CBT Supervision: From Reflexivity to Specialization

Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies

Exposure is an important element of treatment for many evidence-based treatments but can be challenging to implement. Supervision strategies to support exposure delivery may be an important tool to facilitate the use of exposure techniques; however, they must be considered and used in the context of the supervisory alliance. The present study examined relations between supervisory alliance and fidelity to the trauma narrative (TN; i.e., imaginal exposure) component of Trauma-Focused Cognitive Behavioral Therapy. We also examined how supervisory alliance moderated the effect of behavioral rehearsal use in supervision on TN fidelity. We analyzed data from a randomized controlled trial, in which forty-two supervisors and their clinicians (N = 124) from 28 Washington State community-based mental health offices participated. Clinicians were randomized to receive one of two supervision conditions-symptom and fidelity monitoring (SFM) or SFM with behavioral rehearsal (SFM + BR). Supervisory alliance alone did not predict delivery (i.e., occurrence) or extensiveness of delivery of the trauma narrative. Client-focused supervisory alliance moderated the effectiveness of behavioral rehearsal-as client-focused alliance increased, the odds of delivering the TN also increased significantly. Future research should further investigate how to appropriately match supervision techniques with supervisory dyads and explore the interplay of alliance with supervision techniques a supervisor might employ.

Conceptualising and managing supervisory drift

Clinical supervision is widely considered to be an essential component in the translation of evidence-based treatment protocols into routine clinical practice. Experts in the field have produced guidance on the structuring of CBT supervision, yet previous surveys on everyday practices have consistently found that supervisors and supervisees appear to drift from these recommendations. Surprisingly, little has been written on the origins and maintenance of supervisory drift and thus it remains a poorly understood phenomenon. To assist supervisors, supervisees and meta-supervisors in recognising and responding to signs of drift, this paper seeks to build on the understanding of therapist drift by conceptualising how supervisor and supervisee cognitions, emotions and behaviour could intentionally or unintentionally render the supervision process ineffective or at worst harmful. Drawing on therapist schema literature, hypothesised pre-disposing factors for drift are presented together with clinical examples and a range of steps for managing indicators of drift in practice. Further research is needed to gather empirical support for the mechanisms proposed.

Key learning aims

As a result of reading this paper, readers should: (1)

Clinical supervision in CBT training: what do participants view as effective?

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)

Are you sitting (un)comfortably? Action-based supervision and supervisory drift

Action-based methods such as behavioural experiments, role-play and (by extension) ‘chairwork’ are powerful techniques recommended in core supervisory texts for cognitive behavioural therapy (CBT). Despite this, experiential methods are seldom used by supervisors, suggesting that supervision often drifts from a ‘doing process’ to a ‘talking process’. A number of factors contribute to this divergence from best practice, including limited confidence and a lack of familiarity with experiential procedures amongst supervisors. To address this, the current paper presents a variety of action-based techniques for enhancing supervisees’ technical, perceptual, interpersonal, reflective and personal competencies. Behavioural experiments, empty-chair, multi-chair and role-playing exercises for maintaining treatment fidelity, enhancing empathic attunement, repairing therapeutic ruptures, resolving impasses and working through negative countertransference are described, amongst others. Further research is needed to establish the nature and extent of supervisory drift, as well as the efficacy of action-based methods.

Key learning aims

As a result of reading this paper, readers should:(1)

Can we agree on the quality of clinical supervision? Inter-rater reliability of the Short–SAGE (Supervision: Adherence and Guidance Evaluation) scale

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)

An improved competence rating scale for CBT Supervision: Short-SAGE

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.

How Supervisees on a Foundation Course in CBT Perceive a Supervision Session and what they Bring Forward to the Next Therapy Session

BACKGROUND

There is limited research into the effect of supervision in cognitive behavioural therapy (CBT) from the supervisees' perspective.

AIMS

The aim of the study was to acquire knowledge from the supervisees' perspective as to what in particular in the supervision process contributes to the therapy process.

METHOD

Fourteen supervisees on a foundation course participated in the study. A qualitative approach was used with thematic analysis of the participants' written diaries after supervision and therapy sessions.

