Supervision of Clinical Practice: Models
and methods of delivery in a developing
context.
Dr. Bridie Gallagher
Clinical Psychologist
Indigo Child Development Centre
Introductions
• UK trained Clinical Psychologist – supervision is a
crucial competence of UK doctoral training.
– Currently completing distance postgrad course in
supervision.
• Two years working in Cambodia.
• PhD in parenting and child mental health.
• Special interest in working with looked after
children in the UK.
• Indigo provides assessment, intervention,
training, supervision, consultancy to families and
NGOs.
What is supervision?
• 'The act of overseeing; inspection;
superintendence; oversight.'
• "Teaching and learning process that gives
particular emphasis to the relationships between
and among service user, professional, and
supervisor and the processes that interplay
among them".
• “Provides supervisees with feedback about their
performance; offers them guidance in what to do
in times of confusion and need; allows them the
opportunity to get alternate views and
perspectives...”
• “Supervision is an intensive, interpersonally
focused one-to-one relationship in which one
person is designated to facilitate the
development of competence in the other
person”
• “...to achieve, sustain, and creatively develop a
high quality of practice through the means of
focused support and development.
Three main aims
• Formative: Educate or train, to help the professional to
develop.
• Normative: To manage and evaluate performance and
ensure ethical, quality services.
• Restorative: To support and allow those who work in
difficult settings with people in distress to share the
personal impact.
Why is it important?
• Burn out. Reduces Staff turnover in stressful settings
(Medland, Howard-Reuben, and Whitaker, 2004)
• Supervision encourages self awareness and reflection
(Rice et al. 2007). Without reflection we can respond
to people based on our own feelings and experiences
rather than on their needs – become abusive,
oppressive, or ineffectual.
• Evidence shows increased satisfaction of both staff
(Hyrkas, 2005; Ohlson & Arvidsson, 2005) and service
users (Leiter, Harvie, and Frizzell, 1998) when staff
receive adequate supervision.
• To challenge assumptions, prejudice, and develop
services to meet the needs of the service users.
Who provides it?
Ideally...
• More experienced and knowledgeable
professional (For appraisal often needs to be a
manager)
• A clear understanding of the demands of the role
and organisation.
• Training and experience of teaching/training,
supporting, and constructive evaluation and
feedback.
• Receiving their own clinical supervision
Supervision in the Cambodian Context
Supervision is becoming more widely acknowledged as a need:
Stressful working environments
• Wide range of helping professionals working in many areas.
– Vulnerable groups are prevalent
– Systems are under-resourced and under funding threats
• SUPPORT (RESTORATIVE)
Need for staff education and development
• Staff often lack formal and ongoing education and training
opportunities.
• High caseloads and demands mean limited time for development of
staff or ambivalence about investing in staff who are likely to leave.
• PROFESSIONAL DEVELOPMENT (FORMATIVE)
Lack of regulatory bodies and systems to ensure
quality services.
•
Confusion around professional roles (e.g.
counsellor/psychologist)
•
Anxiety for managers is increased and so
the normative functions of supervision
become important.
• MANAGEMENT (NORMATIVE)
Identified Issues
• Staff can feel scrutinised rather than supported. Not a
safe place to share concerns or weaknesses.
• Supervision provided by foreign staff with Western
models and influences. Often not trained in providing
supervision.
• Supervision is seen as a place to offload, not
facilitated/productive so participants cannot develop
and learn.
• Lack of attention to supervisory processes within social
work and psychology training.
• Ambivalence from senior management regarding their
own supervisory needs.
Our Role
• “Experts” in psychological processes, team
dynamics, learning models.
– Clear training and models to draw upon.
• Experience providing supervision to social
workers, support staff, carers, nurses.
HOWEVER...
• Models of supervision are often closely aligned with
psychological models (learning, developmental, and
therapeutic models).
• These models have inherent biases and assumptions
within them about distress, normal behaviour and
relationships.
• There are, therefore, considerable issues with simply
importing Western models of supervision into the
Cambodian context.
• Patel (2004) - Supervision is a primary way in which ideas
and values about human relationships and distress are
communicated and disseminated to professionals.
– Back door colonisation.
• Need for supervisor to have an awareness and
acknowledgement of transcultural issues and power
imbalances.
– Throw out the models!
Common responses
• Colour blindness – it is not a problem I treat and
respect all my supervisees the same no matter
what ethnic or cultural background they come
from.
• Colour conscious – every issue or difficulty is
attributed to cultural differences.
• Denial – the way in which I work is not affected
by differences in culture as it is open and so can
accommodate all different beliefs and
approaches.
• Pragmatist – There is too much to do in
supervision and not enough time I cannot
address every issue...
Working with difference
• Addressing power imbalances and cultural differences is vital
to making a safe space and for effective supervision in any
context.
– Discussing other experiences of supervision and/or
evaluation
– Discussing experiences of oppression or powerlessness
• The supervisor must be able to challenge the supervisees
assumptions without fear.
– The supervisees must also be able to challenge the supervisors
assumptions and prejudices.
– Address differences in gender, ethnicity, role up front
– Agree a shared language for talking about difference.
– Develop strong skills in encouraging reflection.
Indigo and supervision
• Clinical psychologists supervise Cambodian colleagues in
both direct therapeutic work and in providing supervision
• We supervise foreign staff in a variety of roles in Phnom
Penh.
• Our Cambodian psychologist offers supervision.
