competencies should be considered with individual clients being treated and their therapeutic needs to determine the supervisees level of competence to respond accordingly (Johnson et al., 2008). The format of supervision should also adjust to match the developing needs of the students. As the supervisee’s training and competence increase, the intensity of supervision will likely adapt, including how involved and available the supervisor is

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to the trainee and how direct they are in their guidance. An active, involved supervisory role will decrease to a more independent format as the supervisee progresses (Barnett & Molzon, 2014). For instance, with a beginning trainee, a supervisor may think it beneficial to provide specific suggestions and feedback to the supervisee. This may involve viewing a session, reviewing specific CBT skills, and rehearsing potentially more effective means to demonstrate them. However, a more advanced supervisee may warrant Socratic questioning to support them in coming to a clinical conclusion on their own. Additionally, supervision may shift from direct observation, for example, through a two-way mirror, to more indirect means, such as having the supervisee relay the content of the session. This shift among stages of involvement creates the space required to develop independence while also allowing for continued guidance and support.

Creating a Safe Supervisory Environment For a supervisee to flourish, a safe environment and trusting relationship are necessary (Association for Counselor Education and Supervision [ACES], 2011). Supervisees should feel able to express all concerns, experiences, needs, successes, and failures without judgment. This can become a challenge due to the simultaneous need to maintain boundaries and professionalism. Additionally, various therapeutic orientations emphasize different values, such as some encouraging empathy as a prominent component, whereas others emphasize separate therapeutic elements. Therefore, a supervisor’s preference and training could influence their approach to supervision (Falender & Shafranske, 2004). A poor working alliance will likely increase nondisclosures and decrease overall willingness within supervision (Mehr et al., 2010). Alliance and alliance ruptures during supervision are addressed in a separate chapter in this edited volume (see Chapter “Ethics in Supervision”). Additionally, a natural emotional experience in the role of a supervisee is shame due to being aware of limited knowledge and experience. This emotion may foster an urge to hide and not disclose important clinical information (Yourman, 2003). In turn, this can hinder learning and success as a clinician. To achieve an ideal supervisory environment, the supervisee should be able to step out of a place of comfort to try new therapeutic techniques and interventions under the supervision of a competent clinician. To promote this best, we suggest that a supervisor present any feedback or criticism in a manner conducive to maintaining this safe environment while promoting professional skills and growth. We also recommend that a supervisor be open to regular feedback and requests to adjust in the best interest of the supervisee (Barnett & Molzon, 2014). This direct and regular expression of openness to examine supervisory concerns creates comfort and models’ willingness to receive feedback. Furthermore, supervisors should

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acknowledge the power difference within the relationship and encourage self-­ supervision to promote autonomy. To put it in another way, it is supportive to “address the elephant in the room,” namely, to discuss the need for evaluation of clinical competencies and the discomfort or anxiety that it may elicit. Supervisors may wish to normalize these feelings as well as the tendency to have a sense of being an imposter (Mehr et al., 2010). Finally, having supervisors balance criticism and directly address areas of struggle with the practice of highlighting strengths and areas of improvement can enhance clinical skill development within supervision.

Ethical Practice of Supervisees Supervisors are responsible not only for monitoring their own ethical behaviors but also for ensuring supervisees are responding ethically to their clients. A hindrance to the latter is that the supervisee’s limited experience may prevent them from recognizing an ethical concern until only after the mishap has occurred or when it is being addressed in supervision. We recommend to preemptively consider prominent ethical concerns to limit such mishaps. A helpful checklist, proposed by Moffett et al. (2014), is a DCBA model. Respectively, these areas include Danger (is there any concern for harm?), Duty (what are my duties and to whom?), Document (are my records timely and accurate?), Consent (have I obtained appropriate consents?), Confidentiality (am I maintaining privacy?), Competence (do I have the needed professional proficiency?), Consultation (am I using consultation when needed?), Boundaries (are professional boundaries being maintained?), Apply Decision-­ Making Model (what model supports making a decision?), Act (am I following through on the most sound ethical decision?), and Access (what was the impact of the decision made?).

