Supervision of Clinical Practice: Models and methods of delivery in a developing

context.

Dr. Bridie GallagherClinical 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 ContextSupervision 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, 1611-1617.

• 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