A growing number of veterans are accessing treatment for posttraumatic stress disorder (PTSD) through the Veterans Health Administration (VHA) and the U.S. Department of Veterans Affairs (VA). In 2015, over 568,000 veterans received treatment for PTSD from the VHA system, a nearly 14% increase from 2011 (VA Office of Public Affairs and Media Relations, 2016). Increased interest in such services has occurred alongside the VHA offering diverse trauma-focused didactic and training opportunities (Simiola, Smothers, Thompson, & Cook, 2018). The VA has also drafted, revised, and disseminated clinical practice guidelines for VHA providers to follow (Department of Veterans Affairs/Department of Defense, 2017) and collaborates with PTSD researchers to develop consultation programs designed to promote competency with such guidelines (Karlin et al., 2010).
In addition to didactics, clinical practice guidelines, and consultation programs, effective trauma-informed supervision is another core element of VHA PTSD training programs. Trauma-informed supervision includes supervisory processes that increase knowledge and improve skills of supervisees providing trauma-informed services (Berger & Quiros, 2016). Providers delivering PTSD treatment often endorse high levels of exhaustion, burnout, compassion fatigue, and vicarious traumatization (Garcia et al., 2016; Voss Horrell, Holohan, Didion, & Vance, 2011), and trainees may be especially susceptible to developing these problems. Effective trauma-informed supervision could help minimize these burdens, and trainee perspectives can offer insight into how trauma-informed supervision could be impactful. This article describes anecdotal perspectives from two clinical psychology trainees on three beneficial elements of trauma-informed supervision received via an outpatient VHA PTSD Clinical Team.
Fostering Self-Awareness
We believe that effective trauma-informed supervision should promote trainee self-awareness of emotions, biases, identities, and beliefs that arise when delivering trauma-focused psychotherapy. Research has demonstrated that therapists’ unchecked emotional expressions can increase resistance to treatment (Westra, Aviram, Connors, Kertes, & Ahmed, 2012), and that patients can sense negative feelings of their therapist (Wolf, Goldfried, & Muran, 2017). Further, awareness of cultural factors that either facilitate or restrict interpersonal connections with patients could enable trainees to identify sources of compassion fatigue and other contributors to negative patient outcomes. Therapist self-awareness is essential for competent delivery of trauma-focused psychotherapy, especially given the complex presentations of veterans diagnosed with PTSD.
Trainees delivering trauma-focused clinical services in a VHA setting often possess identities and belief systems that are different from those of the veterans they are treating. A trainee with no military history could be encouraged to explore whether this aspect of their identity might impact treatment progress with a veteran, someone whose cultural beliefs may differ given experiences like boot camp, deployments, and other aspects of military experience. The Guidelines for Clinical Supervision in Health Service Psychology (American Psychological Association, 2014) state that supervisors should seek to establish a working relationship with supervisees that possesses a caring dynamic and reinforces honesty, transparency, and professionalism in the supervisory relationship. Thus, consistent with these guidelines, effective trauma-informed supervision in a VHA setting could encourage exploration of trainee/veteran differences while discouraging avoidance of trainees’ responses to veterans’ disclosures. Such discussions could in turn foster self-awareness, facilitate self-discovery of reactions to sensitive topics, and improve understanding of individual thresholds for exhaustion and vicarious traumatization. Supervisors of trainees who treat veterans diagnosed with PTSD are therefore encouraged to assess for, propose coping strategies for, and make referrals for assistance for trainees’ negative emotional reactions, including helplessness/powerlessness in the provider/veteran dynamic (Berger & Quiros, 2014).
Evidence-Based Assessment and Treatment
We also found discussion of the implementation of evidence-based assessments and treatments to be an impactful element of trauma-informed supervision. This component of the supervisory relationship allowed for rich discussions of case conceptualizations and collaborative determination of appropriate treatments given symptom severity and presentation. Effective supervisory recommendations regarding evidence-based assessments included the following:
- Incorporate psychometrically sound self-report measures and interviews, including the PTSD Checklist for DSM-5 (Weathers et al., 2013), the Clinician-Administered PTSD Scale for DSM-5 (Weathers et al., 2018), and other measures to screen for comorbid psychiatric and substance use issues, as veterans with PTSD often present with co-occurring mental health disorders (Brown & Wolfe, 1994; Ginzburg, Ein-Dor, & Solomon, 2010).
- Utilize automated, electronic questionnaire administration platforms if available, like the VHA’s eScreening Program (Pittman et al., 2017). This program allows veterans’ scores on self-report measures to be stored electronically and directly exported into their electronic medical records. Programs like eScreening enable discussion of a veteran’s response to trauma-focused treatment and identification of barriers to treatment effectiveness (e.g., avoidance, poor attendance).
