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Empirically based CBT Supervision: Making Supervision More Effective ABCT Roundtable
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1. Empirically based CBT Supervision: Making Supervision More Effective
Robert Reiser, Ph.D., Director, Kurt and Barbara Gronowski Psychology Clinic, Palo Alto University (AKA Pacific Graduate School of Psychology, Los Altos, CA. (rreiser@paloaltou.edu)
Derek Milne, Ph.D., Director, Doctorate Program in Clinical Psychology
Newcastle University, England. (d.l.milne@ncl.ac.uk)
Donna M. Sudak, M.D., Professor of Psychiatry, Director of Psychotherapy Training, Drexel University College of Medicine.
Leslie Sokol, Ph.D., Director of Training, Beck Institute of Cognitive Therapy and Research.
2. Empirically based CBT Supervision: Making Supervision More Effective
Robert Reiser, Ph.D., Director, Kurt and Barbara Gronowski Psychology Clinic, Palo Alto University (AKA Pacific Graduate School of Psychology, Los Altos, CA. (rreiser@paloaltou.edu)
Derek Milne, Ph.D., Director, Doctorate Program in Clinical Psychology
Newcastle University, England. (d.l.milne@ncl.ac.uk)
3. “We posit that the practice of supervision involves identifiable competencies, which can be learned and in turn promote the supervisee’s clinical competence…” (p.4) (c) Milne and Reiser, All Rights Reserved 2010 3
4. The problem… “We would never dream of turning untrained therapists loose on needy patients, so why would we turn untrained supervisors loose on untrained therapists who help those needy patients?” (p. 606)
“If…supervision is really all that important, then why is training in how to supervise…so limited?... something does not compute.” (p. 604). Emphasis added
(Handbook of Psychotherapy Supervision, 1997 (ed.) Watkins
(c) Milne and Reiser, All Rights Reserved 2010 4
5. Comparative Structures of Cognitive Therapy Sessions and Supervision Sessions_____________________________________________________________________________
6. Expert Consensus and Best Practice Guidelines While a number of expert consensus statements and best practice guidelines for supervision competencies exist:
Falender et al. (2004)
Roth and Pilling (2008)
Falender and Shafranske (2010)
Farber and Kaslow (2010)
There is a very limited evidence base…
7. Consensus Statements on Clinical Supervision In their introduction to A competence framework for the supervision of psychological therapies, Roth and Pilling (2008) note:
“Realistically – or perhaps more accurately, pragmatically - it seems clear that any competence framework would need to be developed, by integrating empirical findings with professional consensus....” (p.6)
10. EBP Guidelines for Supervision In a recent article on guidelines, Milne and Dunkerley (2009) conclude:
“there are some difficulties with existing guidelines, such as the need for guidelines
to be adapted to local/national needs (such as the NHS; Parry, 2000) and to be evaluated and evidence-based.” (p.45) [emphasis added]
11. EBP Guidelines for Supervision Milne and Dunkerley (2009) developed a set of clinical supervision guidelines based on
a systematic review of the evidence for clinical supervision;
developing a model for supervision with broad application; and
including professional consensus and evaluation as part of the guideline development process. (p.45)
12. EBP Guidelines for Supervision Today we will review two key practice guidelines drawn from Milne and Dunkerley (2007) with a strong empirical basis:
Developing a Needs Assessment and Setting the Learning Contract
Facilitating Learning in Supervision
13. Guideline 1:
Needs Assessment and Setting the Learning Contract
14. Supervision contract – what is it? Agreeing on learning objectives (goals) and practicalities (e.g. frequency of supervision) within a formal document
It is one of the best-established practices in facilitating the supervisee’s learning
The supervision contract helps to ensure that the learning needs of the supervisee are taken into account, together with the legitimate interests of others
Because ‘needs’ differ from ‘wants’, some collaborative goal-setting & negotiation may be necessary in normal practice
15. Key Practice Recommendation 1 Conduct a learning needs assessment: gather information about the supervisee that helps to define his/her existing skills, knowledge and attitudes. This platform is important to the supervisory relationship, is critical to clarifying the learning ‘zone’, and facilitates learning (as it builds on prior learning).
16. Key Practice Recommendation 2 Define clear (SMARTER) learning objectives: Specific, Measurable, (etc) goals serve several important functions in supervision (e.g. giving a sense of direction and providing the basis for evaluation). Goals should normally be assigned by the supervisor, and also generated by the supervisee, with some ‘win-win’ negotiation to ensure that needs and not ‘wants’ dominate the supervision contract.
