Keywords

14.1 Introduction

Why do we fall? So we can learn to pick ourselves back up.—Batman

The process of becoming a therapist is no easy feat. During graduate school, students learn how to sit (or play!) in the room with a patient, assess their symptoms, formulate a case conceptualization and treatment plan as well as work to improve the patient’s quality of life. Figuring out this process can leave clinicians feeling plagued with anxiety about making mistakes and not doing a “good enough” job. At the same time, supervisors are tasked with encouraging clinicians to remain engaged in this learning process while teaching supervisees to become effective therapists. When trainees stumble, supervisors teach them how to pick themselves up!

CBT is the gold standard treatment for various psychiatric disorders in youth (Beidas et al., 2012; Friedberg et al., 2014) yet barriers exist in implementing this treatment in clinical practice; either the treatment is not delivered with fidelity or is not delivered flexibly enough to meet the individual needs of patients (Kendall & Frank, 2018). CBT supervisors teach the techniques and process of CBT while also training student clinicians the fundamental basics of conducting therapy sessions (i.e., how to validate and provide empathy, best practices to assess for risk, etc.). In traditional graduate training programs, supervisees typically work under the same supervisor for approximately a year which can be rather overwhelming, and quite impossible, for a supervisor to impart all their CBT wisdom to trainees. Integrating popular culture, humor, and improv in the therapeutic process emphasizes the flexibility and idiographic approach to CBT. Similarly, the use of videos, popular culture, and improvisational theater propels clinicians to learn fundamental therapeutic techniques that can be generalized and implemented with their own patients. In this chapter, we introduce the role of supervision and then discuss how movie clips, popular culture, superheroes, and improvisational theater are vehicles to deliver CBT supervision for children and adolescents.

14.2 CBT Supervision

Evidence-based supervision is just as critical as evidence-based treatment. If we want our patients to receive the highest quality of treatment, then supervisors should prioritize educating the next generation of clinicians to utilize evidence-based treatment. Supervision is a process of education, mentorship, monitoring progress, and consistent feedback in order to teach trainees how to become independent clinicians (Friedberg et al., 2009). Supervisors utilize powerful techniques to teach trainees how to absorb and process information as well as execute treatment interventions successfully. Just as we want our patients to be involved and engaged from the first moment they meet their therapist, we want supervisees to have a similar experience with their CBT supervisor.

14.2.1 Teaching and Training with Movie Clips and Popular Culture

During the COVID-19 pandemic, most supervisors adapted their pedagogical tools to be delivered and taught through online platforms. Virtual or hybrid models of supervision are likely to remain. Additionally, making supervision a fun and engaging process is a key to teach the next generation of clinicians who are “digital natives” since many were born into a world where fluency in technology was an imperative (Prensky, 2001). Training with movies and television/movie clips is a great augmentation to CBT supervision. Movies elucidate poignancies and illustrate the complexity of relationships; they are cost-effective, easily accessible, and you can easily find clips that highlight different cultures and diagnoses (Schulenberg, 2003). For example, in DBT groups, trainees teach 6 months of skills to adolescents and their families. While some skills are easy for trainees to read and then subsequently teach on their own, other skills require a more in-depth explanation. Conducting a chain analysis in DBT is complex as patients gain an understanding of their emotions that lead them to engage in specific, ineffective behaviors (i.e., when Micky* felt very sad, he thought no one cared about him, withdrew to his room, and self-harmed). Working with youth who have suicidal thoughts and self-harming behaviors can feel very daunting for student clinicians. Clinicians-in-training may feel frozen as they sit in a therapy room with Micky, attempting to uphold the ethical principle of non-maleficence and personally help Micky through reducing his self-harming behaviors. Therefore, teaching the skills, like a chain analysis, is easier when trainees feel calm and more self-regulated.

Supervisors can show movie clips to demonstrate a scene of a character engaging in an ineffective behavior while the trainees practice completing the chain analysis worksheet to describe the situation, thoughts, and feelings that led to the behavior. A few examples include Hulk (Lee, 2003) when Bruce is on the floor and expresses to Talbot “you’re making me angry” as he transforms into Hulk; the scene from Frozen when Elsa and Anna get into a fight and Elsa refuses to give Anna the blessing to marry; or the scene from the TV show Parenthood when Crosby throws beer onto Adam’s back after denouncing him as the Best Man for his wedding. Using a popular culture figure or fictional character as the identified patient enables trainees to practice skills in real time, allowing for in vivo feedback. This approach is not only feasible and acceptable to graduate students but can also improve the learning experiences of trainees as training materials are delivered through engaging methods (Gary & Grady, 2015).

