Association of Cotherapy Supervision With Client Outcomes, Attrition, and Trainee Effectiveness in a Psychotherapy Training Clinic

Melissa A. Tanner, James J. Gray, and David A. F. Haaga

American University
Cotherapy supervision has been hypothesized to enhance client outcomes and trainee effectiveness, but there is little empirical evidence relevant to either claim. This study tested both hypotheses, using data from the supervision of psychology doctoral students conducting cognitive behavioral therapy in a university-based clinic. Method: Groups of clients treated by supervisor-trainee duos and groups of clients treated by solo trainees with varying exposure to cotherapy supervision were compared on changes in symptoms as measured with the Outcome Questionnaire (OQ-45) and on dropout rates. Results: Clients showed statistically signicant reductions in symptoms from pretreatment to posttreatment. However, there were no signicant group differences in the magnitude of change or in client retention. Conclusions: No support was obtained for the hypothesized benets of cotherapy supervision. Clients treated by a cotherapy (supervisor and supervisee) team did not improve more than did clients treated by solo trainees. Furthermore, clients treated by (solo) trainees who had received cotherapy supervision did not improve more than did clients treated by trainees who had not received cotherapy supervision. C 2012 Wiley Periodicals, Inc. J. Clin. Psychol. 68:12411252, 2012. Keywords: cotherapy; supervision; psychotherapy training; training clinic; treatment outcome; attrition

Objective:

Cotherapy refers to psychotherapy provided conjointly by two therapists. The practice was rst conceived of by Alfred Adler in the early 1920s as a case conference or consultation with the patient in question as a non-participant observer (Hoffman & Hoffman, 1981, p. 218), the rationale being that the client would benet from the insight generated by the cotherapists through their discussion. The denition of cotherapy evolved to refer to an open dialogue between cotherapists of approximately equal experience level and a client, couple, family, or group (Hoffman & Hoffman, 1981). In the 1940s, an offshoot of this practice arose in which cotherapy was used as a training technique for new therapists. The trainee would sit in on sessions with his or her more experienced colleague, observing and making occasional contributions (Hoffman & Hoffman, 1981). This offered the trainee the opportunity to observe his/her cotherapist in action, as well as to receive feedback about his/her own interventions (Hoffman & Hoffman, 1981, p. 218). Today, cotherapy remains an open dialogue between therapists and client(s) and can be conducted either by a pair of peers or a team comprising a supervisor and trainee (e.g., Yerushalmi & Kron, 2001). Cotherapy as a training method usually begins with the supervisor serving as the primary therapist and the trainee as an active observer, chiming in only occasionally. Gradually, over the course of treatment, the trainee takes on a more active role, eventually inheriting the role of primary therapist as the trainee becomes more condent and autonomous (Hogan, 1964). Cotherapy offers several potential advantages (Esposito & Getz, 2005). Compared with supervision based on trainee notes and after-the-fact reports of what happened in session, cotherapy affords the supervisor a more complete, less selective picture of the clinical material. Relative to supervision based on tape samples, cotherapy can provide more immediate feedback and modeling. Immediate feedback may enable the supervisee to correct mistakes more quickly and
This article is based on a doctoral dissertation completed by the rst author under the supervision of the coauthors, submitted to American University in partial fulllment of the requirements for a doctorate. Please address correspondence to: David A. F. Haaga, Department of Psychology, Asbury Building, American University, Washington, DC 200168062. E-mail: dhaaga@american.edu JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 68(12), 12411252 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).
C 2012 Wiley Periodicals, Inc. DOI: 10.1002/jclp.21902

