Keywords

Schools are becoming de facto child guidance centers (Shernoff et al., 2017; Wolk et al., 2019). Wolk et al. (2019) noted that more services are delivered in schools than in any other publicly funded institution. More specifically, approximately 75% of children requiring behavioral health care obtain it from schools (Shernoff et al., 2017). Shernoff and colleagues also noted that school psychologists and other behavioral health professionals applying evidence-based procedures in school settings extend the reach of this science-informed approach. However, 71% of school psychologists reported that their training in evidence-based treatments in graduate school was inadequate (Hicks et al., 2014). Further, in some systems, the majority of school-based mental health services are provided by master’s degree therapists with variable levels of training in evidence-based treatments. Therefore, good clinical supervision is vital.

Cognitive behavioral therapy (CBT) is often referred to as the gold standard psychosocial intervention for a multitude of childhood disorders (Davis et al., 2019). While CBT’s efficacy and effectiveness support its application, achieving beneficent outcomes is nonetheless challenging. Friedberg et al. (2009a) noted that “cognitive-behavioral psychotherapy is work, not magic (p. 292).” Often, clinicians practicing in treatment-as-usual contexts do not apply CBT with a proper dose, incorrectly implement procedures, and/or select unsuitable treatment targets (Comer & Barlow, 2014). More specifically, Wiltsey-Stirman and colleagues (2013) found that greater than 50% of providers in community-based settings disclosed they significantly modified central CBT principles and practices in their work which may have diluted their effectiveness. Accordingly, helping trainees faithfully implement true CBT in real world school-based counseling is essential, and effective CBT supervision may be a conduit to reaching that goal.

Supervision accounts for approximately 16% of the variance in child psychotherapy outcomes (Callahan et al., 2009). Nonetheless, learning to do CBT with youth is a demanding task. Hence, good clinical training in CBT involves a goal-directed, structured yet personalized approach (Corrie & Lane, 2015; Milne et al., 2008). Consequently, this chapter describes a structured and flexible approach to the supervision of CBT with youth in school-based settings. We begin with an overview of the general supervision model and then proceed to address specific issues in school-based applications.

Supervision Model

A short story introduces this section. Thirty plus years ago, I (RDF) nervously fiddled with my hospital badge naming me as a clinical psychology intern. The room was small and crowded with psychological testing materials as I prepared for the inquiry phase of the Rorschach. The patient and I began the process. We arrived on card 9 to which she responded, “The planet Uranus.” Based on my previous training, I had three choices of queries including restating her response as a question (e.g., “The Planet Uranus?”), asking her a more specific question (“What makes it look like __?”), and simply remarking, “Help me see it as you do.” In my anxiety-fueled haste, I chose option two mispronouncing the planet saying “What makes it look like your anus?” adding to an uncomfortable session. Yet both the patient and I survived this unfortunate circumstance. Unsurprisingly, there was no lecture example or textbook discussion addressing how to handle this situation. Fortunately, my knowing supervisors upgraded me with instructive feedback. Consequently, I learned to be more flexible and conduct an improved Rorschach assessment. While I do not do Rorschach assessment anymore, I have never forgotten their expert guidance.

Getting the hang of clinical practice is like swimming. The requisite skills cannot be fully understood from textbooks and lectures. Rather, wading into the water, splashing around, receiving coaching from an instructor, and then working on perfecting your breathing, kicking, and strokes are key elements. There is an old joke which describes a lost tourist visiting New York City asking a native New Yorker, “How do I get to Carnegie Hall?” The New Yorker replies, “Practice, practice, practice!” Clinical skills and wisdom are similarly dependent on experiential learning. However, practice is never enough to become a clinical maestro. Without crackerjack guidance punctuated with constructive analysis and sometimes critical comments, supervisees and their young clients are left to sink or swim in the deep end of the pool. Calendar (2014) noted that:

clinical supervision is generally believed to be an essential component of clinical training, occurs weekly, and is where the rubber meets the road of opportunity for the supervisee to consolidate graduate training, knowledge, skills, and attitudes and put it into action as a professional (p.143).

