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Clinical supervision is the main method by which mental health professionals acquire the competence to deliver safe and effective therapy. The cognitive behavioural supervision (CBS) approach to supervision parallels CBT in structure and form, which may facilitate learning. Although supervision is integral to trainee development, little is known about what CBS interventions trainees consider helpful. Using a qualitative content analysis methodology, we aimed to identify the specific CBS interventions that trainees find most helpful. Eight trainees completing a CBT rotation in an out-patient hospital setting received weekly individual supervision by staff psychiatrists and psychologists. Following each supervision meeting, trainees completed open-ended responses describing what they found most and least helpful. Responses from 127 meetings were coded using a CBS framework. Overall, trainees found many aspects of supervision helpful. The interventions most frequently noted as valuable were teaching, planning, formulating, training/experimenting, and evaluation of their work. When trainees mentioned unhelpful events, insufficient collaboration and a desire for more or less supervision structure were most frequently noted. These results suggest that the perceived helpfulness of supervision may be tied to the use of CBS interventions that provide trainees with concrete skills that facilitate learning. Further suggestions and implications for supervisors are discussed.
Key learning aims
(1) To identify the aspects of cognitive behavioural supervision that trainees perceive as most and least helpful for their learning.
(2) To integrate trainees’ perspectives with the existing research on supervision satisfaction.
(3) To consider limitations, challenges and future directions of cognitive behavioural supervision research.
Specialised mental health (MH) care providers are often absent or scarcely available in low resource and humanitarian settings (LRHS), making MH training and supervision for general health care workers (using task-sharing approaches) essential to scaling up services and reducing the treatment gap for severe and common MH conditions. Yet, the diversity of settings, population types, and professional skills in crisis contexts complicate these efforts. A standardised, field tested instrument for clinical supervision would be a significant step towards attaining quality standards in MH care worldwide.
A competency-based clinical supervision tool was designed by Médecins Sans Frontières (MSF) for use in LRHS. A systematic literature review informed its design and assured its focus on key clinical competencies. An initial pool of behavioural indicators was identified through a rational theoretical scale construction approach, tested through waves of simulation and reviewed by 12 MH supervisors in seven projects where MSF provides care for severe and common MH conditions.
Qualitative analysis yielded two sets of competency grids based on a supervisee's professional background: one for ‘psychological/counselling’ and another for ‘psychiatric/mhGAP’ practitioners. Each grid features 22–26 competencies, plus optional items for specific interventions. While the structure and content were assessed as logical by supervisors, there were concerns regarding the adequacy of the tool to field reality.
Humanitarian settings have specific needs that require careful consideration when developing capacity-building strategies. Clinical supervision of key competencies through a standardised instrument represents an important step towards ensuring progress of clinical skills among MH practitioners.
Although most psychologists will provide clinical supervision during their career, it can be daunting to step into this critical professional role. This chapter is intended to demystify the process of becoming a supervisor. We will do this by providing broad theoretical models for conceptualizing the practice of supervision and specific practical suggestions that are intended to guide graduate students, interns, postdoctoral fellows, and early career psychologists through the process of learning to be a supervisor. We will review the ethical context of clinical supervision, provide an overview of current competency-based supervision practice, and provide suggestions for how to integrate ethical and multicultural considerations into supervision. Throughout the chapter we use a narrative approach that incorporates the perspectives of an experienced clinical supervisor and the perspectives of the second author from when she was an advanced graduate student just starting her journey towards becoming a competent supervisor.
Supervision is a critical opportunity for a clinical psychology trainee to receive feedback to develop their skills. The chapter begins by describing ways to make the most of this opportunity. Practical steps are outlined that include, goal setting for supervision sessions, planning agendas, ways to learn from sessions recordings, and accounting for supervisory outcomes and activities, and how to challenge yourself to advance beyond the familiar. The chapter also critiques recent developments in “reflective practitioner” approaches to supervision and outlines practical steps to remain evidence-based by using data-driven reflective practice. The chapter concludes with a discussion about how to begin to learn supervisory skills as the clinical psychology trainee anticipates one day moving into a supervisory role.
