Providing Effective Supervision in Clinical Neuropsychology

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Providing effective supervision in

clinical neuropsychology
a b
Kirk J. Stucky Psy.D. ABPP (Rp, Cn) , Shane Bush & Jacobus
c
Donders
a
Hurley Medical Center, Flint, MI
b
VA New York Harbor Healthcare System, St. Albans, NY
c
Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, USA
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PROVIDING EFFECTIVE SUPERVISION IN CLINICAL

NEUROPSYCHOLOGY
Kirk J. Stucky1, Shane Bush2, and Jacobus Donders3

1
Hurley Medical Center, Flint, MI, 2VA New York Harbor Healthcare
System, St. Albans, NY, and 3Mary Free Bed Rehabilitation Hospital,
Grand Rapids, MI, USA
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A specialty like clinical neuropsychology is shaped by its selection of trainees, educational

standards, expected competencies, and the structure of its training programs. The
development of individual competency in this specialty is dependent to a considerable degree
on the provision of competent supervision to its trainees. In clinical neuropsychology, as in
other areas of professional health-service psychology, supervision is the most frequently
used method for teaching a variety of skills, including assessment, report writing,
differential diagnosis, and treatment. Although much has been written about the provision
of quality supervision in clinical and counseling psychology, very little published guidance is
available regarding the teaching and provision of supervision in clinical neuropsychology.
The primary focus of this article is to provide a framework and guidance for the
development of suggested competency standards for training of neuropsychological
supervisors, particularly at the residency level. In this paper we outline important
components of supervision for neuropsychology trainees and suggest ways in which
clinicians can prepare for supervisory roles. Similar to Falender and Shafranske (2004), we
propose a competency-based approach to supervision that advocates for a science-informed,
formalized, and objective process that clearly delineates the competencies required for good
supervisory practice. As much as possible, supervisory competencies are related to
foundational and functional competencies in professional psychology, as well as recent
legislative initiatives mandating training in supervision. It is our hope that this article will
foster further discussion regarding this complex topic, and eventually enhance training in
clinical neuropsychology.
Keywords: Supervision; Neuropsychology training; Competency standards; Supervisor competence.
INTRODUCTION
A specialty is shaped by its selection of trainees, educational standards,
expected competencies, and the structure of its training programs (Patterson &
Hanson, 1995; Stiers & Stucky, 2008). The value of a specialty is dependent on the
provision of competent supervision to its trainees. In clinical neuropsychology, as
in other areas of professional health-service psychology (Falender & Shafranske,
2004), supervision is the most frequently used method for teaching a variety of
Address correspondence to: Kirk Stucky Psy.D. ABPP (Rp, Cn), Program Director, Postdoctoral
Fellowship in Clinical Health Psychology, Chair, Department of Psychology, Hurley Medical Center, 1
Hurley Plaza, Flint, MI 48503, USA. E-mail: Kstucky2@hurleymc.com
Accepted for publication: April 30, 2010.
ß 2010 Psychology Press, an imprint of the Taylor & Francis group, an Informa business
738 KIRK J. STUCKY ET AL.
skills, including assessment, report writing, differential diagnosis, and treatment.

Clinical supervision has been described as a central component of training in
psychology (Romans, Boswell, Carlozzi, & Ferguson, 1995) and as ‘‘the critical
teaching method’’ (Falender & Safranske, 2007; Holloway, 1992, p. 177). Although
much has been written about the provision of quality supervision in clinical and
counseling psychology, very little published guidance is available regarding the
teaching and provision of supervision in clinical neuropsychology.
The primary focus of this article is to provide a framework and guidance for
the development of suggested competency standards for training of neuropsycho-
logical supervisors, particularly at the residency level. In this article we outline
important components of supervision for neuropsychology trainees and suggest
ways in which clinicians can prepare for supervisory roles. Similar to Falender and
Shafranske (2004), we propose a competency-based approach to supervision that
advocates for a science-informed, formalized, and objective process that clearly

delineates the competencies required for good supervisory practice. As much as
possible, supervisory competencies are related to foundational and functional
competencies in professional psychology (Rodolfa et al., 2005) as well as recent
legislative initiatives mandating training in supervision. Although neuropsychology
supervision in the context of related or overlapping practices, such as psychophar-
macology and neuroimaging, were not explicitly addressed in this article, many of
the concepts described and recommendations offered also apply in those contexts.
It is our hope that this article will foster further discussion regarding this complex
topic and eventually enhance training in clinical neuropsychology.
BACKGROUND OF PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL

SUPERVISION
Among the various specialties in psychology, clinical neuropsychology has
long been a front runner in developing organized training standards and formal
guidelines. The majority of doctoral training programs across the country provide
exposure to neuropsychological assessment prior to the predoctoral internship, and
many internships offer a neuropsychological assessment component. Postdoctoral
residency programs that are members of the Association of Postdoctoral Programs
in Clinical Neuropsychology (APPCN) require trainees to go through a standard-
ized curriculum, written examination, and oral examination (Boake, Yeates, &
Donders, 2002). Despite this structured process, we are unaware of any formal
guidelines that specifically detail the provision of advanced supervision in
neuropsychology. Supervisors have typically learned how to supervise through
on-the-job training, with little supervision training or ‘‘supervision of supervision.’’
Peak, Nussbaum, and Tindell (2002) reported that fewer than 20% of
supervisors in clinical psychology had received any formal training in supervision.
However, professional competency is an ethical requirement (American
Psychological Association [APA], 2002, Ethical Standard, 2.01, Boundaries of
Competence), and recent guidelines published by the APA indicate that clinical
supervision is now considered a specific competency (APA, 2006). In response to
this APA statement, several publications about supervision have recently emerged
(e.g., Campbell, 2006; Falender & Shafranske, 2007). At an organizational level,
EFFECTIVE SUPERVISION IN CLINICAL NEUROPSYCHOLOGY 739
psychology has increased its focus on competencies, training standards, site reviews,
and postdoctoral subspecialties (France et al., 2008). Additionally, increased public
recognition that psychological services can improve patient care and outcomes has
led to a need for increased scrutiny regarding appropriate training standards,
evidence-based practice, and supervision. In fact, a limited number of studies have
attempted to determine if clinical supervision actually improves patient outcomes,
but this has proven to be a complicated endeavor. In a review Freitas (2002) noted
that studies of supervision effectiveness are closely linked to psychotherapy outcome
research, and thus a clear understanding of the effects of specific types of
supervision on patient outcomes remains elusive.
The Accreditation Council for Graduate Medical Education (ACGME) has
monitored and surveyed physician residency programs across the country since
19811. ‘‘In academic year 2008–2009, there were 8,734 ACGME-accredited
residency programs in 130 specialties and subspecialties. The number of active