Summary This chapter provided a general introduction to the process of CBT supervision with the aims of defining supervision, discussing competency, and reviewing unique challenges that could limit learning and negatively impact client care if not planned for and adequately addressed. CBT supervision has drawn from developmental and learning models in the past, which have strengthened a few of the more salient elements (e.g., goal-directedness) (Milne & Dunkerley, 2010; Mason & Mullen, 2022). CBT supervisors can leverage their knowledge of cognitive development to construct a developmental trajectory based on their training sites’ activities. The ­construction of this trajectory fulfills two purposes: It clearly communicates what the path could look like for the supervisee, and it supports attainable goal setting.

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The developmental trajectory then helps the supervisor and supervisee as they agree upon levels of support that might be needed throughout the training process. This process creates a shared language and responsibility between the supervisor and supervisee, which, in turn, makes the learning experience more equitable and challenging, pushing the supervisee to be within their zone of proximal development (Proctor & Rogers, 2013; Vygotsky, 1978). Overall, one of the most supportive tools in maintaining effective and ethical supervision is to plan for frank and regular conversations around concerns and expectations (Smith et al., 2012). Part of this routine discussion is a frequent assessment of the supervisee as well as the process of supervision. One measure that could support the latter is the Supervision Outcome Scale, designed to assess the progress of both the supervisee and the supervisor (Tsong & Goodyear, 2014). Regular assessment should also include discerning supervisor and supervisee competence, well-being, ethical knowledge, and focus. Likewise, assessment of the supervisory relationship will allow for the maintenance of boundaries as well as preserving the most conducive learning environment. Such guidelines and expectations for supervision should be clearly outlined in a contract reviewed and signed by both parties to safeguard awareness and adherence. Awareness of the science, practice, and ethical guidelines discussed above is an important first step as one develops their supervisory skills. The future of research and practice of clinical supervision and clinical supervision in CBT provides many opportunities for scientific as well as professional growth. We are hopeful that consideration of the practices outlined in this chapter and the handbook may help spur that growth.

Test Yourself 1. In preparation for supervision, how can you apply backward planning to teach a core CBT skill? 2. Which factor(s) are among the most important to consider when beginning supervision with someone with no/minimal experience with CBT? 3. With a number of supervisees reporting difficult and even harmful supervisory experiences, what are important steps that a supervisor can take to improve the quality of supervision and minimize this risk? 4. In consideration of supervising a trainee who may be from a diverse background or is working with a client from a diverse background, what step(s) should a supervisor take to promote a positive supervisory experience?

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Appendix A: What Does Independence Look Like?

Therapeutic independence

Assessment independence

Preparation • Strong understanding of common factors and goal-setting strategies. • Ability to conduct an effective and efficient intake interview with accurate conceptualization. • Advanced understanding of CBT principles and what techniques can be used to address common presenting concerns at the clinic. • Regularly access scholarly research to stay current on how therapeutic principles of CBT are applied to different populations and presenting concerns. • Basic knowledge of progress monitoring tools and how to apply them in the therapeutic setting. • Plan for session with flexible, evidence-based approach. In session • Notice clinical judgment moments and ability to provide rationale for question or statement made in session. • Aware of other options for questions, statements, or techniques. • Flexible application of CBT techniques and principles with fidelity. • Ability to shift to assess for and shift to comprehensive safety planning session if needed. • Recognize ruptures in the therapeutic relationship and ability to pursue repair. Reflection • Identify plan for the next session from the content of this session. • Identify and processes potential transference and countertransference. Preparation • Review any narrowband measures independently. • Demonstrate flexibility by incorporating any changes to assessment batteries fluidly. • Determine testing battery based on referral concern and brief intake. Testing and scoring • Choose test battery based on referral concern and adjust battery based on observations/findings from testing Day 1 to be approved by your supervisor (e.g., SPs will take more ownership in developing test battery). • Develop fluency in administering and scoring narrowband measures (e.g., increase in speed and efficiency). • Score each assessment with expert accuracy (