17. Key Practice Recommendation 3 Address common content areas: contracts normally cover:
Competencies (specific knowledge, skills and attitudes, as required for the job);
Practicalities, such as the frequency of supervision;
Methods to be used (e.g. mutual observation);
Evaluation arrangements;
Documentation plans;
Professional matters, such as confidentiality.
18. Key Practice Recommendation 4 Review: progress towards the contract goals should be reviewed regularly
19. Video Presentation
Clip number 1
(Session 2:‘Goal-setting illustration’)
20. Guideline 2: Methods of Facilitating Learning in Supervision
21. Facilitating learning depends on the supervisor utilising appropriate methods: A supervision method is a technique for facilitating the supervisee’s learning, such as demonstrating a skill or technique.
The methods employed by a supervisor should be guided by the learning needs of the supervisee.
Methods are classed under three broad headings:
Symbolic (based on the use of words)
Iconic (visual images)
Enactive (action/behaviour)
22. Methods of clinical supervision ‘Symbolic’ methods: (based on the use of words).
Case presentation (asking supervisee to update you on a case)
Questioning and challenging (e.g. “What would you do next?” or “Would that bring about the desired outcome?”
Discussion (e.g. therapy notes, letters).
Instruction/teaching/informing/suggesting
Planning (e.g. what to do in next session).
Facilitating reflection (e.g. “what might you have done differently?”).
Tips and examples from the supervisor’s clinical experience (e.g. what to do when things go wrong).
Feedback/evaluation (e.g. what worked, what didn’t, what needs more work).
23. Methods of Clinical Supervision ‘Iconic’ methods: (based on images)
Modelling by the supervisor, or demonstration on a video (e.g. agenda setting)
Observation by the supervisee (via one-way mirror, sitting in or co-therapy)
Both parties observing and commenting on supervisee’s approach, recorded on audio or videotape.
24. Methods in Clinical Supervision ‘Enactive’ methods: (based on actions)
Role play (e.g. Socratic questioning)
Behavioural experiments (e.g. supervisee trying things out, testing beliefs)
Live supervision (supervisor observes and actively advises during session)
Learning exercises (e.g. supervisee studies video of own or supervisor’s clinical work, possibly using a coding tool, and presents analysis at next supervision session).
25. Knowledge-base A ‘blend’ means adding iconic and enactive methods to the familiar symbolic ones.
The need for a blend of supervision methods is advocated by textbooks.
Surveys suggest that supervisors regard discussing video-tapes of therapy, followed by live supervision and co-working as the most effective methods. Other effective methods are thought to include discussion of casework and demonstrations by the supervisor.
26. Key PracticeRecommendation 1 Take account of supervision contract: in selecting which method to use, aim to work in supervisee’s ‘zone’ (Zone of proximal development: the area that defines the next learning step). These should guide the use of supervision methods, together with the supervision alliance (i.e. the quality of the relationship- e.g. degree of trust or exploration).
27. Key PracticeRecommendation 2 Vary the methods used: this is likely to produce the best results. It helps to ensure variety and stimulation, and encourages supervisees to use different learning modes. Therefore, aim to use a blend of symbolic, iconic and enactive methods.
28. Key Practice Recommendation 3 Encourage work within the supervisees’ experiential learning cycle:
Using different supervision methods will maximise the likelihood that the supervisee will work within the learning cycle.
Supervisees should be encouraged to describe important events from their recent work, including emotionally-charged episodes (e.g. anxiety about meeting a new client). This can lead to helpful reflections (clarifying the supervisee’s understanding). In turn, this should lead to the supervisor offering information and advice (‘conceptualisation’), then round the experiential learning cycle to try things out within supervision (e.g. through educational role-play), or to planning, in order to try something out at work.
31. Key PracticeRecommendation 4 Aim to use 2 or 3 methods in each supervision session: A ‘package’ or combination of methods normally works best. Some methods may be more appropriate for novice supervisees (e.g. case presentation, demonstrating and planning). Other methods, such as challenging, may be more suitable for an experienced supervisee.
