The effects of clinical supervision on supervisees and patients in cognitive behavioral therapy: a systematic review

Clinical supervision is a central part of psychotherapist training but the empirical support for specific supervision theories or features is unclear. The aims of this study were to systematically review the empirical research literature regarding the effects of clinical supervision on therapists’ competences and clinical outcomes within Cognitive Behavior Therapy (CBT). A comprehensive database search resulted in 4103 identified publications. Of these, 133 were scrutinized and in the end 5 studies were included in the review for data synthesis. The five studies were heterogeneous in scope and quality and only one provided firm empirical support for the positive effects of clinical supervision on therapists’ competence. The remaining four studies suffered from methodological weaknesses, but provided some preliminary support that clinical supervision may be beneficiary for novice therapists. No study could show benefits from supervision for patients. The research literature suggests that clinical supervision may have some potential effects on novice therapists’ competence compared to no supervision but the effects on clinical outcomes are still unclear. While bug-in-the-eye live supervision may be more effective than standard delayed supervision, the effects of specific supervision models or features are also unclear. There is a continued need for high-quality empirical studies on the effects of clinical supervision in psychotherapy.     

Contemporary Visions of Psychotherapy Supervision: Sharing Perspective,Identifying Need,and Charting Possibility

Psychotherapy supervision has now celebrated its first centennial, is poised to move boldly forward into its second century of contribution to psychotherapy education, and seems perfectly positioned to further advance our knowledge about and practice of how to effectively facilitate, influence, and mentor our supervisees. Professional interest in and recognition of psychotherapy supervision appears to be at an all time high, and its value as a potentially alchemical educational event seems increasingly incontrovertible. But if supervision is to maintain and even enhance its substance and significance in 21st century psychotherapy education, what are the matters to which we as supervision practitioners, researchers, and theorists must vigilantly attend and vigorously address? In this special supervision issue of the Journal of Contemporary Psychotherapy, we would like to examine some of those matters. The topics that are addressed include: competencies, evidence-based practice, and supervising psychoanalytic/psychodynamic, cognitive/behavioral, humanistic/existential, and integrative/eclectic psychotherapies. The binding theme of “pressing needs and impressing possibilities” will be evident throughout this journal issue. In this introductory paper, I briefly define psychotherapy supervision, consider its beginnings, provide a rationale for this special issue, and identify the specific questions that give focus and frame to each of the succeeding contributions.     

A Constructive Approach to Counseling and Psychotherapy Supervision

Clinical supervision is central to the successful training and ongoing professional development of counselors and psychotherapists. Although clinical supervision shares much in common with psychotherapy, it is a distinct activity from psychotherapy that requires its own distinct theories and techniques (Bernard & Goodyear, 2014). In this article, an approach to clinical supervision (which I refer to as constructive clinical supervision) that is grounded in constructivist principles of learning, growth, and development is presented. In addition to outlining the key constructivist principles that have influenced this approach, I also provide supervision strategies that can be used to facilitate critical self-reflection in supervisees, which includes establishing a solid relationship, asking reflective questions, and implementing reflective-based activities. Additionally, guidelines for conducting supervisee assessment and evaluation in ways consistent with constructivist thinking are described.     

Supervision in der psychotherapeutischen Ausbildung in Deutschland

One of the functions of supervision in psychotherapy training is quality assurance. In order to fulfill this function the quality of supervision itself needs to be high and needs to be controlled. Thus in a large survey of psychotherapy training in Germany questions related to the quality of supervision were included in the survey. Answers to those questions from different samples (trainees, alumni, trainers, training institutes, expert organizations) were compiled. Quantitative and qualitative methods were used. Satisfaction and usefulness ratings with individual and group supervision were high to very high. Supervision amount, group size and frequency were rated as adequate. Criticism pertained to the lack of systematic evaluation, insufficient qualification of the supervisors and lacking integration of supervision into the whole training. As supervision is a very important part of psychotherapy training measures for quality assurance and improvement are necessary.     

Doing things differently: an appreciation of Meltzer’s contribution

In this paper I wish to draw attention to aspects of Donald Meltzer’s ways of working which characterised his practice as a psychoanalyst and which I consider important in appreciating his originality. Several central themes are described and elaborated including: the central relevance of child analysis and the unity of child and adult analysis; the value of working in a clinical group with colleagues; the revision of psychoanalytic theory; joint research and writing projects; Meltzer’s recognition of the power of infant observation as a tool for learning; the commitment to a wider psychoanalytic culture; the particular contribution to the Tavistock child psychotherapy training. Examples from Meltzer’s written archive, both his books and papers, are used to demonstrate and illuminate these themes, alongside clinical material from child psychotherapy work brought to the author’s attention in supervision.     

