not-yet-known not-yet-known not-yet-known unknown Course of Treatment Before we get to the session where Jerimiah reported S/I, I want to take a look at the first supervision meeting where Brian introduced me to Jerimiah. It provides some important background information and best illustrates some of the steps of the SSM. As instructed by the SSM, Brian and I always begin his supervision meetings by looking at his outcome data and attending to the clients who report the clearest signs of high distress and greatest chance for deterioration. Here is an example of what the conversation about Brian’s outcome data sounded like on that first day he presented Jerimiah: Jason: Let’s take a look at your outcome data. It looks like your client Jennifer has a high score, I remember we talked about her last week. Brian: Yeah, I met with her on Tuesday and it was helpful to slow her down in the session, like we discussed in our last meeting. I feel better about how things are going with her. Jason: Great. Okay so who are we talking about today? Brian: I selected my client Jerimiah to talk about today. Jason: Great. Let’s take a closer look at Jerimiah’s outcome data. A closer look at Jerimiah’s outcome data revealed a man who frequently feels frustrated with his home life and sexual life, suffers from headaches and has difficulty sleeping. This information would prove helpful later in the supervision hour when I had to choose a learning goal and behavioral rehearsal for Brian to work on. [Next up on the SSM was Brian showing me his Supervision Preparation Form.] Jason: Okay, please share your screen now and show me your Supervision Preparation Form. Brian: [Reading from the Supervision Preparation Form and the question “Describe the most relevant aspects of the client and the case”.] Jeremiah is married with an infant son. He works as the foreman at a factory that makes medical supplies. His consistent narrative is that he’s frustrated with everyone in his life. Frustrated generally across the board and feels responsible for things and it weighs on him. He sighs often and says that things feel never ending. He also frequently complains about his wife’s nagging. Jason: How old is his child? Brian: He is under 1. Both he and his wife work really hard and they have this little baby. He seems very overwhelmed. Jason: Okay, tell me about the client challenge you are currently facing [the next question on the Supervision Preparation Form] . Brian: I’m not sure where to go with Jerimiah’s continued frustration with others and the burden he feels to get things done. Should I find ways to support him in reaching out for help? Or help him to let go of what might be unrelenting standards? I’m not able to pinpoint exactly what he needs. Jason: Okay, great. Let’s take a look at some video of you and Jerimiah. If you took a peek under the hood of my process during this interaction you would hear the constant hum of my desire to go into conceptual teaching mode with Brain. We are just fifteen minutes into his supervision and I have already had to repeatedly and silently remind myself to practice self constraint when it comes to the urge to go into conceptual learning. Part of this is a result of having to unlearn my many years of TS, the other part is just how gratifying it often feels to follow the pull towards conceptual learning. It’s quite frustrating actually to not use conceptual learning. At first it feels like not having the one tool that you can trust and rely on. Over time I have learned that following DP principles and trusting the SSM actually lead to a different, and more satisfying, destination. This destination is more arduous to get to but ultimately worth it because it is far clearer what has actually been accomplished. Here is just one example of a conceptual learning opportunity that Brian and I could have followed. I happen to really enjoy working with new fathers, I run a group for new dads in my private practice, and I have spent a great deal of time thinking about the challenges men face in the first year of raising a child. Jerimiah is a new father. Brian wants to help Jerimiah with “his burden” and feels like he wants to “pinpoint exactly what (Jerimiah) needs”. This would be a prime moment for a supervision conceptual excursion. I could talk excitedly about my sense of what a new father needs and Brian would feel like his question was being answered. I would feel gratified by sharing something that interests me with someone who is in need of the knowledge. Brian could bring this knowledge back to Jerimiah who seems to be asking for this kind of help. Conceptual learning proposes itself as the way to create a virtuous circle that gratifies everyone. In reality, my personal experience and the research do not support the idea that filling Brian’s mind with good ideas about early fatherhood will actually translate to him helping Jerimiah when they meet again (Ladany & Inman, 2012). As is so often the case in life, what proposes itself as the easy route to gratification requires a second look, and with a second look we see that gratification requires (bah-humbug) discipline, moderation and practice. In checking multiple sources – outcome data, supervision preparation form, video recording – the SSM reminds the supervisor repeatedly not to get overly seduced by the internal and external siren song of conceptual gratification (Stuart, 2024). In this particular supervision hour with Brian that second look would come through watching the actual video of his work with Jerimiah. The final step on Brian’s Supervision