The Supervision Pyramid: A Commonalities-Based Synthesis of Intervention, Relationship, and Person/Personhood
Publication: American Journal of Psychotherapy
Abstract
Adapting the therapeutic pyramid to the supervision of psychotherapy, the author presents and describes the supervision pyramid—a simple meta-model of the broad conceptual organizers of the supervisor’s contribution to the experience and outcomes of supervision. The supervision pyramid consists of three commonalities: supervisor skills and interventions, the supervisory relationship, and the supervisor’s person and personhood. Those three commonalities converge to stimulate supervisee learning and relearning and client improvement and symptom reduction. The implications of this meta-model for supervision conceptualization and conduct and for supervisor training are briefly described.
Psychotherapy works. We have convincing data to that effect (1, 2). But why does it work? Two camps of thought and research have evolved in response to that question: one gives primary emphasis to treatment interventions (specific factors), and the other gives primary emphasis to the treatment relationship (common factors) (3, 4). Although supportive research can be found for either position, it appears that common and specific factors are interdependent and synergistic and that their dichotomization is a false dichotomization (5–8). That reality is perhaps best captured in Wampold’s contextual model of the psychotherapy relationship (2, 9–12), in which the complementary nature of the common and specific factors is accentuated as being integral to psychotherapy effectiveness.
Fife and colleagues (6) proposed a meta-model, the therapeutic pyramid, in an effort to give voice to the powerful intersections of both relationship and intervention in affecting treatment outcome (13). Their therapeutic pyramid is presented in Figure 1. Supporting relationship and intervention, the therapist’s way of being was posited as being the foundational common factor: “The effective use of skills and techniques [or interventions] rests upon the quality of the therapist-client alliance, which in turn is grounded in the therapist’s way of being” (6, italics in original). This pyramid meta-model captures in a simple way some of the complexity—the interacting essentials—involved in making treatment work and, as Fife and colleagues (6) aptly indicated, provokes a host of clinical, training, and research implications that merit consideration.
FIGURE 1. The therapeutic pyramida
aFrom Fife and colleagues (6). Reprinted with permission
As a simple conceptual tool, might the pyramid also be useful in thinking about psychotherapy supervision? In this article, I take up that question. Precedent exists for making reasoned extrapolations from therapy to supervision, what Milne (14) referred to as reasoning by analogy. Reasoning by analogy involves reflecting critically upon what is known in one area to inform thinking in another area, where “the more sophisticated psychotherapy literature [is used to help] formulate and illuminate supervision in some key, common areas” (14). Here I use the therapeutic pyramid as inspiration, adapting it as a source of illumination and formulation, in proposing a similarly structured pyramid for supervision. Neither common nor specific factors function as islands in supervisory practice (cf. 7, 15, 16). Both sets of factors are needed and appear integral to supervision effectiveness (17). The supervision pyramid, like the therapeutic pyramid, captures in a simple way some of that complexity—the interacting essentials that are involved in making supervision work.
The Supervision Pyramid: Analogized and Contextualized
The supervision pyramid is presented in Figure 2. Desired outcomes, critical across all supervisory perspectives, are supervisee learning and relearning and client improvement and symptom reduction; those outcomes are situated at the pyramid’s top. Just as “effective therapy involves not only what we do, but who we are and how we regard clients” (6, italics in original), effective supervision involves what we do as supervisors, who we are as supervisors, and how we regard our supervisees. The three broad conceptual organizers, or commonalities, of the supervision pyramid are the supervisor’s skills and interventions, the supervisor-supervisee relationship, and the supervisor’s person and personhood. Each commonality supports the one above it, substantively contributing to the supervisee’s learning and relearning and, ultimately, to client change.
FIGURE 2. The supervision pyramida
aAdapted from Fife and colleagues’ therapeutic pyramid (6). Adapted with permission
Supervision ideally is a collaboration between supervisor and supervisee, and the supervision pyramid identifies preeminent ways by which supervisors can facilitate that collaboration. Primary focus is given here to the supervisor because supervision is a power-disproportionate, hierarchical experience, with supervisors occupying the power position; supervisors are tasked with evaluating supervisees’ performance and progress and passing them forward (or not); and supervisors set the stage for and tone of the supervision endeavor and its favorable (or unfavorable) unfolding (17–22). Supervision is an asymmetrical experience; supervisors forever strive for symmetry within the asymmetry (23, 24).
