Survey of cognitive behavioral therapy clinical supervisors profile in Brazil

Abstract

Objective:

This research aimed to identify the profile of Cognitive Behavioral Therapy supervisors in this country and to know their training to exercise this professional activity.

Method:

A nationwide online survey was conducted with 180 Cognitive Behavioral Therapy supervisors, 73.8% of whom were female, with a mean age of 40.3 years (SD = 10.03).

Results:

Among the main results, the intense academic training, training for psychotherapeutic practice and time of clinical experience (12.6 years, SD = 7.64) and supervised experience (7.4 years, SD = 7.26) stand out. Only 27.8% of the participants indicated having received specific training for supervisors and there was a lack of indications of training resources for remote supervision.

Conclusion:

This is considered the first research to outline the profile of Cognitive Behavioral Therapy supervisors in Brazil, expanding the vision on this professional activity.

Keywords:
Cognitive behavioral therapy; Demography; Preceptorship

Resumo

Objetivo:

Esta pesquisa teve por objetivo identificar o perfil de supervisores de Terapia Cognitivo-Comportamental no país e conhecer sua formação para exercer essa atividade profissional.

Método:

Foi realizado um survey online em âmbito nacional com 180 supervisores de Terapia Cognitivo-Comportamental, sendo 73,8% do sexo feminino, com a média de idade de 40,3 anos (DP = 10,03).

Resultados:

Entre os principais resultados, ressalta-se a intensa formação acadêmica, treinamento para prática psicoterápica e tempo de experiência clínica (12,6 anos, DP = 7,64) e supervisionada (7,4 anos, DP = 7,26). Apenas 27,8% dos participantes indicaram treinamento específico para supervisor e houve uma lacuna de indicativos de treinamentos de recursos para supervisões remotas.

Conclusão:

Considera-se essa a primeira pesquisa a traçar o perfil de supervisores de Terapia Cognitivo-Comportamental no Brasil, ampliando o olhar para esta atividade profissional.

Palavras-chave:
Demografia; Preceptoria; Terapia cognitivo-comportamental

Psychology is a profession that is still under construction in Brazil, being a reflection of its regional history that has been constantly changing over the years. This understanding, by itself, supports the need to identify aspects that characterize psychologists and their professional practices, in the broad and diversified field of psychology. Research initiatives intended to know who are the professionals that constitute the psychologist class in this country have interested the Conselho Federal de Psicologia (CFP, Federal Council of Psychology). In 1988, for example, it was identified that most psychologists at that time were women (87%), a situation that remained according to the results of the 2012 survey (89%) (Rechtman, 2014). Currently, there are a total of 385,760 Brazilian psychologists enrolled in the CFP (Conselho Federal de Psicologia, 2021).

It is known that, despite the late introduction in the Latin American scenario, until the 2000s, clinical activity was predominant in Brazilian psychologists’ professional practice (Neufeld et al., 2021). Rechtman (2014) points out that the current psychology curricula, even with the changes in the Diretrizes Curriculares Nacionais (National Curriculum Guidelines) in 2004, continue to privilege clinical practice, maintaining this choice as a preference among students and strengthening the clinic as a social representation of psychological practice. On the other hand, she then reviewed her criticism indicating that it should concern the medical model in the clinic, since clinical performance is a structuring element of psychology.

Even though the expanded clinic and the concern of the professional class to increase social reach are growing, Mendoza (2017) discusses some characteristics of the Latin American context that can hamper the dissemination of psychotherapeutic practice in the most diverse communities of this region, while enhancing its elite character. Among such factors, the author includes social inequality and the repetition of an international pattern without cultural adaptations, which does not reflect local social needs and demands. This understanding is reviewed and corroborated by researchers both in connection with Latin America and Brazil (Neufeld et al., 2021), who point out that clinical psychology has received strong European and American influence since its inception in the region. On the other hand, it is understood that the difficulty of scope and social reach of clinical psychology is not exclusive to the aforementioned region, but a worldwide concern. For example, in order to increase the population’s access to evidence-based psychotherapies, in 2007 the United Kingdom created the Improving Access to Psychological Therapies Program, using it as the main strategy to strengthen the dissemination, coverage and range of effective treatments (Barletta & Neufeld, 2020).

