Supervision is broken. Here's how to fix it.

Updated: Nov 22


Imagine you're on a plane and the flight is getting a little bumpy.


The flight attended calls your name over the PA system and you shuffle to the front.


"Here's the deal," the flight attended says, "our pilot had a stroke, and our co-pilot is drunk. I've got to keep the passengers calm. So I need you to land the plane. Don't worry. Air traffic control is going to walk you through it."


"Okay," you gulp.


You move the moaning pilot to the ground and sit in his seat. Air traffic control comes over the headset. "Okay," a raspy voice says on the other end. "I know you're scared. You have every right to be. As long as you do exactly what I say, everything will be okay."


"I'm ready," you say, and stare at the dizzying array of buttons, knobs, switches, slides, levers, dials and gizmos.


"Kid," He says, "all you got to do is land the plane."

"Huh?" You reply.


"It's pretty simple. The first step is to grab the controls." You grab the thing which looks like the steering wheel. "And the second step is to land the plane."


"I-I-I don't think I know how to do that."


"Kid, I'm telling you what to do. You gotta trust yourself. Land! The! Plane!"


Suddenly it's quiet.


Your stomach drops like on a roller coaster.


Sh!T.

The engines have stopped. You're in free fall!


"I need help!" You scream back.


"I AM HELPING YOU! LAND THE PLAN-"


And the plane crashes into a mountain and you all die.

gif

Supervision is like that sometimes. But worse.

 

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The problem with clinical supervision


Too often we tell trainees what to do but not how to do it.


We say things like:

  • "You need to build an alliance with mom."

  • "You need to work on his motivation."

  • "Don't work harder than your clients."

  • "Have you tried mindfulness?"

All of these are big interventions with a thousand micro-skills.


Take "work on motivation." That's so broad and encompasses at least three different sets of skills.


First, trainees need micro-skills around clarify the agenda for the session to make sure they and the client are working on the same goals.


Then they need to make sure the intervention matches the client's expectations, which requires another set of micro-skills.


Finally, they need to work though any resistance that might come up while doing the intervention, which requires another set of micro-skills.


When we talk in broad interventions like "work on motivation," it's like telling trainees, "just land the plane." We're telling them what to do without telling them how to do it.


But it gets worse. Because speaking in broad interventions is not the biggest problem.


The bigger problem is what we do when trainees say, "I don't know how to do that."


The second problem with clinical supervision


I remember when I was in my doc program. I was working with a family and was really confused about what to do. I reached out to one of my professors and asked his advice. He started explaining systemic thinking to me and the more he explained it, the more confused I became.


"Okay, but what do I do?" I finally blurted.


"My job isn't to teach you what to do," he said, "but the more important skill of how to think. That's the thing you've really got to focus on. Once you can case conceptualize everything else flows out of that."


I believed him, but I still felt something was missing.


Later that week I was talking with my licensure supervisor and I told him about the conversation with my professor.


Midway through the story he stopped me.


"Jordan, what those professors at the university miss is it's not what you do, it's who you are in the room. That's what really matters." He said, looking into my eyes meaningfully.


I was annoyed. I was left in a lose-lose. Either I wasn't good enough at case conceptualization or I wasn't working on myself enough.


And I still didn't know what to do with my family!


This happens all the time. Trainees tell us they don't know what to do, and we talk about something else, dismissing their actual concern.


The worst part is often times trainees will turn on themselves in these moments.


Of course. It's hard not to.


I feel like we've all been to a training where something goes over our head. We look around, and everyone is looking up at the trainer with eyes of awe and we think:


If everyone else is getting it, then something is wrong with me that I don't get it.


This is the real problem.


Deliberate Practice Supervision is designed to fix this problem


Deliberate Practice (DP) Supervision is built to solve this problem.


DP supervision is geared around the idea that the best way to guide new therapists is to teach them through using mini-role plays. Case conceptualization is important, as well as person of the therapist issues, but we want to privilege practicing skills because that's the best way to help trainees know what to do in the room. [1]

Sentio, the mecca of Deliberate Practice for counselors, therapists, and mental health professionals, recently gave two trainings on DP for supervision.