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to learn from them more effectively and may yield better sessions for the client as well. Compared with other live supervision methods, such as bug-in-the-eye technology, in which the supervisor delivers instant messages to the trainee on a computer screen not visible to the client, and bug-in-the-ear technology, in which the supervisor delivers feedback through earbuds, cotherapy may be less distracting to trainees. Other, more intrusive live supervision methods, such as the supervisors calling on the phone or knocking on the door during a session observed through one-way mirror, could be disruptive to the ow of sessions and distracting to clients as well as trainee therapists (Klitzke & Lombardo, 1991). Finally, if cotherapists work together well despite their obvious power imbalance, the client may benet from observing and internalizing appropriate ways of dealing with authority (Tuckman, 1996, p. 139). These potential advantages notwithstanding, cotherapy supervision has potential drawbacks as well. First, the addition of a second therapist may complicate the process of developing a strong working alliance between client and therapist. For example, cotherapists intent on presenting a united front and modeling a functional collaboration might devote attention to their relationship at the expense of the relationship with the client (Bowers & Gauron, 1981). Second, if the cotherapists are unsuccessful in creating a healthy working relationship with one another, this dysfunction could have negative consequences for the client. Shainess (1977) argued in this regard that the patient or client is like a child, carefully watching to see what adults do: to copy, to judge, to identify, to decide whether to trust. Therapists must be alert to all their actions and to avoiding the implication, do as I tell you, but not as I do (1977, p. 37). Third, in some settings cotherapy is unlikely to be feasible, and even if feasible it is likely to require more of the supervisors time and energy than other methods of supervision. Time commitment was the main barrier cited for use of cotherapy in a survey of psychology training directors, explaining in part the otherwise paradoxical ndings that although (a) cotherapy was used less than other modes of supervision such as tape review or self-report, (b) it was rated by program directors as the strongest supervisory method (Romans, Boswell, Carlozzi, & Ferguson, 1995). The time involved in conducting cotherapy supervision can perhaps be justied to more supervisors only if favorable effects of cotherapy for trainees, clients, or both are demonstrated empirically. To date there is little empirical research on cotherapy. A recent analysis of semistructured therapy groups for adolescents, led by paraprofessionals, found that clients perceived greater benets from treatment in groups led by coleaders than in groups led by individuals (Kivlighan, Miles, & London, 2012). However, coleadership versus solo leadership was determined by therapist choice, which may have introduced selection biases, and in any event the coleaders were peers rather than a supervisor and supervisee, making the results inconclusive with respect to cotherapy supervision. Esposito and Getz (2005) completed a qualitative study (N = 150 clients) of cotherapy within a counselor education masters program (2005). Both trainees (43% of respondents) and clients (10% of respondents) noted that having the supervisor present in the room provided a signicant amount of support; several trainees referred to their supervisor as a safety net for themselves and their clients. Trainees also mentioned that they were more likely to try new techniques as a result of the presence of the supervisor. One reported, I knew I had back-up so I went ahead fearlessly (Esposito & Getz, 2005, p. 7). Furthermore, both trainees (21% of respondents) and clients (10% of respondents) appreciated the supervisors interventions as didactic exercises and as additional perspectives or viewpoints, respectively. One trainee noted, Moments when I was stuck, it was very helpful for me to have my supervisor intervene and guide me through the counseling session by demonstrating innovative techniques (Esposito & Getz, 2005, p. 7). On the other hand, Esposito and Getz (2005) also described several drawbacks of cotherapy. Some trainees believed that they were less effective as therapists when their supervisor was present in the room; 21% of respondents cited nervousness or discomfort and another 10% cited inhibition, because either they were concerned about being judged or they expected the supervisor to take over the session (Esposito & Getz, 2005). Some clients (13%) also reported inhibited self-disclosure as a result of having two therapists present in the room. One stated, I would have preferred not to share my personal concerns with two people (Esposito & Getz, 2005, p. 8). Furthermore, clients (8%) were aware of the discomfort and nervousness on the part of the trainee and found it to be a distraction. One noted that she felt it was less private and

Co-therapy Supervision in a Training Clinic

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made the counselor nervous (Esposito & Getz, 2005, p. 8). These observations indicate that the therapeutic alliance may suffer as a result of the addition of another therapist, an authority gure in particular. Although this study yielded important insight into factors that may affect the efcacy of cotherapy favorably or unfavorably, it did not address the actual efcacy itself. A study including 33 therapist trainees in a masters-level marriage and family therapy program evaluated effectiveness of cotherapy teams in relation to client outcomes and therapist training (Hendrix, Fournier, & Briggs, 2001). The majority of clients (78%) were seen in couples or family therapy rather than individually. Clients were more likely to complete treatment and accomplish their goals (as judged by therapists and supervisors), and less likely to drop out before the third session in other therapist categories) if treated by a trainee/supervisor team than if they were treated by a single trainee therapist or cotherapy teams comprising two students of various experience levels. The student/faculty cotherapy teams were far more effective, with 55% completers and 5% dropouts, whereas in the other conditions, 18% to 26% completed treatment successfully and 29% to 40% dropped out. Thus, there is little empirical research on the effects of cotherapy for clients, and to our knowledge none that uses standardized outcome measures or that focuses on effects for individual clients as opposed to couples, families, or groups. Moreover, there is no research on the impact of cotherapy on supervisees. If cotherapy is a benecial supervision method, supervisees exposed to it might become better therapists as a result, with this effect showing up in their later solo work rather than or in addition to the cotherapy cases themselves. The research reported in this article is a naturalistic study of cotherapy supervision in a university-based outpatient training clinic. Three supervisors rotate annually the responsibility for supervising psychology doctoral students in conducting cognitive behavioral therapy. One of them uses cotherapy supervision with a single case for each student; the trainees see other cases on their own. The other two supervisors do not use cotherapy supervision. Cases were chosen, via phone screening, based on their suitability for the trainees (clients not accepted for treatment included those who were acutely suicidal or diagnosed with borderline personality disorder features). The supervisor who uses cotherapy supervision selected cases for this method based on scheduling considerations. Thus, assignment is not fully random but it is also not systematically based on variables that would be expected to relate to outcome. The naturalistic nature of the study introduced some interpretive complications that we addressed by using a series of analyses. To clarify the research questions and how they were evaluated, we rst labeled and dened groups of clients in the database, as described in the chart below:
Group label A B C N 30 206 60 Dening feature Cotherapy Solo trainee Solo trainee who received cotherapy supervision (subgroup of B) Solo trainee with no cotherapy supervision (subgroup of B) Solo trainee with prior cotherapy supervision (subgroup of C) Solo trainee with cotherapy supervision but not prior (subgroup of C) Solo trainee with prior meaningful amount of cotherapy supervision (subgroup of E) Operationalization Treatment provided by cotherapy team of supervisor and trainee Treatment provided by trainee therapist only Treatment provided by trainee therapist only, but a trainee who did receive cotherapy supervision on other cases Treatment provided by trainee only, a trainee who never received cotherapy supervision Treatment provided by trainee only. Case began after trainee had received at least one session of cotherapy supervision Treatment provided by trainee only. Trainee later received cotherapy supervision, but case began before trainee received any cotherapy supervision Treatment provided by trainee only. Case began after trainee had received at least eight sessions of cotherapy supervision