full-time and part-time residents for academic year 2008–2009 was 109,482’’
(ACGME, 2010). In contrast, there are currently only 24 APA-accredited
psychology residency training programs in the United States, 13 of which are in
clinical neuropsychology (APA, 2010). Thus, relative to physician residencies,
accredited specialty training in psychology has lagged far behind.
The slow development of training and supervision standards in psychology
specialties has been due to multiple factors, including a relatively low number of
residencies, lack of financial or regulatory incentives to go through the accreditation
process, and the cost of pursuing and maintaining accreditation. Physician
residencies must be accredited by ACGME in order to receive government
(e.g., Centers for Medicare and Medicaid Services [CMS]) funding. Conversely, the
majority of psychology residencies are not funded by CMS. In fact, obtaining APA
accreditation has only recently allowed qualified hospital-based psychology
residencies to apply for funding (Stucky, Buterakos, Crystal, & Hanks, 2008).
However, because the majority of neuropsychology residencies are not primarily
hospital based, they do not qualify for CMS funding. These various factors
contribute to the fact that, unlike physician residencies, psychology residencies tend
to have more individualized models with a fair amount of variability between
programs in supervisory models. Greater availability of federal funds and a direct
linking of financial incentives to program accreditation may help increase the
number of accredited neuropsychology residencies, and thus increase attention to
neuropsychology training and supervisory models.
Although there has recently been increased interest in competency-based
approaches to supervision, little has been written regarding the process of training
or preparing clinicians to supervise trainees in neuropsychology. A PubMed search
revealed no publications that specifically address the training of neuropsychology
supervisors, although attention to the increased need for training standards appears
to be growing (Roper, 2009). It should also be noted that recent outlines and
suggestions provided with regard to ‘‘competency benchmarks’’ in professional
1
The academic medical community supported the development of the ACGME as an independent
accrediting organization. Its forerunner was the Liaison Committee for Graduate Medical Education,
established in 1972 (www.mcw.edu/display/docid2478.htm).
psychology could certainly be used as a base to guide further understanding

and assessment of supervisor training and competence in neuropsychology
(Fouad et al., 2009). In the future we expect that there will be further development
of specific training models that are unique to individual specialties, which eventually
lead to improvement in current accreditation standards for specialty programs.
PURPOSE OF SUPERVISION
The goals of supervision are to promote (a) the development of neuropsy-
chological knowledge and skills, (b) critical thinking and decision making, (c) high-
quality clinical care, (d) investment in career-long learning, (e) meaningful patient
outcomes, and (f) development and fostering of essential attitudes for ethical
practice (e.g., integrity, interpersonal skills, etc.). To accomplish these interrelated
goals, supervisors attend both to trainees’ and patients’ needs on multiple levels. In
its ideal form effective supervision is a transformative process that allows trainees to
overcome gaps in knowledge, limited experience, feelings of inadequacy, and or
limited self-confidence. Therefore the provision of clinical supervision involves a
close mentoring relationship that provides training on multiple levels. At a basic
level, supervisors teach and fine-tune technical skills, help trainees expand and apply
knowledge, and develop critical thinking abilities. At more advanced levels, the
relationship encourages personal and professional identity development, models
professional behavior, provides heuristics for complex decision making, introduces
systems-level thinking, and provides advanced training in the application of various
skills in multiple patient and non-patient care venues.
Competent supervision also includes the mutual consideration of complex
ethical issues, diversity issues, barriers to the efficient and appropriate delivery of
patient care, educational initiatives, and professional obligations. Considering the
degree of complexity and intensity of supervision, it is not surprising that both
trainees and supervisors can experience disappointment in the supervisory
relationship if the purpose, structure, expectations, and goals are not clearly
delineated and adhered to.
IMPORTANCE OF SUPERVISION TRAINING

The provision of supervision to trainees, junior colleagues, and other
professionals is often a job requirement for psychologists (Sutter, McPherson, &
Geeseman, 2002). Supervisors, whether good or bad, can have a profound impact
on the development of a trainee’s professional self-esteem, competence, identity,
values, and biases. Despite the importance of the supervisory role, upon licensure
many psychologists are immediately placed in some type of supervisory role, or they
eventually will be called on to serve as a supervisor, often without formal
preparation or oversight (Barnett, Erickson Cornish, Goodyear, & Lichtenberg,
2007). In many cases, this premature assignment to supervisory roles appears to be
related to a false assumption that patient care and supervisory skills are so closely
related that they will transfer without the need for additional training.
Just as many high-caliber athletes do not turn out to be very good coaches,
and some excellent coaches were never great players, good supervisors have a skill
set that effective clinicians may or may not possess. That is, good clinicians are not
always competent educators or supervisors. Thus supervisors need to be adequately
trained before they engage in this critically important professional activity.
Regarding supervisory competency, reasonable questions to ask are ‘‘What
training do current supervising neuropsychologists have which makes them
competent supervisors, and how did they obtain or develop the competence?’’
Few psychology supervisors go through specific or formal training to develop their
supervisory skills (Majcher & Daniluk, 2009; Scott, Ingram, Vitanza, & Smith,
2000). Furthermore, it is the extremely rare neuropsychology conference that offers
a continuing education workshop on neuropsychological supervision.
Reports of negative supervisory experiences highlight the need for a
credentialing process, ethical guidelines, and specific training standards for those
who plan to provide clinical supervision (Ellis, 2001). Clinical supervision is now
recommended as a core competency area for all psychologists (APA, 2006).