Trainees can also watch a movie and construct a case conceptualization on an identified character. For example, when viewing Wonder (Chbosky, 2017), a movie about a boy named Auggie with facial differences who never attended mainstream school until the fifth grade and has a difficult time making friends, students develop a cognitive behavioral case conceptualization and present the formulation in a group discussion. This process drives a richer discussion and is potentially more generalizable and engaging compared to a one-page case conceptualization. In group therapy supervision settings, videos are an adjunctive teaching method to increase learning retention outside of session, facilitate learning of an initial concept, and vary the teaching methods to increase attention and engagement.

In this digital era, supervisors and trainers are well-advised to leverage technology and alternative platforms that students find easily accessible. The days are likely over when students flock to a library and check out hard-copy books. The new generation of graduate students and clinicians connects through social media, the internet, and technology. Accordingly, educational teaching methods that actively involve students in these learning processes are necessary.

14.2.2 Integrating Superheroes and Therapy

Superheroes are not only reminiscent of favorite childhood movies, but they also demonstrate vital psychological concepts, including how they overcome fears (i.e., Batman with his fear of bats), cope with loss (i.e., when Miles Marker told Spiderman, “No matter how many hits I take, I always find a way to come back”), and deal with grief (i.e., when Doctor Strange said “death is what gives life meaning”). Patients who identify with a superhero’s struggles may feel validated and motivated to overcome these obstacles (Dantzler, 2015). Integrating the use of superheroes as a metaphor in therapy is not new (Dantzler, 2015). Primarily, current literature focuses on clinicians’ anecdotes. These reports largely showcase the use of superheroes as a play therapy component in eclectic therapy or psychodynamic therapy but not cognitive behavioral therapy. However, in this chapter, we integrate superheroes in CBT training.

14.2.3 Implications for Training, Teaching, and Supervision

Supervision typically involves scaffolding and modeling using more traditional techniques. Using popular culture, superheroes, and humor in supervision provides supervisees with an environment that welcomes fun and embracing making mistakes as a learning tool. Supervision in the early process focuses on skill development and case content (Schwitzer et al., 2005). Barriers to effective case conceptualization include gathering enough critical information during the intake process. When trainees are tasked with forming diagnostic treatment plans, they may forget to ask important questions that would be useful in generating an accurate case conceptualization. However, utilizing popular culture mitigates these barriers and allows the supervisees to focus on the main task of improving their case conceptualization skills. Because superheroes and fictional characters are available throughout mainstream media, trainees can easily relate to the character development; superheroes embody superhuman traits, fight for the good of humanity, and usually have a pretty good sidekick. Trainees are empowered to freely explore their own experiences, attitudes, and beliefs about conceptualizing a character’s story rather than placing undue focus on gathering pertinent information. Below is a case example that can propel students’ learning of these foundational therapeutic skills:

Shawna* is a graduate-level clinician who is learning DBT and starting to conduct sessions with older children and younger adolescents. Shawna read through the DBT manuals developed by Marsha Linehan and wanted to improve her own case conceptualization of her patients who engage in impulsive behaviors. She was assigned homework to watch Frozen and utilize the biosocial theory to develop a conceptualization of Elsa and search for themes of extreme emotional states. Shawna presented her findings from the movie and suggested that biologically, Elsa had a higher sensitivity to emotions (i.e., feeling emotions more strongly than her sister, Anna) and a higher biological reactivity (i.e., as evidenced by the way her body responds to emotions where she freezes the world around her). She then formulated that Elsa had a history of invalidation as seen when Elsa accidentally hurt Anna and was subsequently told by her parents that her powers were harmful. The transaction between Elsa’s biological emotional tendencies and social invalidation led her to feel more emotionally dysregulated. For example, the more Elsa experienced intense emotions, the more she froze the world around her, which led to others rejecting her. According to Shawna, Elsa either felt strongly and was rejected or she attempted to hide her own emotions which further pushed people away. Shawna then describes how the song lyrics in the movie clearly highlighted Elsa’s emotional extremes (i.e., Let it Go vs. Conceal Don’t Feel). These emotional extremes reflect the emotional “states of mind” in DBT as emotion mind (feeling very strong emotions) vs. reasonable mind (only logic, no emotions) (see Fig. 14.1).