When talking about clinical psychology, it is acknowledged that supervision is an essential activity to train the psychologist, maintain the quality of the intervention (Barletta & Neufeld, 2020) and foster specific therapist’s skills and knowledge (Sampaio et al., 2021). In this connection, it is a recurrent activity in the formal education of the clinical psychologist, including at graduation time (Barletta et al., 2011) and Lato Sensu postgraduate studies that foster professional practice (Velasquez et al., 2015). This understanding, added to the importance of identifying the professional’s profile (Rechtman, 2014), has led to seek the clinical supervisor and how he/she has been practicing for a long time, despite few data available in the literature. For example, Tyler et al. (2000) selected randomly 300 American Psychological Association associated clinical supervisors faculty. Out of the total of 149 respondents, 71.9% were male, with an average age of 50.5 years (SD = 8.5), with an average time of completion of their doctorate being 18.1 years for women (SD = 7.5) and 24.4 years for men (SD = 8.5). As for the theoretical perspective, 29.8% indicated being eclectic, while 24.6% used the behavioral approach, 17.5% the cognitive approach and 15.8% the psychodynamic, among others. It was identified that supervisors who provided only group supervision spent an average time of 1.8 hours per group (SD = 0.7), while individual supervisions had an average duration of 1h (SD = 0.6). Full-time professors (38.3%) provided an average of 6.7 hours (SD = 5.1) supervised practice per week, with around four supervisees with four cases each. Each student received, on average, 2h30 supervision per week. Among the characteristics described, these authors opened a discussion about the little consideration that supervised practice had at the time for promotion in the teaching career or even for guaranteeing job stability.

Recently there was a survey on clinical supervision in Cognitive Behavioral Therapy (CBT) in the UK (Reiser & Milne, 2016). The invitation to fill out the questionnaire online was sent to a list of 250 supervisors intentionally selected from the British Association for Behavioral and Cognitive Psychotherapies on account of their supervisory knowledge and expertise. Out of the total of 110 respondents, it was possible, among other results, to become aware of the supervision professionals’ profile. Due to the initial selection itself, those professionals had more than 20 years of clinical practice, with an average of 14 years specifically in CBT and more than 12 years of supervision practice. Most were female (75%) with a mean age of 48.8 years. On average, professionals had 5.2 supervisees. Participants training and/or professional activities included: CBT therapists (32%), clinical psychologists (24%), counselors (6%) and psychiatrists (4%). Nurses (29%) were also identified in this role. Since there are differences in norms and regulations on psychotherapy and clinical supervision according to each country and/or region, there may be distinctions for Brazil regarding who performs the supervision activity and what type of activity is being recommended (Ferreira et al., 2021).

In Brazil, since the 1990s, Campos (1998) had already pointed out the shortage of studies that would bring more clarity about the profile and development of professionals who offered supervised activity. In his research, 100 questionnaires were distributed to clinical supervisors in the Southeast region of the country, and of the 18 participants who returned the form, the majority was female (61%), with an average age of 40.5 years, time since graduation 13.5 years and providing clinical supervision during 7.5 years. Although all supervisors had academic training, ranging from specialization to doctoral degrees, none had education or training to perform the supervised activity. In addition, supervision in only two theoretical orientations was identified: psychodynamic approach (67%) and CBT (33%). The author pointed out that from the population of 100 supervisors invited to participate in the investigation, 8% were from the CBT, which suggests the consistency of professionals with the principles of the evidence-based approach for responsiveness to the study. Although there are limitations in the research by Campos (1998) due to the low number of responses, it can be considered as one of the first studies that tried to map the profile of clinical supervisors and their training in the country, which supports investigation merit.

It is also known that there are a few data on psychotherapy supervisors who carry out this activity during clinical internships in the undergraduate Psychology course (Gauy et al., 2015). This group of researchers, seeking to fill this gap, carried out a study with view at describing the supervisors who guided the clinical psychology internships graduation in Brazil, regardless of the theoretical orientation. Since this survey was part of a larger project on school service, online survey respondents who were clinical supervisors constituted the study participants, totaling 147 responses over a two-year period of data collection. The main results indicate that most supervisors were female (77.6%), aged between 38 and 53 years (66.0%) and only 12% supervised in CBT. In addition, most of them worked in private education (56.0%), concentrated in the Southeast (46.0%) and South (32.0%) regions, followed by the Northeast (7.0%), North (5.0%) and Central-West (4.0%) regions. Finally, we identified that the time of professional experience in psychotherapy was 10 years or more for most supervisors (64.4%). Even though, the investigators have pointed out that it was not possible to draw a general profile that could describe the supervisors of clinical practice internships in psychology graduation, they highlighted the importance of research of this nature.