It is an evaluative, hierarchical, and ongoing activity that focuses on protecting client welfare, enhancing trainee development, and maintaining the profession’s integrity (Bailin et al., 2018; Newman et al., 2017). Additionally, competence is the new watchword in clinician training (Barrett et al., 2020; Calendar, 2014; Calendar & Shafranske, 2007, 2014). More specifically, competency-based supervision is defined as:

an approach that explicitly identifies the knowledge, skills and values that are assembled to form a clinical competency and develop learning strategies and evaluation procedures to meet criterion-referenced competence standards in keeping with evidence-based practices and the requirements of the local clinical setting (Calendar & Shafranske, 2007, p. 233).

Supervision content includes generic, school specific, and unique CBT topics. General issues that are addressed include ethical concerns, legal regulations, and risk considerations (e.g., harm to self/others, child abuse, etc.) (Newman & Kaplan, 2016; Sburlati et al., 2011). Alertness to multicultural considerations is also essential (Flanagan, 2015; Newman et al., 2017). According to Newman et al. (2017) attenuating personal biases, identifying and mitigating micro-aggressions as well as knowing when and how to culturally adapt interventions is crucial.

Obtaining first-hand knowledge of supervisees’ work with children and adolescents is also a critical task for supervisors. Acquiring this data may involve direct observation via live supervision or reviewing audio- or video-recorded sessions. Nevertheless, the use of video or audio recording in non-academic settings is rare (Accurso et al., 2011; Bailin et al., 2018). Regardless, relying on verbal reports by supervisees is typically not a recommended training strategy. Delivering corrective feedback is considered a sine qua non (Bailin et al., 2018; Milne, 2009). However, the feedback is often too vague and not delivered regularly. Therefore, in subsequent sections, we advocate for the use of rating scales to ensure feedback is meaningful, effective, and beneficial to supervisees and clients.

An element of supervision that is particular to school settings is consultation and represents a core competency for school-based practitioners (Hicks et al., 2014; Newman et al., 2017). Providers in school-based settings are trained as systems level thinkers (Hicks et al., 2014). Newman et al. (2017) defined consultation in a multi-faceted way. First, consultation is characterized as an indirect service that adopts an ecological focus and collaborative approach. Second, consultative practice involves a systematic focus where target areas are defined and interventions are recommended and then evaluated. Early intervention and prevention of future problems represent common goals. Integrating supervision into school-based care models can have a number of benefits since these providers often practice as the only such professionals at the school. Supervision, whether done in an individual or group format, will create some connectivity and support for the provider. Consequently, supervision in school settings decreases isolation and burnout (Newman et al., 2017).

Cognitive behavioral supervision includes paradigmatic features such as training in case of conceptualization, therapeutic stance variables, session structure, measurement-based care, and interventions. The following section explains these CBT supervision keystones.

Keystones: Basic Principles and Practices of CBT Supervision

Training and supervision in CBT often involves acquiring and applying declarative, procedural, and self-reflective knowledge bases (Bennett-Levy, 2006). According to Bennett-Levy (2006), declarative knowledge represents factual information such as theories, principles, and research findings. In CBT, this material often includes classical, operant, and social learning paradigms, as well as cognitive/information processing theories (Friedberg et al., 2009b). Procedural knowledge refers to learning how as well as when to deliver various interventions (Bennett-Levy, 2006). Self-reflection represents arguably the most advanced knowledge level. Bennett-Levy (2006) believes clinical wisdom is achieved through self-reflective knowledge. Further, Rector and Cassin (2010) cogently wrote “advanced clinical expertise in CBT emphasizes the role of clinical judgment, ability to adapt interventions in response to clients’ needs and feedback and the ability to negotiate obstacles and setbacks in treatment (p. 154).” Not surprisingly, declarative, procedural, and self-reflective knowledge are acquired through supervision and training in case conceptualization, therapeutic stance variables, measurement-based care, and CBT techniques.