Fig. 14.1
figure 1

Biosocial Theory of Elsa from the movie Frozen

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Utilizing film as a training tool is documented in the literature. Presenting the biopsychosocial model to medical residents was studied under the context of “cinemeducation” or “cinemedicine,” a tool to integrate teaching medicine with film (Alexander, 2002; Kadivar et al., 2018). In one study, medical residents were tasked with watching films that highlighted psychosocial factors among common medical challenges (Kadivar et al., 2018). They ranked their level of agreement on items relating to cinemedicine on a Likert scale of 1–4 (strongly agree to strongly disagree). Results indicated that 84% of the students preferred the movie over the traditional lecture, while 89% of the residents agreed or strongly agreed that watching these medical and mental health related films were useful (Kadivar et al., 2018). Instructors and supervisors can integrate the films into the course material. After watching a film for educational purposes, the instructors should debrief and assess whether the trainees understood the key learning concepts (Schulenberg, 2003; Berk and Trieber 2009; Baños & Bosch, 2015).

Analyzing characters from popular fiction and entertainment media assists trainees in the development of assessment, diagnosis, conceptualization, and treatment planning (Schwitzer et al., 2005). Baños and Bosch (2015) noted that Mary Shelley’s (1818) Frankenstein is an appropriate film to highlight the ethical principles of biomedical research, while Marguerite Johnson, a character from Maya Angelou’s (1979) I Know Why the Caged Birds Sing was used to highlight depression (Schwitzer et al., 2005). Supervisors and clinical instructors can curate films to highlight characters from different cultural backgrounds. Films that highlight characters from specific cultural backgrounds and diagnoses lends itself well to culturally enhanced CBT supervision. For example, the Disney movie Moana (Musker & Clements 2016) tells the story about a girl from Polynesia who sets out on a daring adventure to save her community by restoring the islands’ vegetation and fish resources. This movie made cultural references to the beliefs of Polynesians (i.e., Demigods as heroes, explanation of Polynesian mythology) and included Polynesian music throughout. The emphasis on family and generational bonds highlighted the uniqueness of Moana’s culture. As trainees watch Moana, they can consider the various life lessons taught within the movie’s cultural context (i.e., emphasis on family and generational bonds, overcoming fears, and embracing differences). Throughout this process, trainees will learn to flexibly conceptualize youth patients from different backgrounds within a CBT framework.

Cinemedicine also encourages enhanced feedback from colleagues to improve peer consultation skills when used in a group setting. For example, if a trainee is responsible for relaying the patient’s information, factual information is inherently lost like in the game of telephone. Instead, identifying the central patient within a film or book, peers have access to the same information and can offer each other feedback (Schwitzer et al., 2005). There are a variety of ways to include popular culture and film in the trainee process. Groups work together to generate a group case conceptualization which can be conducted during grand rounds or other clinical meetings. It is recommended to practice group consultations with a wide array of practitioners at varying levels of experience to help students refine their own critical thinking skills. Specifically, case conceptualization should focus on fictional characters to diminish concerns of over pathologizing a celebrity which can lead to uncomfortable feelings about diagnosing and treating a person who is not in treatment. Additionally, it is important to note that American mainstream media often lacks appropriate cultural metaphors and perpetuates “popular” characters that maintain negative and inaccurate perceptions for different subgroups. Consequently, an appreciation of the value of diversity is frequently attenuated (Cerny et al., 2014). Box 14.1 contains a list of recommendations for CBT supervisors to consider when incorporating multimedia and popular culture into supervision.

Box 14.1 Recommendations for CBT Supervisors to Consider when Incorporating Multimedia and Popular Culture into Supervision

Assign media clips and films as a way for students to practice skills and formulating case conceptualizations

• If media clips are assigned as independent homework or shown during class, debrief as a group to ensure students learned the key concepts.

• Supervisors should review all content prior to assigning. It’s important to demonstrate culturally appropriate examples and diverse characters.