Below I briefly review and offer support for the pyramid’s five levels, giving primary attention to the three key broad conceptual organizers of intervention, relationship, and person/personhood. Particular emphasis is given to the supervisor’s person and personhood—an often unrecognized but crucially important foundational common factor. Much as the therapeutic pyramid captures the broad essentials of Wampold’s (2, 12) contextual model of psychotherapy, the supervision pyramid captures the broad essentials of the contextual model of supervision—a perspective based on common factors, common processes, and common practices (25).
Outcomes
Although Fife and colleagues (6) did not specifically include client improvement and symptom reduction in their therapeutic pyramid, it was an assumed part of their discussion. That assumed part is clearly reflected in the supervision pyramid, as is supervisee learning and relearning. Both of these identified outcomes capture critical differences between the treatment and supervision processes: supervision is truly a triadic affair, the change process ideally affects client and supervisee, and the influence of supervision that is experienced by the client is exclusively mediated by the supervisee.
Level 5: Client Improvement and Symptom Reduction
Client improvement and symptom reduction, the acid test of supervision (26), sits atop the pyramid. Psychotherapy supervision is fundamentally grounded in the convictions that supervision is a process whereby the therapist’s conceptual understandings and treatment skills are developed and enhanced, those conceptual understandings and treatment skills are transported into and applied in the therapeutic situation, and that application is intended to have beneficial effects for the client (27, 28). These convictions have guided supervision since its inception and continue to do so and are accordingly reflected in the pyramid’s structure. But the harsh reality is that although estimates can be made about the contribution of key psychotherapy variables (for example, alliance and techniques) to patient outcomes (2, 4), no such estimates can be made for psychotherapy supervision. Convincingly demonstrating any such supervisor-to-patient impact empirically is most difficult (29), a desideratum as yet unfulfilled. A small set of sound investigations, most published in the past ten years, is a good beginning, provides an empirical template to emulate, and holds much promise for future study in this area (30–35).
Level 4: Supervisee Learning and Relearning
Although the degree to which different supervision variables actually contribute to supervisee outcome is not known, we do know that supervision benefits supervisees. Some benefits include enhanced self-awareness, enhanced treatment knowledge, enhanced skill acquisition and utilization, enhanced self-efficacy, and a stronger supervisee-patient relationship (e.g., 27, 33, 36–41). Evidence for the impact of the supervisor and supervision on the supervisee is well established (19). The pyramid shows crucial variables that appear to make that impact possible.
Supervisor Contributions
Level 3: Skills and Interventions (or Techniques)
The psychotherapist intervenes and so too does the psychotherapy supervisor. Psychotherapy interventions number in the hundreds (42–44), but the number of supervision interventions is comparatively quite limited. Research and review suggest that much supervision practice involves the use of only six interventions: case conceptualization, providing feedback, modeling, teaching and instruction, discussion, and stimulating self-reflection (25, 45–47). Although implementation may vary across supervisory perspectives, this grouping of six—our specific factors—comprehensively captures much of the transtheoretical landscape of supervision intervention (cf. 23, 24, 48–53). Supervision is eminently educational in nature. These interventions reflect that educational emphasis and are accordingly used for educational purposes.
Interventions are necessary although not sufficient for supervision to have a positive impact; they provide the ritual to accompany myth, the action to accompany conception (17). Supervision is at its best when supervisor and supervisee have a shared belief system—a shared understanding—about what supervision is (myth) and how it is to be conducted (ritual). Supervision intervention is essential for realization of supervision conception and expectation and essential for realization of the supervision relationship. To paraphrase Fife and colleagues (6), the supervisor’s technical mastery truly becomes educative when grounded in relationship and person/personhood.
