Supervision Issues in Cognitive Therapy

by Judith S. Beck, Ph.D.

Originally published in Cognitive Therapy Today, the Beck Institute Newsletter in 2004. 

I have recently been supervising a number of novice therapists and experienced therapists new to cognitive therapy.
At the beginning of (and throughout) supervision, I stress conceptualization, the cognitive model, and structure.
Also from the beginning I stress the importance of using the conceptualization to plan treatment within individual sessions. I ask therapists to keep two questions in mind during a session:Judy Headshot 2016

  • “How can I help this patient feel better by the end of the session?”
  • “How can I help this patient have a better week?”

These two questions have helped my supervisees deliver more effective treatment. One supervisee, Carol, had been a therapist for 22 years. For the most part, before our supervision began, she delivered supportive psychotherapy mixed with some psychodynamic and some problem-solving techniques. Her sessions were quite unstructured. She and patients discussed whatever was on the patient’s mind at the moment. Sometimes the topic involved a current difficulty; sometimes it was related to distressing childhood experiences. Patients tended to drift from one topic to another without closure and Carol followed their lead. When Carol occasionally made suggestion to help solve a problem, she rarely checked on the implementation of her advice at the next session and the problem was dropped unless the patient herself brought it up again.

Carol had been treating Cynthia, a 35-year-old divorced woman, for almost a year. Cynthia’s managed care company, noting that Cynthia had made no progress in that time, contacted us to supervise Carol. Carol was a willing supervisee. She truly wanted the best for her patients and realized that Cynthia was stuck in therapy. Cynthia was severely depressed and alcohol dependent. She had recently gone on disability from her job as a manager in a department store. I could hear from the initial audiotape that Carol sent me of her session with Cynthia that the two had developed a good therapeutic alliance. Therefore, my first goal (along with cognitively conceptualizing the patient) was to get Carol to actively do problem solving with Cynthia, teaching her the cognitive and behavioral skills she needed in the context of solving those problems. I role-played with Carol how to set agendas with Cynthia that contained current problems.

Three difficulties arose. First, when Carol asked Cynthia what problems she wanted to discuss, Cynthia started to describe the problem instead of just naming it. Because Carol did not interrupt and guide her to just name the problem at the beginning of the session, Cynthia did not bring up other crucial problems until the end of the session, if at all. Second, Cynthia put items on the agenda that were not problems she needed help with or was willing to work on. Often these agenda topics were about the way her ex-husband had treated her in the past or complaints about her children. Third, Carol did not add to the agenda herself. Cynthia, hoping to avoid discussions of her alcohol dependence, did not put her drinking on the agenda and neither did Carol.

To solve the first problem, I suggested that Carol model for Cynthia how to name a problem: “Can you tell me what problems you want my help in solving today? Can you just name the problem, for example, problem with drinking, problem with feeling lonely, problem with money?” When Cynthia again launched into a description of the problem, I role-played with Carol how to interrupt her, “Sorry to interrupt, but can you just tell me the name of the problem? Should we call this, “Problem with your son?”

After I recognized the existence of the second and third problems, I helped Carol conceptualize how it was that she thought Cynthia would get better. Through questioning, she was able to recognize that Cynthia most urgently needed to learn skills to deal with her urges to drink, to manage her negative emotions (the precursor to drinking), to solve problems around being alone in the house (which was the only time she drank), and to structure her day and feel productive. I also helped her evaluate Cynthia’s other difficulties and we agreed that Cynthia’s chronic problems with her grown children and with her finances, and the problem of returning to work, were of lesser immediate importance, unless these difficulties led her to feel so upset that they triggered urges to drink. Carol related this new treatment plan to Cynthia and elicited Cynthia’s agreement to give these four areas priority in treatment.

It was difficult for Carol initially to interrupt Cynthia and steer the discussion. I ascertained that Carol did not have any negative thoughts about imposing more structure; she simply did not recognize when she got off course. At first I gave Carol a written list of questions to review with Cynthia. When Carol had difficulty allotting sufficient time to go through the list, I gave her a list of questions for Cynthia to read aloud and answer. Data from these questions were crucial to help Cynthia plan the session. They included questions about frequency and circumstances of drinking, frequency and strength of urges, automatic thoughts related to urges and drinking, and use of coping behaviors. They also included questions about how Carol was spending her days and what had most upset her during the week, as well as problems Carol predicted might arise before their next session. I helped Carol figure out with Cynthia, given their limited amount of time together, what was most important to work on, i.e., what would help the patient feel better by the end of the session and what would help the patient have a better week.

Before we began supervision, Carol’s formula was: To get better, patients need to unburden themselves and receive support and encouragement from their therapist. Carol was beginning to learn a new formula: To get better, patients need to work on solving specific problems with their supportive and encouraging therapist, with a focus on what they can do (and how they can think differently) to have a better week. Setting a good agenda was the first step. Following the agenda and teaching skills in the context of solving problems was the second step. In a future column, I will address this step and further challenges in supervision with Carol.