14.3 Improvisational Theater and Supervising Trainees in CBT with Youth

You know how sports teach kids teamwork and how to be strong and brave and confident? Improv was my sport. I learned how to not waffle and how to hold a conversation, how to take risks and actually be excited to fail.—Emma Stone

As supervisors, our goal is to train clinicians who are proficient, confident in their abilities, tolerant of discomfort, accepting of uncertainty, ethical, willing to take reasonable risks, embracing of their imperfections, interpersonally graceful, and engaging in their work with patients. Incorporating improvisational (improv) theater exercises into conventional CBT supervision may foster these qualities in supervisees. In this section, we define improv theater training, illustrate its application to clinical training, demonstrate the potential fit with CBT supervision, and offer some handy guidelines for CBT supervisors willing to add a dash of improv to spice up their supervision recipes.

14.3.1 Improvisational Theater Training

Improv theater is an art form that dates to the Italian Renaissance period and derives from commedia dell arte (Bedore, 2004; Sheesley et al., 2016; Strohbehn et al., 2020). The development of modern improv in the United States is credited to Viola Spolin (1939) who used the methods to enhance immigrant children’s creativity and self-expression (Felsman et al., 2020; Sheesely et al., 2016). In general, improv theater performances are unscripted, spontaneous narratives (Gao et al., 2019). While fun and laughter often occur during improv exercises, comedy is not the goal. Rather, honesty, flexibility, empathy, tolerance of uncertainty, divergent thinking, and spontaneity are emphasized (Watson, 2011). Finally, training in this form of theater is done experientially (Bayne & Jangha, 2016)

There are several key elements in improv training (Huffaker & West, 2005; Strohbehn et al., 2020). The first fundamental practice is referred to as accepting offers from others. This is often referred to as adopting a “Yes and…” perspective. Yes and involves incorporating others’ ideas and adding to them. This stance serves to maintain interpersonal flow between individuals, attenuate biases, and promote collaboration. Remaining present or embracing a here and now focus is another crucial imperative. Staying present allows greater tolerance of uncertainty and enables risk-taking. Active authentic listening is an obvious essential precept. Finally, openness and willingness to change are required. Consequently, teaching improv to health care providers seems a natural fit.

Training health care providers in improv is an emerging form of education, training, and supervision (Fessell et al., 2020; Gao et al., 2019; Harendza, 2020). Eminent medical institutions such as Northwestern University, Boston University, University of Washington, Johns Hopkins University, Indiana University, and University of Michigan are including improv classes in their curriculum (Gao et al., 2019; Rossing & Hoffman-Longtin, 2018). Many counseling programs also integrate improv exercises in their coursework (Bayne & Jangha, 2016 Bermant, 2013; Harendza, 2020; Hoffman et al., 2008; Lawrence & Coaston, 2017, Romanelli et al., 2017; Romanelli & Berger, 2018). Although few clinical psychology training programs are experimenting with improv, we nonetheless endorse incorporating improv in psychotherapy classes and supervision for reasons articulated below. Therefore, the following sections delineate the relevance of improv to clinical work and offer several practical guidelines for use in supervision/training.

14.3.1.1 Application to Clinical Work

Improv is readily applied to clinical work. Various authors contend improv fosters elemental psychotherapeutic skills ranging from proficiencies in basic micro-counseling skills to more advanced techniques and processes. Improv training promotes rudimentary competencies such as listening and empathic responding (Bayne & Jangha, 2016; Gao et al., 2019; Lawrence & Coaston, 2017; Misch, 2016; Watson, 2011). Many diversity trainers also employ improv techniques with their trainees (Boal, 1979, 2002). Moreover, this work could lay the foundation for better cultural alertness and responsiveness by increasing attention to stereotyping, attenuating implicit biases, and managing micro-aggressions (Hobson et al., 2019). In sum, skills developed via improv training may add to the “secret sauce” that seems to characterize successful treatment relationships.

The level of empathy produced by this theatrical training facilitates better interviewing and case conceptualization (Bayne & Jangha, 2016; Schochet et al., 2013). For example, Schochet and colleagues explained, “The medical interview has notoriously been extremely difficult for students to learn and to move beyond competency toward excellence. It requires managing multiple cognitive skills such as question asking, retaining detailed information and integrating the patient’s story with medical knowledge and clinical reasoning. When building a patient’s history, medical students need to be able to improvise (p. 123)”. In this way, a rich understanding of patients’ stories is potentially achieved.

CBT is a phenomenological approach and works to accelerate change in “here and now” moments during treatment sessions. Therefore, the use of immediacy in session is demanded. Training in improv advances skills in optimizing powerful psychotherapeutic moments (Farley, 2017; Gao et al., 2019; Romanelli & Berger, 2018). In short, improv enables supervisees to be “fully present in the face of uncertainty and anxiety (Fessell et al., 2020, p. 87).”