Level 2: The Supervisory Relationship
The supervisory relationship is the mediator through which intervention is enlivened and enacted; it too is necessary but not sufficient (45). At least three variables are important to consider with regard to the supervisory relationship: the learning-supervisory alliance, the real relationship, and countertransference. These appear to be common components across all supervision perspectives (25, 54).
The learning-supervisory alliance.
Extrapolating from Freud’s (55, 56) writings about the treatment relationship, Fleming and Benedek (57, 58) first proposed the construct of a learning alliance, in which a supervisor-supervisee pact, compact, or partnership is forged for purposes of supervisee development. Then, as now, the learning or supervisory alliance brings into focus the work of supervision—the working relationship that supervisor and supervisee share—which consists of three crucial, interconnected components: the rapport or bond established between supervisor and supervisee (their shared “feelings of liking, caring, and trusting”) (59), the shared goals that guide the supervision process, and the shared tasks that stimulate pursuit of goal attainment (57-60). The alliance’s shared goals and tasks center on developing and enhancing the supervisee’s skills and competencies, developing and enhancing the sense of a therapist identity, and ensuring patient care. Fleming and Benedek (57, 58) envisioned the learning alliance as ideally cocreated and coconstructed, a true working collaboration; their vision has aged well, accentuating the supreme significance of working with and working for our supervisees. Whatever supervisory perspective is deployed, the learning-supervisory alliance lives large in contemporary supervision conceptualization (e.g., 50, 53, 61–66). It is currently the most robust, uniformly embraced, cross-culturally endorsed common factor in supervision, integral to all supervision competence frameworks worldwide (e.g., 67, 68).
The supervisory alliance is also our most robust, empirically supported common factor in supervision. Approximately 50 studies, spanning more than a quarter century, lend support to that statement. In study after study, the supervisory alliance generally has functioned as hypothesized: a favorably perceived supervisee alliance has been quite consistently found to be related to desired supervision behaviors, judgments, or outcomes (for example, more perceived effectiveness of supervision, more satisfaction with supervision, and greater supervisee willingness to self-disclose), whereas an unfavorably perceived alliance has been quite consistently found to be related to the opposite (for example, a higher degree of perceived supervisee stress, higher levels of exhaustion and burnout, and more role conflict and role ambiguity) (38, 69). The supervisor-supervisee alliance appears to provide a solid evidence-based anchor that grounds supervision practice. Ladany and colleagues (50) asserted that the “working alliance . . . is arguably the foundation for effective supervision.” An accumulating body of research strongly suggests that to be so.
Real relationship.
The real relationship gives focus to the more personal, nonwork side of the supervisor-supervisee relationship. Extrapolated from the seminal psychotherapy relationship models of Gelso (70, 71) and Wampold (2, 11, 12), the real (or personal) relationship in supervision can often be thought of as hiding in plain sight, even being quite extraordinary in its very ordinariness (54). It is a dimension of relationship characterized by supervisor genuineness (authenticity) and realism (accurate perception), a sector of experience that is viewed as separate from the work of alliance and separate from distortions (for example, countertransference) that may occur during the supervision process. Some common examples of the real relationship include greetings and parting comments; chit chat; courtesy; friendly interest; self-expression; liking; sharing feelings about events affecting the supervisee (for example, birth of a child or death of a parent); and sharing genuine, appropriate feelings that arise in the supervision situation (for example, sadness over supervision’s termination or happiness over the supervisee’s successes). The real relationship may be based more on a supervisor-supervisee personal bond, whereas the working alliance is based more on a work bond (70). Although research on the real relationship in supervision is only beginning, it is hard to deny the reality of a personal dimension to the supervision relationship. Just as the personal dimension has been supported as pivotal in psychotherapy research (70, 71), there is reason to believe that that the personal dimension may have significant implications for supervision. Some form of real or personal relationship, I maintain, is a critical common factor across all supervision perspectives (17, 25, 54).
Countertransference.