RESULTS

Analyses of supervisees' experiences suggested that a variety of therapeutic interventions were easier to implement if one had the supervisor's support and felt free to decide if and when the suggested interventions could best be implemented. Evaluation in the form of positive feedback from the supervisor indicating that the supervisee was 'doing the right thing' was perceived to be important. A unifying theme when supervisees felt they were not getting anything out of the supervision was that the supervisees did not have a supervision question.

CONCLUSIONS

The results of this research suggest that the supervisor's support during training is perceived to be important for the supervisee. Receiving positive feedback from one's supervisor in an evaluation is perceived to have a great impact on whether the therapist implements the suggested therapeutic interventions discussed in the previous supervision.

A survey of CBT supervision in the UK: methods, satisfaction and training, as viewed by a selected sample of CBT supervision leaders

Internationally, clinical supervision has been increasingly recognized as a core competency and an essential requirement for clinical training. Over the past 10 years, frameworks for supervision competencies have been developed and promulgated in several countries, notably the UK, USA and Australia. But what is the current status of the actual practice of CBT supervision in the UK? We conducted an internet survey with a purposive sample of n=110 accredited British Association for Behavioural and Cognitive Psychotherapy (BABCP) supervisors and trainers (a 44% response rate), selected for their assumed expertise. The results were consistent with past surveys of Townend et al., indicating that the most frequently reported supervision methods tended to reflect many of the recommendations in widely disseminated supervision competency frameworks and recognized best practice statements. Overall, these CBT supervision leaders reported using an impressively wide range of methods, including much more frequent use of role-play, therapy recordings, and direct observation than reported in the Townend et al. surveys or in observational studies. Although satisfied in their supervisory role, respondents indicated the need for improved CBT supervisor training resources, with significant interest in developing competence instruments and group supervision methods. In conclusion, at least for this small sample of CBT supervision leaders in the UK, practice reflects international progress, but training resources are sought to maintain momentum.

Supervising Cognitive Behavioral Therapy Practitioners in Urban Brazil

There is growing interest in the study of supervision as a core aspect of cognitive behavioral therapy (CBT) learning and practice. Standard models of CBT supervision generally contain some components of the following structure: teaching therapist conceptualization skills, interpersonal processes to build a collaborative therapeutic relationship, clinical procedures, and treatment protocols presenting specific procedures for particular problems. As is true for CBT practice, supervision is affected by the cultural context, including macrostructures (e.g., social and economic aspects) and microstructures (e.g., the institution where training is provided). The main goals of this article are (a) to review some of the key elements in clinical supervision of CBT practitioners, (b) to postulate sources of cultural variation that may affect CBT supervision in Brazil, and (c) to illustrate differences between CBT supervision models proposed in the literature and the practice of supervision carried out in Brazil.

Training Cognitive Behavioral Therapy Supervisors: Didactics, Simulated Practice, and “Meta-Supervision”

The delivery of competent clinical supervision is vital to the successful training of new cognitive behavioral therapists, and—in the case of peer supervision and consultation—a boon to the maintenance of therapists’ high professional standards throughout their careers. However, it is only recently that the field of psychotherapy in general and cognitive behavioral therapy (CBT) in particular has implemented formal methods of training clinicians to be competent supervisors. Drawing on recent findings from evidence-based programs of CBT supervision, this article highlights the contents and processes of a graduate training course in CBT supervision involving didactics, readings, and experiential exercises. The 6 major modules of this seminar are explicated, including such topics as the supervisory relationship, enhancing CBT competencies in supervisors and supervisees alike, promulgating ethical practices, and successfully managing the administrative aspects of supervision. In addition, the concept of “meta-supervision” is described and illustrated in the form of a transcript from a long-distance, computer-assisted meeting between a senior consulting supervisor and his junior “supervisor-evaluee.” The transcript highlights the key features of meta-supervision, including the cross-cultural considerations that must be addressed when doing international training.