Another aspect identified as hindering the dissemination of psychology is associated with little professional training and specialized training in the Latin American framework (Mendoza, 2017). The lack of training to exercise some specific professional practices in psychology corroborates the perceived need by the United Kingdom for the creation of the Improving Access to Psychological Therapies Program. Although the clinical supervisors’ CBT training has been indicated as being an essential element (Ludgate, 2016; Milne & Reiser, 2017; Sokol & Fox, 2016), little is known about CBT supervisors in Brazil and their training to perform this professional activity nowadays (Barletta & Neufeld, 2020). The literature has also pointed out the need to include training on the use of technological resources and applications, appropriate pedagogical strategies for remote teaching, ethical and procedural aspects of online intervention (Machado & Barletta, 2015; Sampaio et al., 2021), whether for clinical or supervised practice.

With the growth of CBT teaching in undergraduate psychology in Brazil (Neufeld et al., 2018), the importance of mapping the profile of clinical supervisors in this area increases. It is known that in 2013, the Federação Brasileira de Terapias Cognitivas (FBTC, Brazilian Federation of Cognitive Therapies), the main CBT association in the country, had a total of 1566 members (Neufeld & Afonso, 2013) and that, currently, on the institution’s website (Federação Brasileira de Terapias Cognitivas, 2021), 536 professionals who work in psychotherapeutic practice are listed, but there is no discrimination as to who offers clinical supervision. International CBT associations point out that there is a considerably smaller number of supervisors compared to therapists, although in Brazil such data are scarce, as seen above. For example, British Association for Behavioral and Cognitive Psychotherapies, in the early 2000s, had 1300 psychotherapists and of that total, only 3.6% were accredited supervisors (Roth & Pilling, 2008). In 2020, a similar proportion was observed with 7,500 psychotherapists and, out of this amount, only 4.0% were accredited supervisors (Ferreira et al., 2021). Based on the relevance of knowing the characteristics of the CBT supervisor and the research data gap that translates this mapping, the objective of this research is to identify the profile of CBT supervisors in Brazil, as well as knowing their training to perform this professional activity.

Method

A survey was carried out in the form of an online survey, from April to July 2020. For this purpose, a questionnaire was developed with 19 close-ended questions and three open-ended questions referring to block I of questions entitled “Sociodemographic and Training Indicators”’, and 12 closed-ended and one open-ended questions referring to the questions of block II entitled “Your Supervision Practice”, which served as data for this study. For the dissemination of the research, a partnership with the FBTC was used, in order to invite CBT supervisors from all regions of Brazil, with the aim of expanding the reach to the target audience. The inclusion criteria established to participate in the survey were: exercising or having exercised supervision practices of cognitive behavioral therapy in Brazil, in any region of the country, regardless of the length of time in the profession or in the role of clinical supervisor. Exclusion criteria: supervisors of any approach other than the cognitive-behavioral perspective and psychology professionals who have never played the role of clinical supervisors.

For the descriptive data analysis procedure, the IBM®SPSS® (version 24) was used. For the open-ended questions, content analysis was used (Bardin, 2016), performed by exploring the content in corpora composed of the answers to each question, through the identification of the words and their context units (keyword-in-context), coding and categorization in units of meanings with frequency accounting.

This study was approved by the Research Ethics Committee (CAAE nº 26829419.4.0000.5407, protocol nº 3.854.553). When accessing the instrument’s link, the participant first had to sign the Free and Informed Consent Form, accepting to voluntarily participate in the survey before receiving the questionnaire.

Results

Participants’ profile

A total of 180 CBT clinical supervisors answered the questionnaire; 77.8% (n = 140) were female and 22.2% (n = 40) were male, with a mean age of 40.3 years (SD = 10.03). Basic training indicated that 97.8% (n = 176) were psychologists, 1.7% (n = 3) psychiatrists and one participant held both degrees. The average time since graduation was 15.7 years (SD = 9.41), ranging from 2 to 49 years. In addition, 86.1% (n = 155) of the respondents had a Lato Sensu postgraduate degree, 71.1% (n = 128) a Stricto Sensu postgraduate degree, 9.5% (n = 17) had a post-doctoral degree and 1.7% (n = 3) were associate professors. Out of the total number of participants, 1.2% (n = 2) had only one degree, while 58.3% (n = 105) had both Lato Sensu and Stricto Sensu postgraduate degrees. Respondents were from the following regions: 32.9% (n = 59) from the Southeast, 28.9% (n = 52) from the Northeast, 22.2% (n = 40) from the South, 8.9% (n = 16) from the Midwest and 7.1% (n = 13) from the North. There were no responses from supervisors from the States of Acre and Espírito Santo, and all other states of the federation were represented by at least one participant.