146

27

33

20

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Our rst research question was whether cotherapy improves clinical outcomes. This was addressed by comparing symptom improvement, from the rst session to termination, among clients treated in cotherapy (group A) versus those treated by a single trainee therapist (group B). This analysis maximizes sample size but is ambiguous in that the solo trainee group (B) includes clients treated by therapists who had received cotherapy supervision. If this supervision method confers training benets that extend to other cases, then the inclusion of these cases in the solo trainee subgroup will lead to an underestimate of the efcacy of cotherapy. Accordingly, supplementary analyses compared symptom improvement in the cotherapy condition (A) with improvements made by clients treated solo by trainees who had received cotherapy supervision (group C), which equates for general therapist skill and for general supervisor skill and with improvements made by clients treated solo by trainees who never received cotherapy supervision (group D), which removes from the solo trainee condition any possible carryover effects from cotherapy experience. Our second research question concerned whether cotherapy improves client retention. The same comparisons just described with respect to symptom improvement were repeated, with a dependent variable of percentage of clients completing at least four sessions of treatment. Third, we examined the effect of cotherapy supervision on trainee performance in other (solo) cases, as indexed by clients symptomatic improvement and client retention. The simplest comparisons were between solo cases treated by therapists who ever received cotherapy supervision (group C) versus cases treated by therapists who never received cotherapy supervision (group D). Supplementary analyses restricted the ever-received cotherapy subgroup to clients whose treatment began (a) after any cotherapy sessions had been held including this therapist (group E) and (b) after at least eight cotherapy sessions had been held including this therapist (group G). There is no prior empirical research on cotherapy to guide the choice of session numbers, and we selected eight sessions somewhat arbitrarily as an amount of cotherapy supervision likely to show training effects on the supervisees other cases. Finally, we compared cases treated by a solo trainee who had already received at least one session of cotherapy supervision (group E) with cases treated by a solo trainee who later received cotherapy supervision (group F). These analyses control for both trainee and supervisor general competence and therefore serve as direct within-subject comparisons measuring the effects of cotherapy supervision on trainees work with solo clients.

Method Participants Clients. All clients were treated in individual therapy. There were 30 clients (20 female, 10 male) in the cotherapy condition, with an average age of 32.20 (standard deviation [SD] = 13.92) and an average session 1 Outcome Questionnaire (OQ-45; Lambert et al., 1996b) total score of 56.23 (SD = 30.98). There were 206 clients (127 female, 79 male) treated by solo trainee therapists. Their average age was 36.19 (SD = 13.62) and average session 1 OQ-45 total score was 60.20 (SD = 29.10). Between group differences for sex, age, and pretreatment symptom scores were not signicant. The solo trainee group is much larger because two of the three clinic supervisors do not use cotherapy supervision, and the third does so only in some cases. Therapists. Trainee therapists were third-year students in an American Psychological Association-accredited clinical psychology PhD program. They were for the most part novices in cognitive-behavioral therapy, barring any unusual pregraduate school experience. The rst two years of practicum work in this program comprised nondirective therapy and psychodynamic therapy, respectively, in the university counseling center. Data collected during 1997 to 2009 were used for this study. During this period, 79 therapists (72 female, seven male) worked in the clinic, typically six or seven each year. Supervisors. Three supervisors work in the clinic, taking turns yearly teaching the cognitive-behavioral therapy practicum course the therapists take. All supervisors have expertise

Co-therapy Supervision in a Training Clinic

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in cognitive-behavioral therapy and are licensed psychologists and tenured faculty members in the department of psychology. All three employed group supervision and case discussion as part of the practicum course. Additionally, each supervisor meets at least weekly with each trainee therapist for individual supervision, based on audio or videotape review, chart notes, and trainee reports during supervision. Beyond these common methods, one (male, Caucasian) of the three supervisors used cotherapy as a supervision method for many years, before and during the course of this study, whereas the other two (both male; one Caucasian, one African American) do not.

