Benchmarks for successful psychotherapy supervision
by Debbie Hegarty
The Irish Association of Humanistic and Integrative Psychotherapy (IAHIP) asserts that it is unethical for psychotherapists to practice without regular supervision/consultative support (2018). The British Association for Counselling and Psychotherapy (BACP) similarly asserts:
Supervision is essential to how practitioners sustain good practice throughout their working life. Supervision provides practitioners with regular and ongoing opportunities to reflect in depth about all aspects of their practice in order to work as effectively, safely and ethically as possible.
Supervision also sustains the personal resourcefulness required to undertake the work.
(BACP, 2018: 22)
In short, supervision ensures the therapist’s standard of competence is monitored, maintained, and developed.
There is an abundance of empirical research into the impact of clinical supervision on practice among allied health professionals (Buus & Gonge, 2009; Ellis, 2010; Dawson et al., 2013; Kuhne et al., 2019; Milne et al., 2012; Snowdon et al., 2017; Snowdon et al., 2020 and Wheeler & Richards, 2007). Attempts have been made to determine a correlation between attendance at psychotherapy supervision and client outcomes (Freitas, 2002; Hess et al., 2011; Weaks, 2002 and Watkins, 2011). According to Watkins (2020) the findings are inconclusive but there is compelling data to suggest that supervision enhances the overall effectiveness of the supervisee. The intention for this paper is not to debate the usefulness of supervision. Instead, the focus is on delineating some of the benchmarks of psychotherapy supervision as a distinct activity. I began this voyage of discovery armed with the notion that the values, philosophies and practices that underpin humanistic and integrative practice also inspire the provision of psychotherapy supervision.
Carroll (2010: 1) writes that “The heart of supervision is learning”. This learning is primarily “educative, supportive, growthful, challenging and collegial” (Hewson: 2008: 35). It extends beyond the transfer of knowledge from supervisor to supervisee with a view to changing a mindset or behaviour. Instead, it is “the shift from unknowing to knowing, from defeat to strength, from despondency to hope occurs during a thrilling moment of discovery which imbues the supervisory process with energy, creativity and power” (Shohet, 2008: 161). Proctor (1987) identifies the ultimate intended functions of such a facilitation process to be normative (monitoring), formative (learning and growth) and restorative (support).
Listed below are the four types of supervision:
1. One to one: A dyadic group comprised of one supervisee and one supervisor. In this type of supervision the supervisor typically has more experience than the supervisee.
2. One to one: co-supervision. Both attendees co-lead the process.
3. Group supervision with a designated supervisor (discussed below).
4. Peer group supervision (without a designated supervisor).
Every time you explore your client work with a supervisor or peer you ensure against the potential for burn out, vicarious trauma, power differential blindness and ego-driven interventions with clients. The shadow of care is neglect. Neglect can become evident in many areas of the helping professional’s life, from of a lack of self-care, to negligence in our duty of care to the client, as well as to the wider community.
For a number of reasons, my preferred type of supervision is the group supervision with a designated supervisor. Supervisors are directly and indirectly immersed in a number of relationships. Left unchallenged in a symbiotic style dyadic relationship, supervisors may unwittingly become obstacles to the client work. The group setting provides additional perspectives on the members presenting issues and dilemmas that occur in “service of the client” (Carroll and Tholstrup, 2001: 26). Proctor (2009) argues that although groups are less intimate than dyads, they offer more opportunities in the development of enduring insight and awareness and the working through of more discreet supervisee processes.
Below see some of the generic aims of psychotherapy supervision as I understand them. Later in this section an attempt will be made to outline the specific factors that distinguish group supervision from other types of supervision:
• To collaborate a working contract that is clear, mutually agreed, and enthusiastically supported (contracting will be expanded on later in this paper).
• To foster a genuine interest in developing and enhancing the internal supervisor in the supervisee.
• To truly listen so as to empathically understand.
• To stay curious in the face of pervasive doubt in the supervisee.
• To focus on process as well as content.
• To co-create an alliance where both supervisor and supervisee can contact and express their true selves.
• To model a way of relating to that is respectful, honest, spontaneous, immediate and straightforward.
• To be present to ruptures: it has been my experience that conflict breeds confusion and mistrust but it is by no means an entirely disruptive process.
• To model the therapeutic use of self.