Case Conceptualization

The importance of training supervisees in case conceptualization skills is indisputable (Beck, 2021; Friedberg, 2015; Friedberg & McClure, 2015; Newman & Kaplan, 2016). In fact, it is seen as the “nucleus” of CBT practice (Friedberg, 2015). Supervisees and their supervisors perceive training in case conceptualization as valuable, but they agree that heavy caseloads often limit the time devoted to this skill (Dorsey et al., 2017). Therefore, the ability to teach this skill in an efficient and tractionable manner is vital.

Most supervisees are not ready-made case conceptualizers. Hence, acquiring the fundamental tenets of operant, classical, and social learning theory paradigms as well as information processing models is rudimentary for case conceptualization. There is no substitute for achieving this solid theoretical footing. In fact, Betan and Binder (2010) urged providers “to be so familiar with theory’s concepts, explanations of psychopathology, and mechanism of change that they become automatic in one’s way of thinking about and approaching unique clinical contexts (p. 144).” Once supervisees embed the youth’s unique symptom presentation and ethnocultural context into the learning paradigms, a personalized clinical story can emerge. We recommend trainees read and absorb work by Persons (2012), Kuyken et al. (2008), and Friedberg and McClure (2015) to bolster their proficiency in case conceptualization.

Therapeutic Stance Variables

Training school-based therapists to adopt a proper therapeutic stance is another crucial supervisory task. Adhering to the notions of collaborative empiricism, guided discovery, and immediacy in session represents essential stance components. Practicing via collaborative empiricism refers to establishing a partnership between the provider and youth that is characterized by transparency and guided by reasoned analysis of both objective and subjective data. In fact, Creed and Kendall (2005) declared that collaboration is a core ingredient for a productive therapeutic alliance with youth.

Guided discovery is collaborative empiricism’s cousin. It involves using empathy, Socratic questioning, and behavioral experiments to build a personal data base. This data base is used to evaluate the youth’s conclusions and catalyze new appraisals as well as action plans. The guided discovery process is one of the hardest competencies to acquire. Consequently, we recommend work by Overholser (2018) and Waltman et al. (2020) to support supervisees’ learning.

Additionally, we typically use several scaffolding techniques. In the first exercise, we invite supervisees to practice emotionally neutral stimuli. We begin with the thought, “If I step on a crack, I’ll break my mother’s back.” The trainee then tries to craft questions to question this spurious correlation (e.g., When has your mother’s back ever hurt and you didn’t step on a crack? When have you stepped on a crack and your mom’s back been just fine?). Then, we assign them a more common emotionally tinged belief (e.g., If I stop worrying, something really bad will happen?). Adopting a similar approach, trainees are coached to develop a Socratic dialogue to test this inaccurate assumption (e.g., When have you worried and something bad happened anyway? When have you not worried and something bad not happened?). Finally, we also advise trainees to use various worksheets with youth which include a pre-printed systematic Socratic dialogue (Friedberg et al., 2009a; 2011; McClure et al., 2019). The advantage of these procedures is that the questions are provided for the trainee and youth so they model the Socratic process. Therefore, these resources take the pressure off of beginning trainees and supervisees to craft their own questions.

Session Structure

Maintaining a session structure is a signature practice in CBT and forms a blueprint for clinical work. Mood check-ins/homework review, agenda setting, processing therapeutic content, homework assignment, and eliciting feedback are essential components. Mood check-ins and homework reviews provide a glimpse into the youth’s current status. Agenda setting allocates time and energy to both urgent and continuing concerns. Therapeutic practices are applied to these issues during the processing of content components. Homework assignments are tailored follow-ups to session content that facilitate transfer of learning. Eliciting feedback is done near the end of the session and approximately 10–12 minutes should be allocated to complete the process. During this time, school-based practitioners learn what is helpful, unhelpful, satisfying, and dissatisfying to young clients. Additionally, it is also a time where misunderstandings can be corrected, thus increasing the likelihood of clients appropriately applying techniques in their day to day lives. Supervisors can assist clinicians in applying this structure in an effective and therapeutic way, problem solve when barriers to using the structure arise, and model the structure within the supervision sessions.