Materials
Each client completes the OQ-45 (Lambert et al., 1996b) at the start of each session. The OQ45 is a 45-item self-report inventory; for each item, the client rates her or his functioning on a 5-point Likert-type scale. The OQ-45 yields a total score and scores for subscales reecting Symptom Distress, Interpersonal Relations, and Social Role Performance. The OQ-45 has shown adequate 3-week retest reliability (r = .84) and high internal consistency (alpha = .93; Lambert et al., 1996a). Total scores are highly correlated with scores on measures of anxiety or depressive symptoms and are sensitive to treatment-related change (Vermeersch, Lambert, & Burlingame, 2000).

Procedure
The study was conducted at a university-based, cognitive-behavioral therapy training clinic in Washington, DC. The clinic offers therapy on a low-fee, sliding-scale basis to members of the community. Referrals come from word of mouth, faculty supervisors, local private practice therapists, and local clinics. The vast majority of clients are adults seen in individual therapy. The clinic is not a specialty clinic but instead accepts clients with a wide range of problems and goals. Prospective clients who were in imminent suicidal crisis or diagnosed with a psychotic disorder were referred elsewhere at phone screening, which was conducted by a licensed clinical psychologist. With these exceptions, subject to clinician availability, all clients were accepted for treatment. Structured diagnostic interviews were not routinely used, but chart diagnoses suggested that about two thirds of clients had primary diagnoses of anxiety or mood disorders (Greeneld, Gunthert, & Haaga, 2011).

Results Effect of Cotherapy on Clinical Outcomes and Client Retention Cotherapy cases compared with all cases treated by a solo trainee. Mixed betweenwithin subjects analyses of variance were conducted on OQ-45 total and subscale scores, with supervision group (cotherapy vs. therapy provided by a solo trainee) as the between-subjects variable and time (rst session, last session) as the within-subjects variable. Table 1 shows the results for the comparison of cotherapy cases (n = 30) and all solo therapist cases (n = 206). Time effects were signicant for total scores (partial eta squared = .05), Symptom Distress subscale scores (partial eta squared = .06), and Social Role performance subscale scores (partial eta squared = .03), with the sample as a whole showing modest improvement over the course of treatment. For example, the pre-post within-group change in the solo therapy cases (n = 206) for total OQ-45 scores (Table 1) corresponds to a d of .14, which is conventionally considered a small effect (Cohen, 1988). Group effects were in every case nonsignicant. As shown in Table 1, the most important effects, group X time interactions, were in all instances nonsignicant (ps > .4; partial eta squared below .01). Similarly, of the clients treated by a cotherapy team (n = 30), 83% completed at least four sessions, compared with 79% of cases treated by a solo trainee (n = 206), which was not a signicant difference per Fishers exact test, p = .81.

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Table 1
Cotherapy Versus Solo Trainee Therapy: Patients Symptomatic Improvement
Cotherapy (n = 30) Pre M (SD) OQ-45 Total Symptom Distress Interpers. Relations Social Role Performance 56.23 (30.98) 32.87 (19.45) 12.22 (8.06) 11.26 (5.81) 53.41 (32.13) 30.76 (19.87) 11.81 (8.36) 10.86 (6.17) Post Solo trainee (n = 206) Pre M (SD) 60.20 (29.10) 35.17 (18.25) 14.49 (7.97) 11.13 (5.89) 56.20 (29.55) 32.39 (18.53) 13.95 (8.40) 10.42 (5.71) 0.38 0.28 0.06 0.47 Post Group X Time F (1, 234) p .54 .60 .81 .49

Note. SD = standard deviation; OQ-45 = Outcome Questionnaire.

Cotherapy cases compared with all cases treated solo by trainees who at some point received cotherapy supervision. Analyses comparing cotherapy cases to all those treated by
a solo trainee, while retaining the full sample size, partially confound both therapist skill and supervisor skill with type of supervision. Therefore, we completed supplementary analyses in which cotherapy cases (n = 30) were compared with cases (n = 60) treated solo by trainees who did receive cotherapy supervision. Thus, in both groups the trainee therapists are the same, and the supervisor is the same; the only difference is whether the supervisor sat in on the sessions. Results in Table 2 show that in this comparison, there were also no group X time interaction effects on symptom scores, suggesting that cotherapy cases and solo trainee cases improved to a similar extent. Likewise, the retention rate for cases treated by a cotherapy team (n = 30, 83%) was the same as the retention rate for the same trainees when they were conducting therapy solo (n = 60, 83%).

