Saturday, January 7, 2012

Use of Cognitive-Behavioral Techniques in Clinical Supervision

Edward Wahesh, MS, LPCA, NCC

Beginning counselors often struggle with self-defeating thoughts and negative emotions related to counseling. “I cannot make mistakes as counselor!” is a common example of a belief held by counselors that can contribute to anxiety or other negative emotions. If not addressed, such thoughts and emotions can negatively influence the counselor’s ability to establish robust therapeutic relationships with clients.

Clinical supervision provides an opportunity to assist counselors in identifying the underlying irrational beliefs that diminish their ability to conduct effective therapy. Cognitive-Behavioral Therapy (CBT) has demonstrated efficacy through numerous outcome studies to treat personal problems such as depression and anxiety. The focus of CBT on how beliefs influence mood and behavior can inform the supervision of counselors. Specifically, the philosophy and techniques of CBT can be adapted by clinical supervisors for use with supervisees to increase their self-awareness and to identify and modify beliefs that interfere with their role as counselors.

An example of a CBT technique that can be adapted for use in clinical supervision is the Thought Record. Developed by JS Beck (1995), the Thought Record (originally referred to as the Dysfunctional Thought Record) provides a set of prompts that allow clients to challenge unproductive thoughts as they occur. Clients are instructed to fill out the Thought Record when they notice their mood getting worse. They record the specific situation, related automatic thoughts, associated emotions, alternative responses, and outcomes. The purpose of this exercise is to teach clients how to recognize and dispute self-defeating thoughts. Following an introduction to CBT during supervision, this exercise can be assigned as homework for supervisees to monitor and modify their problematic thoughts related to counseling. The following is an example of how a Thought Record can be completed by a beginning counselor:

Thought Record (JS Beck, 1995)

Date/Time: 11.23.2011 at 2:30pm

Situation:

1. What actual event or stream of thoughts, or daydreams, or recollection led to the unpleasant emotion?

Preparing case presentation for supervision

2. What (if any) distressing physical sensations did you have?

Felt my heart beat faster, difficulty concentrating

Automatic Thought(s):

1. What thought(s) and/or image(s) went through your mind?

I am never going to become an effective counselor

2. How much did you believe each one at the time?

80% (scale of 0-100%)

Emotion(s):

1. What emotion(s) did you feel at the time?

Anxiety

2. How intense was the emotion?

80% (scale of 0-100%)

Alternative Response:

1. Use the following questions to compose a response to the automatic thought(s) and

2. How much do you believe each response?

a. What is the evidence that the automatic thought is true?

My client shows no sign of improvement (70%)

b. Is there an alternative explanation?

Change may take longer than I assume, the client may not be ready to change (50%)

c. What is the worst that could happen and how could I cope?

Over the course of counseling, the client not only does not change, but also gets worse (40%). I can cope by speaking with my supervisor (60%)

d. What is the effect of my believing the automatic thought? What could be the effect of changing my thinking?

My thoughts make me feel anxious whenever I think about the client. My anxiety can interfere with my counseling approach. Changing my thoughts can make me more responsive to the needs of the client (60%)

e. If (friend’s [colleagues] name) was in the situation and had this thought, what would I tell her/him? What should I do about it?

I would tell my colleague that counselors cannot make clients change (70%)

Outcome:

1. How much do you now believe each automatic thought?

50% (I am never going to become an effective counselor)

2. What emotion(s) do you feel now? How intense (0-100%) is the emotion?

60% (Anxiety)

3. What will you do? [Behavioral activation]

Consult with my supervisor

Continue to monitor the presence of this and related automatic thoughts

Cognitive-behavioral techniques used in supervision can aide counselors in developing self-awareness of self-defeating beliefs and negative emotions that can hinder their clinical skills. Prior to incorporating these strategies into supervision, it is critical that supervisors possess competence in the philosophy and techniques of Cognitive-Behavioral Therapy. The following recommended readings provide supervisors with resources regarding CBT and the appropriate use of CBT in clinical supervision.

Recommended Readings for Practitioners:

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY: Guilford.

Fitch, T. J., & Marshall, J. L. (2002). Using cognitive interventions with counseling practicum students during group supervision. Counselor Education and Supervision, 41, 335-342.

Kindsvatter, A., Granello, D. H., & Duba, J. (2008). Cognitive techniques as a means for facilitating supervisee development. Counselor Education and Supervision, 47, 179-192.

Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational,

functional, and supervisory aspects. Psychotherapy: Theory, Research, Practice, Training, 47, 12-19.

Rosenbaum, M., & Ronen, T. (1998). Clinical supervision from the standpoint of cognitive-behavior therapy. Psychotherapy: Theory, Research, Practice, Training, 35, 220-230. doi:10.1037/h0087705

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