Measurement-Based Care (MBC)

Identifying targets and tracking progress toward these goals represent the essence of measurement-based care (MBC) and are congenial with the notion of collaborative empiricism. Various studies demonstrate that MBC is associated with higher rates of treatment progress, speedier treatment responsiveness, and better clinical decision-making (Bickman, 2008; Bickman et al., 2011; Jensen-Doss et al., 2020; Scott & Lewis, 2015). Symptom scales and functional improvement metrics are typically employed in MBC. However, many trainees may not be familiar with common instruments. Becker-Haimes et al. (2020) offer a rich resource describing validity, reliability, and low-cost MBC options. In Table 1, we list some of our recommended instruments for use in school-based settings. Finally, functional outcomes are very compelling. The measures reflect “real life” personalized estimates of improvement. For instance, number of suspensions, visits to the school nurse, amount of out of seat behavior, etc. are examples of metrics when working with youth in school settings.

Table 1 Recommended symptom tracking methods
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Training in Technique

Of course, supervisees typically learn many CBT techniques including behavioral activation, social skills training, relaxation training, contingency contracting, exposures, behavioral experiments, problem-solving, self-instruction, tests of evidence, rational analysis, and decatatrophizing. Unsurprisingly, schooling supervisees in CBT procedures requires considerable workouts to get in good therapeutic shape. A former supervisor of one of the authors (RDF) was fond of repeating, “Practice makes permanent.”

We recommend that trainees initially observe supervisors implementing procedures. This vicarious learning could occur via video and audio recordings as well as live modeling (Sudak et al., 2003). Then, they should engage in role-plays practicing the technique with corrective feedback from supervisors (the reader is referred to the chapter on deliberate practice in this edited volume by Sacks and Vaz (2023)). Enactive supervision is strongly recommended and precisely aligns with the experiential learning model (Bearman et al., 2013, 2017; Beidas et al., 2013, 2014; Dorsey et al., 2017; Friedberg et al., 2009b; Newman, 2013). Supervisors’ modeling and trainees’ behavioral rehearsal are essential components of enactive supervision. When supervision incorporates supervisor modeling, role-playing, and targeted feedback to the supervisee, competency is improved and evidence-based practice is propelled (Bearman et al., 2013, 2017). In a recent study in a community setting, supervisory modeling was used approximately 70% of the time, but unfortunately role-play was utilized in only 1.8% of sessions, and supervisory corrective feedback was delivered in merely 7% of sessions (Bailin et al., 2018). These dress rehearsals should include role-plays augmented with step-by-step color commentary by supervisors.

Nearly a quarter of a century ago, Rosenbaum and Ronen (1998) concluded that CBT is a philosophy of living. Reilly (2000) also wrote, “a cognitive therapist who really buys into the cognitive model uses it in everyday life (p. 34).” Therefore, utilizing CBT strategies on oneself is another valuable way to develop skillfulness (Bennett-Levy, 2006; Bennett-Levy et al., 2008).

Competence and Adherence Rating Scales

Evaluating and tracking supervisees’ progress in written form is essential in CBT. Supervisees self-evaluation tends to overestimate their actual competence (Brosnan et al., 2008; Creed et al., 2016; Ladany et al., 1996; Mathieson et al., 2009). More specifically in the study of practitioners who were observed and rated, 71% of clinicians who called themselves CBT therapists did not demonstrate basic competence (Creed et al., 2016). Therefore, measurement of supervisee competence, fidelity, therapeutic drift (e.g., moving away from the established practices), and adherence (e.g., delivering the approach in the proper manner) is indispensable (Kazantzis, 2003; Kazantzis et al., 2018).