Doing psychotherapy is hard work and frequently occurs in a high stress environment. Periodically feeling uncertain and doubting one’s abilities is common to both beginning and experienced clinicians. Nonetheless, in highly stressful and ambiguous situations, good clinical reasoning, adaptive problem solving, and flexible thinking are especially important. Fortunately, improv training catalyzes these skills (Bermant, 2013; Farley, 2017: Fessell et al., 2020; Gladwell, 2005; Lawrence & Coaston, 2017; Misch, 2016; Schochet et al., 2013 Watson, 2011). Gladwell (2005) argued, “how good people’s decisions are under the fast moving high stress conditions of rapid cognitions is a function of training and rehearsal (p. 114).” An optimistic outlook, tolerance for uncertainty, creative problem solving, and divergent thinking skills are spurred by improv (Felsman et al., 2020; Hoffman-Longtin et al., 2017; Huffaker & West, 2005; Lewis & Lovatt, 2013). Improv training helps students accept uncertainty as well as catalyze reasoned risk-taking, creativity, and poise under pressure (Misch, 2016).

The route to clinical wisdom and competence is filled with potholes. Supervision then involves giving and receiving feedback. As Strohbehn et al. (2020) stated supervisors and trainees alike are well-advised to accept that every learning path is bumpy and marked by mistakes, poor application of skills, and misunderstanding. Many supervisees try to hide their mistakes due to their perfectionistic tendencies and fear of negative evaluation. However, improv increases acceptance of one’s imperfections (Misch, 2016; Watson, 2011).

Good supervision facilitates improving competence via experiential learning and directed feedback. Watson (2011) noted that improv training helps learners accept and incorporate corrective feedback. Tolerating uncertainty, doubt, and making mistakes build professional development, competence, and clinical wisdom. Lewis (2016) argued that the “use of moments of uncertainty to teach the students that the process of finding out the correct answer (diagnosis, medication, formulation) is the most important task in psychiatry (p. 954).” It turns out Emma Stone was exactly right!

Due to improv training’s powerful pedagogical characteristics, it is recommended in a number of medical, psychological, and counseling training settings (Bayne & Jangha, 2016 Bermant, 2013; Harendza, 2020; Hoffman et al., 2008; Lawrence & Coaston, 2017; Misch, 2016; Romanelli et al., 2017; Romanelli & Berger, 2018; Watson, 2011; Watson & Fu, 2016). Improv training improved medical students’ listening, communication skills, and confidence (Hoffman et al., 2008). Schochet et al. (2013) studied the effectiveness of using improv to train medical students in clinical interviewing. Their course content included improv games that focused on mindfulness, active listening, comprehension, agreement, acceptance, thoughtful responding, and clear articulation. They found that 81% of the students considered this experience to be “tremendous.” Eighty-five percent of the class noted that improv was very relevant to their clinical practice. Schochet et al. concluded, “This creative experiential process allowed students to both practice and gain confidence in their interpersonal skills thereby giving them insight to draw upon when facing unique iterative moments in clinical encounters (p. 122).”

Fesell and collaborators evaluated the impact of improv workshops on medical students’ clinical competencies. Their results showed that 90% of the attendees reported the workshops improved their insight and team work skills. Overall, 90% of the medical students gave training favorable ratings. Misch (2016) concluded, “So for physicians, improv training is an opportunity to enhance typically underdeveloped right brain emotional life to feel, read, interpret, and express emotions (p. 346).”

Kaplan-Liss et al. (2018) reported on their efforts regarding teaching an elective communication skills class for medical students. Working in collaboration with the Alda Center for Communicating Science at Stony Brook University, they designed a course employing innovative methods. In particular, the Alda Method emphasizes training in Improvisation for Scientists and Distilling Your Message. The Improvisation for Scientists module focuses on explaining medical/scientific concepts in an understandable, accessible, and jargon-free manner, tolerating uncertainty, and building empathic listening skills. The Distilling Your Message pod teaches students to communicate their ideas through engaging analogies and storytelling. The course received very favorable evaluations with 96% of students endorsing the very highest ratings for the class. Students reported improving their understanding of patients’ lived experiences, enhancing their listening skills, and increasing their comprehension of medical knowledge.

