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Digesting psychotherapy

Last updated:

12 November 2012

Scotland

supervision: is it time to think again?

by Douglas McFadzean

Therapist supervision is widely thought essential. This critical article questions what the word even means and whether it can ever really ensure standards.

The article was originally published in The Therapist, Vol 4, No 4, 19-23, Autumn 1997, and has been republished in Ipnosis, No 11, Autumn 2003. After provoking debate, Douglas concluded:

"Just because supervision is a complex subject, it does not mean that we should not seek straightforward answers to simple questions ... readers will find much theory and analysis in terms of practitioner perceptions but a dearth of evidence from the client's point of view. And to whom do we owe our primary duty of care?"

introduction

The concept of practitioner supervision has now become firmly established in various therapeutic disciplines (1,2,3). Its significance is evidenced by the associated professional and business interests which have emerged in recent years. For example: supervision is an ethical requirement for members of various professional associations; supervisors can seek professional status through accreditation; training courses in supervision are increasingly prevalent; professional associations dedicated to supervision have been formed; and, obviously, the volume of supervision work has increased with the rise in therapeutic practice generally. Professional bodies have proclaimed that supervision ensures the efficacy and ethical standards of a therapeutic relationship (4); both clients and practitioners benefit. And, of course, a profession itself will earn the respect of the public and the legislature by requiring its practitioners to be in supervision to achieve these commendable aims.

Given the evident importance of supervision and its incorporation within therapeutic orthodoxy, we would expect to find a wide consensus on its definition and differentiation from other activities. However, the views from different professional groupings, individual practitioners and countries on what supervision does and does not entail are characterised as much by variation as uniformity. (See box below.)

What is supervision?

"Client-work supervision is a formal process which provides a practitioner with the discipline and support of an experienced colleague in the careful and confidential oversight of the practitioner's work with clients. The supervision relationship is a mutual one and is not, in any way, hierarchical nor must it be confused with formal management." (Confederation of Scottish Counselling Agencies, Code of Practice, 1996)

"Counselling supervision/consultative support refers to a formal arrangement which enables counsellors to discuss their counselling regularly with one or more people who have an understanding of counselling and counselling supervision/consultative support. Its purpose is to ensure the efficacy of the counsellor/client relationship." (British Association for Counselling, Code of Practice for Counsellors)

"This process involves a dynamic, triangular relationship between the development of personal awareness and self-realisation and professional enhancement and advancement. The model of supervision discussed here is different from that within either a mentor, or manager/counsellor relationship. It is an empowering, ongoing, personal experience which is enhanced and redefined within the supervisory relationship." (5)

"Supervision in a hierarchical sense, where the supervisor is senior to the people being supervised, more experienced in the work being done, and who takes some responsibility for their performance, ought to be clearly distinct from consultation ... Hierarchical supervision, however, whether autocratic, well-balanced or fudged, is not the same as consultation ... There is, however, a different type of supervision, where an expert in a particular field teaches someone who may be working in a different organisation or team." (6)


The diversity of views suggests that the assumed maturity of supervision may be illusory and that practice might be influenced more by group pressures than by any underlying supervisory principles. Such a suggestion is supported by the dearth of efficacy studies on the subject and by some of the basic concerns which have already been voiced about supervision (7,8,9,10,11,12,13). (See box below). This article will explore some major concerns, particularly those relating to issues of responsibility and the protection of the client. I contend that a fundamental reappraisal of therapist supervision is long overdue; my intention is to stimulate that debate.