This chapter explores a range of challenges for students as they learn to apply interpersonal skills within the mental health practicum placement and other non-mental health settings. Exploration of the student’s attitudes, expectations and positive engagement within practice begins the chapter. This is followed by discussion of power relations characterising the therapeutic relationship, including the development of emotional competence. The chapter outlines reflective practice as a critical thinking process and clinical supervision for the beginning mental health nursing student. It explores the importance of developing skills to work within a trauma-informed care and practice framework. How to go about developing objectives for practice, the process of self-assessment and personal problem solving are discussed. Reflection, self in-action and post-placement are explored as they relate to learning in mental health. Throughout this chapter, critical examination of the ethical and political influences on care will be highlighted. This chapter also considers non-traditional opportunities to learn, and the experience of transition programs into mental health nursing.
Literature pertaining to cognitive behavioural therapy (CBT) supervision is limited, particularly about CBT supervision during training. This exploratory study outlines the thoughts of supervisors and supervisees in a training context about which elements make supervision effective. Four supervisees and four experienced CBT supervisors (all from a CBT training programme and independent of one another) were interviewed and asked to consider what makes CBT supervision during training effective. Their responses were evaluated using thematic analysis (TA) and key themes identified. The fit with existing literature was considered via the use of an adapted Delphi poll. Two main themes, containing seven subthemes, were identified from the thematic analysis: ‘supervision as structured learning’ and ‘supervisory relations and process’. The adapted Delphi poll was divided into six categories denoting important characteristics of CBT supervision: (1) the supervisory relationship, (2) ethical factors, (3) generic supervisory skills, (4) mirroring the CBT approach, (5) the supervisor’s knowledge and (6) addressing difficulties. There was a good fit between the TA themes and the Delphi categories. For those engaging in CBT supervision, establishing a structure that mirrors a CBT session, alongside a supportive supervisory alliance, may promote effective CBT supervision during training.
Key learning aims
(1) To consider what might make CBT supervision during training a better experience for participants, such as alliance factors and structured learning.
(2) To discover how supervisors’ and trainees’ perspectives fit with existing research on CBT supervision.
(3) To consider some potential supervisory implications related to aspects of CBT supervision that participants find useful.
Clinical supervision is a cornerstone in psychotherapist training, but research in this area is hampered by a lack of validated tools for assessing supervision quality. Short–SAGE (Supervision: Adherence and Guidance Evaluation) is an observational instrument designed for evaluating supervision in cognitive behavioural therapy. The aim of this study was to evaluate the inter-rater reliability of Short–SAGE. Four experienced clinical psychologists participated in three 3-hour Short–SAGE coding training sessions, followed by an additional meeting and coding instructions. In a cross-over design, codings of 20 supervision sessions were then assessed with intraclass correlations (ICC), for both the 3- and 7-point scales of the instrument. In the single measure analyses for both scales, only one item showed ICC in the good range, and the rest of the 14 item ICCs were in the poor to fair range. Moreover, on the 3-point scale, five of the 14 inter-rater correlations were non-significant. For research and training purposes, validated tools to assess supervision quality are highly needed. However, instruments for measuring adherence and/or competence are of little value if the coders do not attain inter-rater reliability. Whether quality of supervision is associated with improvements in supervisees’ competencies is not yet clear. Short–SAGE provides a tool that may enable empirical research in this area. Further studies are needed to assess whether extensive training can improve the inter-rater reliability of Short–SAGE.
Key learning aims
(1) Readers will be aware of the urgent need for validated tools to assess clinical supervision quality.
(2) Readers will be familiar with some existing tools for assessing the quality of clinical supervision.
(3) Readers will be able to identify common problems in the development of instruments for assessing clinical supervision.
Eleven cognitive behaviour therapy (CBT) trainees in Scotland were interviewed regarding their experiences of clinical supervision and its impact on their skill development. Using thematic analysis, the authors developed four main themes: Linking Theory to Practice, Mirroring CBT in Supervision, The Expert Supervisor, and Trainees’ Reluctance to Give Negative Feedback. Clinical supervision was essential in helping trainees to link theory to practice; particularly through audio recordings, discussing formulations, and modelling and role-play. A CBT-specific approach to supervision and a CBT expert supervisor were also identified as valuable to learning. Trainees were reluctant to give negative feedback to supervisors, fearing negative consequences. The findings inform supervision practice.