Psychotherapeutic practice

The average time of experience in psychotherapy was 13.9 years (SD = 9.06), ranging from 2 to 48 years; however, 22.2% (n = 40) of the total number of participants had previously worked with other theoretical orientations. Psychoanalysis was the approach most indicated by supervisors (25.0% or n = 10), followed by Behavior Analysis (20.0% or n = 8), Psychodynamics (17.5% or n = 6), Humanism (10.0% or n = 4), Systemic (7.5% or n = 3), Gestalt (5.0% or n = 2) and Psychodrama (2.5% or n = 1). Thus, the average time of psychotherapeutic practice specifically from the perspective of CBT was 12.6 years (SD = 7.64), ranging from 2 to 44 years, while the average time between graduating and starting clinical care in CBT was 3.1 years (SD = 4.54) ranging from 0 to 21 years.

When asked about which activities they carried out to qualify for clinical care in CBT, there were 551 mentions of different strategies. Out of these, quick educational activities were the activities most reported, such as: 19.4% (n = 107) free courses, 8.3% (n = 46) scientific events, 5.4% (n = 30) workshop and 0.7 % (n = 4) improvement courses. The longest training courses were also indicated: 15.8% (n = 87) Lato Sensu postgraduate courses, 7.1% (n = 39) clinical training courses, 5.1% (n = 28) specific training. Activities involving the clinical profession were also identified as a form of training for the practice itself 13.3% (n = 73) received supervision of clinical practice, 2.9% (n = 16) participated in clinical internships, 1, 3.0% (n = 7) performed daily clinical practice, 0.2% (n = 1) performed personal therapy. Other strategies were: 12.0% (n = 66) individual studies, 5.8% (n = 32) study groups, 2.2% (n = 12) research activities and 0.5% (n = 3) teaching

Supervised practice

The mean time of supervised practice was 7.4 years (SD = 7.26), ranging from 0 to 47 years. Regarding this variation in experience time, four participants had less than one year of practice as a supervisor when responding to the present survey. The 200 mentions about the reasons for starting the supervisory activity included: 40.5% (n = 81) undergraduate activity, 23.5% (n = 47) personal interest, 19.5% (n = 39) professional requirement, 14.5% (n = 29) Lato Sensu postgraduate activity and 2.0% (n = 4) Stricto Sensu postgraduate activity. The mean time between the beginning of clinical practice in CBT and the beginning of supervised practice was 5.2 years (SD = 3.62), ranging from 0 to 21 years.

Only 27.8% (n = 50) of the participants reported that they had undergone training to be prepared for the role of supervisor. There were 70 mentions of different activities by the professionals, which were allocated into three categories (Table 1).

Table 1.
Training carried out to be a supervisor

Trainings/Activities		Answers
		n	%	Cases (%)
About supervision
	Long term	15	21.4	28.4
	Short term	22	31.5	41.6
	Supervision practice guidance	9	12.8	16.9
	Individual study	7	10.0	13.2
Therapeutic practice
	Receive clinical supervision	4	5.7	7.5
	Clinical practice course	4	5.7	7.5
Several
	Non-specific course	6	8.6	11.3
	Teacher training	1	1.4	1.9
	Research training	2	2.9	3.8
Total		70	100.0	132.1

• Note: n: Number of responses.

- Specific training on supervision (75.7% or n = 43), including four possibilities: long-term training (six months or more), short-term training (up to 60 hours), supervision practice guidance, either by receiving supervision or for being an assistant to the supervisor and individual study, that is, without training, but with self-taught activities such as readings, video classes, etc.

- Specific training for therapeutic practice (11.4% or n = 8), including two possibilities: receiving supervision of their psychotherapeutic practice or taking a clinical practice course;

- Several training (12.9% or n = 9), that is, for another activity or not specified, including three possibilities: a course, but whose focus or content was not identified by the participant, training of teaching practice and research training.