Cognitive Behavioral Therapy Supervision in a University-Based Training Clinic: A Case Study in Bridging the Gap Between Rigor and Relevance

Principles and procedures for supervising cognitive behavioral therapy (CBT) were broadly defined in 2 early seminal texts almost 15 years ago (Liese & Beck, 1997; Padesky, 1996) and updated more recently (Beck, Sarnat, & Barenstein, 2008; Newman, 2010). However, the actual practice of CBT supervision often shows poor fidelity to this model (Townend, Iannetta, & Freeston, 2002) with notable deficiencies in the use of direct observation, standardized observational rating systems, and experiential methods in supervision (Milne, 2008). The advent of more specific competency statements on CBT supervision has been a significant leap forward (Falender et al., 2004; Roth & Pilling, 2008) but poses some practical challenges to clinical supervisors in terms of transferring broad competency statements into actual supervisory practice. We address the need for more rigor in CBT supervision within a university training clinic setting and outline some promising ingredients for this specification drawing on competencies, metacognition, and experiential learning theory.

Ten steps to cognitive behavioural supervision

Clinical supervision is recognized as essential for CBT therapists, both during training and in subsequent practice, and there has been a rapidly growing demand for accredited therapists to become supervisors. However, this can be a daunting prospect. Supervision is a highly complex activity with several overlapping purposes, in which the supervisor must enact multiple roles and use varied modes of activity. Research on the process has been limited, but a consensus on good practice and evidence-based procedures is beginning to emerge. Against this backdrop, a sequence of steps to be taken within any CBT supervision session is presented here. The structure is applicable across all levels of expertise. The purpose is to give clear and accessible guidance to supervisors to ensure they adhere to best practice and manage sessions in an efficient, helpful and well-focused style.

An N = 1 evaluation of enhanced CBT supervision

BACKGROUND

Clinical supervision plays an essential role in the development of mental health professionals and is increasingly viewed as a discrete professional specialization. However, research has rarely addressed core issues such as the measurement and manipulation of clinical supervision, so there are very few direct comparisons between the different supervision methods.

AIMS

To operationalize two related approaches, cognitive-behavioural (CBT) and evidence-based clinical supervision (EBCS), demonstrate their fidelity, and then evaluate their relative effectiveness in facilitating the experiential learning of one supervisee.

METHOD

Within a multiple-baseline, N = 1 design, we rated audiotapes of supervision on a competence rating scale.

RESULTS

Findings generally favoured the EBCS approach, which was associated with higher fidelity by the supervisor and increased engagement in experiential learning by the supervisee.

CONCLUSIONS

This preliminary but novel evaluation indicated that CBT supervision could be enhanced. Implications follow for supervisor training and a more rigorous N = 1 evaluation.

Self-reflection in cognitive behavioural therapy and supervision

OBJECTIVE

Supervision is a basic part of training and ongoing education in cognitive behavioural therapy. Self-reflection is an important part of supervision. The conscious understanding of one's own emotions, feelings, thoughts, and attitudes at the time of their occurrence, and the ability to continuously follow and recognize them are among the most important abilities of both therapists and supervisors. The objective of this article is to review aspects related to supervision in cognitive behavioural therapy and self-reflection in the literature.

METHODS

This is a narrative review. A literature review was performed using the PubMed, SciVerse Scopus, and Web of Science databases; additional references were found through bibliography reviews of relevant articles published prior to July 2011. The databases were searched for articles containing the following keywords: cognitive behavioural therapy, self-reflection, therapeutic relationship, training, supervision, transference, and countertransference. The review also includes information from monographs referred to by other reviews.

RESULTS

We discuss conceptual aspects related to supervision and the role of self-reflection. Self-reflection in therapy is a continuous process which is essential for the establishment of a therapeutic relationship, the professional growth of the therapist, and the ongoing development of therapeutic skills. Recognizing one's own emotions is a basic skill from which other skills necessary for both therapy and emotional self-control stem. Therapists who are skilled in understanding their inner emotions during their encounters with clients are better at making decisions, distinguishing their needs from their clients' needs, understanding transference and countertransference, and considering an optimal response at any time during a session. They know how to handle their feelings so that these correspond with the situation and their response is in the client's best interest. The ability to self-reflect increases the ability to perceive other people's inner emotions, kindles altruism, and increases attunement to subtle signals indicating what others need or want. Self-reflection may be practised by the therapists themselves using traditional cognitive behavioural therapy techniques, or it may be learned in the course of supervision. If therapists are unable to recognize their own thoughts and feelings, or the effects of their attitudes in a therapeutic situation, then they are helpless against these thoughts and feelings, which may control the therapist's behaviour to the disadvantage of the client and therapist alike.