• To be inclusive and inviting of difference (diversity is reviewed later on in this paper).
• To focus on lifelong experiential and reflective learning.
• To foster a space for spontaneity and creativity. It was a journey in itself for me to trust the power of creativity in the expression of unexpected domains of my self.
• To encourage a critical evaluation of the theoretical frameworks that underpin practice.
• To stay open and tolerant of new perspectives.
• To be aware and present to here and now responses.
• To communicate in a dialogical way using phenomenological enquiry.
• To look at who is responsible for what (the issue of responsibility is considered later in this paper).
• To be curious about power differentials (power is explored later in this paper). One of my life refrains is that curiosity replaces fear.
• To be curious about the role of shame in the supervision space (shame in supervision is widely reviewed in the relevant literature and deserves a dedicated paper).
• To be directional but not assume expertise over the other in the supervision relationship.
• To review and rate the work and the relationship regularly, deliberately, constructively, formally and informally.
• To hold firmly the wider cultural context.
• To hold firmly our ethical duties and legal issues.
• To commit to being enough rather than being and/or becoming perfect!
The following are some identifiable distinctions specific to group supervision:
• Brainstorming: the more perspectives supervisees have on issues arising in working with clients the better. The designated supervisor encourages input from all parties present into the practice issues that are brought to the supervision space.
• There is less potential in a group setting for one point of view and for confluence and collusion between supervisor and supervisee. We can pay a price intrapersonally in terms of autonomy for interpersonal connection. Confluence (Polster & Polster, 1974) is a type of interpersonal symbiosis between two dissimilar beings, a mutually reinforcing process that requires melding or merging. The conscious and/or unconscious drive is to dissolve differences (diversity is briefly outlined later in this paper) and avoid ruptures. It is worth noting that the resolution of ruptures supports intimacy (Safran and Muran, 2003).
It is my contention that participation in all the above listed types of supervision supports safe and ethical practice, is mutually supportive, enlightening and healing. Consider this thinly disguised metaphor from one of my enduringly favourite novels when contemplating the outcome of supervision:
What is a Caucus-race? said Alice; not that she wanted much to know, but the Dodo had paused as if it thought that SOMEBODY ought to speak, and no one else seemed inclined to say anything. Why, said the Dodo, the best way to explain it is to do it. (And as you might like to try the thing yourself, some winter day, I will tell you how the Dodo managed it). First it marked out a racecourse in a sort of circle, (the exact shape doesn’t matter it said,) and then all the party were placed along the course, here and there. There was no ‘One, two, three and away’, but they began running when they liked, and left off when they liked, and so it was not easy to know when the race was over. However, when they had been running half an hour or so, and were quite dry again, the Dodo suddenly called out ‘The race is over!’ and they all crowded round it, panting and asking, ‘But who has won?’ This question the Dodo could not answer without a great deal of thought, and it sat for a long time with one finger pressed upon its forehead (the position which you usually see Shakespeare, in pictures of him), while the rest waited in silence. At last the Dodo said, EVERYBODY has won, and all must have prizes.’
(Carroll, 1866: 12-13)
“Supervision is not a given. It’s not something someone called a supervisor does to someone called a supervisee” (Carroll, 2010: 16). The supervision space, whether the composition is a dyad or group, is a curious arrangement. All attendees are wounded healers, have tool bags and have the potential for transformational learning (Carroll, 2007). Although the work of supervision is less about intersubjective sparks and flames, the impact on client work can be enlightening. An observer of a supervision session will witness two or more colleagues deliberating over clients. What is often less obvious is that one of the members has a normative, gatekeeping, evaluative and facilitative function. I am interested by the following definition of supervision, which is less traditional than the usual ways supervision is understood but nonetheless applicable:
We have profound learning difficulties when it comes to being present to our moment-to-moment experiences. Disturb the stuck narrative. The supervisory voice acts as an irritator, interrupting repetitive stories (comfort stories) and facilitating the construction of new stories
(Ryan, 2004: 47).