AGAINST RECORDING SESSIONS FOR SUPERVISION

The American Psychological Association’s (APA) 2014 injunction that supervisors must listen to recorded sessions of their supervisees’ work is based on a rich and thorough body of research, and yet it entails a narrative of psychotherapy as a discipline of Science. If psychotherapy is understood as an endeavor also of the Humanities, recording sessions may be anathematic to supervision and training. Developing ideas from Greenberg’s (2015) theory of “controlling fiction,” the writer presents a narrative of psychotherapy in which it is not wise to review recorded sessions in supervision.

     

Supervising Humanistic-Existential Psychotherapy: Needs, Possibilities

The competency movement within professional psychology, evidence-based practice concepts, and the trend toward incorporating psychological services as a component of an integrated care approach within health care settings are major developments in the changing landscape of psychotherapy practice that have important implications for psychotherapy supervision. This article examines each of these developments as they relate to conducting psychotherapy supervision from a humanistic-existential perspective. The current status of supervision guided by a humanistic-existential framework is described, followed by exploration of needs and possibilities for the future evolution of the supervision approach in light of developments in the field.     

Supervising personality assessment: the integration of intersubjective and psychodynamic elements in the supervisory process

The supervision of personality assessment can be likened to the process of teaching art. Much like artistic training, supervision of personality assessment is a complex process that calls for creative integration of different working processes, some more technical and formal and others broader and more complex. On the surface, compared to psychotherapy supervision, supervision of personality assessment is fairly structured and centered on specific tasks such as scoring, making a diagnosis, or determining personality organization. Nevertheless, principles of psychodynamic psychotherapy such as parallel processes are relevant as well. We discuss the process of integrating intersubjective and psychodynamic elements into personality assessment supervision and argue that this integration helps the supervisory work to proceed effectively. We present the role of knowledge, the institution, and parallel processes in the supervisory work.     

“She was on my side,and grounded me when I needed it:” Research supervision in the field of therapy,based on counsellors’ and psychotherapists’ views on their engagement with research

Research‐supported practice is increasingly emphasised within counselling and psychotherapy at all stages of training. Guided by an interest in how to support therapists in their efforts to develop research knowledge during doctoral training, this paper focuses on research supervision. Research supervision is a surprisingly under‐researched area. Little is known to date about how supervisors “go about their supervision” (Bruce & Stoodley, 2013, p. 5), despite the fact that “high failure rates for research dissertations in the social sciences have been partly attributed to student dissatisfaction with supervision and poor student–supervisor relationships” (Armstrong, 2004, p. 134). Between 2016 and 2019, we explored accredited counsellors' and 'psychotherapists engagement with research during or after their doctoral training. This paper explores research supervision with these two previous studies serving as the backdrop (Bager‐Charleson et al., 2018; Bager‐Charleson et al., 2018b), together with a literature review into research supervision within social sciences and psychotherapy. Supervision is discussed as a crucial coping/support strategy to (a) link research with practice in therapy work, practically and epistemologically; (b) contain and make sense of the use of transformative learning; (c) balance “enculturation” with critical thinking and emancipation; and (d) support reflective and reflexive development. This paper discusses an adaptive research supervision model, akin to a “holding bond” (Stevens, 2016) which supports the student to reflexively position her/himself personally, intersubjectively, theoretically and socio‐culturally, whilst “negotiating the tension” (Lee, 2008) during a process of enculturation into the discipline, and also fostering critical thinking and emancipation to contribute to new knowledge.     

The Supervisory Alliance as Quintessential Integrative Variable

The concept of alliance in psychotherapy supervision is now a half century old. But over the course of its first 50 years, how has the supervisory alliance come to generally be viewed by supervision scholars and practitioners? and What is its specific place now within different visions of supervision? In this paper, I would like to consider those two questions by: (a) describing the two enduring perspectives on the supervisory alliance that have dominated and continue to dominate the supervisory scene; and (b) examining the ways in which the alliance appears to currently be conceptualized and implemented across several distinct views of supervision. Each view of supervision is also presented as containing and actuating its own message and meaning about the role of alliance in supervision, and those messages and meanings are accordingly identified. The supervisory alliance appears to now be widely regarded as being a transtheoretical common factor that binds by means of: (a) bond/rapport; (b) supervision goals; and (c) supervision tasks. Much like the therapeutic alliance in psychotherapy, the supervisory alliance has increasingly come to be seen as the very heart and soul of supervision itself and may indeed be the quintessential integrative variable in psychotherapy supervision.     

