Hill, C. & Knox, S. (2013). Training and supervision in psychotherapy. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 775-811). New York: Wiley.
Research on training and supervision in psychotherapy has proven to be very difficult to conduct. Part of the difficulty with the research is that the process under study is highly complex with many interacting variables. Therapists and supervisors have different personal qualities, patients have different levels of problems, training programs differ, supervision styles differ, and therapists and supervisors differ in terms of experience, case load, knowledge, and training background. Nevertheless there exists a moderately large literature on training, supervision, and continuing education in psychotherapy. However, the findings so far have been mixed and somewhat disappointing. In their chapter in the Handbook, Hill and Knox (2013) tackle the difficult task of summarizing this literature and giving some coherence to the findings. Is training and supervision effective? Hill and Knox tentatively conclude that the answer is “yes”. They provide some evidence that novice therapists can be trained in helping skills, that trainees improve over the course of training, that supervision enhances trainees’ awareness of self and others and improves their autonomy, and that experienced therapists, including those in the community can be trained to use manuals. Despite these positive findings, the existing literature also provided some sobering results. These less supportive findings include: that nonsupervised therapists did not differ from supervised therapists on therapy alliance and patient outcomes, that supervision sometimes has negative effects on trainees and their patients, that therapist experience may not be related to better patient outcomes, and that some highly facilitative non-professionals can be just as effective as trained therapists. What contributes to making training and supervision effective? The research in psychotherapy training and medical education is clear on this question: hands-on experience is key to learning a practice-based skill such as psychotherapy. Practice is the most helpful component of skills training. In medical education research, systematic reviews have shown that traditional didactic learning (i.e., classroom style lectures) had no significant impact on physician behaviors or patient outcomes. However, interactive programs (especially supervised rehearsal of skills) did have a significant positive impact on physician behaviors and patient outcomes. Furthermore, psychotherapy supervisees reported that supervisors who were open, empathic, and who provided supportive nurturance in the context of a good supervisory alliance were most helpful to trainees to develop and improve their clinical skills.
Practicing clinicians who want to get the most out of continuing education should look for opportunities in which they get hands-on experience and continuous supervision in providing the psychotherapy intervention. Other than acquiring a limited amount of knowledge, didactic training alone without practice will likely have little impact on practice. The research also indicates that supervisors and trainees who are able to develop a good supervisory alliance, and supervisors who are open and empathic are more likely to result in improved psychotherapy skills in trainees and better outcomes in patients. Binder and Henry (2010) describe the importance of “deliberate practice” in psychotherapy training and continuing education that includes: performing a task at an appropriate level of difficulty, receiving immediate and informative feedback from a supervisor, and having the opportunity to repeat the skill and correct errors.