Heath and Storm (1985) propose that the models of supervision that inform a supervisor’s work tend to parallel their favourite theoretical orientation and often feel like a natural extension of the model of therapy they provide. There are a plethora of models widely practiced in the name of supervision. An attempt will now be made to present a brief overview of two of the supervision models that assimilate well in humanistic integrative practice and, by definition, psychotherapy supervision:
1. The Cyclical Model of Supervision (Page and Wosket, 2015).
2. The Seven Eyed Model of Supervision (Hawkins and Shohet, 2012).
3. Using a theoretical model of supervision safeguards accountability and professionalism, particularly when collaborating with other allied health professionals. Models of supervision support supervisors in focussing the work and providing “a container for creativity and chaos” (Carroll & Tholstrup, 2001: 19). Models of supervision aim to support the supervisee in developing their internal supervisor, promoting autonomy and managing doubts and insecurities in their work with clients. Simpson-Southward et al. (2017: 1242) compare models of clinical supervision and models of therapy, stating that the findings on the effectiveness of the former are inconsistent whereas the latter “rely heavily on empirical research and provide clear and consistent direction on how therapy should be conducted”. They recommend that “there needs to be further development of supervision models to demonstrate their effectiveness” (Ibid: 1243).
Integrative models of supervision, as the name implies, assimilate more than one theory and technique to produce a rich framework that synthesises orientations with similar underlying philosophies. Humanistic integrative models of supervision assume that the supervisee and the client have the innate capacity for self-determination and as such, the supervisor is not the expert.
Burck and Daniel (2018) argue that all theoretical models of supervision are consistent in focusing on the development of the supervisee and placing the wellbeing of the client at the centre of the work. Some models may be more “prescriptive, descriptive or reflective” (Ibid: 22). An important point made by Burck and Daniel (Ibid: 22) is that it is not the type, nor the modality of the supervisor that makes the work useful but instead “the fact that the supervisor, or the supervision group, is other than the supervisee”.
Both models discussed in this paper are process based, with deeply descriptive frameworks, that foster a transformational process.
There are five basic stages in the cyclical model of supervision, each with their own five sub-units (Page & Wosket, 2015). Stages become figural and fade into the background, accordingly, depending on the emerging needs of the client as represented by the supervisee. This model speaks to my heart in that it allows for spontaneity and creativity in the third element, aptly named space. Space, although an arguable notional and abstract element of supervision, is nonetheless intrinsic to a more psychospiritual connection. All we truly have in reaching less superficial connections with supervisees is the uncertainty and ambiguity that the here and now offers. For me the element of space encourages a deeper connection to the self of the supervisee as well as the supervisor as we grapple together with self-limiting beliefs, myths about life and the conflicts that are engendered between the polarised stances of self-governance and interdependence. This model also makes room for practical elements namely the contract, focus, bridge and review:
• Formal agreement between the supervisor and the supervisee
• Ground rules- what is ok and not ok
• Boundaries- establishing clear limitations
• Expectations- co-creating realistic goals, bonds and tasks
• Accountability- who is responsible for what
• Issue- case conceptualisation
• Objectives- clearly defined tasks
• Presentation- where does the supervisory-space-attention need to be given?
• Approach- what interventions can support healing?
• Priorities- are there immediate objectives and risk factors?
• Collaboration- two practitioners working in a collegial way
• Investigation- what ails the client
• Challenge- there is more than one way to skin a cat…
• Containment- supervisee’s process can be leaky and irrelevant to the field
• Affirmation- everything is going to be ok and if it’s not it is still ok
• Consolidation- rational thinking in terms of partnership
• Information giving- a type of chaos detection device
• Goal setting- establishing clear outcomes
• Action planning- co-creating a plan that leads to positive outcomes
• Client’s perspective- what are the client’s needs
• Feedback- how are we doing?
• Grounding- collegial supports
• Evaluation- what works and what doesn’t work?
• Assessment- is this helpful and transformative?
• Re-contracting- if not can we renegotiate collaboratively?