Key learning aims
Readers of this paper will be able to:
(1) Describe trainees’ most valued elements of CBT supervision.
(2) Determine key learning methods in CBT supervision.
(3) Explain the value of modality specific CBT supervision.
(4) Articulate the context of supervision in CBT training and consider mutual feedback as a method to address identified challenges.
The worldwide coronavirus pandemic has forced health services to adapt their delivery to protect the health of all concerned, and avoid service users facing severe disruption. Improving Access to Psychological Therapies (IAPT) services in particular are having to explore remote working methods to continue functioning. Australian IAPT services have utilised remote delivery methods and disruptive technologies at their core from inception. This was to maintain fidelity and clinical governance across vast distances but has allowed training, supervision and service delivery to continue virtually uninterrupted through coronavirus restrictions. On this basis, key recommendations for remote working are outlined. Remote methods are defined as (1) real time delivery, (2) independent delivery and (3) blended delivery. These are applied across three broad areas of remote training, remote clinical supervision and remote service delivery. Recommendations may be of great benefit to IAPT training institutions, clinical supervisors and service providers considering a move towards remote delivery. Challenges, adaptations and examples of applying remote methods are outlined, including case examples of methods applied to low-intensity and high-intensity cognitive behavioural therapy. Remote methods can safeguard service continuity in times of worldwide crisis and can contribute to reducing the impact of increased mental health presentations post-COVID-19.
Key learning aims
(1) To understand the core areas of remote training, clinical supervision and service delivery.
(2) To review and distinguish between three broad methods of remote working.
(3) To understand how to plan remote working via key recommendations and case examples.
The effects of the use of objective feedback in supervision on the supervisory relationship and skill acquisition is unknown.
The objective of this study was to evaluate the effects of two different types of objective feedback provided during supervision in motivational interviewing (MI) on: (a) the supervisory relationship, including potential feelings of discomfort/distress, provoked by the supervision sessions, and (b) the supervisees’ skill acquisition.
Data were obtained from a MI dissemination study conducted in five county councils across five county councils across Sweden. All 98 practitioners recorded sessions with standardized clients and were randomized to either systematic feedback based on only the behavioral component of a feedback protocol, or systematic feedback based on the entire protocol.
The two different ways to provide objective feedback did not negatively affect the supervisory relationship, or provoke discomfort/distress among the supervisees, and the group that received the behavioural component of the feedback protocol performed better on only two of the seven skill measures.
Objective feedback does not seem to negatively affect either the supervisor–supervisee working alliance or the supervisees’ supervision experience. The observed differences in MI skill acquisition were small, and constructive replications are needed to ascertain the mode and complexity of feedback that optimizes practitioners’ learning, while minimizing the sense of discomfort and distress.
One method for appraising the competence with which psychological therapy is delivered is to use a structured assessment tool that rates audio or video recordings of therapist performance against a standard set of criteria.
The present study examines the inter-rater reliability of a well-established instrument (the Cognitive Therapy Scale – Revised) and a newly developed scale for assessing competence in CBT.
Six experienced raters working independently and blind to each other’s ratings rated 25 video recordings of therapy being undertaken by CBT therapists in training.
Inter-rater reliability was found to be low on both instruments.
It is argued that the results represent a realistic appraisal of the accuracy of rating scales, and that the figures often cited for inter-rater reliability are unlikely to be generalizable outside the specific context in which they were achieved. The findings raise concerns about the use of these scales for making summative judgements of clinical competence in both educational and research contexts.