Concerns already voiced

"UKCP (United Kingdom Council for Psychotherapy) has also recognized the problematic nature of the term 'supervision' and at one time suggested "continuing professional development". However, the term 'supervision' is what is currently used in UKCP documents. A 'supervisor's report' is required prior to the accreditation of a psychotherapist by organizations such as AHPP ... In this case the supervisor clearly has an overseeing function. The everyday understanding that 'supervision' involves a hierarchical relationship seems likely to hold sway in the US courts ..." - Richard Mowbray (8)

"In industry, for example, a supervisor is often accountable for the work done by his trainees, as well as for their competence to do it. This connotation can apply also to the teaching and learning of some non-personal caring skills, as for instance when a trainee surgeon is performing an operation under supervision. But it is not at all clear that this is what is meant by supervision in the training of counsellors or psychotherapists or social workers. Does a supervisor in such settings take responsibility for the students' clients?" - James Mathers (13)

"With such a variety of functions being subsumed under the title counselling supervision I am becoming concerned that the unique practice that I had understood counselling supervision to be is becoming more akin to the managerial definition which has connotations of surveillance, authority and control and that many of the roles now being expected of counselling supervision create conflicts for supervisors." - Agnes Dunlop (9)

"... There is one major illusion concerning the practice which must be challenged. Basically, supervision as it is normally practised tells us absolutely nothing about the client." - Dave Mearns (10)

supervision in relation to other activities

The term supervision, like counselling before it, has been redefined by the therapeutic community in a variety of ways which essentially conflict with its commonly accepted or dictionary meanings. Common understanding is that a supervisor has authority, and, crucially, responsibility for overseeing the work of their supervisees. Typically, the supervisor has more senior status and experience or the supervisee is still in training or on probation. Revisions of meaning which eschew any sense of hierarchy or responsibility distort our vocabulary and will inevitably baffle the wider society which a therapist seeks to serve. Qualifying the term with words such as "clinical", "non-managerial" or "non-hierarchical" may satisfy practitioners, but to the public this may only serve to reinforce a suspicion that supervision has become yet another arcane aspect of the therapeutic professions. Therefore, for the remainder of this article, a distinction will be made between supervision as commonly understood and "supervision" as therapeutically redefined.

It is also apparent that the term "supervision" has been stretched to subsume a range of activities which are intrinsically different. For instance, consultation (6) is surely the most precise term to use when one fully competent professional seeks the help of another to do his or her work while retaining full control and responsibility for it. In this case, the consultee supervises what is presented to the consultant. While supervision and interprofessional consultation focus on a practitioner's work, "supervision" additionally focuses on the practitioner and their own need for support and development. Depending on the professional allegiance and individual philosophy of the "supervisor", practitioner-focused activities invoked during "supervision" could include elements of: emotional support; counselling; psychotherapy; psychoanalysis; personal growth work; or advice and guidance on professional development and training.

I know that particular schools of "supervision" will argue that they maintain strict boundaries regarding the presence or extent of such activities during "supervision". My point is that all these activities are distinct from supervision (and consultation for that matter). Granted, in any pragmatic helping relationship the various constituent activities will often become fuzzy at the edges, but there remain core differences, such as the element of responsibility in supervision, which cannot be ignored. Even if therapists continue to fudge these issues the law ultimately will not (8,14). In addition to questioning the appropriateness of certain sub-activities within the "supervision" framework, we must question how effectively they can be carried out. For example, how useful is the emotional support provided to a competent practitioner when several days or even weeks may have elapsed since disturbing events with clients took place? Is it not likely that the practitioner's colleagues, family, friends and dreams (15) will provide the primary channels for discharging such emotions?

There is no doubt that different disciplines, and even different traditions within these disciplines, interpret the term "supervision" in very different and inconsistent ways. It is particularly interesting to note how counselling has embraced "supervision" as essential for ethical practice, redefining its meaning to emphasise its developmental role for the practitioner at the expense of any managerial role. The paradigm in this case echoes that of counselling itself with its emphasis on client empowerment. The similarity ends starkly, however, when the "supervisor" is also expected to police the ethics of practice. "Supervision" within social work does carry significant managerial functions, not least to ensure compliance with statutory requirements. However, when some social workers supplement this form of "supervision" with personal "counselling supervision" (10), the picture becomes very complicated indeed!

protection of the client

In its usual form (one-to-one supervision with one professional who acts as a benevolent overseer but doesn't take responsibility), "supervision" does at least offer direct support to the practitioner. But what confidence do we have that the client is better protected as a byproduct of that support? Even if the public is bemused by the meaning of "supervision", the promise of protection has a strong emotive appeal; the ethical stakes for the therapeutic professions are high (8,18). In most situations the "supervisor" never meets, observes, or otherwise has any direct contact with, the "supervisee's" client.