Most participants (97.2% or n = 175) provided supervision based on Beck Cognitive Therapy, but also 31.2% (n = 56) offered supervision on Schema Therapy, 15.6% (n = 28 ) in Acceptance and Commitment Therapy, 15% (n = 27) in Mindfulness-Based Cognitive Therapy, 10.0% (n = 18) in Dialectical Behavior Therapy, 6.7% (n = 12) in Compassion Focused Therapy, 6.7% (n = 18) in Cognitive Processing Therapy, 5.0% (n = 9) in Cognitive Behavioral Sex Therapy, 3.4% (n = 6) in Rational Emotive Behavior Therapy, 1.2% (n = 2 in each) in Cognitive Hypnotherapy, in Behavioral Therapy, in Positive Psychology, in Emotionally Focused Therapy and 0.6% (n = 1) in Neuropsychology.

The questions were directed to the supervised performance even before the quarantine imposed by COVID-19. Most participants (60.6% or n = 109) reported that they offered supervision either face-to-face or online; 37.8% (n = 68) only face-to-face and 1.7% (n = 3) only online. In addition, 67.8% (n = 122) offered group and individual supervision, while 18.3% (n = 33) only individually and 13.9% (n = 25) only group supervision.

Regarding the duration of the supervised session of the participants who offered individual supervision, 83.8% (n = 139) lasted between 50 and 60 minutes, but could also be 30 minutes (6.7% or n = 12), 90 minutes (8.4% or n = 14) or 120 minutes (4.2% or n = 7). One participant pointed out that supervision lasted 15 minutes and had the function of answering questions, while another participant pointed out that there was no pre-established time, since individual supervision was an additional component to group supervision. Among the participants who offered group supervision, the majority indicated more than one hour of duration, with 41.0% (n = 64) doing it in 120 minutes, followed by 19.3% (n = 30) of supervisions lasting 240 minutes, 18.6% (n = 29) lasting 90 minutes, 7.7% (n = 12) 180 minutes, 1.3% (n = 2 in each) 200, 270 or 300 minutes and 0.6% (n = 1) 150 minutes. Some participants reported group supervision sessions lasting one hour or less: 4.4% (n = 7) lasting 60 minutes, 1.9% (n = 3) 50 minutes, and 1.3% (n = 2) 30 minutes.

The number of people in the same supervision group was diversified; the indications were: 16.4% (n = 24) from two to three individuals, 52.8% (n = 77) from four to six, 13.7% (n = 20) from seven to nine, 15.7% (n = 23) from 10 to 15 and 1.4% (n = 2) from 40 to 50. In addition, five participants highlighted that the number of people who made up the supervision group and the period of the undergraduate course in which supervision training was offered are aspects considered to influence the duration of group supervision.

Results on the frequency with which supervisions occurred varied differently for group and individual supervision. Most group supervisions (61.7% or n = 92) took place weekly followed by 26.8% (n = 40) biweekly frequency, 18.1% (n = 27) monthly, 8.1% (n = 12) one-off and 1.3% (n = 2) every two months. The frequency of individual supervision ranged from 43.9% (n = 72) biweekly, 42.1% (n = 69) weekly, 28.7% (n = 47) punctual and 11.0% (n = 18) monthly. There were also six exceptions that the individual supervision frequency could vary according to the therapist’s demand and/or the complexity of the case attended.

Participants indicated that their supervision was offered to therapists who served more than one intervention audience, but it was not clear whether supervision occurred separately. In the supervisions that focused on individual attendance, the intervention target audience was: 93.3% (n = 168) adults, 66.7% (n = 120) adolescents, 42.8% (n = 77) children 41.1% (n = 74) elderly. In the supervisions that focused on group assistance, the target audience of the intervention was: 27.9% (n = 50) adults, 15.0% (n = 27) adolescents, 10.0% (n = 18) children and 8.3% (n = 15) elderly. In addition, supervisions also took place with a focus on couple care (18.9% or n = 34), 12.2% (n = 22) on families and 4.4% (n = 8) involved large community groups. Participants offered supervision to more than one supervision niche, as follows: 56.1% (n = 101) for undergraduate students, 59.4% (n = 107) for Lato sensu postgraduate students, 10.6% (n = 19) for Stricto Sensu postgraduate students and professionals, 74.5% (n = 134) for psychologists and 11.1% (n = 20) for psychiatrist doctors.

