It was only after I started listening to audio recordings of trainees'
therapy sessions, prior to their supervision, that I began to realize how easy
it was to fudge the story being presented to me. By fudge, I mean spruce up,
exaggerate, lie, or highlight the high points while glossing over the low
points, either consciously or unconsciously.
Traditional supervision methods have built-in biases. Trainees have an
insatiable desire to please their supervisor and a vested interest in
receiving a favorable performance report. Often process notes are not written
immediately after the session but later that evening or even the next day,
subjecting the notes to recall error.
To make matters worse, every supervisor has a different way of measuring a
trainee's performance and has his or her own teaching style. Not infrequently,
supervisees, among them graduates of top psychiatric programs, have surprised
me with lapses in therapy technique. I often wonder what transpired in their
previous supervisions. One observation is that "eclectic"
supervisors are vulnerable to leaving a trail of half-baked techniques that
lack a coherent theoretical conceptualization. The words "My old
supervisor thought that it might be a good idea to try a few mindfulness
techniques" still make me cringe. Worse still, residents with
narcissistic traits can lie their way through training because no one realizes
the true extent of their difficulties in empathizing. Another misguided
trainee was taught (by an analytic supervisor) to answer his beeper during
therapy, presumably because of medico-legal neurosis.
There is a better method for improving the reliability and efficacy of
supervision. The trainee tapes each session using a highquality audiocassette
recorder. The supervisor listens to the audiocassette and, via the Cognitive
Therapy Rating Scale (or similar objective measure), rates the various
components of the therapy on a Likert Scale. The Cognitive Therapy Rating
Scale is made available to the trainee and thus, in addition to evaluation of
competency, is also used for a second purpose—teaching the trainee
exactly what is required for him or her to be deemed competent.
The main advantages of audiotaping trainees' sessions are having an
objective record of what actually happened and being able to identify more
accurately where teaching efforts should be focused. Boundary violations and
deviations from the defined setting (for example, starting late, going
overtime) can be observed with greater ease, even if they are subtle. For
example, a supervisee noted that her Medicaid patient was wearing a new
designername outfit and made a joking comment about it without realizing the
countertransference implications. Because it was on tape, it could be
Another advantage is that two supervisors can rate the same therapy
session, increasing the interrater reliability. Thus, regular therapy sessions
can be evaluated in a naturalistic setting as a quasi-examination.
For trainees, learning and skill acquisition occur rapidly. This adds a
certain excitement and pace to the supervision that trainees seem to enjoy.
Because they know what the supervisor is looking for, they are motivated to
read about and practice the techniques.
Supervisors should address preconceived notions (or distorted automatic
thoughts, in the terminology of cognitive therapy) about recording and privacy
with both patients and trainees from the outset. Cassettes must be carefully
guarded and erased once the supervision is over.
One disadvantage of audio recording is that for every hour of supervision
that the supervisee puts in, the supervisor puts in two. This must be taken
into account when budgeting and allocating the teaching load. Another factor
to consider is that it takes time to learn to supervise with this method; I
underwent formal training through the Beck Institute for Cognitive Therapy and
Research, which offers a program for supervisors.
While cognitive therapists have been pioneers of this form of supervision,
it can be adapted to all forms of therapy.
After five years of using audiotaped sessions for supervision, I am
convinced that traditional supervision should be relegated to a formaldehyde
jar on the museum shelf. The learning advantages to this system outweigh the
technical and organizational extras that it requires.
Could we judge the competence of student drivers by their personal
description of their skills? Most of us would want an objective driving test.
We should not be surprised that an objective method for teaching psychotherapy
has advantages. The real surprise is why it has taken so long for this method
to be widely implemented. ▪