Preparation Form instructs him to “Identify a short segment (1-3 minutes max) from last session’s video that is representative of the identified clinical challenge.” We now turn to the actual video from Brain’s session with Jerimiah where has bookmarked a segment of Jerimiah being upset with himself for arriving three minutes late to therapy: Jeremiah: I just hate being late. It gives me anxiety. Brian: What does this feel like in your body? Jerimiah: The anger I can feel up here [points to his head], the anxiety I can feel it in my stomach. Brian: Oh interesting, the anger is more of a head thing and the anxiety is in the pit of your stomach. Jeremiah: Mmmhmmm Brian: What do you think the anxiety is about? Jeremiah: [unironically] Being late. Brian: [Smiling] But what about the being late makes you anxious? Jeremiah: I think it’s probably from, I’m not sure. Maybe the military. Maybe not from the military. Maybe before, I don’t know. Oh you know what, I think maybe it’s from my mom. She used to bang on our door, “we are going to be late, we are going to be late” So like you wake up and you already got all that anxiety, and you wake up with this, “oh no I’m going to be late” inside your head. So I still get that. Brian: So in a way it’s a left over response from childhood. Jeremiah: From childhood yeah. Yeah Brian: I’m wondering if you are still hearing your mom’s voice? Jeremiah: Now that I mention that, I just hear the banging and the anger. Brian: And how did it feel as a little kid hearing that banging and that anger? Jeremiah: Like literally all I hear is that. And it was my parents’ choice to move like so many cities away from school and we are still going to the same school. But anyways. Your heart races when you hear that “BANG! BANG! BANG! BANG!” Brian: It sounds a little frightening. Jeremiah: [Laughing] It definitely was [I pause the video here and begin talking to Brian] Jason: Ok great. This guy is fantastic. You are going to have a good time working with him, he’s lovable. Brian: He is. [I bring up the SSM on my monitor and use it to guide us through my thinking about the next steps. These steps are: Client Challenge, Therapist Deficit, and this will eventually lead us to a Learning Goal and Behavioral Rehearsal.] Jason: Notice that Jerimiah is saying that he is anxious. I think what happens is that when get anxious, he gets busy and he just keeps doing more. You helped me to see that in your Supervision Preparation Form. He kinda goes (I mimic a stressed out person), “Okay you want me over here, I’ll go over here, you want me over there… I’m there. You want me up at 5AM? Okay, I’m up. You want me to take care of the kids? Great, I’ll do that.” I think that your deficit is that when your client expresses that he is anxious, that you give him more stuff to do. At your request, he’s talking about his body, his history, his behavior. He’s game to do all of this… He will jump around with you wherever you want him to go. It seems, to me, like too many things for him to do. What was your intention in doing this? Brian: Well I think that I am trying to uncover what’s underneath all of the running around and being so busy. In a sense that is all we talk about. If it’s not his wife, it’s his son, if it’s not his son it’s his brother and it’s all of these stories about him “doing it” but feeling angry and anxious about it. I guess my intent was to try to get out of the loop of just recounting all of these stories and get more into what the anxiety is. With the idea that eventually he will make choices that keep him out of this anxiety world. Jason: Okay what’s your sense of how he reacts to your interventions? Do your interventions get him out of the anxious loop? Brian: No, he stayed in it pretty much the whole session. Jason: Yeah, that’s what I saw. I think your intention of getting underneath the anxiety is a good one, but I think you are leading him too much right now. My concern is that by leading him too much, his therapy is going to become another place where he feels like he has to perform for the other person, in this case you. As opposed to him having a better sense of what he wants and what is going on inside of himself. Another challenge that I want to highlight, one that I was aware of during the segment above, is how DP and the SSM require that the supervisor be direct with corrective feedback. In the first months of learning the SSM I found this to be quite uncomfortable. I was hesitant to stick to the clear script that the model lays out, particularly around stating the therapist deficit and asking about the intended outcome of their original intervention. I was not used to being so specific with what I was seeing. I was used to padding corrective feedback with lots of praise and while it was always my intent to be direct, my words would often come out far less direct than intended because I was worried about hurting the supervisee’s feelings. While the SSM and DP require a higher level of directness, what has been relieving to see is that this has not led to the shaming of my trainees. What I have come to learn is that supervisees actually really appreciate direct corrective feedback when contained within the SSM. The more comfortable I have become with my corrective feedback, the more my supervisees are reporting that they can see and feel themselves becoming better therapists in each supervision hour. For me, this does seem to create a virtuous circle where my supervisees are reacting well to my being direct with my corrective feedback and I’m simultaneously feeling myself becoming a