Additionally, the need to include specific training in supervision within graduate
school curricula has been proposed (Falender & Shafranske, 2004). This proposition
carries with it a host of challenges, not the least of which is attempting to train
trainees in the provision of supervision while they are developing basic foundational
and functional competencies.
MODELS OF CLINICAL SUPERVISION

The process of learning to supervise goes hand in hand with the process of
providing clinical supervision to trainees or more junior trainees.2 The use of a
sound model for providing clinical supervision of others helps clinicians become
better supervisors. Thus models of supervision may be applied both to the clinical
supervision of others and to the development of supervisory skills.
Models help clinicians to conceptualize and structure their approach to the
supervision of trainees. A variety of models have been proposed for supervision in
clinical psychological and counseling contexts, with the goal of promoting effective
practice (Falender & Shafranske, 2004; Kaufman & Kaufman, 2006). Three
common general approaches to clinical psychology supervision focus on (a)
administrative issues, (b) clinical issues, and (c) supervisee psychotherapy. The goals
of clinical supervision are to advance professional and technical competence,
professional identity, personal development, and the interactions of professional
and personal development. See Table 1 for a sample of supervisory models.
Although a detailed review of the various models of supervision is beyond the
scope of this article, our experience suggests that many neuropsychologist
supervisors, intentionally or intuitively, incorporate aspects of multiple models.
The model that we propose is based on developmental and process-based
approaches. In neuropsychology, compared to some other psychological specialties,
there is less emphasis on psychotherapy-based or supervisee-as-patient models.
2
The term ‘‘junior trainees’’ is used to emphasize that the process of learning to supervise is optimally
begun when one is a trainee.
Table 1. Models of supervision in

professional psychology
Psychotherapy-based
Developmental
Process-based approaches
Discrimination model
Systems approach
Parallel process
Isomorphism
Interactional
Relationship
Interpersonal process recall
Expert
Supervisee-as-patient
Comprehensive/integrative
One-size-fits-all
No-model
Based on information provided

by Kaufman and Kaufman
(2006).
A PROPOSED MODEL FOR NEUROPSYCHOLOGICAL SUPERVISION

Neuropsychologists practice and provide supervision in a wide range of clinical
and training contexts. As a result, it is unlikely that one model of supervision will
meet the needs of all neuropsychologists. Nevertheless, the following model is
intended to capture core general features of neuropsychological supervision that can
be applied in a variety of contexts. Supervisors are encouraged to adopt aspects of
the model that meet their needs and supplement them with other supervisory
principles as necessary to best meet the needs of their trainees. The proposed model
is an individually tailored, process based, developmental approach. Supervisor
foundational and functional competencies are emphasized.
Individually tailored
Despite similarities in coursework and prior clinical activities, trainees,
including supervisors in training, have unique strengths and weaknesses, interests,
personality traits, and personal lives, all of which can affect the supervisory
relationship. Good supervisors provide foundational experiences for all trainees
while attending to each trainee’s individual characteristics, applying flexibility to the
training and supervisory experiences to maximize the experience for the trainee,
while meeting the needs of the institution and patients.
Process-based approach
Supervisors assume multiple roles, including teacher, consultant, and admin-
istrator. Perhaps most importantly, supervisors model the activities, demeanor, and
interactions of a professional neuropsychologist. Time in individual supervision is
dedicated to detailed discussion of these complex interpersonal exchanges in the
interest of enhancing the trainee’s professional development and understanding

of ‘‘real-world’’ practice.
Developmental approach
Supervisors engage supervisees at their level of professional development,
assigning responsibilities that are consistent with the established and emerging
competencies. Supervisors provide sufficient freedom and graded responsibility for
trainees to share responsibility for decision making in patient care under adequate
faculty supervision. As the knowledge and clinical skills of the supervisee develop,
supervisors reinforce the developing competencies and provide more challenging
and complex tasks and responsibilities. Thus supervisors seek to steadily increase
trainee independence and ability to manage more complex cases in a stepwise
fashion. Supervisors also help supervisees think about their emerging professional
identity and their professional life after training.
General supervisor expectations

Neuropsychology supervisors are expected to provide an appropriate level
of clinical supervision required of trainees during clinically relevant educational
activities. Supervisors strive to formally establish policies and procedures for their
programs to enhance and clarify training. The following general guidelines are
suggested. Please note that these guidelines are considered an important but not
exclusionary set of expectancies.
Clinical responsibilities are conducted in a carefully supervised and graduated
manner, allowing trainees to assume progressively increasing responsibility in
accordance with their level of education, ability, and experience. Supervision
includes timely and appropriate feedback, and trainees are provided with rapid,
reliable systems for communicating with the supervisor.
Supervision of trainees supports the program’s overall educational curriculum,
including didactics, program goals and objectives, etcetera.
All trainee activities are supervised by faculty members who have overall
responsibility for the patient care rendered and the ultimate authority for final
decision making. The particular trainee–supervisor relationship and the
structure of supervision may vary according to the clinical context.
Faculty schedules are structured to provide trainees with appropriate super-
vision and consultation. Faculty schedules are structured to ensure that
support and supervision are readily and consistently available.
The program director and the faculty determine the level of responsibility
accorded to each trainee. If trainee remediation plans are required, the trainee
is informed with regard to due process and their rights during the provisional
status or monitoring period.
Supervisors demonstrate concern for each trainee’s wellbeing and professional
development. Supervisors are trained to recognize the signs of fatigue, excessive
workload, inexperience, and substandard patient care. They seek to prevent
and counteract the potential negative effects of these variables. Supervisors
monitor trainees for personal adjustment difficulties and or counterproductive

emotional reactions to patients that may be detrimental to trainee performance
and wellbeing.
Assignments in clinical settings recognize that faculty and trainees collectively
have responsibility for the safety and welfare of patients. Supervisors educate
trainees regarding the need to avoid dual relationships with patients and
colleagues. They make every effort to ensure that patient care conforms with all
ethical and institutional standards.
SUPERVISOR QUALITIES AND COMPETENCIES