There were 250 mentions of how changes in daily life due to the coronavirus impacted supervised practice, among which: 42.0% (n = 105) the format was exclusively turned online, 24.0% (n = 60) supervision was suspended, 20.8% (n = 52) the frequency and/or demand for supervision was reduced, 3.6% (n = 9) supervised practices became theoretical or case studies, 3.2% (n = 8) change in supervision demand, 1.2% (n = 3) decreased motivation and increased tiredness, 0.8% (n = 2) increased the search for supervision by professionals, 0.4% (n = 1) the impact on interpersonal interaction in supervision. There were also 4.0% (n = 10) of the participants who indicated that no change had occurred.

Discussion

The importance of knowing the different aspects of the clinical supervisor in this country permeates the construction of psychology itself; therefore, there is an interest of national (Campos, 1998; Gauy et al., 2015) and international (Reiser & Milne, 2016; Tyler et al., 2000) researchers in describing supervisor characteristics and their supervisory practices. Since there has been an increase in interest and dissemination of CBT in Brazil in recent years (Neufeld et al., 2018) and a lack of knowledge about CBT supervisors, it can be said that our survey allowed a more comprehensive look on this niche of professional activity. This understanding is based on the greater range of responses when compared to other studies that also sought to outline a profile of the clinical supervisor, especially when specifically addressing CBT.

Added to this, there was also a greater participation of some regions in this investigation, such as the Northeast, that had more responses than the Southern region, coming behind only after the Southeast region. According to Neufeld et al. (2018) there is a spread of Lato Sensu CBT postgraduate courses in these three regions, which may explain, at least partially, the greater reach of participants from the Northeast, beyond the South and Southeast regions. On the other hand, in the Central-West and North regions, there was a smaller reach of participants in this research, corresponding to the regions where there is a minor dissemination of CBT. Based on this geographic distribution, one can reflect on how to enhance the development of CBT professionals in the Midwest and North, especially of clinical supervisors, since they can promote local diffusion, as well as guarantee the quality of psychotherapeutic interventions.

When reflecting on the characteristics of the professionals who responded to the present study, the results indicate continuous female predominance in the profession, corroborating the studies by Campos (1998), Gauy et al. (2015) and by Reiser and Milne (2016), with the exception of the study by Tyler et al. (2000). It was found that all the results of the aforementioned Brazilian studies pointed in the same direction and correspond to the characterizations outlined by the CFP (Rechtman, 2014). Another characteristic found suggests that the respondents of the present study were more experienced professionals, both in relation to psychotherapeutic practice and supervised practice. It was found that some participants started their practice as a therapist and supervisor in other approaches before working from the perspective of CBT. This aspect raises the question of supervised practice, since the supervision models and pedagogical strategies used can vary according to different approaches, modifying the configuration of clinical training, the formulation of the process and the results expected (Barletta & Neufeld, 2020). In addition, even though Aaron Beck’s CBT is almost unanimous as a base theory among the participants of the present study, supervisions were not restricted to this view, but rather, they expanded to other theories within the cognitive-behavioral approach, which are congruent with each other and are based on evidence. This seems to be a characteristic of CBT professionals, who form a basis in Beck’s Cognitive Therapy, but are not limited to this foundation, adding knowledge of cognitive theories with a focus on cognitive restructuring, in constructivist, in integrative and contextual models (Beck & Alford, 2000).

After graduation, the professional can provide clinical care; however, the importance of the psychologist sharpening his knowledge and skills for intervention is encouraged, especially when it comes to a theoretical proposal based on evidence such as CBT (Neufeld et al., 2018). In this connection, it was interesting to see how the participants of the present study seem to follow in the same direction, with a strong academic background, including more than one academic degree for the majority. Few participants were just graduates suggesting that there is a concern with professional development. Another result that can corroborate this reasoning is the average time between graduation and the beginning of CBT care. It is believed that this period of time may be linked to the training period.

Even though there is no rule on the minimum time devoted to clinical practice in order to become a supervisor, it is understood that previous experience as a psychotherapist is crucial (Barletta & Neufeld, 2020). The average time between the beginning of clinical CBT care and the beginning of supervision, according to the finding of the present survey, corresponded to what the guidelines on CBT supervisor accreditation provided by international associations describe (Ferreira et al., 2021). In the work of these authors, the guidelines indicated the need for two to five years of experience as a certified therapist to apply for a supervisory job. It is noteworthy that in this survey it was not verified whether the participant had FBTC certification as a therapist.

