At our clinic, we supervise graduate students and pre-licensed clinicians working towards terminal licensure. Given that many people are attracted to treating things that they themselves can relate to, this often means there is an anxious supervisor, supervising an anxious clinician, who is treating an anxious client! The dual processing and meta-cognitive conversations can get complicated and feel overwhelming! To this end, we think a lot about how best to help anxious therapists provide excellent services.
First, it is worth clarifying what supervision is in order to understanding how anxiety might affect the process. In the most general terms, it is a relationship between two individuals in a similar scope of practice, one of whom has more expertise than the other and the intention of providing guidance based on that expertise. According to Milne (2009), the main function of supervision is to “minimize the non-purposeful activity and maximize intentionality with the goal of directly optimizing clinician competencies, ensuring quality control, and enhancing confidence for the goal of improving patient outcomes.” This highlights the need to identify anxiety at all levels of the supervision process as it could cause interference in patient outcomes. Importantly, supervision is not therapy, however therapeutic issues may come up and may be discussed in supervision for the purpose of reducing their effects on the therapy work.
Anxiety is not all bad however! As research has shown when comparing performance to arousal, there is optimal performance associated with optimal arousal (see the chart below). However, when that arousal reaches a point of anxiety or distress, generally this does impair performance. This is known as the Yerkes-Dodson Curve, and it highlights an evolutionary development in our species that shows our bodies and brains preparing us to perform well, likely in the hopes of increasing our odds at survival. Thankfully, survival in a literal sense is rarely a concern for new therapists or their supervisors, but this does provide some insight about what our bodies are trying to accomplish.
The effects of unmanaged anxiety on clinicians and the therapeutic relationship can be detrimental. Various studies have noted increased likelihood of burnout and compassion fatigue and the use of maladaptive coping strategies such as substance use or avoidance. Further, it can cause clinicians to begin to focus on their own distress rather than helping the client, experience increased anticipatory anxiety, increase self-criticism, and make it very difficult to receive constructive criticism. This can also lead to a lack of rapport and trust between the client and the clinician, which in turn can lead to apprehension by the client to disclose due to a perceived responsibility for the clinician’s emotions. The client may feel unheard, misunderstood, or invalidated.
In an effort to focus on the behaviors that may lead to these detrimental outcomes, a Spectrum of Anxious Behaviors (see below) within supervisee roles has been created based on the concepts of doing “too much” or “too little.” “Too much” represents an over engagement with tasks, cognitions, experiences, conversations, etc. that leads to detrimental therapeutic outcomes, while “too little” is just the opposite, an avoidance of tasks, cognitions, experiences, conversations, etc. This spectrum of anxious behaviors allows us to include a full range of reactivity to anxious distress, for just as one anxious person may totally avoid the stressful stimuli, another may well focus on it completely for way longer or more intently than is helpful. For supervisors, this provides insightful analysis that will allow for helpful support as they investigate where their supervisee is doing too little or too much.
Observational experiences have highlighted some of these "underdoing" behaviors, which can be seen across multiple categories of professional development. Administratively, underdoing it will look like difficulty maintaining boundaries around cancellation policies, frequent appointment misses, and sessions routinely going over-time. In terms of the therapeutic relationship, the supervisee may be resistant to acknowledging a bad fit or lack of skills associated with a client’s concerns. Further, an anxious clinician might allow the client to lead too much in terms of their own care, and then sessions become dominated by the client telling “stories of the week,” processing over and over again without much progress or observable goals. The clinician is often too anxious to cause disagreement or allow for distress, therefore they feel unable to interrupt or push clients towards behavioral goals. Internally this clinician will worry about disrupting the relationship, which can lead to not addressing interpersonal dynamics affecting the therapy work. This type of internal self-criticism can lead the clinician to not engage with members of their treatment team or support system, often feeling they have to hide themselves, so they are not “found out” as being wrong, incorrect, or less than.
On the other side of the spectrum, we have “over-doing" it, in which the same anxiety and distress pushes the clinician towards an increase in behaviors in ways that can appear beneficial but often cause dysfunction. The supervisee might note, “Well, I am just trying to be as prepared as possible!” The reality is, however, that these behaviors often manifest as over-control, which does not allow for flexibility or deeper learning. A more obvious sign of these types of distress behaviors is excessive reassurance seeking, both in and out of session. This may look like repeatedly asking the supervisor if what they are doing is right or good enough without being able to take in and process the responses. Sometimes new clinician will feel the need to ask the clients themselves reassuring questions. While it certainly good to check in or gain clarification on what the client sees as helpful, if unmanaged, this can have negative effects on the therapeutic relationship and leave the client feeling like the clinician is not the expert or that they need to be taken care of.