Effective supervisors have similar qualities (Barnett et al., 2007; Kennard,
Stewart, & Gluck, 1987; Majcher & Daniluk, 2009; Martino, 2001; Watkins, 1995).
Such qualities optimize supervisory experiences for supervising clinicians and their
trainees (see Table 2).
As part of their responsibility to promote patient care, supervisors serve as
gatekeepers who can dissuade clinicians from practice if they are not in the right
field or perhaps can modify the trainee’s educational program and supervision to
increase the chances of helping them work through or resolve glaring weaknesses.
Supervisors have an obligation to maintain program standards, quality patient care,
and integrity. Despite appropriate support and training some trainees may not
possess or be able to develop the requisite competencies and essential attitudes for
professional practice. Although it may not be a common occurrence, in these
instances supervisors take appropriate steps to ensure that trainees are not simply
passed through the system, especially when there are concerns about trainee
competence or patient safety.
Similarly, good supervisors are sensitive to dissatisfaction in trainees and,
recognizing that the power differential may prevent some trainees from initiating
discussion of their concerns, actively elicit feedback from trainees about their
experiences of the residency and supervision. When inviting such feedback,
supervisors are open to, and accepting of, negative impressions, and they use the
information for positive change or discussion of the trainee’s expectations.
Competence is generally acquired through a defined sequence of education
and training involving didactic and experiential participation (American
Table 2. Qualities of effective supervisors
Interest in training
Available
Flexible
Respects trainees
Supportive – not overly critical or punitive
Cultivates supervisory relationship – trusting, collaborative, honest
Cultivates an atmosphere of intellectual, clinical, and professional curiosity
Emotional investment in the trainee’s professional development
Compiled from Barnett et al., 2007; Kennard et al., 1987; Majcher &
Daniluk, 2009; Martino, 2001; Watkins, 1995.
Psychological Association, 2006). Critical thinking and analysis, judgment, assess-

ment skills, and decision-making ability are fundamental components of profes-
sional competence (Roberts, Borden, & Christiansen, 2005). Competent supervisors
have two more specific types of competence (Barnett, 2000). First, supervisors have
competence in the area they are supervising. Second, supervisors have competence
in supervision itself. Thus clinical and supervisory activities require overlapping but
distinct skills sets; effective clinicians are not necessarily effective supervisors.
The process of acquiring supervisory competence is developmental, incre-
mental, and context dependent. The preparation of trainees for supervisory roles
starts with their first supervisory experience and continues throughout, and
hopefully beyond, their formal training. Trainees are often unaware that their early
training experiences establish a foundation and perspective regarding the role of
supervision. Quality training programs provide trainees with progressive experi-
ences in supervisory roles at various levels of training, which gradually helps them
develop a measure of confidence and competence in the training, education, and
supervision of junior colleagues. New supervisors are expected to have different
training and support needs than those with more experience. New supervisors who
only ‘‘learn by doing’’ are more likely than those with more formal training to
unintentionally create negative training experiences for their trainees. In addition to
these general supervisor competencies, more specific foundational and functional
supervisor competencies are also necessary (Rodolfa et al., 2005) (see Table 3).
FOUNDATIONAL SUPERVISOR COMPETENCIES

Reflective practice/self-assessment
Neuropsychology supervisors develop an advanced level of metacompetence;
that is, an ability to recognize what they do not know or need to know. They model
this metacompetence to trainees with regard to how and what they are doing to
maintain their clinical competence (e.g., conducting ongoing research, reading
Table 3. Foundational and functional competencies

for psychology supervisors
(1) Foundational
(a) Reflective practice – self-assessment
(b) Scientific knowledge and methods
(c) Relationships
(d) Individual and cultural diversity
(e) Ethical and legal Standards – policy issues
(f) Interdisciplinary systems
(2) Functional
(a) Assessment-diagnosis-case conceptualization
(b) Intervention
(c) Consultation
d) Research evaluation
(e) Supervision training
(f) Management – administration
Based on information provided by Rodolfa et al.

(2005) and Fouad et al. (2009).
scientific journals, attending professional conferences). Observing a supervisor

struggle with or discuss challenging clinical or professional issues helps trainees
understand that learning is a career-long process and that professional collaboration
and humility are essential components to ongoing ethical and evidence-based
practice. Effective and ethical supervisors are committed to training and actively
‘‘self-evaluate’’ or discuss supervisory issues regularly in order to improve their own
supervision skills.
Scientific knowledge and methods

Competent neuropsychology supervisors are knowledgeable about the
recommended general training standards for neuropsychology (Association of
Postdoctoral Programs in Clinical Neuropsychology, 1997; Hannay et al., 1998).
They make every effort to follow the guidelines and use them to improve their
program and the overall provision of supervision. Supervision is accomplished in
a multimodal fashion including but not limited to informal ‘‘elbow-to-elbow’’
discussions during clinical activities, formal individual meetings, group supervision,
case conferences, assignment and review of reading materials, didactic training, and
journal clubs. Scientific principles and findings are actively integrated into evidence-
based practice and training. Supervisors also strive to obtain teaching services from
other internal and external faculty to provide trainees with broad exposure to the
field and complimentary fields (e.g., neurology, psychiatry, physical medicine, and
rehabilitation).
Relationships
Supervisors help trainees learn and practice strategies to effectively work and
communicate with others. When possible, neuropsychology supervisors encourage
parallel training with physician residents and other health care staff through patient
care rounds, diverse educational opportunities in different departments or teaching
services, grand rounds, and observation of lectures provided by various profes-
sionals working within the medical setting. Supervisors recognize that the trainee
needs to develop an understanding and healthy respect for other clinicians in order
to be an effective member of the health care team. Ideally, in clinical rounds and
other hospital-based experiences, neuropsychologists and physicians teach each
other, for the benefit of each other and patient care (Stucky, Chew, & McIntosh,
2008). Furthermore, exposure to parallel training helps neuropsychology trainees
understand that they have unique skills and can provide important services and
perspectives that other disciplines may not have.
Individual and cultural diversity

