The Tao of Direction: Structure and Process in Clinical Supervision

The Tao of Direction: Structure and Process in Clinical Supervision

by Jay Reeve
Therapist Jay Reeve offers advice on balancing structured, direct instruction and process-oriented exploration in supervision sessions with new therapists.

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Most of my time in the hospital where I work is spent providing clinical supervision in psychotherapy. My supervisees are a mixed lot in terms of their training: doctoral students in clinical psychology, psychiatric residents and fellows, as well as bachelor-level line staff. Naturally, my style of supervision varies according to their experience and training, but not as much as one might think. Advanced psychiatric fellows who have completed their residency training and are pursuing postdoctoral studies sometimes get anxious about the stuff of basic psychotherapy: what to say next, what to do if a patient is mad at them, and so forth. On the other side of the coin, there are milieu therapists without any college training who can craft and implement therapeutic interventions stunning in their creativity and depth. There is no clear way to tell what sort of therapist a person will be from the degree and training they have—a counterintuitive truth reflected in the research which documents the lack of correlation between therapist training and therapist efficacy. The unpredictability of what kind of therapist a student will turn out to be is part of what's interesting about my job—the job of clinical supervisor.

There is, however, a great divide between the students that I supervise, a difference only minimally related to their training and professional background. This great divide is their need for, and comfort with, structure and process in supervision. It's a difference that is certainly echoed in certain stylistic differences between schools of psychotherapy (e.g., psychodynamic theory vs. CBT), and between certain professional tracks (e.g., psychiatry vs. social work). Despite these culturally encrypted differences, therapists from a variety of backgrounds fall into a variety of places along the structure-process spectrum.

One of the best examples of these differences comes from a course in psychiatric interviewing that I co-lead along with a psychiatrist who is also heavily involved in training. Some students have a hard time adjusting their diagnostic interviewing techniques to their client's developmental level. In other words, you can't really do a standard mental status exam with a six-year-old and expect to get much data. On the other hand, while a play session with a child can yield a tremendous amount of information, it is useless for assessment purposes if not driven by a fairly conscious and thought-out plan (examining social interactions, assessing whether the child is reacting to internal stimuli, formal testing, etc.). In the course of learning to teach the best method for assessing children, my colleague and I have to weigh what students need to offer the best approach for each client. For some, they need let go of the crutch of the History of Present Illness and Mental Status Exam in order to really listen to the child and catch the flow of moods and interactions. For others, they need clear direction and tools by which they might make sense of the child's often chaotic presentation. These are quite different needs, but both are the responsibility of the supervisor to understand and address with each supervisee.

In this paper, I will use the Chinese philosophy of Taoism as a metaphor for understanding these different needs, particularly approaches to clinical supervision. In traditional Chinese philosophy, universal balance is represented by the popular Tao symbol: a depiction of the contrasting forces of yin and yang in constant and creative symmetrical tension (see the symbol at top).
The aim of the sage, according to the classic text the Tao Te Ching, is to remain "centered in the Tao."
The aim of the sage, according to the classic text the Tao Te Ching, is to remain "centered in the Tao."1 This is also referred to as the state of wu wei—literally, 'doing nothing', although understood as the state of balance that allows the operation of the principle of the Tao. In psychotherapy supervision, a similar creative tension exists between structure and process. The sage role in this case is fulfilled, of course, by the psychotherapy supervisor.

Creative Tension in Psychotherapy Supervision

The very discussion of supervision as a complex and multifaceted interaction may be somewhat surprising to many supervisees. In my experience, students frequently think of "supervision" as being entirely directed by the overall feel or personality of the supervisor, as in the frequent comment, "Paula is a good (or positive, bad, aloof, or intense) supervisor," as if there were only one form of supervision of which each teacher was capable.

As anyone who has spent some years as a clinical supervisor knows, there are a variety of schools of thought regarding the best form of supervision. These schools of thought are frequently related to the theoretical orientation of the supervisor, and the difference between and within these different philosophies can create a kind of dynamic tension within supervision. This tension is often embodied in contrasting comfort levels of student and teacher with different supervisory techniques, and can be thought of as occurring within a spectrum ranging from highly didactic and directional to highly exploratory and relational: the yin and yang of supervision.