Table 2
Cotherapy Versus Solo Therapy by Trainees Who Received Cotherapy Supervision: Patients Symptomatic Improvement
Solo trainee who received cotherapy supervision for other cases (n = 60) Pre M (SD) 61.50 (28.56) 36.67 (18.16) 14.94 (8.35) 12.16 (5.80) 57.86 (28.45) 34.11 (17.80) 14.44 (8.99) 11.37 (5.67) 0.16 0.10 0.02 0.65 Post

Group X Time F(1, 88) p .69 .75 .88 .42

Cotherapy (n = 30) Pre M (SD) OQ-45 Total Symptom Distress Interpers. Relations Social Role Performance 56.23 (30.98) 32.87 (19.45) 12.22 (8.06) 11.26 (5.81) 53.41 (32.13) 30.76 (19.87) 11.81 (8.36) 10.86 (6.17) Post

Note. SD = standard deviation; OQ-45 = Outcome Questionnaire.

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Table 3
Cotherapy Versus Solo Therapy by Trainees Who Never Received Cotherapy Supervision: Patients Symptomatic Improvement
Cotherapy (n = 30) Pre M (SD) OQ-45 Total Symptom Distress Interpers. Relations Social Role Performance 56.23 (30.98) 32.87 (19.45) 12.22 (8.06) 11.26 (5.81) 53.41 (32.13) 30.76 (19.87) 11.81 (8.36) 10.86 (6.17) Post Solo trainee (n = 146) Pre M (SD) 59.66 (29.40) 34.57 (18.30) 14.30 (7.83) 10.71 (5.89) 55.51 (30.05) 31.69 (18.83) 13.75 (8.17) 10.03 (5.70) 0.45 0.35 0.07 0.34 .50 .56 .79 .56 Post Group X Time F (1, 174) p

Note. SD = standard deviation; OQ-45 = Outcome Questionnaire.

Cotherapy cases compared with cases treated solo by trainees who never received cotherapy supervision. It is possible that the results in the immediately preceding subsection
underestimate benecial effects of cotherapy supervision for clients. If trainees benet especially from cotherapy supervision and therefore are more competent in their solo cases as well, then differences would be minimized. To address this method issue, we conducted additional analyses comparing the outcomes of cotherapy cases (n = 30) with those of solo trainee cases (n = 146) treated by therapists who never received cotherapy supervision. These results appear in Table 3. Again, there were no signicant group X time interactions. There was also no signicant difference in retention rate between the cotherapy cases (n = 30, 83%) and the retention rate among cases treated solo by trainees who never received cotherapy supervision (n = 146, 77%; Fishers exact test, p = .63). Taken together, this series of analyses consistently suggests that therapy provided by a supervisor-trainee duo did not differ signicantly in effectiveness from therapy provided by a solo trainee in terms of client outcome or client retention for at least four sessions.

Effect of Cotherapy Supervision on Trainee Effectiveness as a Solo Therapist

Our second major question addressed possible carry-over effects of cotherapy supervision to trainees work in cases they treated by themselves. Trainee effectiveness was again measured with respect to clients symptomatic improvement as well as client retention (four sessions or more).

cotherapy supervision at some point (n = 60) were compared with those treated solo by therapists who never received such supervision (n = 146). The rst analysis was a mixed between-within analysis of variance with therapist exposure to cotherapy supervision as the between-subjects variable, time (pretreatment vs. posttreatment) as the within-subjects factor, and OQ-45 scores as the dependent variable. With respect to total scores and scores for each of the subscales (see Table 4), there were signicant time effects such that clients reported reduced symptoms at posttreatment. However, there were no signicant group effects, and, more importantly, no signicant group x time interactions. Retention rates also did not differ signicantly between solo trainee cases that did (83%) receive cotherapy supervision and those that did not (77%) ever receive cotherapy supervision (Fishers exact test, p = .45). Thus, clients treated solo by a trainee who received cotherapy supervision at some point in his or her career were no more likely to remain in treatment at least four sessions, and they did not

Solo treatment by a therapist who ever received cotherapy supervision versus by a therapist who never participated in cotherapy. Clients treated solo by a therapist who received

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Table 4
Solo Therapy by Trainees Who Received Cotherapy Supervision Versus Trainees Who Never Received Cotherapy Supervision
Ever received cotherapy supervision (n = 60) Pre M (SD) OQ-45 Total Symptom Distress Interpers. Relations Social Role Performance 61.50 (28.56) 36.67 (18.16) 14.94 (8.35) 12.16 (5.80) 57.86 (28.45) 34.11 (17.80) 14.44 (8.99) 11.37 (5.67) Post Never received cotherapy supervision (n = 146) Pre M (SD) 59.66 (29.40) 34.57 (18.30) 14.30 (7.83) 10.71 (5.89) 55.51 (30.05) 31.69 (18.83) 13.75 (8.17) 10.03 (5.70) 0.11 0.10 0.10 0.09 .74 .76 .91 .76 Post Group X Time F (1, 204)

Note. SD = standard deviation; OQ-45 = Outcome Questionnaire.