There were amazing!


Afterward Sentio sent out an email with examples of the five essential steps of DP Supervision.


The mini-class, was soo good, I wanted to share it with you. Here's the email.


The 5 steps of Deliberate Practice Supervision for Counselors.


Step 1: Validate supervisees’ struggle

Supervisee: My client just isn’t working at anything, he shows up every week and complains the whole session. No matter what I try, he doesn’t change what he’s doing. Supervisor: That’s really frustrating. It’s difficult to feel like you’re working hard for a client and don’t understand why things are stuck. We all experience this at times. Supervisee: Yeah, like he just vents and vents but never does anything to even try and change things for himself.

Step 2: Ask what the client *specifically* says that cues the supervisees’ frustration

Supervisor: Well let’s look at this, what specifically does he say when he’s expressing a complaint? Supervisee: He will say something like, “my wife keeps nagging at me to stop drinking, she’s the one who’s got the problem! She has no idea what it’s like to work all day.”

Step 3: Ask what the supervisee tends to say in response

Supervisor: Ok, that’s helpful! And what do you tend to say in response to him when he says things like that? Supervisee: Umm, I tend to like explain back to him that she does work because raising kids is work, and ask him what makes it hard for him to look at his own drinking.

Step 4: Normalize and collaborate on skill

Supervisor: That makes sense, and in some situations that would work with a client. With this client in particular, do you have any ideas of what you’d like to try differently when he voices his complaint? Supervisee: Um, I think it could go better if I slow down and reflect that his work seems stressful to him, and maybe just explore more with him. Maybe say something like, “It sounds like your work is really stressful, and you don’t feel people understand that.” I don’t think he’s ready yet to look at his drinking, even though I want to push him in that direction.

Step 5: Briefly explain rationale and begin rehearsal

Supervisor: I think that’s a great idea, I love the idea of trying to meet him more of where he is, and recognizing he may be in pre-contemplation with his drinking. This intervention will be along the lines of Motivational Interviewing, where you’ll practice more reflecting than explaining or questioning. Let’s practice to give you a feel for it, and see where any hard parts are. I’ll be him, and cue you in with his phrase, and try responding to him with that great reflection you thought of. Remember this is a no-stakes environment in here! Stumbling is part of the process, and I’m right here to help. *And as always, remember it’s helpful to do at least 3 rounds of rehearsal with the same cue. It’s a little uncomfortable for everyone, but so helpful in building the supervisees’ fluency and confidence.


The DP Supervision Checklist


As you can see, the entire process is focused on getting the trainee to do a mini-role play around where they're getting stuck with the client.

Sentio created a Cheat Sheet for supervisors to use to keep all of this front of mind. But, since I've been studying human motivation and gamification (more on that later), I tweaked their cheat sheet and made it a bit more user friendly.


Let me introduce the Deliberate Practice Supervision Checklist. You can get it below.

How are you making Clinical Supervision and Consultation actionable?


Case conceptualization is important. Who you are in the room is important. These things are a huge part of therapy. The problem comes when we privilege these things so much that we forget to hear supervisees when they say, "I don't know what to do."


When trainees say they don't know what to do, what they are really saying is something is missing. As supervisors, consultants, and trainers it's our job to give trainees a full well-rounded experience.


Because when supervisees can show up authentically in the room, and conceptualize what's happening, and know what to do, well, that's when they can really fly.


Otherwise we just leave them to crash and burn.


Best, Jordan (the Counselor)

-Fin-

[1] These things are very important. There's actually a "secret" DP Supervision technique for person of the therapist issues. You can find it in Dr. Tony Rousmaniere's Mastering the Inner Skills of Psychotherapy, but it's not being taught mostly because it's really hard to teach. I learned it from Tony himself, and have found it extremely powerful personally for working through my issues when they come up in therapy. Hopefully sometime in the future Sentio will give a training on that as well.

 

If you liked this post, consider reading this next. I think you'll like it ;) It's about the micro skills of repairing alliance ruptures.

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