Supervisees may also engage in over-control of the sessions, feeling the need to constantly have a worksheet or specific tool to use in every session. While these tools are beneficial, the inability to work more broadly in the scope of the modalities used in therapy is often a sign that the clinician is seeking “perfect interventions” and is fused to negative thoughts and emotions experienced during sessions. This can also look like over-preparing prior to session, and over-responding to the client in session.
It is important to note that it is not always just that the supervisees are anxious, but sometimes there are contextual issues within the work and the training that can lead to an increase in anxiety and distress. As supervisors, it is important to keep an eye on these variables and work to curtail them as much as possible. Lack of training is probably the most obvious, and while there is going to be a period where the new clinician will need to move forward without the full scope of training, being given the detailed information about specific modalities, being clear and direct about expectations during internship or pre-licensed work and encouraging the supervisee to get more experience within these expectations are helpful and important.
As almost any clinician will tell you, getting the degree, as great an accomplishment as it is, is really just the beginning! Additionally, supervisors need to be mindful of the amount of work that interns or pre-licensed clinician are doing—while it is important for the supervisee to gain experience and make a living, that experience has to come at a rate and speed that allows them to process and grow. Sometimes this means fewer clients on their caseload, increased supervision meetings, or increased consultation with other therapists within the specialty. Finally, it usually a good idea for all clinicians, but especially new ones, to engage in their own therapy. This can feel scary for some as they worry about stigma and how they will be perceived, but multiple studies have highlighted the increase in therapeutic effectiveness and confidence when clinicians are engaged in their own therapeutic process.
Some cognitive themes, which are often present in people’s lives prior to graduate school, can have a marked increase during training. Therapists are not immune to these themes and becoming aware of them is an important part of progress and can highlight some parallel processing. For example, intolerance of uncertainty, which often comes out in thoughts like “I can’t handle not knowing!” will cause the newer clinician distress as uncertainty is unavoidable in this work. Another theme that will cause some increase in distress is excessive responsibility, which sounds like “It’s my job to fix this!” This will undoubtedly lead to an increase in self-critical thoughts and feelings and can mirror two other cognitive themes; cognitive rigidity and perfectionism. Cognitive rigidity in therapeutic work can look like an unwillingness to alter or be flexible with the textbook understanding of modalities and interventions, which can be extremely limiting. Perfectionism, which can often be seen as contributing to excessive responsibility and rigidity, will push the new clinician to try to find the “perfect” intervention that likely does not exist. Lastly, and perhaps most importantly, the inability to tolerate distress can have profoundly negative effects on the therapeutic relationship and on the mental health of the clinician. This again highlights the need for clinicians to utilize their own therapy, for while supervisors can be helpful in this area, it will be up to the clinician themselves to work on increasing their willingness and tolerance of distress.
In order to help with these concerns from the supervisor role, some prompts have been created that will allow for some discussion, curiosity, and exploration of these issues. These prompts will help the supervisee, and the supervisor engage in flexibility, curiosity over judgement, and might even increase learning and confidence. Here are some more prompts specifically for supervisors to ask the supervisee:
Overall, through the use of these prompts and the previously noted spectrum, the goal for supervisors is to help build brave supervisees that can move toward their own goals and develop deep understanding of their work. To do this, the supervising clinician will want to begin to move away from utilizing relaxing, coping, and challenging thoughts to more Socratic questioning and functional analysis. Pushing the supervisee to notice their own thoughts and the relationship they have with those thoughts, while also being curious about the function of those thoughts and the function of the clients’ thoughts and concerns as well.
The supervisor will also want to recognize co-rumination or co-compulsive discussion, which can look like “venting” or re-processing over and over and attempt to move towards resisting reassurance and increasing awareness of session patterns. Additionally, supervisors will want to encourage moving away from manualized treatment to “reading the room” and being flexible in session so as not to be over-directive or over-controlling, but instead work to meet the client where they are. Finally, one of the hardest moves is going from trying to find the perfect intervention to modeling mistake making, with an emphasis on identifying how the supervisee moves forward after a mistake or an ineffective intervention, usually through the use of curiosity, openness, non-critical reflection.