Table 5
Solo Therapy by Trainees Who Had Previously Received at Least One Session of Cotherapy Supervision Versus Trainees Who Never Received Cotherapy Supervision
Previously received cotherapy supervision (n = 27) Pre M (SD) OQ-45 Total Symptom Distress Interpers. Relations Social Role Performance 67.10 (28.49) 40.26 (17.90) 14.59 (7.82) 12.06 (5.88) 62.42 (28.04) 31.69 (16.75) 13.65 (8.12) 11.25 (5.81) Post Never received cotherapy supervision (n = 146) Pre M (SD) 59.66 (29.40) 34.57 (18.30) 14.30 (7.83) 10.71 (5.89) 55.51 (30.05) 31.69 (18.83) 13.75 (8.17) 10.03 (5.70) 0.06 0.10 0.45 0.07 .81 .75 .50 .80 Post Group X Time F (1, 171)

Note. SD = standard deviation; OQ-45 = Outcome Questionnaire.

experience greater improvements from pretreatment to posttreatment, relative to those treated by trainees who did not receive cotherapy supervision.

Solo treatment with a therapist with prior cotherapy supervision versus with a therapist who never participated in cotherapy. Analyses in the preceding subsection may be
overinclusive in that a little over one half of the cases treated solo by trainees who received cotherapy supervision began before they had been exposed to cotherapy supervision. Accordingly, we next compared only the subset of cases treated solo by a trainee who had already received at least one session of cotherapy supervision prior to the start of therapy (n = 27) with those treated by a solo trainee who did not ever receive cotherapy supervision (n = 146). With respect to total scores and scores for each of the OQ-45 subscales (see Table 5), there were signicant time effects such that clients reported reduced symptoms at posttreatment. However,

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Table 6
Solo Therapy by Trainees Who Had Previously Received at Least One Session of Cotherapy Supervision Versus Same Trainees Before They Received Cotherapy Supervision
Previously received cotherapy supervision (n = 27) Pre M (SD) OQ-45 Total Symptom Distress Interpers. Relations Social Role Performance 67.10 (28.49) 40.26 (17.90) 14.59 (7.82) 12.06 (5.88) 62.42 (28.04) 31.69 (16.75) 13.65 (8.12) 11.25 (5.81) Post Received cotherapy supervision later (n = 33) Pre M (SD) 56.92 (28.21) 33.83 (18.16) 15.22 (8.86) 12.24 (5.82) 54.12 (28.68) 31.90 (18.54) 15.06 (9.70) 11.46 (5.64) 1.57 0.64 2.24 0.11 .22 .43 .14 .74 Post Group X Time F (1, 58)

Note. SD = standard deviation; OQ-45 = Outcome Questionnaire.

there were no signicant group effects, and no signicant group x time interactions. Likewise, retention rates did not differ signicantly between solo trainee cases in which the trainee had already received at least one session of cotherapy supervision prior to the start of therapy (81%) and solo trainee cases in which the trainee never received cotherapy supervision (77%; Fishers exact test, p = .80). Thus, with respect to symptomatic improvement or client retention, there were no differences between clients treated solo by a trainee who had alreadybefore the start of the casereceived cotherapy supervision and clients treated solo by trainee therapists who never experienced cotherapy supervision. A limitation of the analyses in this subsection is that one session of cotherapy supervision is a very limited amount of instruction. Accordingly, we repeated the analyses with the cotherapy experience subgroup limited to cases (n = 20) in which the trainee therapist began the case having had at least eight prior cotherapy sessions. Results1 were very similar, with no signicant differences in symptomatic improvement (all group X time interactions p > .2) or retention, p = .48, between groups. Solo treatment with a therapist with prior cotherapy supervision versus with the same therapist before she or he received cotherapy supervision. Finally, clients treated by a solo trainee who had already received at least one session of cotherapy supervision prior to the start of therapy (n = 27) were compared with clients treated solo by these same trainees before they had received cotherapy supervision (n = 33). This analysis controls for supervisor and therapist general competence and isolates the variable of whether the trainee had or had not yet beneted from cotherapy supervision. As shown in Table 6, there were no signicant group x time interactions in this analysis. Likewise, retention rates did not differ signicantly between those treated after the trainee had received cotherapy supervision (81%) and those treated before the trainee had any cotherapy supervision (85%; Fishers exact test, p = .74).

Discussion
Cotherapy provided by a supervisor-trainee duo has been practiced for decades. Possible advantages and disadvantages have been identied, but little empirical research comparing cotherapy to other forms of supervision has been conducted. In this naturalistic study conducted in a
1 Details

of these analyses may be obtained from the corresponding author.