Newman and Kaplan (2016) differentiated formative and summative evaluations. Formative assessments are regular, on-going measurements, whereas summative ones are more official and periodic evaluations (e.g., at 3 month, 6 month, 9 month, 1 year). In CBT, ratings of supervisees are typically obtained and processed on a weekly basis. The gold standard for gauging trainee competence, fidelity, and adherence in CBT is the Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980). While this CTRS is the established barometer, there are some limitations to using this scale with clinicians working with youth (Affrunti & Creed, 2019). Consequently, considering scales that are specific to conducting CBT with youth is a promising option and one that can be incorporated into clinical supervision.

The Cognitive Behavioral Therapy scale for Children and Young People (CBTS-CYP; Stallard et al., 2014) and the Cognitive Therapy Rating Scale for Children and Adolescents (CTRS-CA; Friedberg & Thordarson, 2014) tap specific competencies in CBT with youth. The CBTS-CYP enjoys solid psychometric properties achieving good convergent, discriminant, and face validity as well as inter-rater reliability (Stallard et al., 2014). The CTRS-CA demonstrated good internal consistency (Cronbach’s alpha = .95) and favorable user-experience data reflecting ease of scoring and perceptions of accurate estimations of trainee competence (Thordarson, 2016).

Specific Training Strategies in CBT Supervision

Supervision as a training approach to continual learning should be viewed as a collaborative method of skill development. As mental health professionals, we often view supervision as something for unlicensed providers or those still in training, but there are significant benefits to incorporating a supervision model into all clinical services. To be effective, this type of supervision should maintain the qualities of other supervisory arrangements, which include being consistent and structured, and include clear and collaborative goal setting and communication. Adhering to the theoretical constructions and basic processes outlined in the first part of the chapter is key. This portion of the chapter will address specific training strategies and some of the unique opportunities and strategies that present within the supervision model in school-based clinical services.

Specific Clinical Approach to Supervision Strategies in School-Based Settings

Supervision for school-based therapists will benefit from a clinical focus and structured approach. Similar to how therapy sessions benefit from session structure, having structured supervision schedules is beneficial to the supervisee. It conveys the importance of the supervision, the value placed on supervision by the supervisor and the broader system, and makes the supervision a predictable part of the therapists’ role. This means these appointments should not be seen as flex time that can be regularly skipped or overridden with other meetings. This also implies that if a scheduling conflict does arise, rescheduling should occur as soon as possible. Supervisees are well-advised to maintain contact with supervisors in order to update them on clinical developments. Weekly meetings are ideal and curbside consultations on and as needed basis are recommended. Less frequent meetings will not address pressing clinical issues, and consequently building comfort to openly discuss cases may take longer.

Unstructured supervision without clear goals can easily fall into a pattern of lengthy case sharing and sessions with no clear purpose. Therefore, fewer opportunities for professional development and growth emerge. In order to be meaningful and address goals around improved clinical proficiency, supervisors and supervisees must work collaboratively and commit to the time and effort needed for success. This requires more preparation, greater focus, and a belief in this model. For example, the use of MBC and role-plays as described earlier in the chapter are key to effective supervision. Consider the problems in the following example of an individual supervision session.

Supervisor::

Good morning, how’s everything going? How’s your caseload?

Therapist::

Hmmm let me think… This past week has been super busy. Lots of new cases, and several students are struggling with one of the teachers being out on a medical leave. I have kept up pretty well with my notes, but have a few to tie up, including a new student I started with this morning.

Supervisor::

Any cases that are particularly challenging you want to discuss?

Therapist::

Well since I haven’t written up the intake from this morning yet that may be a good one to discuss as I am not yet set on the primary diagnosis and need a plan for him – he is a pretty complex case.

Supervisor::

Why don’t you tell me a bit more about him?