32. Key Practice Recommendation 5 Supervisors should provide (and invite) feedback regularly, to monitor how these methods are working
Encourage open and honest communication
33. 2. Illustration of Learning Methods Video demonstration of a supervisor using a blend of methods
(Session 4: ‘Mutual engagement in task’)
34. Use of Feedback Provide corrective, supportive feedback: the different methods can provide a lot of useful information on a supervisee’s competence and learning.
Feedback should be used to guide the acquisition of competence, and to consolidate this learning.
35. Evaluation can be: ‘Formative’ (i.e. corrective feedback)
or
‘Summative’ (a formal judgement; ‘gate-keeping’)
Both entail a judgement, by the supervisor of the extent to which a supervisee demonstrates attainment of the learning objectives (i.e. is fulfilling the agenda / supervision contract)
36. Feedback Definition:
‘Providing knowledge of results,
informational feedback or reinforcement as
a consequence of the supervisee’s actions’.
37. Knowledge Base Research findings and professionals agree about the importance of evaluation and feedback.
Milne (2002) identified feedback as a high frequency behaviour in studies of effective supervision
38. Key Practice Recommendation 1 Refer to the learning objectives:
The specific goals agreed within the supervision
contract should provide the basis for feedback and
evaluation.
The criteria for feedback and evaluation should be
clear within the contract- both parties should
know how progress will be assessed (e.g. by
reference to a competence framework; &/or by
using a standard form from within a local training
program).
39. Key Practice Recommendation 2 Give your feedback / evaluations in a professional way: a balance between positive and negative comments (strengths and weaknesses) is usually appropriate, identifying specific improvement goals and agreeing an action plan (i.e. constructive feedback / criticism).
encourage self-evaluations by the supervisee.
40. Key Practice Recommendation 3 Don’t rely entirely on your impressions as a supervisor, though these are legitimate (but remember to be clear that such feedback is only a personal impression / opinion)
Try to also use different assessment methods, in order to decide what to feedback, and to give your feedback extra validity.
The methods can include direct observation (e.g. based on a tape, or on co-working), written material (e.g. clinical reports), self-report (the supervisee’s account of their work), clinical outcome data (e.g. client’s symptom profile), or detailed clinical discussion.
41. Key Practice Recommendation 4 Review your approach regularly:
Ensure that you have opportunities for formal and informal reflection, and get guidance on your approach (e.g. at departmental / professional meetings; attendance at supervisors’ workshops /reading the profession’s guidance documents).
42. 3. Illustration of Feedback Video demonstration of a supervisor giving feedback
Session 5: Evaluation and feedback: Summary and mutual feedback”
43. 43 (c) Milne and Reiser, All Rights Reserved 2008
44. References
Kaslow NJ, Borden KA, Collins FL, Forrest L, Illfelder-Kaye J, Nelson PD, Vasquez MJ, Willmuth MEL (2004). Competencies conference: future directions in education and credentialing in professional psychology. Journal of Clinical Psychology 60, 699–712.
Liese, B.S. and Beck, J.S. (1997). Cognitive therapy supervision. In: Watkins, E. (Ed.): Handbook of Psychotherapy Supervision. NY: Wiley.
45. 45 (c) Milne and Reiser, All Rights Reserved 2008
46. References Roth, A. D. & Pilling, S. (2008) Use of evidence based methodology to identify the competencies required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioural and Cognitive Psychotherapy, 36, 129 –147.
Watkins, C. E. (Ed.). (1997). The Handbook of Psychotherapy Supervision. NY: Wiley.
Watkins , C.E. (1998). Psychotherapy Supervision in the 21st Century: Some pressing needs and impressing possibilities. The Journal of Psychotherapy Practice and Research, 7:93–101. (c) Milne and Reiser, All Rights Reserved 2008 46
47. 47 (c) Milne and Reiser, All Rights Reserved 2010
48. Supervision Practice Platform a) Supervision style or ‘stance’ (relationship qualities – e.g. support vs. challenge)
b) Supervision methods and techniques (e.g. use of feedback and experiential methods; formats – e.g. group; 1:1)
c) Supervision goals/agenda (including topics, settings, links, admin issues)
49. Supervision Practice Platform d) Supervision roles (e.g. consultant; teacher; model; colleague)
e) Supervision model/orientation (e.g. ‘tandem’/integrative)
f) Supervision philosophy: Personal core beliefs and values (e.g. assumptions arising from own training e.g. own theory of learning); rationality; freedom – e.g. as ‘adult learner’ -; respect; trust; collaboration; compassion: personal & professional