Hawkins and Shohet’s (2012) model of supervision has seven relational steps or eyes:
Supervision is a joint endeavour in which a practitioner with the help of a supervisor, attends to their clients, themselves as part of their client practitioner relationship, and the wider systematic context, and by doing so improves the quality of their work, transforms their client relationship, continuously develops themselves, their practice and the wider profession
(Hawkins & Shohet, 2012: 5)
Weaks (2002) concluded that the supervisory relationship is the central factor in “good enough” (Hawkins & Shohet, 2012: 4) supervision. Necessary to the application of good enough supervision is the supervisor’s willingness to co-create a safe and collegial supervisory space. Hawkins and Shohet (2012) note that forming a “collective endeavour” (ibid: 184) is key in developing an effective supervisor/supervisee working alliance. The good enough supervisor models the core attitudinal conditions of authenticity, non-judgement and empathy therefore creating a safe, trusted, reflective space where support, validation, challenge and opportunity for transformational learning is realised (McMahon, 2014):
1. The client
2. Interventions used with the client by the supervisee
3. The relationship between the client and the supervisee
4. The supervisee
5. The relationship between the supervisee and the supervisor
6. The supervisor and their own process
7. The client/therapist/supervisor total situation in its wider context and contexts (including the whole consideration of the ethical and professional dimensions)
I will now offer a brief review of some of the salient factors that are deeply synthesised into the provision of psychotherapy supervision.
Williams and Mohamed (2013) argue that the psychological mechanisms employed in racism are universal and liable to be engaged when the context is favourable. In our hearts people are more alike than different. What makes us different is multifaceted and needs to be named and respected in the supervisory relationship. Our differences include how we respond to ourselves, others and the world. Our responses are shaped by our experiences, how we make sense of those experiences, our social environment and the culture, race, creed, sexual orientation, disability we identify with. In psychotherapy supervision, the supervisor pays attention to the tendency for confluence (Polster & Polster, 1974) to occur interpersonally when two or more people are trying to get along. The key to managing difference in any relationship is to hold an open stance that communicates curiosity rather than fear or threat. In psychotherapy supervision models, the supervisor encourages the supervisee to embody the liberal principles and practices of acceptance, patience, tolerance, curiosity, social justice, individual freedom and choice, equal rights and minority rights.
Ethical decision making
“In this modern world where pressures to act decisively conflict with a fear of being blamed, supervision can provide a much-needed time to reflect” (Shohet, 2008: 13). Decision making can be extraordinarily difficult to discern for helping professionals. ‘Consult, consult, consult’ is my personal refrain whether I am working with clients, supervisees or students. A good question to ask in any ethical dilemma is ‘have I exhausted all resources available to me before I make my decision?’ Consider who to consult? Can you declare that everyone involved in the decision-making process with you is professionally competent and sober at the time? Can you stand over the decisions you made in terms of beneficence? I like to imagine decision-making in my work as two or more people rolling up their sleeves, mucking in collaboratively, with the wellbeing of the client at the heart of the process.
There is an obligation to protect the public from dangerous clients, the clients from dangerous people whilst all the while balancing ensuring confidentiality. Legal responsibilities can differ from jurisdiction to jurisdiction and practitioners need to familiarise themselves and equip themselves accordingly. In Ireland psychotherapists are categorised among other mental health professionals as mandated persons and have obligations under The Children’s Act (2015) to report and assist in concerns related to child safety to our national child protection agency, TUSLA.
Contracting: Preparation vs response
“If you fail to plan, you are planning to fail”
Franklin, Benjamin, 1706-1790
I have an increasing hunger and curiosity for all that existential philosophers and theorists offer in terms of practice. I am learning to accept that death is inevitable and as soon as life begins, we exist in the uncontrollable reality of loss, separation, endings and death. Unavoidable. Fine and then I want to embrace what I can control which is my responses to this dilemma. Whilst accepting of the uncertainty of practice, I note that planning and contracting allows for a certain amount of preparation for worst case scenario. Admittedly, we can’t know what we don’t know and recent family bereavements have taught me that I can’t predict or control the unexpected disruption and adjustments needed to adapt and survive after a sudden death. It simply cannot be scripted. I can factor into the supervision relationship considerations of what causes ruptures and wonder where the clients might be heading with their current choices as well as what gives humankind hope. Contracting may not be applicable to every eventuality. I purposefully make a distinction between planning for, or preparedness, and simply responding in the title of this section on contracting because although most contract are at best general, they are not so general as to be hollow in a crisis. Contracts resource us as we fall forward rather than just falling.