Integrating improv theater courses into psychotherapy training curricula appears promising (Romanelli et al., 2017; Romanelli & Berger, 2018). Romanelli and colleagues (2018) claimed “psychotherapy can be seen as a kind of improvisational theater where therapists and clients co-create the reality of every moment (p.26).” This “here and now” focus is quite congenial with contemporary views of CBT with youth (Friedberg & McClure, 2015; Gosch et al., 2006). More specifically, when discussing therapeutic process issues in CBT with children and adolescents, Friedberg and Gorman (2007) argued “psychotherapeutic moments are charged with the urgency and genuineness of emotional experience in present tense and real time (p.189).” The use of improv theater games in treatment seems to enliven the clinical encounter, general excitement in sessions, facilitate the exploration of heretofore neglected possibilities, and model appropriate social risk-taking (Romanelli et al., 2017; Romanelli & Berger, 2018). Consequently, incorporating these methods in CBT supervision and training is well-advised.

Romanelli et al. (2017) designed and studied a semester long course combining training in improv methods with more psychodynamically oriented psychotherapy. Students’ comments revealed very favorable course evaluations. In particular, they reported their clinical intuition, spontaneity, flexibility, playfulness, presence, use of immediacy, and confidence increased as a result of the seminar. Romanelli and his co-authors concluded the course propelled students’ skills in being “mindfully aware,” “present in the moment,” and “openly animated.” It is noteworthy that many of these processes are also explicitly rated on the Cognitive Therapy Rating Scale for Children and Adolescents (CTRS-CA; Friedberg, 2014) which is used to evaluate clinicians’ competencies in conducting CBT with youth (Friedberg, 2019; Gudino, 2020; Johnson & Phythian, 2020).

Several authors have also integrated improv training into a traditional counseling courses (Bayne & Jangha, 2016; Farley, 2017; Lawrence & Coaston, 2017). Their course content included common improv exercises that were selected due to their focus on emotional awareness, tolerating uncertainty, and embracing spontaneity. Lawrence and Coaston (2017) concluded that training in improv may propel counselors’ collaborative abilities and capacity to engage patients.

In sum, improv theater exercises foster multiple clinical skills ranging from basic micro-competencies to more advanced proficiencies. Empathy, critical reasoning, cultural alertness, use of immediacy in session, and enhanced therapeutic presence are some of the practices fueled by this training. Good decision-making while under pressure, tolerance of uncertainty, and increased emotional awareness are also strengthened. Thus, incorporating improvisational theater games into supervision of CBT with youth is a meritorious notion.

14.3.2 CBT Supervision and Improv: Arranged Marriage or Perfect Union?

Fusing CBT principles and practices with improv methods represents a perfect union. The two paradigms share many features. The common focus on collaboration, authenticity, presence, and experiential learning empower integration. CBT supervision with youth is facilitated by supervisors who are authentic, supportive, collaborative, and foster robust learning environments (Corrie & Lane, 2015; Friedberg, 2018; Gordon, 2012; Newman & Kaplan, 2016). Collaboration and guided discovery are central aspects of CBT supervision (Friedberg, 2018; Newman & Kaplan, 2016). Improv training aligns precisely with these conventions. Improvisation techniques change the communication landscape between supervisors and supervisees. Rossing and Hoffman-Longtin (2018) claimed that improv disables the power imbalance between teacher and learner. More specifically, improv shifts the pedagogical focus from delivering information “to” trainees to constructing an educational partnership with them.

Friedberg (2015) argued CBT with youth is not the same as treating mini-adults. Playfulness, transparency, and fun are essential when working with young patients. In our experience, beginning child clinicians are disinclined to appear whimsical or even somewhat goofy in session. By using improv in training, trainees can liberate themselves from the chains of unnecessary orthodoxy. Boal (2002) aptly remarked, “If everyone is ridiculous, then no one is (p. 92).”

Improv exercises and practices can be seamlessly assimilated into traditional supervisory methods. CBT supervisors routinely ask trainees to summarize supervisory sessions and elicit feedback from them. Improv training offers a unique and compelling take on this practice. Rossing and Hoffman-Longtin (2018) recommended asking three basic summary questions to help students acquire and apply skills learned in improv (e.g., What? So What? and Now What?). The “what” questions prompts recall of the session. “So what” calls on students to discern the skill’s relevance. Finally, “Now What” encourages learners to act their new found knowledge and skills.