Supervisors also help trainees become more aware of cultural, ethnic, and
other diversity-related issues that can impact neuropsychological assessment and
treatment services. Supervisors are also aware of their own biases and help trainees
increase their awareness of, and work through, their potential biases, which might
act as barriers to quality patient care.
Ethical and legal considerations

Neuropsychology supervisors have an understanding of common ethical
dilemmas confronted in their practice contexts, have a model for addressing novel
ethical challenges that emerge (e.g., Bush, 2007), and encourage supervisees to
discuss ethical issues.
Ethical supervisors do not provide supervision in areas in which they do not
have specific training or competence (APPCN, 1997, Principle 2.1, Accountability).
Ethical neuropsychologists delegate aspects of the supervisory experience to other
clinicians who are better prepared to do so.
Neuropsychology supervisors have an understanding of the Rehabilitation
Act 1973 and the Americans with Disabilities act (ADA) of 1990 (P.L. 101-336),
which directly promoted normalization, empowerment, and maximal community
integration of individuals with disabilities. A reasonable degree of advocacy for

patients is an expected area of competence, although care must be taken to ensure
that excessive or otherwise inappropriate advocacy is avoided. Neuropsychology
supervisors understand and convey to trainees how evaluations and their results can
impact quality of life, access to services, treatment, rehabilitation, and overall
function in the home and community.
Interdisciplinary systems
Supervisors have a detailed familiarity with the clinical setting, including its
culture and the interplay between multiple disciplines. This understanding includes
knowledge of the similarities and differences between the training models of other
disciplines. Supervisors help trainees understand and experience these differences in
the interest of developing, camaraderie, mutual respect, teamwork, and the ability
to work within the system to maximize the effectiveness of patient care services.
Good supervision requires that the trainees learn not only how to report results
from their assessment but also how to communicate practical recommendations to
the treatment team, family, and other interested parties.
The supervisor models respectful and appropriate professional behavior with
all hospital staff. Although professional competition and ‘‘turf battles’’ occur in
many clinical training settings, a competent supervisor helps trainees understand
such conflicts at a systems level and makes every effort to avoid taking them
personally. In situations in which teamwork is not optimal or has been
compromised, supervisors model professional problem solving, using their skills
as psychologists to effect positive change as opposed to avoidance or other
counterproductive responses.
FUNCTIONAL SUPERVISORY COMPETENCIES

Assessment, diagnosis, and case conceptualization
Neuropsychology supervisors have the ability to help trainees think through
problems rather than force-feeding answers to them. A cornerstone of supervision
is the promotion of evidence-based differential diagnosis and treatment planning.
Effective supervision teaches trainees how to integrate diverse sources of
information to not only arrive at a working diagnosis but also to establish a more
thorough understanding of behavioral patterns with clinically meaningful
recommendations.
Intervention
Neuropsychology supervisors make every effort to maintain evidence-based
practice. They model practices that focus on the practical concerns of patients.
Supervisors convey awareness that a diagnosis or explanation of cognitive deficits,
without offering practical recommendations or interventions, is often insufficient.
Supervisors regularly assess trainees’ abilities to integrate appropriate neuropsy-
chological and clinical knowledge in the care of patients.
Consultation
Supervisors help trainees identify the central consultation questions or issues.
They respond to those questions and concerns in a timely and constructive manner,
with appropriate documentation that is easily accessible and intelligible to the
person(s) requesting the consultation. They recognize that the purpose of
assessment varies depending on the setting, referral question, and current
treatment plan.
Research evaluation
Neuropsychology supervisors teach trainees how to critically review and
contribute to the scientific literature. They advocate for a scientist-practitioner
model with a focus on efficiency, outcome, and cost-effective practice. Supervisors
help trainees integrate the findings of peer-reviewed research, and they model the
use of informed judgment when evidence is lacking or controversial.
Supervision training
Supervisors-in-training are initially provided with structure, support, educa-
tional materials, and encouragement as they assume the new role. Depending on the
amount of time spent providing supervision to more junior trainees, those who are
learning to provide supervision benefit from receiving individual supervision of their
supervision on a weekly basis during their first year of providing supervision. This
frequency allows for close oversight and timely feedback regarding the supervisory
activities. Additionally, for those who work in larger departments, faculty meetings
afford supervisors another opportunity to discuss training and supervisory issues.
These venues allow more experienced supervisors to provide feedback to those in
training.
Supervisors are aware of and utilize various teaching techniques such as the
Socratic Method, supportive inquiry, formative and summative evaluation, and
skills coaching (Overholser, 1991, 2004). The Socratic Method involves a process of
teaching by asking thought-provoking questions and helping trainees arrive at
answers through the process of inquiry. Socratic questioning can be a particularly
effective tool for helping trainees learn critical-thinking and deduction skills, and
new supervisors can learn to use the method in their supervision of more
junior trainees.
Management and administration

Supervisors educate trainees about the business of healthcare and the delivery
of neuropsychology services with attention to its impact on patient care, clinical
outcomes, and program viability. Supervisors help trainees understand billing and
reimbursement issues, restrictions caused by insurance coverage, travel or commu-
nity limitations, cultural variables, and systems issues.
Business literacy in the practice of neuropsychology is also a goal pursued
during training. In a study conducted by Donders (2002), enhanced training
regarding reimbursement and billing issues was the number one suggestion for the
improvement of residencies. Additionally, supervisors help trainees understand
hospital governance structure; institutional priorities, dynamics and politics; and
other variables that can impact neuropsychological practice. Trainees benefit from
learning the difference between allied health staff and medical staff. When possible,
they are encouraged to participate in committees in the practice setting that will
expose them to non-clinical roles that they might assume in an institution.
THE STRUCTURE OF SUPERVISION