CONCLUSION

Training and supervision focused on self-reflection are beneficial to both supervisees and their clients. The more experienced the supervisor is, the more self-reflection used in therapy and supervision.

How do supervisee's learn during supervision? A Grounded Theory study of the perceived developmental process

To contribute to a model of CBT supervision, we interpreted supervisees' understanding of the processes involved in their receipt of supervision. Second, we assessed the utility of a Grounded Theory Methodology (GTM) to study supervision. Supervisees were interviewed about their experiences of supervision, within a cross-sectional, qualitative design. In-depth, face-to-face individual interviews were conducted with seven trainee clinical psychologists. Their perceptions of supervision were analysed by means of a constructivist revision of GTM. A conceptual model is presented, to show the learning process from the perspective of the supervisees. This suggests that the receipt of supervision was experienced against a developmental backdrop involving a progression along two continua: competency and awareness. A set of core processes (Reflection, Socratic Information Exchange, Scaffolding, Supervisory Alliance) were thought to interact, enabling appropriate learning across developmental stages. This was thought to facilitate movement through individualized Zones of Proximal Development (ZPD). The fidelity construct of ‘receipt’ is complex and does not lend itself to quantification and measurement using a positivistic approach. By contrast, GTM was a useful methodology to use in this context. Further research using a similar methodology may further contribute to a model of CBT supervision.

A qualitative comparison of cognitive-behavioural and evidence-based clinical supervision

Despite the acknowledged importance of clinical supervision, controlled research is minimal and has rarely addressed the measurement or manipulation of clinical supervision, hampering our understanding and application of the different supervision methods. We therefore compared two related approaches to supervision, cognitive-behavioural (CBT) and evidence-based clinical supervision (EBCS), evaluating their relative effectiveness in facilitating the experiential learning of one supervisee. Drawing on a multiple-baseline N = 1 design, we gathered mostly qualitative data by means of an episode analysis, a content analysis, a satisfaction questionnaire, and interviews with the supervisor and supervisee. We found that the EBCS approach was associated with higher supervision fidelity and increased engagement in experiential learning by the supervisee. This case study in the evaluation of supervision illustrates the successful application of some rarely applied qualitative methods and some potential supervision enhancements, which could contribute to the development of CBT supervision.

SAGE: preliminary evaluation of an instrument for observing competence in CBT supervision

Clinical supervision plays a recognized role in facilitating practitioner development and in promoting therapeutic fidelity, but instruments that can support such activities by measuring competence in supervision are rare and often psychometrically compromised. As part of a research programme intended to raise the empirical status of supervision, we describe the initial psychometric development of a new instrument for observing competence (Supervision: Adherence and Guidance Evaluation; SAGE). This instrument is suitable for measuring CBT supervision, and can be administered by self-rating or by an independent observer. Preliminary tests of the reliability and validity of SAGE suggest that it is a promising tool for evaluating supervision. In addition, SAGE can be applied readily and has good utility. In these respects, SAGE appears to have some advantages over existing instruments, and may therefore provide a basis for enhancing research and practice in CBT supervision. Suggestions for future research on SAGE are outlined, particularly the need for a generalizability analysis.

