Healing the Incest Wound, originally published in 1988, was a landmark achievement in the modern era of trauma psychiatry and psychology. Christine Courtois, PhD is one of the pioneers who helped rediscover the long-neglected effects of pandemic childhood sexual abuse and to introduce treatment models that could help incest victims reclaim their lives. The original book became a classic, providing guidance and support to countless clinicians during a time when there was a profound dearth of information on the subject of incest. Now, more than 20 years later, Courtois has succeeding in integrating the explosion of knowledge and expertise developed over the intervening years into a comprehensive and authoritative second edition. In the original edition, she relied largely on her own experience and expertise along with the relatively few published papers concerning sexual abuse and posttraumatic responses. In this current edition, she has supported her observations with the empirical evidence and clinical wisdom of hundreds of publications. Courtois has heightened the complexity of her thinking with the expertise of other professionals in the trauma field – many of whom based their efforts on her earlier work.
As in the original edition, Healing the Incest Wound is divided into three sections. Section I provides a meticulous review of the characteristics, categories, epidemiology and dynamics of incest. Section II describes the many and varied aftereffects of incest. Perhaps most helpful to practitioners is Section III that comprehensively details the treatment process: the philosophy, goals, sequencing, diagnostic considerations and psychotherapeutic processes, as well as specifics concerning treatment modalities and special populations. This second edition is nearly twice length of the original. Quality should not be judged by quantity, but the additions and elaborations in this edition provide information that is timely, relevant and useful.
It is testament to the quality of the original edition of Healing the Incest Wound that Courtois’ observations and understanding of the nature, effects and treatment of sexual abuse have held up extremely well. For example, in the 1988 original edition, based on nascent research and anecdotal experiences in the trauma field, Courtois speculated about the association of sexual abuse with deficits in physiologic, developmental and psychological functioning. In this new edition, there is a wealth of data and findings that support these negative effects of sexual about in virtually all domains of human functioning. The new edition also helps to integrate many diverse approaches to treatment that have been developed in the past decades including feminist, traumatic stress, developmental/attachment, relational, and loss/bereavement perspectives, which can be of enormous assistance to clinicians in using effective and eclectic approaches in their treatment of sexual abuse survivors.
In the current edition of Healing the Incest Wound, Courtois describes the stage-oriented treatment model for complex PTSD. Developed in the 1990s, this model of treatment proposed that effective treatment for severely and chronically abused individuals requites an early stage of safety and stabilization along with building functional and relational skills prior to active work on the traumatic events themselves. Courtois offers a clear and concise description for stage-oriented treatment for complex PTSD, a model which has become the standard of care for severely traumatized patients. Throughout the remainder of the book, she further elaborates on the issues that will allow clinicians to learn about how to provide skillful, effective and helpful care to some of their most challenging patients. Consistent with developments in the trauma field, the current edition offers a new focus on both the intricacies of working with patients who have sustained immense relational damage and the effects on the clinicians who treat them. Courtois pays particular attention to how the dynamics of the original abuse become reenacted in the transference-countertransference relationships in the therapy.
Although this book is a truly academic work and a source book for both historical and current information in the trauma field, its primary value is for practicing clinicians. For example, there are nuanced discussions of the assessment process concerning how to interview and how to detect hidden presentations of sexual abuse. There are also detailed discussions of new newer treatment modalities including various cognitive-behavioral techniques, EMDR, expressive therapies, and more recent proposed treatments such as sensorimotor, somatosensory and energy techniques. As an added benefit, Treating the Incest Wound concludes with comprehensive appendices that provide a rich resource for both professionals and survivors of sexual abuse.
I have been an unapologetic admirer of Courtois over many years as a colleague, a collaborator in teaching workshops, and a reader of her published works. She is one of those gifted professionals who can combine the kind of meticulous academicity, clinical wisdom, warmth and compassion that is so evident in Healing the Incest Wound.

