Do We Need a Supportive-Therapy-Specific Psychotherapy Supervision?

Psychotherapy supervision is a (if not the) primary means by which the traditions, practice, and culture of psychotherapy are taught, transmitted, and perpetuated—it is the preeminent educational medium through which ideology becomes enlivened and translated into a practical product (1). Although much has been written about the crucial issues confronted when supervising some forms of psychotherapy (e.g., parallel process in psychoanalytic supervision; treatment fidelity in cognitive-behavioral supervision), far less information is available about supervising supportive psychotherapy. We are lacking in any concrete examination into the provision and crucial issues confronted in the evolving process of supportive psychotherapy supervision.

Supportive psychotherapy involves a complex set of competencies that can be challenging to learn and master (2, 3). Supportive psychotherapy supervision is similarly challenging: such work involves some supervision-specific competencies that are important to acquire and poses some unique challenges for the supervisor. See Box 1 for some selected examples of provider and supervisor competencies (4–6). These unique supportive treatment supervision challenges, however, have typically gone unconsidered in the supervision literature (with most attention instead being given to supportive therapy teaching and instruction). Of most supervisory concern, I contend, is what can occur when beginning therapists/supervisees first start providing supportive treatment. The very nature of the treatment, in contrast to other, more defined treatment modalities (e.g., cognitive-behavioral therapy), can come to have greater wear and tear on the formation of the new professional’s identity as a therapist and development of a sense of practice self (i.e., self-conviction about truly being and becoming a psychotherapist).

While it is developmentally normative for beginning psychotherapists to experience a learning regression (e.g., where they become anxious, insecure, self-questioning, and self-doubting) and feel a concordant sense of demoralization (7), that regression and demoralization, I maintain, can indeed become a far more painfully felt experience with regard to supportive therapy’s learning and practice. Two particular factors—the often chronic nature of the patient conditions involved (e.g., schizophrenia) and the nature of supportive treatment itself (i.e., focused on symptom relief and better adaptation)—appear to converge with the therapist’s beginner status to create those potential problems. New therapists can have considerable difficulty and may struggle with, or even resist, the symptom relief/better adaptation nature of supportive psychotherapy, oftentimes (consciously or unconsciously) holding to unrealistic expectations about themselves, their patients, and treatment outcome; they want to do more for and see more being done by their patients, perhaps hoping for a “cure” or “transformation,” and may regard that lack of “expected” treatment progress as an indictment on their fitness to provide therapeutic service. Thus, deeply troubling conflicts can get actuated and mobilized around treatment goals and purpose, therapeutic progress and stagnation, and the therapist’s sense of self-efficacy and self-definition. Where goals and purpose are concerned, supervisees often struggle with the following: What are the specific goals of supportive treatment? What is the purpose of our therapy? Further, where therapeutic progress and stagnation are concerned, supervisees may agonize over these questions: Where is there any patient change? Why do I see no movement? Additionally, where self-efficacy and self-definition are concerned, supervisees often wrestle with the following: Do I really have what it takes to be a therapist? Why is this particular type of therapeutic work so problematic for me? Why am I not getting it?

Such therapist development issues, although common across all treatment approaches, can frequently and repeatedly rise to the forefront and require ongoing attention and redress in supportive psychotherapy supervision. That can become especially so when there is too heavy a caseload of supportive psychotherapy patients, when the patient pathology across caseloads is invariantly acutely severe, and when therapist understanding of and readiness for supportive work tend to be low. It appears especially important that supervisors be informed by and mindful of these potential concerns when new therapists’ caseloads and supportive psychotherapy patients are considered.

Analogizing from Jerome Frank’s seminal work about patient remoralization and treatment persuasion and healing (8), supportive psychotherapy supervision itself can at times become, even needs to be, an exercise in educational remoralization and supervisory persuasion and healing. The supervisor is called upon to serve as a remoralization agent, bastion of hope, and purveyor of faith for the demoralized supervisee (7). Education in and of itself can be a most valuable component of that remoralization process. For instance, supervisors can provide supervisees with relevant assigned readings (9, 10), provide direct developmentally focused instruction, and even offer periodic educational reminders to supervisees as needed (e.g., “Let us think back to our discussion about therapist development stages from two weeks ago and consider how those stages might apply to what you are experiencing in treatment now”). Three areas that seem most important for supervisors to educationally target are (a) the very therapist identity formation experience in which supervisees are involved (e.g., considering developmental issues, such as autonomy versus shame and doubt, inherent in the growth process); (b) the challenges of providing supportive treatment and working with patients who often suffer from chronic psychiatric illness (e.g., maintaining realistic treatment expectations); and (c) how the combination of those variables can trigger the new therapist’s own doubts and insecurities. Absent such encouraging and normalizing elements from the supervisor, new supervisees who are providing supportive psychotherapy can be left to figure it out on their own. As Appelbaum (11) has made abundantly clear, however, the ethos of “going it alone” is not a helpful practice for any supportive psychotherapist, that seemingly being particularly so for the beginning, inexperienced, unpracticed therapist. Thus, ongoing supervision can accordingly be an immensely beneficial and fortifying mainstay, a buffer against and potential antidote for the often inherent stresses and ambiguity of learning to be a competent supportive psychotherapist.

Supportive psychotherapy may no longer be neglected (12), but its supervision process surely is. Because supportive psychotherapy supervision is so vital to competent therapeutic practice; can be a highly challenging, demanding form of supervision to implement; and can involve its own set of unique challenges, that very uniqueness needs to be addressed more specifically and substantively in the supervision literature. I contend that beginning supportive therapy supervisees most need and benefit from psychotherapy supervision that is specific to supportive psychotherapy. We are lacking in any such articulated vision of supervision, however. From my viewpoint, that needs to change.