better supervisor. There is a sense that both therapist and supervisor are both pushing themselves to grow through use of DP and the SSM. This is supported by the SSM’s novel features. Directness is much easier when it does not rely solely on words. With outcome measures and video recordings my clinical observations are supported by multiple sources and there is very often a shared sense with my supervisees that my directness about their clinical deficit is well supported by the video and/or outcome data (Haggerty & Hilsenroth, 2011). Directness and corrective feedback are another area where the over reliance on conceptual learning can be problematic. In aiming to build a procedural learning environment, far less time is spent getting lost in trying to translate complicated clinical concepts that often widen the sense of a learning gap between supervisor and supervisee. With procedural learning, it’s understood that direct corrective feedback is going to come with a chance to learn to address the deficit through the behavioral rehearsal process, a far more attainable goal than trying to translate something as complicated as “borderline tendencies” to an early career clinician. Directness and corrective feedback become particularly important in establishing a learning goal and leading supervisees through behavioral rehearsals because the process works the best when there is a clear establishment of a target and bullseye. This is another way that the SSM avoids shaming the supervisee because it allows for praise to be pointed towards actual accomplishments that take place within the supervision hour once a skill has been rehearsed and improvement is clear. Let’s take a look at my setting up Brian’s learning goal and behavioral rehearsal with his client Jereimiah: [I rewind the video to point in the video where Jerimiah explains that being late gives him anxiety to illustrate my point.] Jason: He’s describing being anxious. How about we practice empathic reflection. So, anything that he says, I want you to convey the words he said back to him in an empathic way. I want you to try to match his tone when you respond to him and then wait. I think this will help because it will make him feel understood and will set you up nicely to ask him what he sees as most important to discuss in his therapy. [I rewind the video and I pause at the place where Brian is going to try out the skill.] Jeremiah: I just hate being late. It gives me anxiety. Brian: You hate being late. Jason: Okay, try it again but this time include his anxiety. [I rewind the video] Jeremiah: I just hate being late. It gives me anxiety. Brian: You hate being late. It makes you anxious. It makes you feel responsible I suppose. Jason: Okay, the first part was good. You captured his words. You rushed ahead there at that last part, we aren’t making a conjecture about what he might be feeling here, we are just staying with his experience. Also, your tone is a little flat. This guy is really anxious after only being 3 minutes late, you want to capture some of that in your tone. [I rewind the video again] Jeremiah: I just hate being late. It gives me anxiety. Brain: Yeah, you hate being late, it gives you a feeling of anxiety. Jason: That’s sounding much better. How did that feel… Actually no, sorry on a scale of 1-10. One being super easy, ten being super hard. How was that for you? Brian: I’d say about a 3. Jason: Great. Let’s do it just one more time and this time really dig into the tone then we can move along. [I rewind video] Jeremiah: I just hate being late. It gives me anxiety. Brian: Yeah.. you hate being late, it gives you a big feeling of anxiety. Jason: Nice. I liked the slight pause after you said yeah and you really captured the tone. [From here we moved into a rehearsal where Brian asks Jerimiah, “What would you like to talk about today?” I decided to model this for Brian.] Jason: Okay, let’s practice asking him what he would like to get out of his therapy in this session. I think this will help because my gut instinct here is that he is feeling too much anxiety right now and I think it’s best to let him off the hook from talking about it directly. As I said, I think when he feels anxious, he feels that he just has to perform and I don’t want this to become another place where he has to perform. I’m going to model this one for you. [Rewinding video] Jeremiah: I just hate being late. It gives me anxiety. Jason: [Modeling to the client video] Yeah, Jeremiah. I hear that you feel anxious and you really hate being late. Being on time sounds really important to you. Would you like to talk about that today? [I now speak to Brian and rewind the video] Okay, why don’t you give it a try? Jeremiah: I just hate being late. It gives me anxiety. Brian: Okay, you are three minutes late so that gives you anxiety. Showing up on time is clearly important to you, that makes sense. Uhh… I’m wondering. What um do you want to talk about today. Jason: Scale of 1-10 how was that for you? 10 being really difficult and 1 being easy. Brian: Probably a 7. It felt kind of like a non-sequitur because I just want to follow his anxiety. Jason: Okay. Let’s try it again. [We run through this exercise of Brian inviting Jerimiah into defining how he would like to utilize his therapy hour until Brian has found more fluidity with his words, tone and other non-verbal cues. This rehearsal will take us to the final minutes of Brian’s supervision for that day. At the end, I will tell him to, “use the same segment of the video of Jerimiah that we watched together and practice empathic