As graduate students we receive training not only in academia but in a myriad of different clinical settings, which often lead to a wide range of experiences in terms of supervision. Because of the emphasis that is placed on clinical/practical training for clinical psychology programs in particular a graduate student’s competencies are strongly related to the quality and type of supervision that he or she receives during practica experiences.  Given this, how important do you think it is for supervisors of graduate students to receive training in the area of supervision?  Should there be specific competency requirements for psychologists or other mental health clinicians who plan to train graduate students?

Jeff Barnett Responds:

This is a really important question. Clinical supervision is an essential aspect of every psychologist’s professional training. We each participate in supervision during different stages or phases of our professional growth and development. Without it, we couldn’t develop the competence needed as professionals. Yet, the quality of the supervision we receive is of great importance. Inadequate, unethical, or insufficient supervision has serious ramifications for our developing competence as well as for the clients to whom we provide professional services.

Competence is generally thought of as being comprised of knowledge, skills, attitudes and values, and the ability to implement them effectively. In general, we obtain much of the knowledge we need from academic course work, reading, attending seminars, and the like. We also should be able to obtain additional knowledge from our clinical supervisors. Our skills are developed primarily in clinical supervision. Our supervisors also serve as professional role models; we learn and develop many of our professional attitudes and values from the examples set by our supervisors.

It is essential that supervisors possess two major types of competence; competence in the clinical areas they are supervising and competence in being a supervisor. It is definitely important that supervisors have training in being a supervisor. Like any other clinical role, it has it’s own literature, research, and requisite skills. Merely having been supervised in the past is not a sufficient credential for being a supervisor. Also, just because a job may require a psychologist to supervise a certain number of trainees, that doesn’t mean one is competent to provide the supervision. One must first obtain the necessary training to develop needed competence so that one may provide supervision skillfully and ethically. There are different models of supervision, various methods of supervision, and a number of clinical and ethical issues supervisors should be aware of.

Some jurisdictions require clinical supervisors to have  a certain number of hours of continuing education in clinical supervision for their license to be renewed every two years if they are to provide clinical supervision. That’s a good start, but a minimal requirement. Training programs should require that potential supervisors submit documentation of their training, experience, and competence in providing supervision before being allowed to supervise students. This may involve submitting continuing education certificates, transcripts, a statement of professional experience, and/or letters of recommendation. But, often training programs have a difficult time getting supervisors for their students since the supervisors are often volunteers. As a result, programs may just be glad to get supervisors for students and may not be as careful or thorough in screening potential supervisors. Just as supervisees receive written and verbal feedback throughout the course of supervision, perhaps supervisors should receive written feedback and evaluations from supervisees that are shared with training programs.

There are also many ethics issues that supervisors and supervisees should be aware of. Additionally, there’s a body of research that highlights the qualities of effective and ineffective supervisors (and supervisees!) that both supervisors and supervisees should be aware of. I also believe that there should be an informed consent agreement or supervision contract completed at the outset of the supervision relationship that clarifies all roles, responsibilities, obligations, and the like. These issues and other relevant ones are addressed in the PowerPoint slides below that are from a presentation on the topic I gave recently.

I hope this is helpful. If you have any comments in response to what I have written here or if you have other questions please don’t hesitate to ask. I also welcome others’ comments and questions as well. I wish you much success in your training. A final thought is to keep in mind that as a supervisee, you are an active consumer of a service. You must be provided with the needed oversight, training, supervision, mentoring, and role modeling that are needed for you to flourish and develop as a professional psychologist.

Best wishes – Jeff

Ethical and Legal Issues in Supervision

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Conceptual skills needed for evidence-based practice of psychotherapy: A few recommendations.