Evaluating the training of clinical supervisors: a pilot study using the fidelity framework

Theevaluation of supervisor training has featured weak measurement and lacked a coherent framework, limiting effectiveness. A literature review was first conducted to clarify the current status of supervisor workshop evaluations, related to the promising fidelity framework. This consists of five criteria: the workshop's design, the training (competence of the trainer), the delivery of the workshop, the learning of the participants (receipt), and the clinical practice outcomes (enactment). Second, we applied this framework to the training of supervisors (n = 17) in a cognitive-behavioural therapy (CBT) approach, by analysing one trainer leading two successive supervisors’ workshops. The review of the literature indicated that there were significant psychometric and conceptual deficiencies in the current evaluation of supervisor training. The data from the case-study analysis suggest that the manual-based workshop could be delivered with high fidelity by this trainer (e.g. the CBT approach to supervision received 89% approval). The fidelity framework provided a systematic, feasible and coherent rationale for the evaluation of supervisor training. Our preliminary findings indicated that the workshop was successful. To fulfil its promise as an improved way of evaluating supervisor training, the framework should be piloted with other trainers, instruments and workshops, using controlled designs.

Towards evidence-based clinical supervision: the development and evaluation of four CBT guidelines

Clinical supervision is central to evidence-based practice (EBP) and continuing professional development (CPD), but the evidence base has made little impact on supervision, a major form of CPD. We unite the two by developing four evidence-based guidelines for cognitive behavioural therapy (CBT) supervision. The guidelines were designed to address the supervision cycle (i.e. collaborative goal-setting; methods of facilitating learning; evaluation and feedback) within the context of the supervision alliance. Guideline development followed the National Institute for Clinical Excellence approach, including a representative stakeholder working group (with local service users and supervisees), a national group of supervisors and supervisor trainers, plus an expert reference group. A total of 106 such participants completed an ad-hoc guideline evaluation tool, designed to provide a multi-dimensional reaction evaluation of the guidelines. The guidelines were all rated favourably, satisfying the key initial criteria of accuracy and acceptability, and were judged to represent a CBT approach to supervision. It is concluded that the use of the guidelines might help CBT supervisors to better meet demands for CPD (including specialization in supervision) and EBP.

Acquiring and Refining CBT Skills and Competencies: Which Training Methods are Perceived to be Most Effective?

Background: A theoretical and empirical base for CBT training and supervision has started to emerge. Increasingly sophisticated maps of CBT therapist competencies have recently been developed, and there is evidence that CBT training and supervision can produce enhancement of CBT skills. However, the evidence base suggesting which specific training techniques are most effective for the development of CBT competencies is lacking. Aims: This paper addresses the question: What training or supervision methods are perceived by experienced therapists to be most effective for training CBT competencies? Method: 120 experienced CBT therapists rated which training or supervision methods in their experience had been most effective in enhancing different types of therapy-relevant knowledge or skills. Results: In line with the main prediction, it was found that different training methods were perceived to be differentially effective. For instance, reading, lectures/talks and modelling were perceived to be most useful for the acquisition of declarative knowledge, while enactive learning strategies (role-play, self-experiential work), together with modelling and reflective practice, were perceived to be most effective in enhancing procedural skills. Self-experiential work and reflective practice were seen as particularly helpful in improving reflective capability and interpersonal skills. Conclusions: The study provides a framework for thinking about the acquisition and refinement of therapist skills that may help trainers, supervisors and clinicians target their learning objectives with the most effective training strategies.

Collusion in clinical supervision: literature review and case study in self-reflection

Interpersonal dynamics are a recurring impediment to effective clinical supervision and can lead to phenomena like collusion between the supervisor and supervisee. Collusion involves both supervisor and supervisee engaging in safety behaviours that serve to conveniently avoid and escape from difficult topics and challenging methods. Whilst minimizing the short-term threat to supervisor and supervisee, collusion will tend to undermine the effectiveness of supervision and limit significantly its long-term value to patients. In order to consider how best to address collusion, we review the cognitive-behavioural therapy (CBT) and related literature on collusion, focusing on how it has been formulated and managed. We then provide a case study featuring a supervisor who was colluding with the supervisee's avoidance behaviours (i.e. filling supervision sessions with superficial reflections on his casework) by not challenging these reflections or moving to another learning mode (e.g. experimenting). We develop a CBT formulation of this pattern of supervision as part of the self-reflection process, led by a consultant. Self-reflection appeared to be a useful tool for improving the supervisor's understanding of this dysfunctional process, and strengthened the supervisor's confidence in utilizing relevant skills in the future.