Adapting Gelso and Hayes’ (72) definition, supervisor countertransference is defined here as “the supervisor’s internal and external reactions that are shaped by the supervisor’s past and present emotional conflicts and vulnerabilities” (54). Countertransference refers to blind spots, areas of vulnerability, or issues that get in the way of conducting supervision effectively—preexisting problematic perceptions or ideas that supervisors carry into the supervision situation. All supervision perspectives, regardless of whether they specifically use the term countertransference, make space for this type of carryover and emphasize the importance of recognizing and managing the intrusion of such interfering, problematic behaviors or mindsets on supervision (52, 61, 63, 73–79). In that respect, such carryover reflects a commonly acknowledged, troubling challenge to optimal supervisor functioning. Recognizing and managing supervisor countertransference—ideally using it to inform and illuminate, not compromise and contaminate, the supervisory perspective—is also vital in helping supervisees recognize and manage their own transference and countertransference experience (80).
Level 1: The Supervisor’s Person and Personhood
Although Fife and colleagues (6) labeled the bottom block of their pyramid as way of being, I have chosen to relabel that block as the supervisor’s person and personhood. Although a host of variables may be involved in the supervisor’s person and personhood, emphasis is given to two crucial considerations: way of being and supervisor presence.
Supervisor presence.
Presence has increasingly emerged as an eminently important common factor in psychotherapy (81–85). Reasoning by analogy (14), I contend that presence is an equally and eminently important common factor for the effective practice of psychotherapy supervision. Presence is a prerequisite for supervisor-supervisee relationship development; it is the ground—the hub—upon which alliance and real relationship are built (cf. 84, 85). Supervisor presence, defined as the state of having one’s whole self in the supervisor-supervisee encounter, being completely in the moment on a host of levels (82), involves at least four critical features: being in touch with one’s own healthy and integrated self, being receptive and open to and immersed in the present, allowing in-the-moment expansion of one’s awareness, and having full intention and being fully functioning so as to be of service to one’s supervisees and their clients (cf. 82, 84). It is the supervisor’s “being here,” “being now,” “being open,” and “being with and for” during supervision (81), a generative mix of appreciative openness, concerted encouragement, support, and expressiveness (85). Supervisor presence models and invites, showing by doing and ideally eliciting the supervisee’s presence in return.
Way of Being.
Perhaps Anderson (86) captured the essence and intent of way of being best. It “conveys to the other that they are valued as a unique human and not as a category of people; that they have something worthy of saying and hearing; that you meet them without prior judgment.” It is foremost an open, genuine attitude of caring, passion, and compassion toward our supervisees as learners and the vulnerabilities that they experience in the learning situation. That attitude is nicely put on display by Lewis (87), in this passage that I have always appreciated for its sensitivity and humanity: “The successful supervisor will be able to allay the anxiety of the supervisee. . . . Here you are not anonymous or abstinent. Here you are a real person. Here you show your warmth and openness and acceptance. Here you praise, support, encourage, and advise. Here you show your empathy to the vulnerability of a learner. Here you share your own experiences, your own mistakes. Here you share your own doubts and anxieties as a learner.”
Supervisors value the person and personhood of their supervisees, privilege and prioritize their supervisees’ needs, and are fully committed to the constructive instigation of therapist development.
Fife and colleagues (6) contended that the desired therapeutic way of being is best captured by means of an I-Thou as opposed to I-It stance (88). The same could be said for psychotherapy supervision. Whereas I-It views the other as object not subject, where someone becomes something (6), the I-Thou view is antithetical in every way, forever guided by such cardinal watchwords as respect, engagement, appreciation, valuing, prizing, and generativity. Supervisors ideally hold an I-Thou attitude about supervision and bring that attitude with them to each session, the foundational building block for supervisor-supervisee connection.