Recent developments have led the UK government to deem clinical supervision ‘essential’ to a safe and effective national health service. Cognitive behavioural therapy (CBT) supervision has been increasingly operationalized and manualized, but there are few psychometrically sound observational instruments with which to measure CBT supervision. This paper reports the factor analysis of a promising 23-item instrument for observing competence in CBT supervision (Supervision: Adherence and Guidance Evaluation: SAGE). N =115 qualified mental health practitioners (supervisors and their supervisees) rated the same supervision session by completing SAGE. A principal components analysis indicated that a two-factor solution, identified as the ‘Supervision Cycle’ and the ‘Supervisee Cycle’ components, accounted for 52.8% of the scale variance and also demonstrated high internal reliability (α = .91 and α = .81, respectively). These findings provide the basis for a shorter, 14-item version of SAGE, clarify the factor structure of SAGE, ease implementation, and afford more succinct feedback. Short-SAGE also improves implementation yield, taking half the time to complete as the original 23-item scale. These conceptual and practical improvements strengthen the role of SAGE as a promising observational instrument for evaluating CBT supervision, complementing self-report assessments of competent CBT supervision with an instrument that can fulfil the distinctive functions that are provided through direct observation.
Currently recommended psychotherapies for depression are not always delivered in a consistent manner. There is an assumption that the use of clinical supervision will ensure reliable treatment and patient recovery. However, there is limited research supporting this assumption. This study explored the role of supervision in the treatment of depression. In particular, it examined how supervisors’ own characteristics and those of patients can influence the focus of supervision sessions. Clinical supervisors who worked with cognitive behavioural therapy (CBT) therapists treating depression cases were asked to indicate their supervision focus for three different patient vignettes. These vignettes varied in clinical complexity. Participants’ intolerance to uncertainty and their self-esteem were also assessed. Supervisors tended to focus their supervisees on the use of evidence-based therapeutic techniques for both straightforward and complex cases. However, their approach was less evidence-based for diffuse cases. Three supervisory types emerged: an ‘Alliance- and Technique-Focused’ group, a ‘Case Management-Focused’ group, and an ‘Unfocused’ group. Personal characteristics of the supervisors varied across the groups. The content of supervision sessions is influenced by factors from outside the therapy process. These factors might cause supervisors to avoid focusing on evidence-based aspects of therapy, thus feeding therapist drift. Suggestions are made for new supervision protocols that consider the supervisor's personal characteristics.
Clinical supervision is regarded as one of the most important components of psychotherapy training. In clinical practice, it has been found that the implementation of clinical supervision varies substantially and often differs from the recommendations made in the literature. The objective of the current study was to investigate the frequency of topics (e.g. ethical issues) and techniques (e.g. role play) in the clinical supervision of psychotherapy trainees in Germany. To this end, we considered supervisions in cognitive behavioural therapy (CBT) and psychodynamic therapy (PT). A total of 791 psychotherapy trainees (533 CBT and 242 PT) were asked via the internet to provide information about their current supervision sessions. We found that clinical supervision in psychotherapy training addressed topics that are central for the effective treatment of supervised patients (i.e. therapeutic interventions, therapeutic alliance, maintaining factors, and therapeutic goals). However, the most frequently used intervention in clinical supervision in psychotherapy training was case discussion. Rarely were techniques used that allowed the supervisor to give the supervisee feedback based on the supervisee's demonstrated competencies. For example, 46% of the supervisors never used audiotapes or videotapes in the supervision. Differences between CBT and PT were rather small. Current practice regarding the techniques used in clinical supervision for psychotherapy trainees contradicts recommendations for active and feedback-oriented clinical supervision. Thus the potential of clinical supervision might not be fully used in clinical practice.
Background: Although supervision is believed to be an important strategy for training practitioners in evidence-based practice, little is known about how it should be organized and conducted to promote implementation fidelity. Aims: To explore supervisor behaviours that might facilitate supervisees’ proficiency in motivational interviewing. Method: In this exploratory study, ten supervisors from a primary prevention intervention of childhood obesity responded to semi-structured interviews about their supervision behaviours. A mixed method approach was used; both qualitative and quantitative data were collected and analysed. Results: The supervisors reported using several sources of information for evaluating and providing systematic feedback on supervisees’ performance. However, the majority did not use the available objective measures of proficiency as the primary source. Moreover, half of the supervisors argued that objective feedback might have a punishing effect on the supervisees. Conclusions: Variation in the use of supervision components that previous research has proposed to be potentially influential to the process and outcome may lead to less efficient supervision. Findings suggest that appropriate supervision activities conducted in each supervision session require clear supervision principles that specify the content and procedure of the supervision, as well as regular adherence monitoring of the supervision sessions.