- Record behavioral observations and qualitative perspectives provided by patients during clinical encounters and integrate such data with self-report measures to guide treatment decisions and case conceptualizations. We found supervisors’ use of the “predisposing, precipitating, perpetuating” model of the development of PTSD (McFarlane, 1989) to be a useful method of case conceptualization when integrated into supervision meetings.
Our perspectives on the benefits of evidence-based therapy-oriented supervision consistently corroborated recommendations found in the VA’s Clinical Practice Guideline for PTSD (Department of Veterans Affairs & Department of Defense, 2017):
- Supervisors should advise trainees to educate veterans about effective PTSD treatments, share resources from the VHA’s National Center for PTSD, and engage in shared decision-making when selecting an initial course of treatment.
- Supervisors should encourage trainees to implement manualized, individual, trauma-focused psychotherapies like Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017) and Prolonged Exposure Therapy (Foa, Hembree, & Rothbaum, 2007), whose theoretical rationales include cognitive restructuring and exposure components, respectively.
- Supervisors should avoid excluding veterans from PTSD treatment if they have a co-occurring substance use/mental health condition, as engagement in trauma-focused treatment may not exacerbate co-occurring problems (e.g., Norman et al., 2019).
Socratic Method
A final aspect of trauma-informed supervision that we found to be effective was the use of the Socratic method during supervision meetings. Socratic dialogue is an integral component of cognitive therapies like CPT that facilitates self-realization of distorted cognitions and beliefs. The Socratic method also aligns with the developmental approach to supervision, which defines progressive stages of supervisee development from novice to expert (Stoltenberg & Delworth, 1987), and argues that supervisors should not provide supervision that is above the skill level of the trainee. Because trainees delivering CPT are learning skills in Socratic dialogue, the use of the Socratic method in supervision has two direct benefits: direct observation of the Socratic dialogue by the trainee and self-initiated discovery of burnout, compassion fatigue, and other common trauma-focused therapist reactions. Modeling of skills in supervision predicts skill implementation in therapy sessions (Bearman et al., 2013), lending evidence to the benefits of the use of Socratic questioning in supervision. That said, veterans with PTSD are often at high risk for suicide (Jakupcak et al., 2009), so blending Socratic dialogue with more directive supervision may be appropriate in cases when patients are at high risk of self-harm.
Conclusions
Exploring trainees’ emotional reactions, encouraging measurement-based and evidence-based care, and incorporating Socratic questions into the supervisory relationship all reflect trauma-informed supervision practices that could enable trainees to become effective trauma-focused psychotherapists. These practices promote development of several profession-wide competencies, including professional values, assessment, intervention, communication, and consultation, that are essential for clinical practice. Trauma-informed supervisors are encouraged to use open-ended questions and a trainee-centered orientation to supervision, as doing so enables more comprehensive conceptualization of PTSD presentations and ensures that trainee psychotherapists are engaging in adequate self-care. Trainees, in turn, are encouraged to engage in a case formulation process that jointly relies on validated, evidence-based assessments and qualitative observations and perspectives to ensure quality psychological care.
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Author Bios
John Correa, Ph.D. is a postdoctoral fellow in the Interprofessional Advanced Fellowship in Addiction Treatment at the VA San Diego Healthcare System (VASDHS). He earned his Ph.D. in clinical psychology from the University of South Florida and completed a predoctoral internship in the VASDHS/UCSD Psychology Internship Training Program. Dr. Correa’s clinical and research interests focus on the intersection between behavioral medicine and addiction psychology, with an emphasis on studying nicotine and tobacco use. Dr. Correa maintains interest in developing, evaluating, and disseminating evidence-based smoking cessation interventions that target at-risk populations, particularly veterans with co-occurring mental health or substance use disorders.
Jessica Tripp, Ph.D. is a postdoctoral fellow in the Interprofessional Advanced Fellowship in Addiction Treatment at the VA San Diego Healthcare System (VASDHS). She earned her doctorate in clinical psychology from the University of Memphis and completed her predoctoral internship in the VASDHS/UCSD Psychology Internship Training Program. Her graduate and postdoctoral research and clinical training has focused on treating individuals with posttraumatic stress disorder and co-occurring substance use disorders. Dr. Tripp’s research has examined mediators of the relationship between PTSD and substance use/suicidality, including trauma-related guilt and emotion dysregulation, as well as the construct of moral injury.