The supervisor’s I-Thou stance reflects that most fundamental conviction: how you are is as important as what you do (89). I-Thou is also well reflected in supervisor enactment of such guiding and abiding values as eminent valuation, abiding fidelity, and relational privilege (90). Eminent valuation refers to the supervisor’s valuing supervision supremely, viewing it as preeminently crucial for supervisee learning, and consistently putting that view into practice during supervision. Abiding fidelity refers to the supervisor’s being studiously loyal and committed to supervision as a field of practice and his or her own continuing development as a supervision practitioner. Relational privilege refers to a supervisor’s granting high privilege to the supervisor-supervisee relationship and treating it accordingly, regarding the jointly forged relationship as being the crucial mediator that ultimately makes the totality of supervision work. When these values and principles of action are put in place, the supervisor’s way of being is apt to be increasingly mutative and educationally liberating.
Although I-Thou discussions are most apt to be found in humanistic-existential supervision writings (e.g., 49, 91), an I-Thou (way of being) stance is not model dependent and is by no means the exclusive property of any one perspective (cf. 6). It is a way of wanting to be with an other that prizes and prioritizes the supervisee and his or her learning. Evidence for that foundational attitude of humanity and humaneness, caring and concern, investment and engagement, and passion and compassion can readily be found across all supervisory perspectives, no matter how disparate (e.g., 23, 24, 62, 64, 74, 76, 92). Way of being is what we as supervisors bring with us to supervision, and, ideally, we do so constructively and in at least “good enough” fashion each time.
Unfortunately, that is not always the case. Research suggests that some supervisees experience either inadequate or harmful supervision or both. In two recent seminal studies involving more than 600 respondents from the United States and Republic of Ireland, Ellis and colleagues (93, 94) found that virtually 100% of participating supervisees reported experiencing inadequate supervision at some point (for example, when the supervisor “does not listen” or is “not committed”); about 50% reported having experienced harmful supervision (for example, “had sexual relationship” with supervisor). Whatever might be contributing to such outcomes, it does not seem a stretch to surmise that when such troubling behaviors occur, the supervisor’s way of being has been compromised (or perhaps was never in place) and is not serving as supervision’s guide.
Using the Supervision Pyramid
Conceptual and Practical
Fife and colleagues (6) identified several potential uses for the therapeutic pyramid, some of which seem also to apply to the supervision pyramid. For example, the supervision pyramid— which is a meta-model or model of models—is by definition of cross-theoretical applicability and can be informative for individual, couple, and family therapy supervision (cf. 6). When supervision problems exist at one level, the solution may often be found at an underlying level (cf. 6). When supervisees are struggling in supervision, might this be due to the supervisor’s use of ill-fitting interventions? Could there be a problem in the alliance? Might a rupture event have occurred that needs attention and reparation? Could alliance strain be due to a problem in the supervisor’s way of being (for example, being inattentive or uncommitted)? The pyramid provides a simple way of thinking about levels of engagement, how they may each contribute to a relational problem or to progress, and how relationship and intervention are inescapably interdependent.
Educational
But perhaps the pyramid finds its greatest use as a tool of education. Although the various pyramid levels are routinely considered during any beginning supervision seminar, the pyramid itself (Figure 2) provides an economical way to capture those different levels in a visually descriptive, easily accessible, eminently graspable way. It is particularly well suited for use in beginning supervision seminars, orienting new supervisor trainees about supervision’s core broad essentials, some of the components that compose those essentials, and how the supervisor’s attitudes and actions contribute to the realization of those essentials. We lack information about valuable, available teaching tools for training supervisors (95). I propose that the supervision pyramid is one such readily available, valuable tool.
Conclusions
Reasoning by analogy (14), I have adapted and extrapolated the therapeutic pyramid (6) to the supervision situation. The supervision pyramid consists of five levels: The supervisor’s person and personhood, the supervisory relationship, the supervisor’s skills and interventions, supervisee learning and relearning, and client improvement and symptom reduction. The pyramid provides a visual display of how we as supervisors have an impact on the supervision experience, showing the broad commonalities through which facilitation or fracture can occur. I believe that this pyramid can be especially valuable in training supervisors—providing an accommodating, content-rich learning structure, promoting role induction, and provoking profitable discussion—and I have described it here with those purposes in mind.
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Received: 5 July 2016
Accepted: 20 January 2017
Published online: 15 August 2018
Published in print: November 01, 2018
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The author reports no financial relationships with commercial interests.
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