Therapist::

Sure, he is about 13 or 14 I think. He is new to this school, just moved here from I want to say Illinois, I would need to double check that. He is struggling with the move and lost his grandmother last year (therapist goes on to describe the history and listing the details known about the student).

The lack of structure and clear expectations set the supervision session up to be less focused and effective. The therapist is using the time to talk through the information gathered from the case, which may still lead to some fruitful discussion of conceptualization but is less efficient and effective than when the clinical expectations are set and focused on early. Now consider this better alternative.

Supervisor::

Good morning, I hope you are having a good start to the week. Last week we set a goal of focusing on interventions that can be started during the intake session based on the diagnosis and conceptualization, so we have that on today’s agenda. Anything else you want to be sure we add to the agenda today?

Therapist::

Hmmm let me think… This past week has been super busy. Lots of new cases, and several students are struggling with one of the teachers being out on a medical leave. I have kept up pretty well with my notes, but have a few to tie up, including a new student I started with this morning.

Supervisor::

OK let’s add coping with teacher’s medical leave and documentation to our agenda. Do you have the conceptualization for the intake this morning ready enough to discuss, or should we push that one to next week?

Therapist::

Well since I haven’t written up the intake from this morning yet that may not be a good one to discuss as I want to give it some more thought. I do have a case from the other day that I was able to conceptualize during the intake and tried introducing behavioral activation at the end of the intake, so I would like some feedback on how I approached that and my plans for the next session.

The supervisor’s approach in the second example helps guide the meeting to focus on the formerly agreed upon goals and allows the therapist time to use the skills previously taught to conceptualize the new intake before presenting it. If the supervisor jumped in to discussing the new intake, 20 minutes of the supervision session may have been wasted by the therapist working through their thoughts while talking aloud about the case. By focusing on cases the therapist has had a chance to conceptualize already, the supervision can remain focused on the skills and goals they have previously agreed to address.

Unique opportunities of this approach include continued learning. As therapists, we all get used to using certain interventions and may have limited experience with some presenting concerns. In school-based services, therapists often are the only behavioral health provider for a particular school, and supervision provides opportunities for connectivity, peer support, and further professional development. In some systems, this is accomplished through group supervision meetings where each therapist has the benefit of hearing from peers and a community/team learning model can be directed and facilitated by a supervisor. The recent advancements in telehealth and virtual meetings have increased the feasibility of this model as each provider only needs to dedicate the time of the supervision meeting (typically 45–60 minutes) rather than the travel time it may have previously taken to and from the office. Virtual meetings also reduce hours taken away from clinical care, increase connections amongst team members, and consequently have led to greater interpersonal support. These opportunities for connection and consultation support a team culture and facilitate collaboration among therapists working across a system.

Creating a team culture open to this supervision model can have some challenges. Therapists’ prior supervision experiences may vary significantly. Some providers may have been previously supervised in a structured, clinically driven approach. Others may have had a more casual or unstructured supervision experience. Many school-based providers are likely to have had supervision only when unlicensed. Thus, there can be challenges for supervisors in setting up clear and consistent expectations under this model. The positive impacts of supervision can be maximized by collaborative discussions about expectations as well as the supervisor adhering to the model. It also offers a nice parallel process for therapy. Table 2 summarizes common challenges, strategies for addressing them, and sample scripts.

Table 2 Common strategies, challenges, and scripts
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Consider the example of some supervisees experiencing supervision time as being unstructured punctuated by sharing challenging and frustrating clinical situations without movement to problem solving, learning, and development. There is a place for sharing thoughts, feelings, and frustrations in supervision, and time needs to be allotted for such expression, but supervision cannot stop there or it loses the true opportunities for competence building and professional development. Having agendas and clear goals will propel skill development. The example below illustrates how adhering to an agenda while also allowing space for the supervisee to express their feelings and experience may look in a supervision session:

Therapist::

I am so frustrated with a case I saw this week. I really need to talk about it as I can’t stop playing the exchange over and over in my head.