The therapeutic relationship between client and practitioner is assessed using whatever information the practitioner can, or chooses to, present to the "supervisor". The figure below [or see the updated version which shows more clearly how information is inevitably both filtered and fabricated in the "supervision" process]:

Protecting the client?

provides a tongue-in-cheek illustration of the inevitable filtering of information in the "supervision" process. This is disconcerting enough for exchanges of information which are manifest without considering mechanisms which may be latent. To be convincing, the argument that "supervision" protects the client has to address at least the following points adequately:

professionalization and the supervision business

Paradoxically, "supervisors" can effectively have significant power over their "supervisees", even though their working relationship is declared non-hierarchical and non-authoritative. It is a common feature of accreditation schemes, job and promotion opportunities, training courses, staff appraisal schemes, and service monitoring to require reports from the "supervisor" on how satisfactory a therapist's practice is. The situation will become even more confused if "supervision" and the "supervisor" play a part in the assessment of practitioners for the attainment of vocational qualifications (16). When a therapist's career and earning prospects depend on a "supervisor's" approval, it is very likely that their practice will tend towards conformity rather than creativity.

"Supervision", with its links to professional ethics and codes of practice, training, accreditation schemes and practitioner status, has now established its niche in the hierarchies of therapeutic disciplines. A substantial oncost is incurred to satisfy professional "supervision" requirements and it should be justifiable to those who have to pay, especially the public, that the efficacy and safety of therapeutic practice are correspondingly improved. It would be naive indeed not to recognise that mandatory therapist "supervision" serves professional vested interests well by generating an increasing volume of training business and high status work. Unfortunately, organisations in the voluntary sector, in particular, often encounter difficulty in diverting scarce resources to meet "supervision" requirements. External professionally acceptable "supervisors" may have to be contracted, despite the likelihood that the pooled experience of the organisation's own workers would provide "good enough" support to practitioners.

Of course, we must also consider the requirements for the "supervisors" of "supervisors"; their "supervisors" in turn and so on up the "supervision" pyramid. When we near the top, the pyramid generally flattens out and "peer supervision" becomes acceptable, supposedly because of the seniority and experience of the practitioners. "Supervision" has then largely transmuted to what must be, in effect, interprofessional consultation.

conclusions

Therapists should be accountable for their work and have ready access to effective sources of support and consultancy. I have no doubt that the vast majority of therapists do use their "supervision" in good faith and as positively as imperfect arrangements permit. However, we must not delude ourselves or the public that a clutch of distinct activities and functions can be replaced by a simplistic "one size fits all" approach.

In a field where much ambiguity has to be tolerated, some practitioners seek the shelter of clearly defined professional hierarchies and practice frameworks. By appearing to simplify matters, institutionalized "supervision" may satisfy these needs for security but it may also stifle creativity and cause unnecessary rumination of competent practice. The mechanisms which enable the crucial balance to be struck between confidence and reflection have to be sufficiently sensitive to the individual practitioner's qualities, experience and type of work (17).

More questions may have been raised than answered, but none more important than this: who is supervising whom? There is undoubtedly a traditional reluctance within some of the therapeutic disciplines to define or recognize formal lines of responsibility; the attempted revisions in meaning of the term "supervision" illustrate this. If "supervision" has become an essential component of professional ethics and codes of practice then surely it is absurd if we, and the public, do not know who is responsible when something goes wrong.

