On supervision and treatment teams

Throughout most of my career as a public sector psychologist, working in a variety of settings, I was blessed with good supervision. The few times I either didn’t have a clinical supervisor (as in Jamaica) or didn’t get adequate supervision, I felt like I was walking a tightrope without a net. A good supervisor will listen to you as carefully as you listen to your clients, and give you feedback on how you’re doing.  Positive feedback validates your work and increases your confidence that you’re on the right track, and negative feedback teaches you humility and provides valuable instruction.

As in therapy, a good supervisor asks the right questions. (When the person you’re talking to asks spot-on follow-up questions, you know she’s listening and understands you, whether it’s a friend, therapist, or supervisor.) As your supervisor gets to know you, he will validate your competencies and strengths, be part of your continuing education as a clinician, and insure that you know the appropriate scope of your practice. He will offer constructive criticism when necessary, and may suggest resources for your professional development. He will alert you to possible ethical issues.

At  the beginning of individual supervision, the therapist being supervised might have to staff each case in some detail, until the supervisor gets to know her strengths and limitations. Later in supervision, the therapist might provide brief updates on the progress in cases already staffed and spend more time on new, or challenging, cases. In group supervision, participating clinicians may be asked to prepare case presentations, usually on their most challenging cases.

The other group setting where clinicians might be asked to present cases is in treatment team, which is a kind of group supervision. In community mental health centers (CMHCs) and other treatment facilities, each new case has to be staffed,  and the treatment plan has to be approved by a multidisciplinary treatment team. Not only do treatment teams insure that all treatment is reviewed by colleagues on an ongoing basis, they also serve a professional development function. The ideal treatment team consists of one-or-more psychiatrists, psychiatric nurses (or nurse practitioners), psychologists, social workers, counselors, and possibly specialists such as art therapists or activity therapists. Each discipline represented on a treatment team brings a different area of expertise to the table. In the best treatment teams a kind of cross-pollination of ideas occurs, as treatment plans are generated and reviewed.

I’ve been a treatment team member at CMHCs, juvenile and adult prisons, and hospitals. The smallest, at a rural satellite office of a CMHC, consisted of only a psychiatrist, a psychiatric nurse (my supervisor), and me. The largest consisted of something like fifteen members, with people from all or most of the helping professions listed above. Some treatment teams might give assignments to its members, such as  asking a psychologist to do some psychological testing for a client on someone else’s caseload. In facilities run on the medical model, treatment teams are headed by psychiatrists. In a well-run treatment team, everybody has a voice.

I’ve not only appreciated, but enjoyed most of my treatment team experiences. Working with colleagues from a variety of disciplines has broadened my knowledge and increased my appreciation of the unique contributions offered by each profession. The highest goal of both clinical supervision and treatment team staffing is to insure that clients receive effective treatment, tailored to their unique needs. I have fond memories of interactions I’ve had with a number of my clinical supervisors over the years and – full disclosure – I fell in love with one of them. We’ve been married for almost thirty years.

Maria, a psychiatric nurse, was my third clinical supervisor, and I admired her before I fell in love with her. I had the silly notion – grounded in my own insecurities as a young therapist – that group therapy wasn’t effective with chronically mentally ill clients. She set me straight, telling me that I’d be leading  a weekly group with some of my most challenging clients, and offering to co-lead the group with me until I felt competent to lead it on my own. She was my first role model for doing group therapy.

We felt awkward at first when we started dating, but Maria did the right thing and talked to her supervisor about it. He reassured her: These things happen. You know what you’re doing.

The rest is history.

 

What it takes to be a psychotherapist

These are just my opinions, based on my thirty-plus years as a psychotherapist. I suspect that the first thing it takes to be an effective therapist is to feel a calling to the profession, as in a religious calling, or vocation.  I may be wrong in this belief, but I don’t think many people enter the profession with the goal of becoming wealthy or famous. (I think the same is true of the best teachers.) A basic qualification is that you’re a compassionate person by nature. I grew up thinking I was going to be a career Army officer, like my father and his father; but at the end of my service obligation I resigned my commission and decided to study psychology on the GI Bill. I knew I wanted to be a healer, not a soldier.