Recognizing Spirituality as an Important Factor in Counselor Supervision

Despite the recent, growing emphasis on spirituality in the counseling and psychotherapy literature, information regarding spirituality and the supervision process is limited. The purpose of this article is to help supervisors and supervisees enhance awareness of spiritual values in supervision. Factors such as counselor competency, conceptualization of spirituality, cross‐cultural awareness, and the similarity of clients' and counselors' values form a foundation for developing effective intervention and supervision strategies. A series of research questions is proposed to spur a program of empirical exploration.     

The counsellor and the GP: The gulf and the isthmus - or the dilemmas of difference

Research supervision in the field of counselling and psychotherapy is a fruitful area for investigation in view of the fact that the research supervisory relationship is powerful and highly charged, whether consciously acknowledged or not. Researchers trained as counsellors and psychotherapists possess the skills to facilitate the emergence of, and work creatively with, impasses and crises, both in the research itself and the supervisory relationship, as a result of their training and experience in dealing with crisis and catharsis in clinical work. This paper will demonstrate these points using a case vignette from my work as a supervisor of research dissertations undertaken by students on a Masters in Therapeutic Counselling course. Drawing on narrative analysis, clinical supervision theory and discursive analysis it will look at the strengths and weaknesses of a ‘psychotherapeutic’ approach to research supervision.     

Psychotherapy Supervision in the New Millennium: Competency-Based, Evidence-Based, Particularized, and Energized

Psychotherapy supervision has increasingly become or is on the fast track to becoming competency-based, evidence-based, particularized, and accountable. In this paper, I explore how that appears to be so by: (1) briefly considering the concepts of ??competencies?? and ??evidence-based practice?? as preeminent guides for psychotherapy supervision practice and training; and (2) briefly reviewing the current status, pressing needs, and future possibilities of psychoanalytic, cognitive-behavioral, humanistic-existential, and integrative psychotherapy supervision. Based on my examination, the following conclusions are proposed: (1) the supervision relationship, individualization, developmental differentiation, and self-reflection (for supervisee and supervisor) appear to be crucial cornerstones for the conceptualization and actuation of supervision process and practice across psychotherapy-based supervision approaches; (2) all indications suggest that three emphases??competency-based supervision, evidence-based practice, and accountability??will continue to substantially influence, affect, and inform psychotherapy supervision practice for its near and distant future; (3) psychotherapy-based supervision approaches will need to be and indeed appear to now be in the process of becoming increasingly particularized in how each of their respective approach-specific competencies are defined and explicated; and (4) psychotherapy supervision has come to be increasingly viewed as an educational process and practice that is best facilitated by: (a) a rich and enriching supervision training environment that vigorously addresses and attempts to meaningfully integrate declarative, procedural, and reflective knowledge bases throughout the supervisory endeavor; and (b) the considered and deliberate utilization of facilitative technology that has the potential to substantially enhance and expand the value of the supervisee??s training/supervision experiences. Some discussion is provided about those four conclusions, and a retrofitted psychotherapy supervision for the new millennium is considered.     

Supervising Psychoanalytic Psychotherapy: Present Knowledge,Pressing Needs,Future Possibilities

Existing research from the fields of education, cognitive science, neuroscience, and psychoanalytic psychotherapy points us toward possibilities for the future of psychoanalytic supervision. This research suggests that we need to go beyond communicating abstract knowledge and make our supervisory relationships more experiential, participatory, relationship-focused, and personal in order to teach usable knowledge, develop complex psychotherapeutic skills, and facilitate emotional and relational development in our supervisees. The author concludes that a relational model of supervision fits this pedagogical profile. After grappling with our resistances to change, the author hopes that more psychoanalytic supervisors will make use of a relational model of supervision, as well as drawing upon new technologies and neuroscience-based teaching techniques.     

Practice‐based supervision research: A network of researchers using a common toolkit

Aim: Given that various systematic reviews of supervision literature have revealed how little is known about supervision, that studies are not usually routed in practice, and that a multitude of diverse measures are used, the primary aim of this project was to support and encourage practitioner research related to supervision using a prescribed common set of instruments. Method: Funded by the British Association for Counselling and Psychotherapy (BACP), a Supervision Research Practice Network (SuPReNet) was established. A toolkit (a series of measures) that could be used routinely by practitioners was selected following the assembly of available measures of supervision and an assessment of them. Findings: The appraisal, conducted by the three authors, yielded five core measures, free for anyone to use, and accessible through the SuPReNet website. The measures are being piloted through a practice research network at a university counselling and psychotherapy research clinic where supervision data are being collected through a special module of CORE Net. Discussion: The potential yield from this initiative for practitioners, researchers, and the developing evidence‐base is discussed and a model proposed for the next generation of research on supervision.     