Yang... Technique-based Supervision

On one end of the spectrum lies the pole of absolute structure. Let's call this pole the yang of supervisory technique.

In the yang mode, the supervisor and trainee approach psychotherapy supervision as a matter for technical instruction, in which the supervisor instructs the trainee in the technique of psychotherapy.
In the yang mode, the supervisor and trainee approach psychotherapy supervision as a matter for technical instruction, in which the supervisor instructs the trainee in the technique of psychotherapy. Supervision in this mode is dominated by a didactic approach, wherein the teacher instructs students in techniques and interventions. This may include instruction in the use of manualized treatments, specific techniques and theoretical points, assigned readings, and what to say and not say in therapy. The aim is to instruct the trainee in specific ways of doing therapy, and for the trainee to demonstrate increasing proficiency in this technique, as evaluated by the supervisor.

In this mode, student success is measured by the degree to which they adhere to the specific instructions provided by the supervisor. At worst, this technique-based approach results in humorless, dry, and rigid supervision that leaves students feeling as if their own ideas, personality, and technique have no value; however, it can be a great comfort.
I can remember a number of occasions when I wanted nothing more than for my supervisor to tell me exactly what to do.
I can remember a number of occasions when I wanted nothing more than for my supervisor to tell me exactly what to do. These were generally occasions during which I felt insecure, out on a therapeutic limb, or in danger from an ambiguous or delicate situation with a client. Students especially yearn for direct guidance when confronted with crisis situations or confusing boundaries. Whenever the student is frightened by the natural ambiguity of the therapy situation, clear direction can seem like a safe port in a storm.

There may, of course, be times when a supervisee needs to feel assaulted by ambiguity in order to develop the toughness and resilience they need in order to do the work. However, prolonged duress never leads to growth, and for novice therapists, anxious therapists, and therapists in crisis, a good dose of yang supervision can be a very good thing.

Yin... Process-based Supervision

At the other pole lies what we might call the yin of supervision.

In the yin mode, the supervisor engages the trainee in an examination of the process of psychotherapy.
In the yin mode, the supervisor engages the trainee in an examination of the process of psychotherapy. Supervision at this end of the spectrum is non-directive: the student is encouraged to express feelings about, and associations to, the clinical material. This may include frequent commentary on the parallel process that occurs in the supervisory relationship, as well as explorations into the student's state of mind and emotional reaction to both the therapy and the supervision. The aim is for the supervisee to explore, as broadly as possible, the experience of doing psychotherapy, and verbalize any of the unconscious conflicts or anxieties that impede their development.

In this mode, a student's success is measured by the degree to which the trainee demonstrates his or her own emerging therapeutic style. At its worst, process-based supervision can lead into a vague terrain that resembles a cross between poor psychotherapy and a social occasion. Students often complain of this happening, saying that their supervisors "always answer a question with a question." Although this may sound like an exaggeration, or even a joke, it is all too often a real assessment of their supervision.

In contrast to the rigidity of yang supervision, yin supervision risks leading to a feeling on the part of the students that they have literally learned nothing. However, when done well, this process-based form of attention can lead to the richest and most rewarding of supervisory experiences: those when the student begins to experience the pervasive nature of process which echoes through therapy, supervision, and other interactions. One of my most treasured memories of psychology internship supervision was my child therapy supervisor teaching me to return again and again to the process of play with my young clients, which led to my dawning recognition of the success of my interventions. In yin supervision, the process makes itself known.

Working The Yin-Yang Supervision Balance

Supervisors tend to find their own teaching style on this yin-yang spectrum based on their own training and personalities. Those supervisors who are more behaviorally oriented and solution focused tend to cluster towards the more structured side while those who are more psychodynamic and existential tend towards the more process-focused side. However, this general statement has a thousand exceptions: Robert Langs is as concerned with the precise structure of an intervention as a behaviorist, and the new breed of Zen CBT practitioners (like Jeremy Safran) are exquisitely attuned to process. The balance between structure and process varies within and between each school of therapy. Yet another wrinkle is the effect of the interaction between supervisor and student on this balance. I have been struck by the degree to which students, based on their own personalities, prior training, and the style of their supervisor, insist upon either more yin or more yang.