Supervisor::

I am sorry to hear you had such a frustrating case. Those types of cases can really consume our thoughts afterwards. We can add this to our agenda for today. We had also planned to discuss adherence to homework assignments and some new strategies you were going to try with two of your patients to increase adherence. Did you want to start with the case or the homework discussion.

Therapist::

I would really like to start with the case, it is really on my mind.

Supervisor::

Thanks for bringing this case up. We will make that our first item today but before we start, I just want to understand if you have specific questions you want to discuss or do you want to focus on your experience with this case and how it is impacting you?

Therapist::

I think I really just want to talk about how it impacted me. I rarely get triggered by cases, but this one really got to me (therapist shares details of the session, thoughts and feelings; supervisor provides active listening and reflective statements).

Supervisor::

You have really done a great job talking through your own thoughts and feelings about this case, and it sounds like despite the frustrations you experienced you provided the student with clear and appropriate next steps and interventions. How are you feeling about the case and your plans for next steps?

Therapist::

I feel much better. I think I just needed to share some of my frustration and get some reassurance that I handled it appropriately.

Supervisor::

I am glad to hear the discussion was helpful. I just want to be mindful of time as I see we only have about 15 minutes left, and you had wanted to discuss the homework adherence topic today. Do you want to transition to that item or is there more you would like to discuss regarding this case?

Therapist::

Let’s switch over to talking about homework adherence. I have some examples of what I tried this week that I want to share.

This dialogue illustrates how supervision can serve multiple purposes as well as the value of structure and the articulation of clear expectations. Support for difficult cases is important and can be balanced with skill building and development by having open discussions about how the supervision time will be used. In this example, the supervisor worked collaboratively with the supervisee to modify the agenda to allow time for reflecting on a challenging case while also making sure the goals for the case discussion are clear (“to talk about how it impacted me”).

Other challenges in supervision with school-based clinicians and therapists can include over- and under-sharing about cases and clinical challenges. Some supervisees may talk for lengthy periods of time about a case by describing every piece of history and walking the supervisor and other group members through the sessions. This level of detail without an overall summary can reflect a lack of clear case conceptualization. The supervisee may benefit from support around organizing the symptoms and challenges into a more coherent conceptualization that will guide treatment decisions and interventions. This type of presentation by supervisees also may reflect the need for additional training or scaffolding around case conceptualization or can reflect a lack of preparation or feeling overwhelmed by the case. Using a structured approach to supervision and case presentation can help shape this behavior while also building skills. When first starting supervision, it is often helpful to have an opportunity for modeling the desired approach to case presentation. For some supervisees, addressing this skill first in individual supervision before bringing cases to the larger group can be beneficial.

In contrast, other challenges can present if school-based providers under-share or do not engage in the discussions. This may reflect a lack of confidence, especially in group settings. Some supervisees may observe quietly, not sharing their own cases, and rarely speaking up to offer input into those cases shared by others. This can be addressed through individual supervision to determine if there are true knowledge gaps that need to be remediated or whether strategies for increasing self-efficacy are more appropriate. Plans can then be made collaboratively between the supervisor and supervisee to increase participation in the group setting. Specifically, the individual supervision could work to identify the areas the supervisee is most comfortable giving input, and then the supervisor can call upon that supervisee to share at relevant points of time during the group discussion. This graduated training process can build confidence and foster success experiences.

Individual Versus Group Supervision

Supervision models can vary across school systems and may be dependent on resources available. There are unique opportunities for competence building offered by both formats. Individual supervision is often helpful for early career providers, during the onboarding of new school-based personnel, and when new areas of expertise are being developed. It allows for more focused, individualized approaches and can help with obtaining baseline skills prior to joining a group supervision format. Group supervision is a great way to build a culture of continual learning, group cohesion, and shared experiences while also combatting providers’ burnout and feelings of isolation.