Large-group psychotherapy in a day treatment program

The potential for psychotherapy in a large-group format has been discussed since the 1960s. Day treatment programs provide optimal support for such groups. One program type, which has maintained large-group psychotherapy as a central feature for over twenty years, is described. Essential features include an integrated therapeutic team, with clearly defined leadership, that is open to examination of its own process. Such groups may not only provide effective therapy, but are also readily amenable for teaching and research in psychotherapy.     

An Investigation of Genetic Counselor Experiences in Peer Group Supervision

Peer supervision groups have been studied in counseling fields including psychotherapy and social work. However, limited research exists regarding genetic counselor peer supervision groups. In the present study five major research questions were investigated: (1) How prevalent is peer group supervision among genetic counselors? (2) What motivates genetic counselors to join and continue to seek peer group supervision? (3) What comprises the content, agenda, and structure of group meetings? (4) What are participants’ perceptions of group dynamics, including conflicts, cohesion, and leadership? and (5) What are the perceived benefits and limitations of participating in peer group supervision? A total of 214 genetic counselors completed an online survey, and 70 (34.8%) reported being involved currently in peer group supervision. Fifteen of these 70 respondents were interviewed regarding their experiences in peer group supervision. Inductive analysis of their responses yielded 11 domains and 37 categories. Practice implications and research recommendations are discussed.     

Phenomenological research on supervision: Supervisors reflect on ‘being a supervisor’

A study using a phenomenological research method was performed to reveal the meanings of the concept ‘supervision’, from the supervisor's perspective. Eleven supervisors of counselling and psychotherapy from a humanistic/existential framework answered the open question: “What does being a supervisor mean?”. Content analysis and frequency measuring were performed, revealing six groups of statements; six facets describing the experience of supervision: ‘structuring’, ‘teaching’, ‘nurturing’, the ‘supervisor as person’, ‘supervisor as colleague’, and the ‘triangle, client-therapist-supervisor’. Structuring was the largest category, and the first three categories together represented more than 75% of the statements. The results showed that ‘teaching’ and ‘nurturing’ were very similar in their importance, as represented by the number of statements in each. Further research should address the possible relation between supervisors' perception and experience of their role and the theoretical framework of counselling and psychotherapy in which they are based, The phenomenological research method in this study has shown the possibility of doing research on processes without ‘betraying’ the subjective perspective.     

Why using “consciousness” in psychotherapy? Insight,metacognition and self-consciousness

Since its early development, clinical psychology has questioned the impact of “consciousness” on the determination of human responsibility across psychiatric disorders. In recent years, specific clinical approaches have focused on “consciousness” work that could play a key role in psychotherapy. We focused our research on clinical psychology's consciousness-related concepts of insight, self-consciousness, and metacognition. Insight and metacognition, for example, have prompted increased interest in schizophrenia (SZ), bipolar disorder (BD), and, more recently, borderline personality disorder (BPD) treatments as representative of the latest advances in the cognitive and behavioral therapy field. Here we review cognitive, social, and clinical psychology research measuring “consciousness” in BPD, SZ, and BD, exploring the implications of different conceptualizations of consciousness-like concepts for treatment adherence, symptom evolution, and related aspects of psychotherapy. Our results show the overall relevance of using measures of clinical and cognitive insight, emphasizing the more central role of cognitive insight and metacognition in psychotherapy, as it appears that consciousness can remain useful if understood as a cognitive skill. The inclusion of a conceptualization of self-consciousness is important in order to address the social component of psychotherapy, as it does in biopsychosocial approaches. We discuss the implications of such results for global efficacy, for the relevance of the “consciousness” concept to clinical psychology, and for the potential need to keep operationalizing different conceptualizations of it in psychotherapy. We open the debate on the definition of consciousness to motivational aspects of change and to general considerations of both legal and ethical aspects.     

Group supervision meets technology: a model for computer-mediated group training at a distance

Technological advances make the application of computer-mediated communication a supervision tool for group psychotherapy training when students and faculty are at a distance. A brief review of the literature on computer-mediated group dynamics provides the context for training applications. A model group supervision is described and clinical training examples are presented. Recommendations and guidelines for using computer-mediated supervision are proposed.