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university-based training clinic, client retention and clients symptomatic improvement did not differ signicantly between cotherapy cases and cases treated solely by a clinical psychology graduate student trainee. Time effects were signicant for total symptom scores and subscales measuring symptom distress and social role performance, such that clients were improving on average during treatment but not differentially as a function of supervision method. There was also no evidence of any generalization or carry-over effects. That is, the solo trainee-treated clients of trainees who had received cotherapy supervision did not fare any better than did the clients of solo trainees who had not received cotherapy supervision. As was true of prior research relating cotherapy supervision and clinical outcomes (Hendrix et al., 2001), cases were not randomly assigned to cotherapy versus solo trainee treatment. It is therefore possible that more difcult cases were seen in cotherapy, offsetting its advantages. However, there is no reason to believe that more difcult cases would enter the training clinic during the 1 year out of every 3 in which the practicum students are supervised by the one supervisor using cotherapy training. Within that cohort, the supervisor selects cases for cotherapy supervision based on scheduling considerations. An additional limitation of the research is that outcome was measured only via self-report and only with a generically applicable measure, the OQ-45 (Lambert et al., 1996b). Some clients in our training clinic are treated for relatively focused problems (e.g., trichotillomania, compulsive skin picking, compulsive hoarding), and the success, or otherwise, of treatment might not be captured well by a broadband symptom measure. Perhaps in part for this reason, overall average change, while yielding a signicant Time effect, was modest, with total OQ-45 scores averaging 59.70 at pretreatment and 55.85 at posttreatment. By comparison, OQ-45 total scores declined from 71.02 on average at pretreatment to 52.41 at posttreatment in a recent university counseling center study (Choi, Buskey, & Johnson, 2010). However, this comparison is somewhat misleading in that it is based on completer analyses, and only 18% of participants in Choi et al. (2010) completed posttreatment evaluations. Also, unlike in our sample, the Choi et al. (2010) participants were all university students, and 90% of them were treated by licensed psychologists on the counseling center staff, whereas our clients were drawn mainly from the general public and treated by graduate student trainees. More generally, reliance on the OQ-45 as the sole measure of outcome in our study applied to cotherapy and solo trainee cases alike, and in any case for the majority of our clients with primary diagnoses of anxiety or mood disorders, the OQ-45 is a reasonable choice for monitoring treatment efcacy. Symptomatic improvement as measured by the OQ-45 in an earlier sample drawn from this same clinic was sufciently sensitive to show signicant differences in treatment response between those who make sudden gains and those who made sizable improvements more gradually (Greeneld et al., 2011). If method limitations are not responsible for our null results, then the question arises as to why our ndings differed from those of Kivlighan et al. (2012) on group therapy with paraprofessional group leaders, and especially from those of the most similar prior study, Hendrix et al. (2001). As noted in the beginning of this article, Hendrix et al. (2001) found that cotherapy (supervisortrainee) cases were more likely to complete treatment and attain their goals than were clients treated by either student-student teams or an individual student trainee. One possibly relevant difference is measurement method. Whereas we used standardized client self-reports to measure outcome, in Hendrix et al. (2001), supervisors and therapists rated whether treatment goals were attained. Given that they could not be masked to the nature of the treatment and supervision methods, any expectancies favoring cotherapy supervision might have inuenced results. Alternatively, the key difference may have been our client samples. In Hendrix et al. (2001), clients were couples and families, whereas in the present study, clients were individuals. Perhaps the advantages of cotherapy supervision are more pronounced in the couples, family, or group context, in which the sheer number of differing client perspectives makes it difcult for a novice trainee working solo to both keep on task and form effective bonds with each client. A solo trainee backed up by after-the-fact meetings with a supervisor might be better able to handle individual therapy cases. Along these lines, it seems noteworthy that cotherapy is widely accepted as a training and supervision method in the group therapy literature, though for the most part,

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this acceptance is based on theoretical considerations and anecdotal observation rather than outcome research data (Luke & Hackney, 2007). Future research on this topic could extend our work in several ways. First, it would be benecial to collect longer term follow-up data, both in terms of client outcomes and with regard to carryover effects for trainees. It is possible that cotherapy supervision favorably inuenced the development of student therapists in ways they were not able to translate into improved treatment effects the same year but that could be evident later. Second, it would be important to include larger sample sizes, particularly in the cotherapy supervision group, to enhance statistical power. Third, it would be useful to measure other, more proximal effects of supervision in addition to client outcomes and retention. For instance, cotherapy supervision might enhance therapist self-efcacy to implement treatment techniques, or therapist skill in using methods learned via modeling from the supervisor. It might also inuence for better or worse the client-therapist alliance, as discussed earlier in this article. To our knowledge, no empirical research on cotherapy supervision has directly measured any of these phenomena. Fourth, it would be benecial in future research to randomly assign clients to trainee therapists, therapists to supervisors, and within supervisors trainee therapists to cotherapy supervision versus solo trainee treatment. A larger pool of supervisors than that used in our study (n = 3 total, just one using cotherapy as a training technique) would help determine the generalizability of results. Finally, it would be helpful to include individual therapy and group, family, or couples therapy in the same study, so that the possibility that cotherapy is particularly useful when more than one client is in the room could be evaluated more denitively.