{from: Psychotherapy Bulletin 45(2): Online Version}

Kenneth L. Critchfield (University of Utah) & Sarah Knox (Marquette University)

“Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” APA Presidential Task Force on Evidence-Based Practice (2006, p. 273)

An advanced graduate student therapy trainee recently expressed concern about treatment of a difficult case seen in one of her placements. She was frustrated with a supervisor and torn between utilizing knowledge of the patient’s treatment history and family patterns versus following a different path suggested by a particular treatment manual. The frustration had been stirred up in context of a group discussion about tailoring treatments to fit individual patients, and using the empirical literature to do so. She asked: “But doesn’t the research literature say that fidelity to treatment will bring the best effects? A patient I’m seeing now doesn’t like the approach for specific reasons, and it also hasn’t worked for her in the past. But, how can I respond to my patient’s needs and still be evidence-based? Isn’t it unethical to deviate from the manual if it is empirically supported?” Her plan before this discussion was simply to comply with supervisory input to follow the manual, but without much hope for its success with this patient.
The questions asked by this psychotherapist-in-training points to several challenges we face as educators and supervisors in the age of evidence-based practice. On the one hand, we need to provide specific training for empirically supported interventions. On the other hand, we need to help therapists develop the conceptual tools necessary to continue integrating research findings into their clinical work, and apply all these skills in a manner that takes into account individual client needs, preferences, and unique context (APA, 2006).

Reflecting our field’s current emphasis, the trainee mentioned above has been taught that empirically supported treatment packages (ESTs) represent the most ethical approach to treatment because of their proven track record in research (cf. Chambless & Crits-Christoph, 2006). She has even been told to steer clear of “non-EST” approaches by some faculty advisors. Given these directives, plus the constraints of time around provision of therapy in graduate training, she has focused almost exclusively on learning ESTs. As a result, she has considerable skill implementing a number of treatment packages for specific disorders, and can cite their empirical basis in randomized control trials (RCTs) with accuracy.

Her skill set as a psychotherapist is still quite limited, however. While she is gaining skill with a few interventions developed for discrete diagnoses, she has received little encouragement to be aware of (much less think integratively about) the broader empirical literature or identify principles that could help her more flexibly generalize and tailor her interventions (e.g., Castonguay & Beutler, 2006). When faced with clients whose needs do not easily fit the molds the models she knows, she is at a loss.

As educators, we should not be pleased with this result. Without additional input, this young psychotherapist will go out into practice with a relatively rigid skill set of limited applicability. The frustration she already feels suggests she is at risk for eventual “burn out” as a practitioner.

Old and new views of evidence based practice

Our trainee’s problems reflect tensions in our field over how best to weigh and apply research evidence. The primary view that has guided this young therapist’s education has held sway for roughly a decade and places emphasis on developing, testing, and disseminating treatment packages for discrete disorders (e.g., Gotham, 2006; McHugh & Barlow, 2010; Kazak et al, 2010). A treatment qualifies as an EST based on successfully replicated, randomized control trial (RCT) studies (multiple single-case studies with strong research controls may also qualify for EST status; Chambless & Hollon, 1998). Lists of ESTs were initially compiled in an attempt to demonstrate that psychosocial treatments produced effects comparable to pharmacological interventions and should therefore receive research funding, training, and reimbursement in the era of managed care (APA Division of Clinical Psychology, 1995). An RCT study answers a single question about psychotherapy very well: “Does therapy X have an effect on disorder Y, if all other factors are controlled?” The information provided by an RCT directly addresses the needs of an administrator overseeing a large system of care who wishes to ensure that “on average” there will be a positive effect if a particular approach is implemented. In an RCT, treatments are usually applied to a single category of disorder by clinicians trained to a high level of adherence. Randomization is used to distribute pre-treatment characteristics such as personality type, age, gender, motivation, and prior treatment experience evenly across groups so that they are unlikely to be responsible for any group differences in outcome. Dissemination of an EST tends to flow logically from the same research design: psychotherapists are trained to adhere to the EST manual and apply it with patients having a particular disorder (McHugh & Barlow, 2010; Kazak et al, 2010), just as in the case of our frustrated trainee.