Staff and Parent Consultation

As previously mentioned, consultation with staff and parents is essential in school-based CBT. Time, signed releases of information, and lack of availability all pose barriers to a collaborative treatment approach. Obtaining signed releases of information is time-consuming and may delay collaboration. We recommend completing these forms during an initial intake session, so they are in place for ongoing consultation. In many instances, the school setting both removes some barriers and facilitates consultation with school personnel and parents. For example, some staff members may be more accessible if they work in the same building as the supervisor. Nonetheless, it can still be challenging to schedule mutually convenient meeting times. School-based providers can have set appointment times during the day that align with staff availability so that consultation discussions can be scheduled and completed more consistently versus trying to “catch” someone between classes or sessions.

Clearly outlining the consultation plans as well as what and how information will be shared is important. Documentation of consultations is also pivotal. Treating these sessions as structured meetings with clear agendas can assist with maximizing the time and effectiveness of the consultations. For example, a sample agenda between the therapist and primary teacher for an 8-year-old student being seen for difficulty with self-regulation and self-expression when presented with challenging academic problems is contained in Box 1.

Box 1 Sample Agenda for Consultation with School Staff

Teacher shares observations of specific behaviors in the classroom since the last consultation occurred.

  • What calming behaviors have you observed the student using?

  • What situations have presented during which the student may have benefited from using calming strategies?

Therapist shares specific interventions student is learning to increase self-regulation in the classroom.

Therapist shares ideas for how the teacher can prompt and reinforce the use of the strategies in the classroom.

Identify any monitoring/tracking that will occur and set date/time for next consultation.

Some of these same strategies that are beneficial with school staff can also assist with keeping consultations with parents/caregivers meaningful and goal-focused as well. In school-based mental health services, caregivers may be less accessible compared to an outpatient treatment location. The use of telehealth has expanded options for collaboration, and there are options to “call in” parents/caregivers including them for part or all of a session during the school day. This approach will keep parents informed of treatment progress, allow opportunities for them to share their observations, work on shared goals, and teach them interventions for use at home. With students in person and caregivers participating via telehealth, there are many opportunities to role play interventions and address the role of the caregiver in prompting and reinforcing the use of the techniques at home. A sample agenda for parental consultations in contained in Box 2.

Box 2 Sample Agenda for Parental Consultations

Parent/caregiver shares observations of specific behaviors in the home since the last consultation occurred.

  • What calming behaviors have you observed the student using?

  • What situations have presented during which the student may have benefited from using calming strategies?

Therapist shares specific interventions student is learning to increase self-regulation in the home.

Therapist shares ideas for how the parent/caregiver can prompt and reinforce the use of the strategies in the home.

Therapist shares how the interventions are being prompted/reinforced in the classroom and provides update on progress.

Identify any monitoring/tracking that will occur and set date/time for next consultation.

Conclusion

School-based mental health delivery is removing many barriers to children and teens receiving much needed behavioral health services. However, as this delivery method has expanded rapidly, there is much variability in what and how it is being delivered and whether oversight or fidelity checks are in place. There is a shortage of access to evidence-based mental health treatment interventions for children and adolescents, while at the same time we are facing workforce shortages in all areas of behavioral and mental health care. This means that much of the workforce is comprised of early career therapists, and, depending on training backgrounds and programs, they may not have the breadth and depth of training in evidence-based interventions to match the complexity and scope of concerns that present in school-based mental health services. The incorporation of supervision by a more expertly trained provider increases access to effective mental and behavioral health care while also expanding the experience and skills of the supervisees. Setting up a consistent, evidence-based model of supervision that is supported by all stakeholders across the system will benefit students, school staff, families, and providers.

Test Yourself

  1. 1.

    Describe components needed for successful CBT supervision in school settings.

  2. 2.

    What are the 5 basic principles and practices of CBT supervision?

  3. 3.

    What are some strategies for addressing supervisees’ long descriptions of cases during supervision sessions?

  4. 4.

    Describe potential interventions to consider if supervisee is struggling to engage school staff in the treatment for a student.