Wolverine Human Services

Rob Web

Dr. Robert Hindman, Beck Institute Clinical Psychologist

One of our psychologists, Robert Hindman, Ph.D., has been involved in a research study on how to effectively train an organization in CBT. The lead investigator is Cara Lewis, Ph.D., a former Beck Institute Scholar and Professor of Psychology at Indiana University where she has a dissemination and implementation science lab. Dissemination and implementation science studies the best ways to take practices which research shows are effective, train clinicians to use them properly, and keep clinicians using the best practices after the training is over.
Drs. Lewis and Hindman began the project in 2012 with an organization in Michigan, Wolverine Human Services (WHS), which provides treatment to adolescents who need residential treatment services. WHS contacted the Beck Institute to provide their clients with evidenced based CBT. Before the training began, Drs. Hindman and Lewis met with the administrators, clinicians, and staff at all levels of the Wolverine organization to identify any factors or Image 1barriers that could get in the way of successful implementation of CBT. They developed a plan to address the potential obstacles, and worked with Wolverine to make the necessary changes.


So far, Drs. Hindman and Lewis have conducted two trainings at Wolverine Human Services and are scheduled for their next visit this month. They also work with Wolverine between visits; Dr. Lewis helps them successfully complete the implementation plan, and Dr. Hindman provides supervision to their clinicians and supervisors in CBT. At their March visit, Drs. Hindman and Lewis will begin training the supervising clinicians on how to supervise their staff in CBT, so that after the 5-year training program is over, Wolverine can continue to provide high quality CBT to its clients.



Jonathan R.

This is a fantastic training opportunity for pediatricians who want to use cognitive behavior therapy to supplement medication management. [My supervisor] has been enthusiastic and patient and is a wealth of knowledge. It has added a wonderful dimension to my practice and I would recommend this for any practioneer who deals with behavior issues in kids.

Simone P.

The supervision was far more than I could have known to expect. [My supervisor’s] teaching was very helpful; she always had lots of recommendations for literature and her supervision was strengths-based. I learned something new every session and I looked forward to our sessions every week! [She] was collaborative and asked for feedback each session, and our working together evolved to fit my specific needs as time went on. It was truly woth the time, cost, and commitment! I learned so much!

Maria M.R.

[My supervisor] was helpful in so many ways… [he was] always pinpointing which therapeutic interventions were most helpful for the patient, and which were less effective, always in a very constructive way, and providing me a rationale of his feedback. [He] was not only interested in helping me with my therapeutic skills, but he provided me with book references, articles — any and all information that could empower my knowledge in cognitive therapy… and he showed remarkable attention towards my concerns and questions. His clinical supervision was a very important element in the improvement of my clinical skills.  I truly recommend [this program]. Thank you!

Lisa L.

[My supervisor was] a fabulous teacher – dynamic and energetic. Covered any type of client or issue we wanted to discuss. Thank you!

Robert D.

I cannot thank you, and Drs. Judy and Aaron Beck, enough for the fantastic experience that this past year has been. It is without doubt one of the highligths of my career to date. I have valued enormously your thoughtful, clear, and clinically rich supervision. The latter focus on [supervision of] supervision was also rewarding for me. It can be easy to work in isolation from other cognitive therapists when working in a busy early intervention in-service, so to have the time to revisit first principles of CBT has been immensely helpful.

John O.

Being a psychologist is a second career for me.  Previously, I was a business person and recognized the need for continuous improvement in order to stay competitive.  The Beck Institute’s Supervision Program has allowed me to pursue continuous improvement in my clinical skills.  The training they provide is world-class AND a great value.  Week after week, in case after case, my supervisor provided me with actionable feedback on how to deliver more effective Cognitive Therapy.  One reason they can do this is because they really listen to the work samples you provide.  This hands on approach is an ideal often touted but rarely achieved in practice.  My participation in The Beck Institute’s Supervision Program has allowed me to help my patients develop the skills they need to solve problems more effectively and manage their emotional well-being through the use of cognitive-behavioral skills.  I recommend this training to every mental health professional.

Cindy W.

Thank you so much for all of your assistance over the past year. It has been a remarkable experience for me. I found that the supervision experience was essential in truly learning Cognitive Therapy Techniques and I am proud to say that I am now certified as a Cognitive Therapist! This past year has taught me more than I have learned in the last 10 years! [My supervisor] is a wonderful teacher and an asset to your supervision program.

Jo M.

I could not have asked for a better supervisor. [My supervisor] is so skilled in case conceptualization and CBT techniques that each supervision session with him was invaluable. He was able to help me understsnd each of the cases I reviewed with him. He was particularly helpful in helping me come up with case conceptualizations for my toughest cases, and taught me to use the conceptualization to guide my therapy sessions. [He] pretty much has supervision down to a science. I only wish I had been able to work with him longer.