Socratic dialogue is a staple in both CBT supervision and training in improvisation. Strohbehn et al. (2020) asserted that “Socratic or open-ended questioning is especially useful in promoting critical reasoning and represents one manifestation of improv pedagogy (p. 390).” Socratic dialogues enable learners to interrogate their own belief systems and create new perspectives. The ability to see clinical phenomena from multiple angles is essential for professional development.

Both CBT with young patients and improv foster presence a here and now focus and experiential learning. Experiential learning nourishes increased self-efficacy, approach behavior, and believable cognitive reappraisals (Kendall et al., 2006) Like the Elvis Pressley (1968) classic song, youth prefer “a little more action, a little less conversation” in CBT (Friedberg, 2015). Incorporating improvisational methods in supervision teaches supervisees to maximize pivotal moments in therapy and emphasize action.

14.3.3 Tips for CBT Supervisors

Using improvisational theater exercises to train clinical students calls for numerous supervisory skills (Bayne & Jangha, 2016; Hoffman-Longtin et al., 2017; Misch, 2016). Supervisors are encouraged to be enthusiastic and energetic when leading games (Bayne & Jangha, 2016). Further, providing a rationale to trainees for experimenting with exercises during supervision is recommended. Supervisees need to know how improv is relevant to their clinical work and professional development. Hoffman-Longtin and colleagues urged supervisors to explicitly communicate to their mentees that improv games are designed to facilitate a specific mindset or perspective which embraces ambiguity and spontaneity.

Remembering the importance of “here and now” moments in supervision and training is crucial. When supervising psychiatric residents, Lewis (2016) disclosed, “I try to remind myself that each moment on clinical service may be the important moment that changes a student’s perspective (p. 953).” Potentiating the power of here and now moments breathes life into clinical supervision. Trainees are far more likely to apply their acquired skills and knowledge when they see them as relevant and memorable. Further, if supervisees have played the game themselves in supervision, they are more likely to use the exercise with their patients.

Hoffman-Longtin et al. (2017) alerted supervisors to expect trainee avoidance. Practicum students, interns, and post-docs may be reluctant to take risks posed in improv exercises due to pressure to prove their worth and desire to belong (Rossing & Hoffman-Longtin, 2018). Rossing and Hoffman-Longtin believed that professional staff who are overly invested in prestige will approach improv timorously.

Graduated tasks will enable most trainees to scaffold their skills and may mitigate their apprehensiveness. Indeed, graduating these tasks is similar to delivering exposure. The key is to coach supervisees to lean into discomfort with unfamiliar exercises. Additionally, just as Newman (1994) urged therapists to gently persist (p. 94) when patients avoid so too are supervisors to do the same with avoidant trainees. For instance, a supervisor could invite the trainee to explore their reluctance by saying, “Yes this game makes you feel a bit uneasy and how willing on scale of 1–10 are you to give it a try?” Then the supervisor may continue by saying, “What makes you a __, right now?” and “What do you expect to happen?” This type of Socratic dialogue allows the trainer to set up the game as an experiment.

Like exposure, debriefing improvisational theater exercises is crucial. It is recommended that supervisors help their mentees make sense of their experiences. Debriefing catalyzes the learning by molding conceptual anchors. Questions such as “What is the take-away message from this game?” “What was useful/not useful about this exercise?” “Based on your experiences in the game, what things can you use in your work with young patients?” and “When you got stuck during the game, what did it teach you about doing CBT?” Box 14.2 contains some additional helpful Socratic debriefing questions culled from the literature.

Box 14.2 Useful Debriefing Questions

Lawrence and Coaston (2017)

 What was this experience like for you?

 What did you notice in the pattern of your responses

 How difficult was this? How easy?

 What risks did you take? Avoid?

 What did this teach you about ____?

Bayne and Jangha

 What was it like for you to be in the here and now?

 What is the value of this game?

Finally, fostering spontaneity, flexibility, tolerance of imperfection, a sense of universality, and FUN are the goals when integrating improvisational theater games into supervision for CBT with youth. Supervisors should welcome trainees’ discomfort and errors. Everyone gets stuck when doing both CBT and improv. Creating an atmosphere where stuck points are abided, reasoned risk-taking is championed, and sharing imperfections are applauded is vital. Remaining mindful of these tips can avoid improv becoming “um-prov” where supervisees are hesitant and halting participants who pause and say “Um” (Box 14.3).