Here is what I can know. Psychotherapists, similar to other allied health professions, are governed by codes of ethics approved by their members and work under the principle that these codes will not be breached or violated. A clear, mutually agreed and regularly reviewed contract between supervisor and supervisee provides structure, sets a realistic and achievable standard for the work, protects against harm and is an integral part of self and other care. Fundamental to collaborating on an ethically considered and appropriate supervision contract is explicitly establishing who is accountable for what. Supervisors gain an understanding of the client’s world by way of the supervisee’s account of that client. Although supervision is a joint effort, supervisors are third party witnesses to the account, nothing more. Consequently, it is the supervisee’s responsibility to maintain an ethical and professional duty of care to the client. It is, even so, the responsibility of the supervisor to oversee the welfare and safety of the work with the client and be cognisant of the fact that the client is at the centre of decision-making at all times. At the base of avoiding harm is the need to locate what role the supervisor and the supervisee has in the client’s therapy. Clear contracting that explicitly defines roles and responsibilities, as well as other factors such as limits to confidentiality, ensures against conscious failure. In my experience, contracting has not negated spontaneity, immediacy and creativity. These factors are intrinsic for any psychotherapeutic encounter. It is worth stating that negotiating transferential relationship dynamics, as well as other unforeseen impasses can only be worked through as they emerge in the field. Having said that, mutually agreed actions taken in the name of supervision affect the welfare of all the people involved and must be made with the least amount of risk. Simply, building towards a clear, mutually agreed supervision contract is a win-win.
Power differentials and parallel processes
Power differentials between supervisor and supervisee, and between the supervisee and the client exist but are rarely managed. Left unnoticed, power imbalances can develop into abuse. Power differentials in therapeutic relationships are subtle and difficult to detect. Abuse can be caused by acts of commission, acts of omission, or both. Stephen Karpman’s (2014) concept of The Drama Triangle makes best sense of abusive systems and how implicit power differentials play out in relationships.
The Drama Triangle is not something you do to someone, it’s something you do with someone. It has been described as an insidious, sometimes unconscious, game driven by a desire to gain control by coercing and manipulating and tends to masquerade as protection and/or affection.
Each player can assume three potential positions in the game, namely the persecutor, the victim and the rescuer. At any given time, players will act out of one or more of the three positions, but each player will have a favourite position. The persecutor is the evil twin of the rescuer. The victim feels unable to manage and is overwhelmed (not by feelings but ideas about themselves) and indirectly and unconsciously engenders either the rescuer or the persecutor. The outcome of the game is always the same. Everyone feels bad.
Supervisees pulled into The Drama Triangle with clients can replay the dynamics unconsciously in a parallel process with the supervisor. Consequently, it is vital to have supervision of your supervision, and to be aware of the indicators of the game. Sanderson observes that one such indicator is dissociation (becoming detached from oneself, others and one’s surroundings) and another is avoidance of intimacy with people outside of the relationship (2010). Supervisees might uncharacteristically find themselves withholding their work in the name of protection.
I like to locate myself generally and professionally in the space between certainty and doubt, symbiotic blending and autonomy, unwitting negligence and ardent nurturing, rising above a minimum expectation in my duty of care but not so dominant or all-knowing that I disempower. I aspire to foster healing and recovery in this in-between place, yet at times in an aim to establish bonds with a supervisee, I find myself entrenched in primitive processes and adopting polarised positions. The way-out of this symbiotic process for me is to reconnect with my internalised, good enough caretaker. In keeping with a desire for a more collegial relationship with supervisees and to foster a deeper connection, I prefer to name this process explicitly and engage in dialogue to discover what needs to happen to let go of perfectionism and other blocks to meaningful contact so that the real work of supervision (resourcing and transformation) can begin.
Finally, at times psychotherapists can feel defeated in their efforts to help clients. Supervision potentially offers a working space where the defeated part can be brought to life, owned and hope restored. I say potentially because if the supervisor has not integrated the defeated part in themselves, the defeated part in the supervisee will, rightfully, stay exiled. Some admittedly lofty and aspirational but nonetheless achievable tasks that support the in-between stance in psychotherapy supervision have been summarised in this paper. I have no desire to promote myself as an expert on the functions, aims or tasks of supervision or what it takes to make supervision effective. The benchmarks of supervision delineated in this paper are by no means complete; instead they are an evolving catalogue of attitudes and objectives that help in keeping me grounded in my internalised good enough caretaker.
Debbie Hegarty is an accredited Humanistic and Integrative psychotherapist, supervisor and trainer and has been providing psychotherapy and consultation services for over 15 years. Debbie’s background is in adult mental health and she is a former member of An Garda Síochána. Debbie volunteered on the Editorial Board of Inside Out and served a term as Chairperson of IAHIP
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