The Scandal of Clinical Supervision: Here’s the Shocker (Part 1 ...

 

Like most psychotherapists, you are likely to regard clinical supervision as highly integral to your professional development.¹I cannot imagine not having someone to turn to for case consultations and guidance, especially when I’m stuck in the rut and not making progress with a case.

Clinical supervision has be hailed as the “signature pedagogy” of choice in the field of  psychotherapy.² In an important review done by Edward Watkins³ (I highly recommend reading it), he examines the past 30 years of research, churning out in total 18 empirical studies that specifically examined the impact of supervision and client outcomes. Dr. Watkin’s points out that out of the 18 studies, only 11 were related to the impact of supervision on outcome. Critically, he says,  “…the collective data appeared to shed little new light on the matter: We do not seem to be any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome.”

In case you are wondering, 3 decades worth of stalemate is quite a long time, given the prevalence of clinical supervision as the learning method of choice by psychotherapists.

More recently, fellow ICCE associates, Tony Rousmaniere and Robbie Babins-Wagner and others conducted a large five-year dataset consisting of 23 supervisors involved in a naturalistic setting ⁴, supervision was found to be not a significant contributor on client outcome. Rubbing salt to the wound, the supervisors’ experience level, profession (social work vs. psychology), and qualifications did not predict differences between supervisors in client outcomes as well.

Now, if we piece all of this together, it sounds like this. Even though most of us wholeheartedly swear by it that our experience of clinical supervision helped us to grow and develop as practitioners, it rarely makes a den on our client improvement.

The Danger 

Why isn’t clinical supervision translating to benefit for our clients? Here are three speculations:

1. Theory-Talk:

Often, the encounter in clinical supervision revolves around case discussion, theoretical formulation, case formulation, and even gossip (isn’t that when we talk about someone without him or her present?). This mostly fits under the umbrella of conceptual knowledge, and does not delve further in the actual moment-by-moment interactional pattern. (See future post on 3 Different Types of Knowledge.)

2. Pat-on-the-back:

What feels good doesn’t necessarily equate to what helps us grow. While it is important to take care of the supervisee’s ego, at times we fail to focus on their “growth edge”, that is, taking care of the supervisee’s sense of self as a helper, and helping them going ever so slightly beyond that comfort zone.

3. The lack of a monitoring progress:

We therapists are an optimistic bunch. In the absence of real-time monitoring of outcomes and engagement, session-by-session, we fail to detect deterioration, or at least the lack of progress.

Even when we do use routine outcome monitoring devices, like the Outcome Rating Scale (ORS) & Session Rating Scale (SRS), Outcome Questionnaire (OQ-45), or Clinical Outcome Routine Evaluation-Outcome Measure (CORE-OM), we fail to integrate this in the supervisory process in a meaningful fashion.

I once had a supervisee who insisted on his shortfall in helping a particular client. He didn’t have her ORS/SRS graph at that moment. I insisted that he brought it in the following meeting. Here’s what the client is saying from the graph’s information: outcomes where gradually improving, and alliance had a dip at the 2^nd session, but continued to pick up thereafter. And here’s what the supervisee was essentially saying: Things aren’t improving.

We then spent time to work through the supervisee’s uncertainty, while holding in mind that the client is likely to be reporting benefit from the engagement. We then need to take our eyes and ears from the perspective of the client to lead us further. It turns out that the therapist was concern about answering to the referral concern posed by the referring psychiatrist, which wasn’t the client’s main issue at hand. Then we proceeded to work out how to attend to the primary client, which is the patient seeking help, and how to address the secondary client, which is the referring psychiatrist.

The marriage of data and clinical knowledge emerged a type of dialogue that is richer, and aids clinical decision making.

Summary:

Beware of the 3 common pitfalls in clinical supervision. They are “theory-talk”, “pad-on-the-back”, and the lack of monitoring progress.

For some ways to improve the situation in clinical supervision, see the next post on The Scandal of Clinical Supervision: How to Resolve It (Part 2 of 2).

 

References:

 

1. Orlinsky, D. E., Botermans, J.-F., & Ronnestad, M. (2001). Towards an empirically grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Australian Psychologist, 36(2), 139-148. doi: http://dx.doi.org/10.1080/00050060108259646

2. Watkins, C. E. (2010). Psychotherapy Supervision Since 1909: Some Friendly Observations About its First Century. Journal of Contemporary Psychotherapy, 1-11. doi: 10.1007/s10879-010-9152-2

3. Watkins, C. E. (2011). Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. The Clinical Supervisor, 30(2), 235-256. doi: 10.1080/07325223.2011.619417

4. Tony G. Rousmaniere, Joshua K. Swift, Robbie Babins-Wagner, Jason L. Whipple & Sandy Berzins (2014): Supervisor variance in psychotherapy outcome in routine practice, Psychotherapy Research, DOI: 10.1080/10503307.2014.963730