Background: Psychological therapy services are often required to demonstrate their effectiveness and are implementing systematic monitoring of patient progress. A system for measuring patient progress might usefully ‘inform supervision’ and help patients who are not progressing in therapy. Aims: To examine if continuous monitoring of patient progress through the supervision process was more effective in improving patient outcomes compared with giving feedback to therapists alone in routine NHS psychological therapy. Method: Using a stepped wedge randomized controlled design, continuous feedback on patient progress during therapy was given either to the therapist and supervisor to be discussed in clinical supervison (MeMOS condition) or only given to the therapist (S-Sup condition). If a patient failed to progress in the MeMOS condition, an alert was triggered and sent to both the therapist and supervisor. Outcome measures were completed at beginning of therapy, end of therapy and at 6-month follow-up and session-by-session ratings. Results: No differences in clinical outcomes of patients were found between MeMOS and S-Sup conditions. Patients in the MeMOS condition were rated as improving less, and more ill. They received fewer therapy sessions. Conclusions: Most patients failed to improve in therapy at some point. Patients’ recovery was not affected by feeding back outcomes into the supervision process. Therapists rated patients in the S-Sup condition as improving more and being less ill than patients in MeMOS. Those patients in MeMOS had more complex problems.
This paper reports from a study of an intervention aimed at strengthening mental health nursing staff supervision. We developed and tested a short-term group-based meta-supervision intervention as a supplement to usual supervision. The intervention drew on action learning principles to activate and inspire supervisees to develop strategies for influencing their own supervision practices. The core ‘meta-supervisory’ process was organized round participants’ reflections on the possible benefits of supervision, their perceived barriers to realizing the benefits, and the articulation of concrete actions to overcome the barriers. In this paper, we introduce previously reported findings from the study and present two novel supplementary analyses of data from the meta-supervision process. First, we analyse a transcript of an audio recording made during the intervention, which illustrates how supervisees generate empowering psychosocial resources through the group processes. Second, we analyse supervisees’ paraphrased accounts of barriers to effective supervision and their accounts of personal projects to overcome the barriers. Barriers ‘outside’ the supervision setting primarily inspired projects aimed at creating structural change, whereas barriers ‘inside’ the supervision setting inspired projects aimed at creating individual change. The meta-supervision intervention was effective in increasing participation in supervision, but it shared the same problems of resistance and reluctance as often observed in supervision in general. In the discussion, we compare our ‘bottom-up’ approach to activating supervisees and implementing supervision practices with ‘top-down’ approaches. The meta-supervision intervention illustrated the importance of engaging supervisees in their own supervision and suggested how it can have both individual and organizational benefits.
This article describes the clinical supervision of Multisystemic Therapy (MST), which takes place in the context of a quality assurance and quality improvement system that is used to support the transport and implementation of MST nationally and internationally. Information is provided about the assumptions, objectives, structure, process, and content of MST supervision; training and support provided to supervisors; methods used to measure adherence to the supervision model; and, findings supporting linkages between supervision, therapist adherence, and youth outcomes. MST supervision is considered in the context of recent efforts to identify empirically supported approaches to supervision and of recent developments in implementation research.
NHS Education for Scotland (NES) has developed a suite of training to address the learning and development needs of supervisors of psychological therapies in the National Health Service (NHS) in Scotland and to support quality of evidence-based practice in psychological therapies, in light of the recent expansion in this area of healthcare. In parallel with the structure of the recently developed supervisory competency frameworks, an initial training package addressing generic (cross-modality) supervision competences was supplemented by the development of a training package to meet the specific needs of supervisors of CBT: NES Specialist Supervision Training in CBT (NESSST CBT). A blended learning package was developed, in light of the emerging evidence around the effectiveness of e-learning, to produce a flexible and learner-centred training package. This paper describes the development, delivery and planned evaluation methods of NESSST CBT. Lessons learned during implementation are outlined, along with key challenges regarding the future of supervision training in Scotland and the UK.