By contrast, “evidence-based practice of psychology” (EBPP) has been defined by an APA Presidential Task Force (2006) as invoking all available research methodologies and focusing treatment on individual clients:

“It is important to clarify the relation between EBPP and empirically supported treatments (ESTs). EBPP is the more comprehensive concept. ESTs start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances. EBPP starts with the patient and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome. In addition, ESTs are specific psychological treatments that have been shown to be efficacious in controlled clinical trials, whereas EBPP encompasses a broader range of clinical activities (e.g., psychological assessment, case formulation, therapy relationships). As such, EBPP articulates a decision-making process for integrating multiple streams of research evidence—including but not limited to RCTs—into the intervention process.” (p. 273)

Ultimately, the APA application of EBPP requires a higher standard from therapists and educators, and is likely to be worth the effort if it allows therapists like our trainee to effectively answer the questions she poses and meet the needs of her client. In addition to training with discrete treatment packages and intervention “tool kits,” the most successful therapists will also be prepared with sufficient background and conceptual skills to integrate what is known from across the research literature, combine it with clinical expertise, and apply it in ways that are flexible and responsive to client characteristics.

Skills needed for successful EBPP

The “competencies movement” in psychology seeks to identify the skills and attitudes that need to be acquired for professional development (Fouad et al, 2009; Kaslow et al, 2009). Its focus is comprehensive and sees psychotherapy skill acquisition as unfolding across levels of graduate training and professional practice. Competencies are divided into two broad classes, those that are “functional,” reflecting discrete domains of professional activity (assessment, intervention, consultation, supervision, research/evaluation, supervision, teaching, administration, and advocacy), and those that are “foundational,” cutting across functional domains (professionalism, reflective practice, knowledge of scientific methods and findings, relationship skills, sensitivity to individual differences and cultural diversity, attention to ethical and legal standards and policies, and ability to interface with interdisciplinary systems). We wish to draw particular attention to foundational competencies that involve scientific method and recommend a particular kind of scientifically-minded thinking style vital for evidence based practice.

Scientific-mindedness

By scientific-mindedness, we refer to a clinician’s willingness to engage in a process of inquiry that should involve not just consideration of the empirical literature, but also evidence available directly from clients. Ideally, the process begins with careful assessment that results in an individual case formulation, that is, a set of hypotheses about the sources and maintaining factors associated with an individual’s problems. Interventions are then selected in light of the relevant literature, and in consultation with the patient about his or her needs and preferences. Ongoing evaluation of therapeutic impact then provides data about the effects of the intervention and can lead to flexible modification or a change in course as needed, and in collaboration with the client. Lambert and colleagues (e.g., Slade, Lambert, Harmon, Smart, & Bailey, 2008) provide evidence that feedback from formal, ongoing monitoring of symptom states can improve outcome. To extend this logic, depending on the individual formulation of a client, relevant outcome data may also involve clients’ patterns of thinking, feeling, or relating with others, motivation for change, quality of the in-session relationship, and more. To summarize, the proposition here is that psychotherapists be trained in a manner that leads to primary identity as a clinical scientist whose work places emphasis on generating and testing individual-level hypotheses about change, in a context of collaboration with clients and consultation with the empirical literature.

Critical thinking and integration

Critical thinking involves evaluating logic and weighing evidence. As applied to psychotherapy, it involves the ability to understand and evaluate published research results as well as to accurately assess the circumstances and experiences of individual clients. The complement to critical thinking is integrative ability, which involves being able to pull together different studies, different strands of data, and synthesize them into a specific hypothesis with associated plans of action. Examples of integrative thinking would include pulling assessment data together into a case formulation with clear implications for treatment, detecting areas of overlap and convergence between multiple treatment methods, and using clinical experience to inform treatment decisions. With critical thinking, clinicians learn how to break problems into separate parts, evaluate and analyze underlying logic. Then, using integrative abilities they shuttle in the opposite direction, synthesizing information, generating new hypotheses and possible solutions that respond to unique circumstances. Both skills are needed.