reflection and inquiring about what he would like to get out of the therapy session for at least 10-minutes until our next supervision session.” ] Peering into the DP rehearsal process from the outside, it can appear deceptively reductive. (This can even be true from the inside when first learning the model.) It’s easy to think that, with all of the complications that are in a therapy session, it is simply too reductive to focus on just a 10-second clip of video and rehearsing two (prettys simple sounding) skills. However, one entry way to understanding the discipline, complexity and rich learning that is taking place in the DP rehearsal process for both supervisor and therapist can be found in a small moment during this vignette from my work with Brian. Notice the moment in the rehearsal when I started to ask Brian how the exercise felt and then I quickly corrected myself and asked him to rate the difficulty of rehearsing empathic reflection on a scale of 1-10. I corrected myself because asking “how it felt” was likely to lead us into the subjective-land of feelings and I was trying to keep us focused on the objective-goal of learning the skill. In this way, DP rehearsal can be thought of as being somewhat similar to learning and practicing mindfulness. In mindfulness practice, the practitioner is taught that we spend the vast majority of our time consumed in thoughts and feelings about the past and future. We are instructed to do something different and quite challenging (which can also appear reductive) that of clearing a space to notice what is happening in the present moment. One way to do this is through noticing other simultaneous processes in our field of awareness (for example, breath, outside noises and bodily sensations). In the same way, DP is asking supervisor and therapist to not chase interesting conceptual thoughts and feelings which our minds quite naturally gravitate towards and instead stay focused on these other areas that DP and the SSM call into the supervision field of awareness – for example, the 1-10 difficulty scale, the repetition of rehearsal and learning to focus-in closely on skills and their multiple criteria. For the supervisor, choosing just one skill, articulating it clearly and then turning it over to the therapist to try-out requires knowing when to let go of an idea, managing the anxious tendency to keep explaining and then trusting that something of value will emerge. Meanwhile, the therapist is asked to “show” and not “tell” during rehearsal and this involves being in the moment enough to brave the exposure of being watched doing something new (Anderson & Perlman, 2020; Axelsson, Kihlberg, Davis & Nyström, 2023). For both therapist and supervisor there is a need to agree to watch together what unfolds in the rehearsal process, without getting lost in interesting thought digressions or overwhelmed by anxious feelings, and come to a shared agreement that something new has been integrated well enough that it can be used effectively when the therapist returns to their client. A couple of weeks after Brian presented his work with Jerimiah in supervision, I received Brian’s email alerting me to Jerimiah reporting S/I. Of course, there is always a level of concern with S/I, however, I also found myself hopeful that this was a good sign. My hope was that the interventions that Brian and I had practiced in his supervision had opened a space for more of Jerimiah’s feelings and that Jerimiah was taking the opportunity to risk sharing some of his burden with Brian. When I met with Brian later that week, I got a fuller picture of Jerimiah’s S/I that had come up in their session. Jeremiah had reported his S/I on his outcome measure before his therapy session. Brian reviewed the outcome measure before their session and did a good job of bringing it up right at the beginning of their time together. The outcome measure provided an easy jumping off point for a conversation about Jerimiah’s anger and how this anger can lead to his wish, “to just keep on sleeping.” The deficit that I saw in Brian’s work with Jerimiah after the S\I was named in session, was that he responded to the challenge of Jerimiah’s anger by trying to problem solve with him about how to manage the people who were making him angry. For example when Jerimiah reported that he was so mad at his wife for buying fast food when they were trying to stick to a budget, Brian responded by asking if Jerimiah ever expressed these feelings to his wife. This led to Jerimiah expressing how frustrating it is to talk to his wife and how she “never really listens.” My sense was that Jerimiah needed to become more skilled at identifying and understanding his own internal feelings before he could successfully bring them to his wife and that problem solving in this way was going to miss an important opportunity to be with Jerimiah’s while he was having big feelings. We ended up taking the different examples of Jerimiah’s anger (there were lots of them in the session) and practicing different ways to organize them through metaphor (“that sounds like more of a pebble anger and the other one is a boulder of anger, is that right?”) and empathic conjecture (“I wonder if boulder sized feelings make you want to go to sleep and not wake up?”). At the end of the supervision hour, my hopeful feelings had been confirmed and that Jerimiah had taken a positive risk in opening up his feelings in his therapy. It looked to me like Brian and Jerimiah were laying a good foundation for Jermiah to learn to better manage his feelings, burdens and stress.