The Scandal of Clinical Supervision: How to Resolve It (Part 2 of 2)

 

In the previous post, I described the 3 common pitfalls of clinical supervision, which are “theory-talk”, “pat-on-the-back”, and the lack of monitoring progress.

Here, three key methods are suggested on how to enhance the use of clinical supervision.

Here’s How:

Keep in mind the use of the “3-Dimensional Perspective” I proposed in an older post Why Our Self-Assessments Might be a Delusion of Reality. I suggested this to guard against the fallacy of the illusion of expertise.

Quick recap: The three approaches are

1. The use of formal client feedback measures;

2. Video recordings of sessions; and

3. Clinical supervision.

In order to fully benefit from clinical supervision, I’d suggest the following three features:

1. Stay Close to Client Engagement:

We often assume that we have consensus to pursue a particular track with our clients.

First, make sure we have consensus on the goals. Then explicitly check on client’s willingness to engage in a particular area.

We make the mistake that once the client explicates a goal, that we have her will on-board, which may not be the case. For example, a  client might have a goal on making friends as she is experiencing loneliness that’s making her depressed. Through therapy, it’s established that she sees herself as unlovable, based on her past abusive relationship with her father and recent divorce. The self-attacks keeps her isolated and depressed.  The therapist cannot simply assume that since there is consensus on the goal (i.e., to develop friendships), that she is willing to work on her self-deprecation, which has been keeping her away from the social world. The therapist needs to ask – by knocking on the doors of her inner life – and to request for permission to be invited in as a guest.

“Is this something you want to work on?”

 

Second, the therapist needs to systematically monitor if client is engaged in the process and rationale of the particular method of treatment. For example, where working with her core emotions through a two-chair dialogue, does she see the rationale for doing so? Does she see the causality of how her self-attack is keeping her depressed?

Third, all of the above can only take place when there is an emotional bond and a sense of emotional safety working with you. Take the time to check in on their perspective on this. (Also see Matthew Bambling and colleagues excellent supervision study1).

2. Listen to the Music First:

Imagine a friend comes to you and tries to describe to you a beautiful and inspiring song that he recently heard. Would you rather him continue his description with his best of intentions, or would you rather him let you have a listen to the piece of music instead?

Without a skip of a beat, I’d pick the latter.

This is where the value of recording your sessions reaps its rewards. Bring in the audio/video recordings of the session to supervision. Hearing the start of a session is often useful; how we start a session has a ripple effect on how the rest of the hour unfolds. Thereafter, pick a 10 min segment to let your supervisor listen/watch. This clip could be one of the following:

a. thin slice of the representation of the quality of the engagement;

b. a difficult interaction/alliance rupture moment; or

c. If you do not have either of the above, randomly pick some where in the middle of session. You would be surprised at would might be useful from this!

This is not only helpful in clinical supervision, but also useful in self-supervision. (More on this in a later post).

When a sound rationale is given to clients on the purposes of recording (e.g., “I record my sessions so that I get to ensure the highest service delivery and experience in therapy… I would review them, and sometimes with the help of a supervisor, when necessary.”), clients are more likely to agree. Clearly, when the client is not comfortable of the idea, do not process with the recording. Let them know that you respect their choice. Nonetheless, the rate of compliance to be audio/video recorded is dependent more on the therapist than the client.

3. Use Routine Outcome Measurement + Revisit The Case: 

For supervisors: Try out this little experiment. Once you’ve got your supervisees routinely monitoring their client outcomes using measures, get your supervisees to pick 3 cases that show no improvement and advise them to bring them up in supervision.

Pick another 3 cases that show no improvement, and put them on your “wait-list,” that is, hold off providing case consultation on these cases. The verdict: see if there’s a difference in outcomes for the 2 groups (Supervision vs. No Supervision) of 6 cases. This definitely lacks the rigor of a randomised clinical trial (RCT), but it is definitely worth testing it out. Whatever the verdict is, reflect on it. What factors in your supervisory encounter impacted the supervisee/therapist to act similarly or differently, that led to client improvement, or the lack of?

For supervisees: Do likewise, and note down what pointers you applied into your 3 cases in the supervision group. How did it go? Did it help, or was it off-the-ball? Did it have an impact on the outcomes and alliance ratings? Either way, reflect this back to you supervisor.

This lets your supervisor know how on-target their guidance has been, and allows continuity or re-calibration when needed.

Stick-It: 

Reference:

1. Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16(3), 317 – 331. doi: 10.1080/10503300500268524