A supervisory relationship is a type of contract, and the specifics are
presented, reviewed, and discussed. Inefficient or substandard training can occur
when expectations and goals are not clearly laid out for both the trainees and
supervisors. Programs and supervisors are encouraged to write out policies and
procedures, program standards, and formal goals to help trainees understand that
their training and supervision entails much more than just ‘‘I teach, you learn.’’
Quality supervision is a dynamic process, and supervisors encourage trainees to take
an active or proactive role. Suggestions for promoting the structure of supervision
at the residency level are provided.
Training timeline
Clinical neuropsychologists are specialists, but they also need a broad
knowledge base because of the diverse patient population served and the broad
range of services they may be called upon to provide. To develop the advanced
knowledge and clinical skills required of the independent practitioner, the Houston
Conference policy statement recommended a full-time 2-year postdoctoral residency
(Hannay et al., 1998). In most instances, comprehensive training in neuropsychol-
ogy cannot be effectively accomplished in one postdoctoral year.
For licensure purposes, supervisors and supervisees must be aware of the
requirements of the jurisdictions in which supervision is provided and where
licensure will be pursued. The Association of State and Provincial Psychology
Boards (ASPPB) offers a Model Act for Licensure of Psychologists (ASPPB, 1992),
which some jurisdictions have adopted. This act recommends 2 years of supervised
professional experience, one of which must be at the postdoctoral level. The 2 years
of supervised postdoctoral experience typically required by neuropsychology
residencies satisfies the licensure requirement, and some neuropsychology residents
become licensed psychologists during their residency.
Role induction and program introduction

When trainees start new programs, supervisors promptly review with them the
program’s policies and procedures, structure, expectations, and schedules.
This information is often provided in both written and oral forms, with both
parties signing and retaining copies of the documents. This orientation meeting is
also used to set goals and establish an understanding about how supervision will be
provided. Although some of this information may have been provided during the
pre-employment or initial training period, supervisors recognize the value of

reviewing the material in more depth. Additionally, supervisors understand that
they may need to periodically remind trainees (or themselves) about the various
expectations. With new programs, supervisors seek guidance from more experienced
faculty and prepare policies and procedures regarding supervision and training
standards at the new site.
Format/logistics of supervision
APA postdoctoral residency accreditation standards require that supervision
is primarily provided on-site. There need to be at least two different supervisors per
trainee, and ‘‘At a minimum, a full-time resident will receive 4 hours of structured
learning activities per week, at least 2 hours of which will include individual, face-to-
face supervision’’ (APA Commission on Accreditation, 2009, p. 23). However,
supervision is a dynamic process and should not be limited to private office
interactions. Additional supervision time is spent at the patient’s bedside, in hospital
rounds, previewing charts with residents prior to clinical appointments, and in other
settings where trainees can observe supervisors in real-world practice. ‘‘Training
supervisors are accessible to the residents and provide them with a level of
guidance and supervision that actively encourages timely and successful completion
of the program’’ (APA Committee on Accreditation, 2009, p. 23), which
includes their clinical, administrative, and scholarly responsibilities. These
guidelines do allow for additional forms of supervision, such as in a group
format, and for some supervision to be provided by non-psychologists (e.g., during
‘‘rounds’’ with physicians); however, the guidelines are clear that regular, on-site,
face-to-face supervision is the primary requirement for proper postdoctoral
residency training.
It can be helpful to have residents check in with supervisors halfway through
neuropsychological evaluations or hospital consults to review initial results, make
further suggestions, and, if necessary, adjust the assessment plan. We recommend
that ‘‘elbow-to-elbow’’ supervision and case discussion occur on a frequent basis
during various activities such as formal rounds or team meetings. Group
supervision can also be an effective way to expand the trainee experience.
Trainees can vicariously learn from one another, brainstorm about challenging
issues, and engage in peer support. Furthermore, group supervision is often a

venue in which senior residents can practice providing supervisory services to
interns and first-year residents while still under the watchful eye of staff/faculty
supervisors.
Finally, there has been recent solicitation for public comment about the value
and or pitfalls of telesupervision (http://apaoutside.apa.org/AccredSurvey/public/).
This medium has the potential to increase access to supervision. In remote locations
this option may be necessary. However, in our opinion telesupervision in
neuropsychology is best used as an adjunct to onsite supervision, because it
cannot replace the value to trainees of observing and interacting with supervisors
in multiple clinical activities and contexts.
Goal setting
Good supervisors assess trainee professional development and adjust super-
vision accordingly. Supervisors respectfully help trainees view themselves as a
‘‘work in progress’’ and explain that being a neuropsychologist requires a personal
commitment to career-long learning. Furthermore, supervisors recognize that
trainees may not be fully aware of their weaknesses, yet they remain respectful and
collaborative while increasing trainee self-awareness and metacognition.
Feedback
On at least a weekly basis, supervisors discuss the appropriateness of
interventions suggested and used, the rationale for assessment approaches
employed, the clarity of documentation, the effectiveness of communication with
other professionals, and other aspects of trainee behavior that directly impacts
patient care. Supervisors also provide formal feedback regarding trainee progress on
set goals, clinical effectiveness, and professionalism. Formal written feedback and
discussion occurs at minimum of twice per year. The written evaluation is signed by
both supervisors and trainee and is placed in trainee’s program files for future
reference.
Additionally, trainees are required to conduct a self-evaluation at least twice a
year, with review by supervisors. Finally, trainees are asked to complete formal
written evaluations of their programs and supervisors. To increase trainee honesty
and comfort with providing feedback, evaluations of programs and supervisors are,
whenever possible, submitted anonymously, treated confidentially, and reviewed by
someone one other than the primary supervisor. Attempts are also made to obtain
feedback from trainees after the completion of the program. Follow-up surveys help
determine trainee success rates in the job market and the degree of preparation they
received from training. In addition to trainees’ evaluations of their training,
outcomes such as job placement, performance in the board certification process,
and national licensing exam are all used to assist with program development and to
address problematic trends as needed.
Supervisors understand the uses and differences between formative evaluation
(i.e., periodic evaluation and feedback during the process of training) and
summative evaluation (i.e., meeting specific program exit criteria). Formative
evaluations are often based on observations within and external to the supervisory
relationship. We recommend that supervisors use multiple tools for trainee
assessment and evaluation. Some supervisors may use checklists of trainee
knowledge, skills, and behavior checklists; ratings of patient–trainee observations;
and written evaluations by peers and staff. The ‘‘competency assessment toolkit’’
provided by Kaslow et al. (2009) is an excellent resource and strongly recommended
reading for training programs and supervisors.
The evaluation of trainees’ case presentations and or lectures can also be
instructive. Many organizations also use patient satisfaction ratings, oral or written
examinations, measurement of patient outcomes, or ratings of written vignettes or
simulated patients. Formal outcome measures can be a more standardized and
reliable means of examining trainee progress. Summative evaluation requirements
can include successful passage of the state licensing examination, completion of
specific projects, or a series of acceptable formative evaluations throughout