– As a counsellor he offers a supportive function.
– As a psychologist he can offer teaching or advice in a wide
range of areas including managing distress, encouraging positive
behaviour in parents, carers, individuals, and supporting the
development of a strong team.
– Encouraging staff to reflect upon their own practice, develop
alternative perspectives, and be creative in their responses to
problems or challenges. (Interested to hear your feedback on
these very Western ideas of “good” supervision.)
Training supervisors...
• CLEAR model (Hawkins, 1985)
– Contract
– Listen
– Explore
– Action
– Review
• Simple model to help guide the process and to
provide structure without imposing theories.
• Supervisee (or group) takes responsibility for
the topic.
• Requires flexibility and reflexivity in the
supervisor but is also useful for new
supervisors.
- Supervisors develop the ability to challenge and
address sensitive and complex issues through their
own supervision.
Contract
• Practicalities
• Ground rules
– Both allow the supervisor to create a safe space
• As supervision can have three functions these
should be negotiated explicitly between the
organisation, supervisor, and supervisee.
– Is this purely supportive?
– Is there a focus on staff learning and development? In
what area?
– Will the supervisor be assessing/evaluating?
• What is the priority? “How can we best use this
time?”
Listen
• Supervisors must be skilled in active listening.
• Supervisees must be given time to clearly define their
issue, feeling, approach, relationship and have that
validated – empathy is key
• We often jump in to offer advice and solve the issue.
• If a supervisee feels dismissed, not heard, or
misunderstood then they will not be able to learn or
share in future. They must feel safe.
• If they are offered solutions immediately they do not
develop as problem solvers.
• The supervisor helps to reframe problems so they feel
soluble, and moves the story along by making new
connections.
Explore
•
•
•
•
•
•
Questioning
Reflection
Generating new insight
Challenge assumptions
Create different options together
Evaluate thoroughly, challenge assumptions of
the models or approaches that inform these
options.
Action
• The supervisee – having explored and
evaluated options and discussed their
outcomes, chooses an action.
• The supervisor helps them to plan how they
will approach this and what first steps they
must take.
– Role play or practice
Review
• Just as important as contracting.
• Review the outcomes of actions from last
session and any problems
• Review the supervision
– Seeking feedback allows reflection on the process,
what works, what does not feel helpful
– Modelling a process that makes professionals
better at their jobs (Hubble, Duncan, & Miller,
1999 )
Benefits.
• Differences are addressed at the outset and there are
clear goals for the session (even if this is merely to
share a difficult case – or a successful case!)
• A safe space is created by ground rules and clear
expectations.
• The supervisee is supported to develop their own
solutions (possibly with the help of the group)
• The supportive and educational functions can be
addressed in the same process
• The supervisor can evaluate their own performance
and adapt to the needs of the supervisees in response
to the review.
Case Studies
• Please choose a case study
• read it alone
• Feedback to the group:
• What role (formative/normative/restorative)
might you assume as the supervisor?
• Can you think of some questions that might open
up reflection and different perspectives?
• What assumptions might need to be challenged?
Summary
• Supervision is for the benefit of the organisation, the professional,
and the service users.
• Supervision has three main functions (support, managment, and
professional development); all are important and need adequate
attention.
• Supervising is a SKILL and requires training and supervision not just
experience in the field.
• Supervision from foreign staff based on Western models must be
questioned and constantly reviewed.
• Transcultural supervision requires that differences are addressed
and discussed.
• The CLEAR model offers a useful framework for training supervisors.
• Supervision is an ongoing need not just for new or junior staff.
Questions and Discussion
Bibliography
• Hawkins, P. (1985) Humanistic Psychotherapy supervision: a conceptual
framework. Self and Society: Journal of Humanistic Psychology, 13, 69-79.
• Hubble, M.A,. Duncan, B. L ., & Miller, S. D. (1999). The heart and soul of
change: What works in therapy. Washington DC: American Psychological
Association.
• Hyrkas, K. (2005) Clinical Supervision, burnout, and job satisfaction among
mental health and psychiatric nurses in Finland. Issues in Mental Health
Nursing, 26, 531-556
• Leiter, M. P., Harvie, P., & Frizzell, C. (1998) The correspondence of patient
satisfaction and nurse burnout. Social Science and Medicine, 47, 16111617.
• Mannix et al (2006) Effectiveness of brief training in Cognitive Behaviour
Therapy techniques for palliative care practitioners. Palliative Medicine 20:
579-584
• Maslach, C. (1976) Burned-out. Human Behaviour, 5, 16-22.
• Medland, J., Howard-Reuben, J., & Whitaker, E. (2004). Fostering
psychosocial wellness in oncology nurses: Addressing burnout and social
support in the workplace. Oncology Nursing Forum, 31, 47-54
• Ohlson, E., & Arvidsson, B. (2005) The nurses conception of how clinical
supervision can promote their mental health. Nursing Science and
Research in the Nordic Countries, 25, 32-35.
• Patel, N. (2004), Difference and Power in Supervision: The Case of Culture
Racism, in I. Fleming, & L. Steen (eds). Supervision and Clinical Psychology.
Hove: Brunner-Routledge, pp.108-134
• Rice, F., Cullen, P., McKenna, H., Kelly, B., Keeney, S., & Richey, R. (2007)
Clinical supervision for mental health nurses in Northern Ireland:
formulating best practical guidelines. Journal of Psychiatric and Mental
Health Nursing, 14, 516-521