Supervisors and educators can model these thinking skills and invite the same from trainees in concrete ways. For example, problems presented by an individual client could be used to demonstrate and directly apply principles of evidence-based practice. Students could be assigned to scour the empirical database about some aspect of the client’s presentation. The contents of EST manuals and other relevant material would be reviewed with an eye toward finding specific interventions of relevance. Once this review has occurred, the underlying logic and evidentiary base for treatment would be taken into consideration, as would areas of potential convergence across multiple studies or schools of thought. A mindful, collaborative, application of what has been learned would then be applied with the specific case. Optimally, supervisor and trainee would become engaged in an active, collaborative, evidence-based endeavor involving careful assessment, consultation with the empirical literature, hypothesis formation about useful interventions, and systematic evaluation of their impact for an individual case. Three key elements of EBPP are present in the foregoing suggestion: primary focus on the individual through use of case conceptualization methods, active use of the existing evidence-base, and exercise of EBPP as a process of decision-making and empirical inquiry. At first, the training model would be slow and resource intensive, with a great deal of time spent focused on individual cases. With time and practice, the process can be abbreviated and tailored to training needs as clinical skills are effectively practiced and internalized.

Relationship skills and EBPP

One of the more consistent findings in psychotherapy research studies with many different treatments and disorders is that a positive therapeutic relationship correlates with improved outcome (Horvath & Bedi, 2001; Wampold, 2001). Resources are increasingly available to summarize empirical work on the alliance and provide specific training recommendations (e.g., Muran & Barber, 2010; Norcross, 2002). The most studied aspect of the therapeutic relationship is the alliance, which consists of the affective bond between a patient and therapist, as well as their agreement about goals and therapeutic tasks for reaching them. Evidence-based practice may be particularly well-suited to enhance collaboration to the degree that it begins with focus on the individual client, thereby planting the seeds for a strong alliance.

Final comments

The approach outlined here suggests that the curriculum for psychology training needs to include greater emphasis on “foundational” competencies so that skilled intervention is learned and applied in broader context of EBPP. Scientific-mindedness, critical thinking, integrative capacity and relational skills all must be modeled and practiced across the curriculum so that they become part of the language and culture of evidence-based professional practice. We believe that a basic introduction to evidence-based practice should occur from the earliest phases of psychotherapy training, rather than being treated as an ‘advanced topic’ to be learned only after diagnosis-specific interventions and ESTs have been mastered. Perhaps the easiest place to start implementing EBPP in training settings is simply to introduce the APAs definition of evidence-based practice and encourage critical thought and discussion about its elements and implications, as recommended by Levant and Hasan (2008). An edited volume by Norcross, Beutler, and Levant (2006) also provides a related, excellent overview of the issues and challenges our field faces integrating science and practice as the empirical database continues to grow.

Ultimately, our hope for future trainees is that they will continue to push and expand boundaries of our current knowledge, improving client outcomes through a process of active engagement with the evidence-base. 

References

APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.

American Psychological Association Division of Clinical Psychology. (1995). Training in and dissemination of empirically-validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, 3–27.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work. New York: Oxford University Press.

Chambless, D. L., & Crits-Christoph, P. (2006). What should be validated? The treatment method. In J. C. Norcross, L. E., Beutler, & R. F. Levant, (Eds.) Evidence-based practice in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association, (pp. 191-200).

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7-18.

Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. S., Madson, M., et al. (2009). Competency benchmarks: A model for the understanding and measuring of competence in professional psychology across training levels. Training and Education in Professional Psychology, 4(Suppl.), S5–S26.

Gotham, H. J. (2006). Advancing the implementation of evidence-based practices into clinical practice: How do we get there from here? Professional Psychology: Research and Practice, 37, 606–613.

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In Norcross, John C. (Ed), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. (pp. 37-69). New York, NY, US: Oxford University Press.