Box 14.3 Recommendations for Supervisors

Be enthusiastic and energetic

Specifically link improv procedures to clinical skill development

Explain that improv is designed to train tolerance for ambiguity and appreciation of spontaneity

Emphasize the importance of the here and now

Expect and process avoidance

Employ graduated tasks

14.3.4 Improv in CBT: Specific Examples

CBT supervisors may need a stockpile of improv exercises. There are a number of excellent texts which contain many improv exercises (Bedore, 2004; Boal, 2002; Rooyackers, 1998) Additionally, various internet sources list valuable improv exercises (www.medicalimprov.org). Finally, Table 14.1 presents a selection of games culled from several scholarly articles and texts.

Table 14.1 Improvisational exercises and their foci
Full size table

I (RDF) began to integrate improv in supervision while training child psychiatry fellows and post-doctoral psychologists in the Cognitive Behavioral Therapy Clinic for Children and Adolescents at Penn State Milton Hershey Medical Center. Initially, the fellows and post-docs were initially reluctant and skeptical. Their many work demands and time constraints made them wary of “wasting” any time on irrelevant activities. However, by giving them a clear rationale, setting up a comfortable environment, and providing some coaxing, their willingness increased. Subsequently with greater exposure, practice, and laughter, they increasingly embraced the games. In the paragraphs below, I describe a few games we played in supervision.

One word story (Bedore, 2004) is a group game where players work as a team to construct a story one word at a time. The group creates a story by members adding one word each when it is their turn. This game teaches supervisees the value of listening, cooperation, reciprocity, and cognitive flexibility.

Famous Movie Lines is a game that involves a player reciting familiar lines from popular movies (e.g. “Say hello to my little friend,” “You had me at hello,” “Mama, what’s my destiny?”). However, the player must express an emotion not readily associated with the particular line. The lines are written on slips and placed in a box. Various emotion cards (e.g., mad, sad, ashamed, excited, fearful, etc.) are put in another box. Students then pick one line and an accompanying emotion. For instance, a student may have to say “You had me at hello” in an angry agitated tone. Often, this exercise is a nice ice-breaker and introduction to silliness.

Many beginning and even advanced behavioral health clinicians struggle to explain diagnoses, case conceptualizations, assessment findings, and the course of treatment to patients and their families in understandable ways. Often, their stilted language is flooded with jargon. Consequently, treatment engagement and adherence suffers. Learning to talk to patients so they understand is a pivotal skill.

Time traveler (Fessell et al., 2020) is an improvisational game that promotes clear and cogent communication. In this exercise, players take turn explaining a new invention (cell phones, the internet, vaccines, cable TV, self-driving cars, etc.) to a time traveler from the fourteenth century. Trainees need to bring down these technological and scientific advances into simple, jargon free explanations so the traveler from the distant past understands. Supervisors give the players corrective feedback when the players fall back on professional patter or arcane shop talk.

The Blind Car (Boal, 2002) is a favorite game I (RDF) used in supervision as well as in family treatment (Friedberg, 2006). The exercise involves one blindfolded trainee being “driven” in a room by a second team member. The car is steered by the driver applying gentle pressure to the shoulders of the member playing the car (e.g., pressure to right shoulder turns right, press on both shoulders go forward, etc.). Obstacles can be set up in the room so the car has to turn, go in reverse, and so on. Not surprisingly, this game enhances trainees’ capacity to trust, give up control, and tolerate uncertainty.

Improv exercises are welcome additions to training large groups of practicing professionals. They facilitate more active participation and fun in long training sessions. Additionally, some of the games are also used in CBT with youth so students get the opportunity to experience the exercise for themselves. A favorite group training game is Group Photo (Rooyackers, 1998) and it is also applicable to treating socially anxious young patients (Friedberg & McClure, 2015). Group Photo involves several group members working together to pose for a picture doing a common activity (e.g., going to an amusement park, attending a surprise birthday party, standing in a long line waiting the bathroom, etc.). Players not involved in the photo try to guess the scene.

14.4 Conclusion

I have one super power. I never give up.—Batman

Like Batman, supervisors want their trainees to never give up learning and developing. Supervisors are challenged to come up with new ways to instruct and inspire their mentees. Getting stuck in the same sometimes tired routines is a common problem. In this chapter, we presented the idea of integrating movies, popular culture, and improvisational theater techniques into supervision for conducting CBT for youth. Ideally, these strategies may foster supervisors and trainees achieving their superpowers.

*All case examples have been sanitized.