When I have supervised students in process-oriented, psychodynamically based programs, their most frequent request has been for basic and specific instruction in the craft of psychotherapy.
These students often complain that their training is long on theory and short on practical advice on what to say to the client.
These students often complain that their training is long on theory and short on practical advice on what to say to the client. Students can speak with great authority and insight about their own processes and anxiety regarding treatment, but sometimes have few ideas about dealing with a session that runs over time, taking a basic mental status exam, or confronting a parent in family therapy. In these situations I tend towards a concrete, detailed brand of structured supervision as shown in the following supervision with Steven.

Supervising Steven

Steven was a third-year doctoral student in clinical psychology, participating in the practicum program (which I directed at the time) in a large state psychiatric hospital. Steven was bright, articulate, and a pleasure to talk with. Early in the supervision process, he began to talk in articulate detail about his relationships with his patients and the feelings they evoked. He noticed and articulated precise, delicate points of countertransference, and related them to his own childhood and family experiences. Since Steven's love for process discussions paralleled my own, I was happy to engage in a sort of philosophical free-floating supervision. When Steven was assigned the case of an angry and highly verbal young patient with a history of serious acting out, he was initially excited at the prospect of conducting in-depth therapy. However, it rapidly became clear that his patient was unable to tolerate even mild explorations of charged issues and Steven became resistant to discussing the case. After a supervisory session in which Steven had difficulty relating the most basic, concrete details about his client's functioning, I realized that something was clearly amiss. I asked him to tell me, in concrete detail, what the session had been like. He admitted that he had little idea of how to proceed with the patient without angering him. I realized that Steven was not comfortable navigating the early stages of alliance-building with a client who was difficult to engage and that he needed some specific instructions. We talked in concrete detail about chair placement and session length and crafted several scripted interventions. Steven later told me that he had been embarrassed to ask such basic questions, but felt greatly relieved by my willingness to give him step-by-step suggestions for this client who had overwhelmed his knowledge acquired with much healthier patients.

In contrast, students from more experimentally based programs (like CBT or other manualized approaches) seem more confident in employing a variety of thoroughly researched and empirically validated techniques, but are not as able to verbalize their own sense of how therapy is progressing. These students are often paralyzed by anxiety when faced with situations that do not conform to the manual and have little understanding of how their own feelings about their clients play out in the course of therapy. With these students, I have found myself adopting a free-floating and exploratory approach to supervision, encouraging them to verbalize and explore their own experience of their treatment. Of course, this fits my preference for the yin supervisory style.

Supervising Gayle


Gayle, unlike Steven, was in her fourth year at a highly regarded research-heavy and behavioral-oriented doctoral program in clinical psychology. Working in a hospital setting made Gayle anxious but she was one of the better students I had ever supervised. She rapidly took to assessment and group therapy, particularly when working with manualized treatments. Gayle was a consummate professional—well-groomed, well-spoken, and in general, the stereotype of a successful lawyer or businessperson, not the typical doctoral student in psychology. I was impressed with Gayle, and perhaps more significantly, proud of Gayle. I suspect that feelings of pride evolve in all clinical supervisors, feelings sometimes evocative of parental pride, in particular towards promising, impressive students, and Gayle was nothing if not impressive.