Kaslow, N. J., Grus, C. L., Campbell, L. F., Fouad, N. A., Hatcher, R. L., & Rodolfa, E. R. (2009). Competency Assessment Toolkit for professional psychology. Training and Education in Professional Psychology, 3, S27-S45. doi: 10.1037/a0015833

Kazak, A. E., Hoagwood, K., Weisz, J. R., Hood, K., Kratochwill, T. R., Vargas, L. A., Banez, G. A. (2010). A meta-systems approach to evidence-based practice for children and adolescents. American Psychologist, 65(2), 85-97.
Levant, R. F., & Hasan, N. T. (2008). Evidence-based practice in psychology. Professional Psychology: Research and Practice, 39(6), 658-662.

McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: A review of current efforts. American Psychologist, 65(2), 73-84.

Muran, J. C., & Barber, J. P. (2010). The therapeutic alliance: An evidence-based approach to practice and training. New York: Guilford.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.

Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Evidence-based practice in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association.

Slade, K., Lambert, M. J., Harmon, S. C., Smart, D. W., & Bailey, R. (2008). Improving psychotherapy outcome: The use of immediate electronic feedback and revised clinical support tools. Clinical Psychology & Psychotherapy, 15, 287-303. doi: 10.1002/cpp.594

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ, US, Lawrence Erlbaum Associates Publishers.

The Division of Psychotherapy is pleased to offer an exciting convention program this year in San Diego!  We want to thank everyone for their fine submissions and let you know that we very much appreciate the time and effort that goes into these. Unfortunately, because of limitations of program hours (based on the number of members in our Division who attend the APA Convention), we are unable to accept all the quality submissions that we would like. Our blind raters work very hard at rating each program and there are many submissions that we hope to see again next year. This year’s program will be exciting and inspiring for both our younger and later career members. Many of the leaders in the field will present their latest thinking, research, and clinical strategies for us to take back to our offices and institutions. We were also able to participate in planning the plenary sessions that APA sponsors, which will be very relevant to psychotherapy.

We are conducting suite programming this year and hope that you will all drop by when you have a few minutes or more to share your experience, to network, and to share some nourishment. We are very excited this year to offer “Brunch with Barnett,” a suite program on psychotherapists’ self-care and life balance on Saturday morning with Dr. Jeff Barnett.  Please check back to our website for greater details and information on registering. We will keep you posted about further suite programming as we go.

Please carefully review our program and highlight those sessions that you want to attend. Don’t forget to encourage early career psychologists and students to attend our “Lunch with the Masters” where there will be copious food and a very popular book raffle. This year, our masters include Drs. Jeffrey Magnavita Judith Beck, Louise Silverstein, Florence Kaslow, and others.

We think there is an abundance of riches here and (unfortunately!) deciding what to attend will be a challenge.

See you all in San Diego!

2010 Division 29 Convention Program

Learn more about the members of the Task Force and their agenda.

Supervision is a fact of life for most of us.  We experience years of supervision in our professional training sequence and possibly afterward, and many of us move on to becoming supervisors of other professionals.  In their classic text, Coping with Conflict, Mueller and Kell (1972), some of the earliest writers in the field of supervision, suggested that because of the “oversight” provided by the supervisor, there is a natural power differential in the supervisory relationship that can be a crucible for discord.  Influenced by a psychodynamic perspective, they suggest that supervision is a clinical relationship within which supervisees can learn healthy management of power differences, as well as of conflict.  They suggest that conflict in supervision, if not handled skillfully, can be passed on to the therapeutic relationship through parallel process, or tacit learning.  Likewise, however, if handled skillfully, supervisory conflict can be a source of positive learning and development for supervisees, and this learning about being in healthy clinical relationships can be passed on to clients/patients.