training. Some residencies use mock oral examinations as well.
Contractual and financial considerations

Most trainees receive a salary and benefits from the institution that hosts
the training program. Supervisors may or may not have influence regarding how
the contract is written. Because most neuropsychology training programs are not
funded like physician residencies, continuation of the program is often dependent
on revenue from various sources, including billable services (Stucky et al., 2008).
Trainees are required to document services not only to learn appropriate practice,
but also to assist with billing.
Although neuropsychology residents learn to bill for their services, CMS
forbids billing Medicare for trainee clinical work; therefore some programs find
themselves in a very challenging situation. Trainees need the experience of treating
and assessing patients with Medicare, but doing so often limits the hours of billable
service the program can submit. In some cases this reality jeopardizes the
institution’s willingness to continue hosting a program that is not at least budget-
neutral. In the current economic climate, hospitals are much less able to fund
programs that cannot pay for themselves. Furthermore, CMS funding is only
available for hospital-based psychology residencies, which effectively restricts the
majority of APPCN programs.
Thus requirements for residents to bill for their services, in the absence of
CMS funding, put programs in a ‘‘catch 22’’ situation. Neuropsychology trainees
are informed about this dilemma, and a balance is struck between training and
practical billing issues. Supervisors outline and explain their programs policy
regarding this dilemma. This discussion exposes the trainee to the way in which
supervisors conscientiously address complex ethical, clinical, business, and policy-
related issues. This situation can also help trainees learn more about real-world
practice while ensuring program viability. During this entire process, it is clear that
supervision must remain an integral part of the training program that cannot be
sacrificed for economic benefit.
References and letters of recommendation

Supervisors have an obligation to provide honest and straightforward
references when letters of recommendation are requested. Trainees are informed
that their strengths and weaknesses will be presented. Nonspecific boilerplate letters
tend not to be particularly helpful to trainees or the readers of those letters.
We recommend that supervisors give trainees copies of letters that have been written
on their behalf. Ultimately, a letter of recommendation can serve as another form of
trainee feedback regarding their performance and competence as a clinician. Some
training programs in medicine in which former supervisors or programs were not
forthcoming regarding trainees’ deficiencies have been found to have been negligent
and have been held liable for damages (Roberts, 2007).
SUPERVISEE COMPETENCIES
The purpose of supervised residency experience in clinical neuropsychology
is to provide advanced education and training so that trainees develop competency
in the specialty and are able to promote the wellbeing of patients. Supervisors
understand the competencies that their supervisees need to develop.
The Accreditation Council for Graduate Medical Education (1999) provided
competencies for medical residents. Similarly, we describe eight core areas in which
neuropsychology residents pursue and establish competency (see Table 4). These
should be considered in addition to current functional and foundational
competencies already outlined for professional psychology (Fouad et al., 2009).
Supervisors attend closely to the development of the core competencies by
their supervisees, and supervisor training reinforces the importance of guiding
supervisees toward the establishment of competent clinical abilities.
COMMON BARRIERS TO TRAINING IN SUPERVISION

There can be many challenges to the provision of effective supervision.
Counterproductive personality dynamics, contrasting styles, disagreements among
faculty, unclear evaluation procedures, and vague goals are among some of the most
common barriers. Additionally, many trainees have limited access to junior trainees
Table 4. Competencies for medical and neuropsychology residents
Medical residents Neuropsychology residents
1. Patient care Neuropsychological knowledge

2. Medical knowledge Treatment/Intervention
3. Practice-based learning and improvement Teaching
4. Interpersonal and communication skills Consultation and relationships
5. Professionalism Practice administration
6. Systems-based practice Outcome assessment/Quality assurance
7. Supervision
8. Research/evidence-based practice
for supervisory opportunities. As a result, it is not always possible to use the

hierarchical medical model whereby faculty/staff train and supervise senior residents
who in turn train and supervise more junior residents. Many settings in which
neuropsychological residencies exist do not also offer internships or externships, so
there are limited opportunities for neuropsychology residents to provide supervi-
sion. In such instances, it may be possible for neuropsychology residents to
supervise trainees or members of other healthcare professions, or trainees can role-
play with supervisors, temporarily switching roles for purposes of supervision
training.
Faculty development programs, and expectations that residencies will have
formal faculty development plans to improve supervisor quality, have been of
increasing interest of the ACGME (2010), and neuropsychology may benefit from a
similar approach to professional development. As previously described in this
article, limited federal funding for neuropsychology training programs, compared to

the funds provided for medical residencies, restricts neuropsychology training
opportunities. Limitations in clinical training programs by extension limit super-
visor training opportunities. We recommend that new supervisors be assigned or
allowed to choose a faculty mentor who meets with them monthly to discuss their
supervision practice. Faculty mentors may also decide to have the supervisor
perform a self-evaluation, which could be compared with confidential supervisee
evaluation of the supervisor. This would allow the new supervisor and mentor to
identify areas of strength and potential growth. Following a set monitoring period
(e.g., 6–12 months) determinations could be made regarding the new supervisors
ongoing training and support needs.
NEUROPSYCHOLOGICAL SUPERVISION COMPARED TO OTHER FORMS