One factor in my calling to be a therapist was the gratitude I felt for having been raised by loving parents, in a loving family. I had a happy childhood, and the older I became, the more aware I was of my good fortune. My father felt called to lead men in combat; I felt called to help people who hadn’t been blessed as I had been, to heal and grow.

That’s not to say that a happy childhood is a prerequisite for being a good therapist. Sometimes the compassionate nature that’s a basic requirement for the profession comes from painful personal experience, and empathy for others. Dialectical Behavior Therapy (DBT), a highly effective therapy for people diagnosed with Borderline Personality Disorder, was the brainchild of Dr. Marsha Linehan. It was born from her own struggles with mental illness, and her own painful road to recovery. I’ve known a number of good therapists who were themselves in treatment for a mental illness.

Therapists are flawed human beings, like everyone else, and I’m not saying that your life has to be in anything-like-perfect order for you to be an effective therapist. But in order to be able to separate your own needs from those of your clients, you need to have the kind of self-awareness and insight that come from leading a balanced life, in which your own basic needs are being met. Any blind spots about your own personality and needs will be blind spots in your understanding of your clients’ personalities and needs. (In my opinion all therapists have blind spots; it’s a matter of how many and how big. That’s where good supervision – and an openness to being supervised – comes in.) If you  have significant unresolved conflicts in your own life, you probably need to be in therapy, yourself. Having the experience of being in therapy (some therapist training programs require it) will surely help you to be a better therapist.

You have to have the ability to be present and caring with many people who are in pain, without becoming functionally depressed. This is another reason why you’ll need to have your own psychic house in order, if you’re going to be able to help other people. In most clinical settings, being a psychotherapist carries a lot of responsibility with it. It’s a very stressful profession. If you work with clinically depressed people, you have to be prepared for the possibility that one of your clients may commit suicide. Especially if you work in the public sector, you may also have to work with violent people.

If you have a tendency to be judgmental, you can’t be a good therapist. You’re bound to encounter clients whose values are very different from your own. You have to accept the client as he is in order to help him change. Carl Rogers called this “unconditional positive regard,” and maintaining this radical acceptance may call for frequent attitude adjustments on your part. This requires self-awareness and emotional stability. It’s okay for a therapist to be a flawed human being, as long as you have some awareness of your flaws.

You need to enter the profession with an awareness of your limitations as a helping professional. You’re not there to fix people or to solve their problems. There are people entering therapy who are looking for a rescuer, because they think they need to be rescued and nobody in their social support network has been able to rescue them. (The “rescuer” is a role played by certain people in many dysfunctional families.) All you can do as a therapist is to try your best to establish a helpful relationship with your client(s) and to work with them in good faith on goals that were mutually agreed-upon. Among the appropriate roles you may play as a therapist are teacher, facilitator, coach, and even cheerleader. But you aren’t going to rescue anyone.

Sometimes you’ll fail to be helpful, despite your best efforts. Sometimes a client you thought you had a good relationship with, and were helping, will abruptly drop out of therapy; and you’ll never discover why. Sometimes you’ll feel “in over your head” with a client, not knowing what you should say or do next in your efforts to facilitate positive change. That’s when you need to appreciate the limits of your abilities to help alleviate suffering in a person you’ve come to care about. You may find that you’re not able to help someone you really, really want to help. These are humbling experiences. These are times when you need a good supervisor.

Those are the human qualities I think you need in order to become a psychotherapist. In terms of academic requirements, generally you need to have a graduate degree in psychology, sociology/social work, nursing, counseling, or a related field. If you work in the public sector, you may be “credentialed” to deliver specified clinical services, without having to be licensed in your profession. If you want to work in the private sector or have your own private practice, you’ll have to be licensed.