The main reason listed by the participants of this investigation to become a supervisor was linked to teaching, whether in undergraduate and/or postgraduate classes Lato Sensu and Stricto Sensu. Since the supervised clinical internship is part of the psychologist’s training, that is, a necessary step in undergraduate courses (Barletta et al., 2011) and often offered in Lato Sensu postgraduate courses (Velasquez et al., 2015), it is recognized that this practice in the formal education of the clinical psychologist is the gateway to the beginning of the supervisor’s activity. It is also understood that some Stricto Sensu postgraduate courses also focus on the development of the therapist and, consequently, this can be an opportunity to train the clinical supervisor.

In Brazil, there are no formal guidelines for the accreditation of the CBT supervisor, but unlike in the 1990s, when there was no type of supervisor training in this country, during last year there were signs of an increase in the interest in the subject (Campos, 1998). For example, in 2020, the I International Symposium on Teaching and Supervision of CBT was held, as well as the creation of the Associação de Ensino e Supervisão Baseados em Evidências (Association for Evidence-Based Teaching and Supervision). This current movement reverberates what the international literature has discussed about the need for clinical training for therapists, as well as specific training for supervisors (Sokol & Fox, 2016). In the words of Milne and Reiser (2017, p. 2) “[…] this is a timely moment to attempt to tackle the long‐standing gaps and build a bridge for CBT supervision as a professional specialization”. In this connection, such initial actions may suggest an increase in the dynamics of adequate professional training, which is still considered a gap in Latin America, with the break in the reproduction cycle of the practice that is little contextualized and without cultural adaptations (Mendoza, 2017; Neufeld et al., 2021).

On the other hand, recognizing that this is an initial movement, the results of the present investigation suggest that there are still few CBT supervisors with specific training to perform this function. Among the answers that pointed to carrying out supervisor training activities, short-term activities, that is, with up to 60 hours, were the most mentioned. Ludgate (2016) points out that shorter courses are offered more frequently and tend to promote theoretical knowledge, but with few pedagogical resources that encourage experiential learning, considered to be the most important for the development of open or complex skills necessary for the supervisor and the therapist (Barletta & Neufeld, 2020; Sokol & Fox, 2016). The results of the present survey also showed that other activities recognized as necessary for the training of the supervisor were carried out, albeit by a smaller number of participants. More extensive courses as well as supervisors’ supervision courses have been suggested; this is a practice that has not yet been systematized in the global context, but is of vital importance for the honing of supervisory skills (Milne & Reiser, 2017).

A subject that also drew attention in this survey is the differences between individual and group supervision. Some differences were already expected, such as the longer duration of group supervision, also found in other studies (Tyler et al., 2000). An unexpected difference was the shorter duration in supervisions, both for group and for individual supervision. Although shorter-term supervisions had a very specific focus (for example, answering questions), a discussion arose about the supervisor’s ability to manage time, as well as to achieve the goals established in that supervised meeting, which, in turn, refers to the need for qualification and training for this activity (Barletta & Neufeld, 2020; Milne & Reiser, 2017; Sokol & Fox, 2016).

The duration of group supervision also depends on the number of supervisees, as indicated by some participants of this survey. Unexpectedly, the results showed that a few supervision groups included many supervisees, with 10 or more students, up to groups of 50 individuals. In the study by Machado and Barletta (2015) with supervisees of a Lato Sensu postgraduate course in CBT, one of the students’ complaints, both in the face-to-face and remote supervision modality, was the size of the group supervised. It is believed that in such large groups, the supervisor’s management to achieve the educational purpose of developing CBT competences should be even more necessary, since the difficulty increases and the resources, both pedagogical and material, may be scarcer.

The Cognitive-Behavioral Group Therapy literature has indicated that the use of group intervention is a strategy to reduce costs, but it is also an excellent opportunity for competence development (Bieling et al., 2008). The authors point out that the orientation and/or training groups should not exceed 15 participants, while the therapeutic groups can reach 12, both with the participation of two facilitators, namely, a therapist and a co-therapist. In clinical supervision, whose essential functions are formative, normative and restorative (Barletta & Neufeld, 2020), the objectives of the aforementioned groups are intersected, including: (a) the importance of developing competences from the training of the professional repertoire, (b) the guarantee of ethical, contextualized and health-protective interventions, and (c) care for the well-being of the supervisee, safeguarding the professional’s mental health. By establishing a parallel between the logic of intervention and clinical supervision, one can reflect on the number of participants facing the balance between cost and possibility of developing clinical skills, as well as the inclusion of a pair of facilitators, as a supervisor and co-supervisor in larger groups.