OF SUPERVISION IN PSYCHOLOGY
Although neuropsychological supervision overlaps in many ways with
the supervision provided to trainees in clinical psychology and other psychological
specialties, important differences exist in both the process and content of
supervision. In general, neuropsychological supervision offers a greater focus on
standardized assessment methods and procedures and the statistical methods
relevant to such assessment. Neuropsychological supervision also offers more
‘‘elbow-to-elbow’’ supervision, often on medical or rehabilitation units, than
occurs in supervision in some other psychological specialties. Of course, there is a
much greater focus on studying brain–behavior relationships and applying that
knowledge to understand patients and promote their wellbeing.
In contrast, it seems likely that neuropsychological supervision provides much
less of a focus on parallel process and relationship approaches to training. That is,
neuropsychological supervision generally does not assume that the supervisee–client
relationship parallels the supervisee–supervisor relationship, and although modeling
professional behavior is valuable, the supervisee–supervisor relationship itself is not
the primary medium through which supervision and supervisee professional
development occur.
CONCLUSIONS
Clinical competence does not equal supervisory competence and neuropsy-
chology trainees and practicing clinicians who are considering or are new to
supervisory roles must develop supervisory skills. Although APA has taken the
position that supervision should be considered a specific competency, formal
supervisory training standards for neuropsychology are currently in their infancy,
and there are multiple barriers to supervisor training. Funding limitations, lack of
residency exposure, small faculty size, and limited access to formal supervision
training programs are a few of the barriers that can adversely affect adequate
training in the provision of competent supervision. Consequently, it is not unusual
for self-aware neuropsychologists to feel somewhat overwhelmed, self conscious,
nervous, and or conflicted about their developing roles as supervisors.
In other cases under-prepared, but well-meaning, clinicians may not recognize

the demands or complexities of supervision until they have had a number of
negative trainee experiences and/or outcomes. Additionally, some neuropsycholo-
gists enter into supervisory roles and never realize that they lack foundational
supervisory skills and that the training they are providing is substandard. We
believe that marginal or poor supervision negatively affects patient care and
ultimately the profession of clinical neuropsychology.
Preparing future supervisors is an incremental, developmental, and contextual
process. Our position is that neuropsychology residency programs need to have a
formal plan for teaching trainees how to supervise others. Additionally, we
recommend that residency programs demonstrate an investment in faculty
development efforts, expectations, and monitoring. In this article we have proposed
a model for training in neuropsychology supervision in the U.S. The model
emphasizes exposure to, and discussion of, supervisory skills early in training and
continuing into one’s professional career. Although challenging, trainees can learn
fundamental supervisory skills while also developing foundational and functional
competencies in clinical neuropsychology.
To promote development of supervisory skills, trainees or other supervisors-
in-training can be placed in situations where they have to teach or supervise the
work of junior colleagues and interdisciplinary team members. Role-playing with
more senior faculty/staff can also be a valuable exercise. Of course, supervisor
training activities, like clinical activities, need to be overseen by the faculty/staff
supervisor. It is our hope that the profession of clinical neuropsychology will
increasingly recognize the importance of formal training in supervision and expand
on the information and training that is currently available.
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PROVIDING EFFECTIVE SUPERVISION IN CLINICAL

Kirk J. Stucky1, Shane Bush2, and Jacobus Donders3

A specialty like clinical neuropsychology is shaped by its selection of trainees, educational

Keywords: Supervision; Neuropsychology training; Competency standards; Supervisor competence.

skills, including assessment, report writing, differential diagnosis, and treatment.

advocates for a science-informed, formalized, and objective process that clearly

BACKGROUND OF PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL

residency programs in 130 specialties and subspecialties. The number of active

psychology could certainly be used as a base to guide further understanding

IMPORTANCE OF SUPERVISION TRAINING

recommended as a core competency area for all psychologists (APA, 2006).

MODELS OF CLINICAL SUPERVISION

Table 1. Models of supervision in

Based on information provided

A PROPOSED MODEL FOR NEUROPSYCHOLOGICAL SUPERVISION

interest of enhancing the trainee’s professional development and understanding

General supervisor expectations

monitor trainees for personal adjustment difficulties and or counterproductive

SUPERVISOR QUALITIES AND COMPETENCIES

Table 2. Qualities of effective supervisors

Psychological Association, 2006). Critical thinking and analysis, judgment, assess-

FOUNDATIONAL SUPERVISOR COMPETENCIES

Table 3. Foundational and functional competencies

Based on information provided by Rodolfa et al.

scientific journals, attending professional conferences). Observing a supervisor

Scientific knowledge and methods

Individual and cultural diversity

Ethical and legal considerations

integration of individuals with disabilities. A reasonable degree of advocacy for

FUNCTIONAL SUPERVISORY COMPETENCIES

Management and administration

THE STRUCTURE OF SUPERVISION

Role induction and program introduction

pre-employment or initial training period, supervisors recognize the value of

issues, and engage in peer support. Furthermore, group supervision is often a

specific projects, or a series of acceptable formative evaluations throughout

Contractual and financial considerations

References and letters of recommendation

COMMON BARRIERS TO TRAINING IN SUPERVISION

Table 4. Competencies for medical and neuropsychology residents

Medical residents Neuropsychology residents

1. Patient care Neuropsychological knowledge

for supervisory opportunities. As a result, it is not always possible to use the

article, limited federal funding for neuropsychology training programs, compared to

NEUROPSYCHOLOGICAL SUPERVISION COMPARED TO OTHER FORMS

In other cases under-prepared, but well-meaning, clinicians may not recognize

Accreditation Council for Graduate Medical Education. (1999). General competencies.

American Psychological Association. (2002). Ethical principles of psychologists and code of

Holloway, E. L. (1992). Supervision: A way of learning and teaching. In S. D. Brown &

Martino, C. (2001, August). Secrets of successful supervision: Supervisor and supervisee