Can "supervision" continue to carry the burden of so many functions surrounding a therapist's work without the proverbial straw breaking the camel's back? Or is "supervision" more akin to a chameleon which naturally changes its appearance to blend in with the particular therapeutic environment in which it finds itself? I submit that much more debate and research are required before supervision can lose its commonsense meaning or start to guarantee the efficacy and ethical standards of therapy.

Comments from supervisees

"... I believe there are aspects of the "therapeutic mentality" which can be intrinsically abusive - particularly where a professionalized fetish is made of the supervisory experience by assuming that the psychodynamic perspective counts for more than a humanistic perspective. Ultimately how one sees the professional support process turns on one's view about the nature of power in human relationships, authority and hierarchy. My own humanistic instincts have led me to think about supervision in a new way - as a process of co-created professional support, a shared experience of mutuality, rather than as a formal professionalized relationship that emphasizes the values of authority and hierarchy and the myth of expertise."

"... You definitely need a first meeting with a supervisor to decide whether you suit each other. And do you go to someone with the same orientation as you or different? I think both can be beneficial ... It comes down to personal relationships as to whether you can work with this person or that person ... You want someone who is going to stretch you, make you think further ... I think it is wise to change supervisor after a couple of years. I had the same one for four years and eventually you get to the point where you are even using the same phrases ..."

"I think good supervision, like good therapy, is about helping the person supervised to be the therapist he or she is trying to be. It's about fostering their particular qualities and distinctiveness. It shouldn't be about imposing a system ... I have in the main valued the contribution of peers more than that of more experienced supervisors ... I think supervision is essential while you are becoming a psychotherapist but it takes various lengths of time for people to get to the point where they feel confident enough to manage without - and at the least that probably takes several years. I don't think that supervision must continue indefinitely. There comes a time, I think, when you aren't gaining any more and the therapist has to go out on their own ..."

references

  1. Hawkins, P & Shohet, R (1989). Supervision in the Helping Professions. Milton Keynes: Open University Press.
  2. Charles-Edwards, D, Dryden, W, & Woolfe, R (1989). Handbook of Counselling in Britain. London: Tavistock/Routledge.
  3. National Health Services Management Executive (1993). A Vision for the Future. London: DHSS.
  4. British Association for Counselling (1990). Information Sheet 8: Supervision.
  5. Long, A, & Chambers, M (1996). Supervision in Counselling: a channel for personal and professional change. Counselling, 7(1): 50-54.
  6. Steinberg, D (1989). Interprofessional Consultation. Oxford: Blackwell Scientific Publications.
  7. Proctor, B (1994). Supervision - competence, confidence, accountability. British Journal of Guidance and Counselling, 22(3): 309-326.
  8. Mowbray, R (1995). The Case Against Psychotherapy Registration. London: Trans Marginal Press.
  9. Dunlop, A (1997). Counselling supervision (letter). Counselling in Scotland, June 1997: 6-7.
  10. Mearns, D (1995). Supervision: a tale of the missing client. British Journal of Guidance and Counselling, 23(3): 421-427.
  11. Bond, T (1993). Standards and Ethics for Counselling in Action. London: Sage Publications.
  12. Mander, G (1996). Supervision in counselling (letter). Counselling, 7(2): 99-100.
  13. Mathers, J (1978). The Accreditation of Counsellors. British Journal of Guidance and Counselling, 6(2): 129-139.
  14. Cohen, K (1992). Some Legal Issues in Counselling and Psychotherapy. British Journal of Guidance and Counselling, 20(1): 10-26.
  15. Griffin, J (1997). The Origin of Dreams. Worthing: The Therapist Ltd.
  16. Advice Guidance Counselling and Psychotherapy Lead Body (1997). Observation in Assessment Project, May 1997.
  17. Kottler, J A (1993). On Being a Therapist. San Francisco: Jossey-Bass.
  18. Dawes, R M (1994). House of Cards: Psychology and Psychotherapy Built on Myth. New York: The Free Press.
  19. Goleman, D (1996). Emotional Intelligence. London: Bloomsbury.


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