Conclusion
In conclusion, if our results prove replicable and are not explained by methodological limitations, then their implications are fairly clear. Cognitive-behavioral therapy supervisors can choose to review tapes and discuss cases with trainees, or they can add live cotherapy supervision to the mix, according to their own preferences, realizing that the choice most likely will not make a systematic difference in the trainees ability to retain clients in treatment or help them reduce symptom levels. In some ways this lack of substantial or signicant differences based on the supervision method may not be overly surprising. Given the many inuences on treatment effects, including client factors, individual therapist effects, and client-therapist t, it is asking a lot to expect a supervision method to make a consistent difference in treatment results. It has proven difcult to show that selecting one bona de treatment for a disorder over another (Wampold et al., 1997) or executing a particular treatment protocol in ways rated as more competent (Webb, DeRubeis, & Barber, 2010) has a signicant effect on average treatment response, and the same may be true of the choice among plausible supervision methods.

References
Bowers, W. A., & Gauron, E. F. (1981). Potential hazards of the co-therapy relationship. Psychotherapy: Theory, Research, and Practice, 18, 225228. Choi, K-H., Buskey, W., & Johnson, B. (2010). Evaluation of counseling outcomes at a university counseling center: The impact of clinically signicant change on problem resolution and academic functioning. Journal of Counseling Psychology, 57, 297303. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd edn.). Hillsdale, NJ: Lawrence Erlbaum Associates. Esposito, J. F., & Getz, H. G. (2005, Fall). In-the-room supervision: Reactions of supervisors, supervisees, and clients. Retrieved from http://unx1.shsu.edu/ piic/fall2005/esposito.html Greeneld, M. F., Gunthert, K. C., & Haaga, D. A. F. (2011). Sudden gains vs. gradual gains in a psychotherapy training clinic. Journal of Clinical Psychology, 67, 1730. Haley, J. (1996). Learning and teaching therapy. New York, NY: Guilford Press. Hendrix, C. C., Fournier, D. G., & Briggs, K. (2001). Impact of co-therapy teams on client outcomes and therapist training in marriage and family therapy. Contemporary Family Therapy, 23, 6382. DOI: 10.1023/A:1007824216363

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Hoffman, L. W., & Hoffman, H. J. (1981). Husband-wife co-therapy team: Exploration of its development. Psychotherapy: Theory, Research, and Practice, 18, 217224. Hogan, R. A. (1964). Issues and approaches in supervision. Psychotherapy: Theory, Research, and Practice, 1, 139141. Kivlighan, D. M., Miles, J. R., & London, K. (2012). Are two heads better than one? The relationship between number of group leaders and group members, and group climate and group member benet from therapy. Group Dynamics: Theory, Research, and Practice, 16, 113. Klitzke, M. J., & Lombardo, T. W. (1991). A bug-in-the-eye can be better than bug-in-the-ear: A teleprompter technique for on-line therapy skills training. Behavior Modication, 15, 113117. Lambert, M. J., Burlingame, G. M., Umphress, V., Hansen, N. B., Vermeersch, D., Clouse, G., & Yanchar, S. (1996a). The reliability and validity of the Outcome Questionnaire. Clinical Psychology and Psychotherapy, 3, 106116. Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., & Burlingame, G.M. (1996b). Administration and scoring manual for the OQ-45. Stevenson, MD: Professional Credentialing Services. Luke, M., & Hackney, H. (2007). Group coleadership: A critical review. Counselor Education and Supervision, 46, 280293. Romans, J. S. C., Boswell, D. L., Carlozzi, A. F., & Ferguson, D. B. (1995). Training and supervision practices in clinical, counseling, and school psychology programs. Professional Psychology: Research and Practice, 26, 407412. Shainess, N. (1977). Conscience and the psychotherapeutic pursuit. Voices, 13, 3639. Tuckman, A. (1996). Mitigating the power imbalance in supervisee/supervisor co-leadership teams. International Journal of Group Psychotherapy, 46, 137139. Vermeersch, D. A., Lambert, M. J., & Burlingame, G. M. (2000). Outcome Questionnaire-45: Item sensitivity to change. Journal of Personality Assessment, 74, 242261. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona de psychotherapies: Empirically, all must have prizes. Psychological Bulletin, 122, 203215. Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 200211. Yerushalmi, H., & Kron, T. (2001). Participant supervision in co-therapy. Israeli Journal of Psychiatry and Related Sciences, 38, 102114.

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