As Gayle approached her third month in training with me, I noticed that she tended to be very reticent in taking on longer-term individual therapy cases. In her screening interview she had been direct in saying that her interest was not individual therapy, but I had assumed that she would show the same professional enthusiasm in this task as she had in others and would treat it as a challenge. After encouraging Gayle a number of times to take an individual therapy case and encountering her resistance, I realized that our structured and technical supervision sessions were not getting at the real issue. Despite my hesitation at the prospect of altering the pattern of a largely successful supervisory interaction, I set aside an hour of the supervision to talk, in an open-ended way, about her reluctance to take on individual cases. Although she was initially resistant to this discussion, I stayed the course, letting her set the pace and being utterly nondirective. Although the discussion ended up spanning three sessions of supervision, and included some lengthy periods of silence with which we were both uncomfortable, Gayle was able to finally discuss in detail her anxiety about her ambiguous and unstructured client interactions. With that admission, and my recognition that I had been exerting an unconscious pressure on her to maintain her 'perfect student' façade, we began the slow process of training her in individual psychotherapy. Gayle had needed some yin supervision that I had finally been able to supply.

Listening for Gaps in Supervisee Skills

In supervision, as in psychotherapy, the challenge is to allow the trainee to move beyond rigid adherence to structure or process towards a graceful transition along the spectrum depending upon what is most necessary at the time. In order for students to learn this graceful transition, we as supervisors also must take the same journey towards greater flexibility. Of course, we can't all be the best at every style and approach, but stretching a bit is in the interest of everyone, student and supervisor. For myself, this has involved a greater willingness to meet the student's need for greater structure by finding the kind of structure that I can endorse, which can be a great challenge, professionally and personally. This same stretching is necessary for those supervisors who do not naturally explore the process of therapy. To the extent that I have been able to meet the challenge, the key for me has been learning to listen more fully and deeply to what my students need, and this, in the end, may be the key to understanding and utilizing the Tao of supervision: the need for balance.

I remember a conversation I had with a student who was recounting her anxiety over whether or not she was sufficiently empathically attuned to her client. I responded by telling her that she was worried enough about that issue that she didn't need to focus on it at all; I certainly didn't have such concerns about it. Instead, I recommended that she focus on creating sufficient structure within the therapy to provide a safe container for her client. In other words, she should cultivate a safe place for exploration and understanding. She was putting all her energy on one side of the Tao of therapy. I tried to invest the other side with energy in order to achieve some balance. She knew that she was unbalanced—her anxiety told her that. Only by listening to her was I able to learn that as well and provide the right balance of supervision that she needed to keep growing in her work.

In Taoist philosophy, truth does not lie in one pole or the other, in yin or in yang. Instead, the task of the sage is to provide what is lacking for balance.
In becoming better supervisors, our job is to listen for the gaps in our students' skills, the aridity in the overly structured pedant, the looseness and fuzziness in the "touchy-feely" therapist, and to provide what is lacking
In becoming better supervisors, our job is to listen for the gaps in our students' skills, the aridity in the overly structured pedant, the looseness and fuzziness in the "touchy-feely" therapist, and to provide what is lacking—not because the students need to become more like us, but because striving for balance is growth enhancing and valuable in itself.

When they think they know the answers
People are difficult to guide
When they know that they don't know
People can find their own way


Notes

1 All quotes from Tao Te Ching (S. Mitchell, trans.), HarperPerennial; 1991.



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Jay Reeve is a clinical psychologist who serves as a senior psychologist at Bradley Hospital in Providence, RI, and is a clinical assistant professor of psychiatry at Brown Medical School. He is the Director of the Bradley Hospital Predoctoral Psychology Program, and is actively involved in teaching and supervision with psychiatric residents, post-doctoral fellows, psychology interns, and psychology practicum students. He also holds a Master's degree in Theological Studies from Harvard University, and has published on topics ranging from the psychotherapeutic treatment of pediatric AIDS sufferers to discussing tragedy with children.

See more about Jay at his university webpage:
http://www.brown.edu/Divisions/Medical_School/andera/person.php?id=2152

CE credits: 1

Learning Objectives:

  • Supervisors and supervisees will gain a clearer understanding of the differences between process-oriented and structure-oriented clinical supervision.
  • Supervisors will be able to identify supervisory situations in which process-oriented or structure-oriented supervision is more appropriate.
  • Supervisors will learn how to keep structure and process in balance in supervision so they can best train supervisees that are stronger in one area and weaker in another area, always working toward an integrated, balanced approach to therapist professional identity and interventions.