Although, at the present time, the use of virtual and remote communication tools is at its height, favoring access to potential survey participants, the collection was carried out at the time of quarantine due to the COVID-19 pandemic. It is considered that this context may have had a negative impact on the number of responses received, since emotional, family, social, labor and financial repercussions are observed, as well as the need to adapt to the new scenario, which can affect subjective well-being (Sampaio et al., 2021). It is noted that this observation was also found in the results of the present study, as one of the consequences perceived by the participants, including the low motivation and increase in the fatigue of the supervisees and in responses such as: “I have noticed that professionals also need personal care”. These results suggest the need to look at the professional as a person, whether the one who practices psychotherapeutics or the one who also acts as a clinical supervisor. Investment in professional self-care becomes essential in order to enhance the personal care of those who will help others, as well as increasing their own management and understanding of CBT, such as emotional regulation, cognitive restructuring and coping strategies in the face of the difficulties of everyday life (Bennet-Levy et al., 2015). In addition, the present survey also highlighted the change in supervision demands, especially due to the need to include mental health care issues in view of the pandemic to help patients, such as aspects of remote intervention to facilitate clinical care, corroborating with the findings by Sampaio et al. (2021).

It was expected that there would be indications from study participants about the need to develop supervisory skills associated to remote care. This information did not appear, perhaps because the issue was not addressed directly to the participants. Sampaio et al. (2021) pointed out the inability of mental health professionals to use technological resources for remote care when training is insufficient. It is believed that the same need for training echoes in supervised practice. The data from the present investigation showed that the quarantine imposed changes both in the offering form and in the activities provided in the supervision, as well as in the frequency and demand of this activity, leading to the suspension and/or more spacing in the supervised meetings. In this way, supervisors were forced to make adaptations without necessarily preparing or training. It is believed that the use of technology in educational processes, including supervision, is a way of no return, which indicates the need to include this subject in the supervisors’ training.

Final Considerations

The CBT has been increasingly studied and applied in Brazil; thus it becomes essential to identify the profile of who provides the therapist’s development of this approach. Knowing the characteristics of clinical supervisors in CBT, as well as their practices and training, can help the reflection on the need to strengthen support for this professional practice.

The results of the present investigation showed characteristics considered to be supervisors’ qualities, such as psychotherapeutic clinical experience, considered one of the supervisor’s requirements. A profile of experienced supervisors with a high academic background and more than one degree, in addition to training in the clinical area, was also identified. Such characteristics suggest that the CBT supervisors who agreed to participate in the present survey were concerned with continuous education and to increase their knowledge of psychotherapeutic clinical practice. Although this is an important consideration, it detects a limitation of the study, since it is considered that this research has only covered supervisors who have dedicated themselves to this career more intensely and, therefore, with continuous professional improvement behaviors. It is therefore questioned whether supervisors who do not have the possibility or culture of constant updating, or even are not allocated in academic spaces, were not motivated to respond or did not have access to this survey. Thus, there may be a portion of professionals who offer clinical supervision who were not accessed and it is therefore important to find new ways of screening such professionals to learn about their supervisory practices.

The results also indicated some difficulties and gaps in supervised practice. For example, the lack of specific training of the survey participants for supervised practice in CBT, which may be associated with the lack of perception of this need in Brazilian culture and the still initial movement of offering training for supervisors in this country. Other difficulties listed concern institutional issues where supervision takes place and the pandemic moment. It is understood that the institution’s rules can impact the supervised process such as the number of students per supervision group, while quarantine imposed mandatory changes in the supervision activity.

Since there is no record, registry or accreditation of clinical supervisors in Brazil, we do not know how many professionals are CBT supervisors in this country. Since no other study with a similar objective had the same range of responses, it is understood that the present survey is of great value, since it is the first to outline the profile of CBT supervisors in Brazil. It is understood that this study can be considered as an important expansion for this professional activity, even though it is not possible to generalize the results of this investigation to the population of Brazilian supervisors.

André Luiz Monezi de Andrade
Editor

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Support

• Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Scholarship (Process: 307703/2020-7)

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  How to cite this article: Barletta, J. B., Araújo, R. M., & Neufeld, C. B. (2023). Survey of cognitive behavioral therapy clinical supervisors profile in Brazil. Estudos de Psicologia (Campinas), 40, e210072. https://doi.org/10.1590/1982-0275202340e210072en

Publication Dates

• Publication in this collection
  26 June 2023
• Date of issue
  2023

History

• Received
  27 Apr 2021
• Reviewed
  04 Jan 2022
• Accepted
  04 Aug 2022