Supervision scholars have noted that supervisees frequently do not reveal to their supervisors when they feel uncomfortable (Ladany, Hill, Corbett, & Nutt, 1996).  They fear reprisal, breaches in the relationship, and poor evaluations.  It is estimated that up to a third of mental health professionals have experienced some form of bad or harmful supervision at least once.  In fact, when asked, many of us can vividly recall at least one difficult, if not detrimental, experience with a supervisor.  The experience of harm in supervision has been well documented (Gray, Ladany, Walker, & Ancis, 2001; Kozlowska, Nunn, & Cousins, 1997; Nelson & Friedlander, 2001), and most of the harmful experiences described in the literature have occurred as a result of mishandled conflicts.

I and some colleagues recently conducted a study of “wise supervisors,” or supervisors considered by professional therapists to be the best in the field (Nelson, Barnes, Evans, & Triggiano, 2008).  They were asked how they thought about conflict in supervision and what strategies they used to work with conflict.  Findings indicated that “wise” supervisors understood that conflict is a normal (albeit discomfiting) occurrence in clinical relationships and saw it as an opportunity for growth for their supervisees and themselves.  They were unusually humble and willing to acknowledge and accept their shortcomings.  They valued and enjoyed supervision and communicated this enjoyment to their supervisees.  They saw a positive supervisory relationship as key to negotiating eventual differences with their supervisees and worked to foster trust in the supervisory relationship.  Many indicated that they discussed race, gender, and other differences with supervisees early on, as well as the power differential inherent to supervision, and processed related tensions.  They were willing to set clear boundaries and expectations and to communicate these to supervisees from the outset.  Though they set high expectations, they also valued and worked to facilitate developmentally appropriate learning in their supervisees.

All supervisors endorsed the use of interpersonal process as a key strategy for managing conflicts.  They seemed able to reflect on the process of conflict in supervision and what they had learned from past conflicts.  They were open to observing markers of supervisee discomfort, as well as their own, and addressing their observations openly in session with supervisees.  They actively considered the developmental needs of a supervisee in determining a course of action to address conflict.  Many indicated that they regularly undertook self-examination to understand the role they played in a conflict situation, and in cases of highly challenging conflicts, many sought outside counsel from trusted colleagues. A key strategy mentioned by all participants in the study was revisiting and clarifying role expectations with supervisees, renegotiating if necessary.

Most of the strategies mentioned by the supervisors in this study seem like common sense, and indeed they do represent the best of common sense.  They also represent the strategies of the courageous.  Rather than assuming a defensive or superior stance, these supervisors were open to owning their role in interpersonal conflicts.  They were willing to address conflicts openly with their supervisees in spite of the added discomfort such conversations create.  Thus these wise supervisors were courageous and open, and this openness is what earned them nominations from their peers for being outstanding supervisors.  We all know that the basic humanness of the therapist should be at the core of any psychotherapy relationship.  It is this same humanness in supervisors that creates the most optimal setting for supervisees to learn to negotiate conflicts.  Such in vivo learning in supervision can provide outstanding training in the nuances of negotiating difficulties in clinical relationships and serve as a model that supervisees can incorporate into psychotherapy.

Gray, L. A., Ladany, N., Walker, J. A., & Ancis, J. R. (2001). Psychotherapy trainees’ experience of counterproductive events in supervision.  Journal of Counseling Psychology, 48, 371-383.

Kozlowska, K., Nunn, K. & Cousins, P. (1997). Adverse experiences in psychiatric training. Part 2. Australian and New Zealand Journal of Psychiatry, 31, 641-652.

Ladany, N., Hill, C. E., Corbett, M. M., & Nutt, E. A. (1996). Nature, extent, and importance of what psychotherapy trainees do not disclose

Nelson, M.L., & Friedlander, M.L. (2001).  A close look at conflictual supervisory relationships: The trainee’s perspective. Journal of Counseling Psychology, 48, 384-395.

Nelson, M.L., Barnes, K.L., Evans, A.L., & Triggiano, P.J. (2008).  Working with conflict in clinical supervision: Wise supervisors’ perspectives.  Journal of Counseling Psychology, 55, 172-184.