La supervision en thérapie cognitive et comportementale (TCC) vise à développer les compétences techniques, réflexives et éthiques du thérapeute. Si les principes déontologiques encadrant la pratique clinique sont bien établis, le processus décisionnel réel du thérapeute confronté à un dilemme éthique demeure peu décrit dans la littérature, en particulier lorsque des résonances personnelles influencent l’évaluation clinique.

Illustrer le rôle de l’auto-réflexion structurée en supervision dans l’élaboration d’une décision éthique argumentée lors d’une situation clinique complexe.

Présentation d’une étude de cas issue d’une supervision en TCC. L’analyse repose sur une conceptualisation interactionnelle thérapeute-patiente, l’identification d’un conflit de valeurs et l’application d’un processus de résolution de problème guidé par le questionnement socratique.

La supervision a permis d’identifier l’impact des schémas personnels de la thérapeute sur son jugement clinique, de clarifier les principes éthiques en tension (autonomie, bienfaisance, non-malfaisance, honnêteté) et de transformer une réaction intuitive en décision raisonnée. La mise en œuvre de cette décision a contribué à renforcer l’alliance thérapeutique et l’autonomie de la patiente.

L’auto-réflexion guidée en supervision constitue un outil central pour la gestion des dilemmes éthiques en TCC. La combinaison d’une analyse fonctionnelle interactionnelle et d’une résolution structurée de problème offre un modèle clinique transférable permettant d’expliciter le raisonnement éthique du thérapeute.

Clinical supervision is a fundamental component of practice in cognitive behavioral therapy (CBT). Its role extends beyond the development of technical therapeutic skills to include the enhancement of therapists’ reflective capacities, emotional regulation, and ethical judgment. While ethical principles guiding therapeutic practice — such as autonomy, beneficence, non-maleficence, and justice — are well established in professional codes, the actual process by which therapists make ethical decisions in complex clinical situations remains insufficiently explored in the literature. In particular, little attention has been paid to how therapists manage ethical dilemmas when their personal beliefs, emotions, or experiences influence their clinical judgment.

This article examines the role of structured self-reflection during supervision in helping therapists reach ethically reasoned decisions. Through the presentation of a clinical case derived from CBT supervision, the authors illustrate how supervision can transform an intuitive or emotionally driven reaction into a thoughtful and ethically grounded decision-making process.

The case study concerns Émilie, a CBT therapist with ten years of experience, who seeks supervision regarding her patient Luna, a 25-year-old woman suffering from low mood and diminished self-confidence following repeated romantic failures. Luna reports a history of unsuccessful relationships and expresses feelings of worthlessness. A significant factor in her distress is her relationship with her mother, who exercises strong control over her personal and romantic life and frequently criticizes her choices.

During therapy, Émilie works to strengthen Luna's self-confidence and encourage her autonomy, particularly in relation to her mother's influence. After several sessions, Luna happily reports that she has met a new partner who seems attentive, attractive, and successful. However, Luna's mother strongly disapproves of the relationship and labels the man a manipulative narcissist. Initially, Émilie supports Luna's independence and encourages her to rely on her own judgment rather than her mother's criticism. The situation becomes ethically complex when Émilie realizes that Luna's partner is a physiotherapist she had previously encountered and found suspicious. Later, another patient informs Émilie that the same man had contacted her through a dating application, reinforcing the therapist's doubts about his behavior. This discovery creates an ethical dilemma for Émilie: she wonders whether she should reveal the information she possesses or remain neutral in order to respect professional boundaries and confidentiality. Supervision becomes essential in helping Émilie analyze the situation. Through structured self-reflection guided by the supervisor, the therapist examines the similarities between her own emotional responses and Luna's experiences. This process highlights how personal schemas and emotional reactions can influence clinical judgment. Using an interactional functional analysis based on CBT principles, the supervisor and therapist explore how both the patient's and the therapist's beliefs and interpretations contribute to the evolving situation. To address the ethical dilemma, the supervisor guides Émilie through a structured problem-solving process inspired by the model of D’Zurilla and Goldfried. This process involves clarifying the dilemma, identifying the conflicting values, generating possible solutions, and evaluating the potential advantages and risks of each option. Two main alternatives emerge: either subtly questioning the partner's reliability without disclosing specific information, or openly sharing the information she possesses while allowing the patient to make her own decision. Through Socratic questioning and ethical reflection, Émilie ultimately decides that honesty and beneficence should guide her action. She chooses to share the relevant information with Luna in a transparent and empathetic way, while emphasizing that the final decision remains Luna's. The discussion is carefully prepared during supervision to ensure that the information is presented respectfully and without imposing the therapist's personal opinion. When Émilie later reports the outcome, Luna initially reacts with distress but ultimately accepts the information and investigates further. She eventually discovers additional evidence confirming the partner's problematic behavior and decides to end the relationship. This experience strengthens her self-confidence and supports her progress toward autonomy. Shortly afterward, Luna begins a healthier relationship and concludes therapy successfully.

Guided self-reflection in supervision plays a critical role in managing ethical dilemmas in CBT. By combining interactional functional analysis, Socratic dialogue, and structured problem-solving, supervision helps therapists clarify their values, manage emotional reactions, and make ethically sound decisions. Ethical competence in psychotherapy therefore involves not merely applying abstract rules, but developing the ability to reflect critically and think clearly in complex clinical situations.