Supervision in Clinical Practice

A Practitioner's Guide

Joyce Scaife

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781134845552
• Edition: 3
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

This fully updated edition of Supervision in Clinical Practice: A Practitioner's Guide is packed with practical examples from personal and professional experience. Since the publication of the first two editions, health and social care organisations have become increasingly risk averse, resources more strained, and moves have been made towards stifling levels of clinical governance. In this edition Joyce Scaife counters the idea of supervision as a constraint and challenges some of the thinking associated with 'evidence-based' practice when this focuses on what can be easily measured rather than what matters.

Joyce Scaife explores frequently encountered dilemmas including:

• How can supervisors facilitate learning?

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• What are the ethical bases of supervision?

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• What helps to create and maintain an effective working alliance?

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• How can supervisors balance management and supervision roles?

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• How can supervisors work equitably in an increasingly diverse and pluralistic world?

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Supervision in Clinical Practice remains an indispensable text for supervisors and supervisees who practice clinically in a range of professions, including applied psychology, counselling, psychotherapy, psychiatry, nursing and social work.

Chapter 1

Supervision

Is it worth it?

Most every decision approached with care

Prompts doubt or delay. But we wear

Rose-tinted glass when life is peaking

And if, retrospectively speaking,

Effort brings progress, strength or mirth,

Why dwell unduly on questions of worth?

(Hannah Scaife, 2018)

Before going further and exploring the subject of supervision, it struck me that right at the outset there are some fundamental questions to address in deciding whether or not to expend effort on reading and learning about it, such as these:

Is it worth doing?

Is it worth training to do it?

Is it worth organisations introducing/supporting it?

I have concluded that the literature does not provide easy and straightforward answers to these questions although my own perspective is that supervision is essential to my practice and well worth the effort necessary to do it well both as a supervisor and supervisee. I may not be able to convince you of this but want to highlight the issues that I think are worthy of consideration in exploring answers to these questions.

Is it worth doing?

When I first became a psychologist, I was taught to be a scientist practitioner and that my approach to the work needed to be founded in sound scientific research and findings. A scientific approach involved carrying out research in which I made attempts to control extraneous factors in order to explore the relationship between the dependent and independent variables in which I was interested. In my clinical work, the randomised controlled trial (RCT) was the gold standard for deciding whether evidence was valid and reliable. The scientific paradigm continues to exert a major influence on the practice of psychology and could be seen as underpinning movements advocating evidence-based practice, demonstration of competencies and ‘what works for whom’ (Roth and Fonagy, 1996).

Over time, as a result of my practice and wider life experiences, I have come to be sceptical about this approach in so far as it is able to encompass and account for all of my experiences. Some of my colleagues appear to have had similar thoughts since the skills now required for qualification as a clinical psychologist emphasise the importance of the reflective practitioner as well as the scientist-practitioner. I tried to express this in a ‘soapbox’ article about the meaning and place of evidence in considering the process of supervision (Scaife, 2012). Extracts are reproduced here:

The Mexican Sierra has “XVII-15-IX” spines in the dorsal fin. These can easily be counted, but if the sierra strikes hard on the line so that our hands are burned, if the fish sounds and nearly escapes and finally comes in over the rail, his colors pulsing and his tail beating the air, a whole new relational externality has come into being – an entity which is more than the sum of the fish plus the fisherman. The only way to count the spines of the sierra unaffected by this second relational reality is to sit in a laboratory, open an evil-smelling jar, remove a stiff colorless fish from the formalin solution, count the spines and write the truth… . There you have recorded a reality that cannot be assailed – probably the least important reality concerning the fish or yourself.

It is good to know what you are doing. The man with this pickled fish has set down one truth and recorded in his experience many lies. The fish is not that color, that texture, that dead, nor does he smell that way… . The man with his pickled fish has sacrificed a great observation about himself, the fish and the focal point, which is his thought on both the sierra and himself.

(Steinbeck, 2000: 2)

Although I am not a fisher, I am in sympathy with John Steinbeck in his preference for the experience of the live creature, in my case as an avid snorkeller. And as a clinician and supervisor, there is much about practice which I find does not lend itself to the counting spines approach. This is because I experience my work as a relational process in which I aspire to be fully engaged both personally and professionally with other live creatures, which does not always seem to map well onto the ubiquitous mantra of ‘evidence-based’ practice. I want to use my soapbox to offer a challenge to the notion of ‘evidence’ as it often seems to be portrayed in my discipline.

I sometimes find myself in situations at work where I am unsure of what I am doing or taking actions which do not appear in a treatment manual, especially when I am under my desk with a child shooting aliens or walking round the town centre talking to a teenager who is unable to sit still long enough otherwise to bear to talk about his feelings. Donald Schön (1987) said:

In the varied topography of professional practice, there is a high hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and nonrigourous inquiry?

(Schön, 1987: 3)

I am reassured by the writing of authors such as Michael Mahoney who describes working with a man who had been struggling with chronic and intense depression. The sessions were invariably difficult and draining and on this occasion he seemed even more despondent than usual:

“How are you, John?” I asked.

Almost a minute went by before he responded, “I am getting worse,” he whispered.

I waited for him to elaborate, but there was only silence. (Meanwhile, inside me, there were the voices of my very human self saying, “Oh, God! Why me? Why tonight? He is my last client. I just want to go home.”) Finally, to break the silence and foster some movement, I said, “How so?”

He was silent for perhaps half a minute, and then he said, “I used to be depressed. [long pause] Now I can’t feel anything… .” His words and voice died off in weakness as he uttered this.

Quietly, unconsciously assuming his voice tone, I said, “Nothing?” (Inside me the voices continued, “Damn! This is going to be a long hour!”)

[short pause] “Nothing.”

We continued in silence for several minutes. Finally, without looking up he said, “You don’t say anything … just like my analyst.”

Perhaps his words struck an old sensitivity. I don’t know. But I heard myself say, “John, would you mind standing up?” When I heard myself voicing these words, my immediate internal reaction was one of panic (“Michael, what the hell are you doing? Where are you going with this?”).

John looked at me for the first time in the session. His puzzlement was obvious as he said, “What? … What did you say?”

Almost mechanically, I repeated, “Would you mind standing up?” Again, my insides echoed disbelief. (“Jesus Christ, Michael! What are you going to do if he does stand up? What are you going to do if he doesn’t?”)

(Mahoney, 2003: 183)

John finally did stand up and asked, “Now what?” Michael Mahoney said to him sheepishly, “I don’t know.” The client became angry. His voice became stronger as he made critical comments. ‘His face was alive with contempt.’ Mahoney suddenly said, “John, are you still not feeling anything?” The client’s face went from ashen to red and his mouth fell open. He said, “You son of a bitch! You tricked me!” thinking that his therapist’s actions had been planned.

For me, this extract illustrates Donald Schön’s murky swamp of professional practice and the value, importance even, of spontaneity and clinical experience in the difficult work that we do because the materials we work with are our fellow human beings. I don’t think that Michael Mahoney’s intervention would, by most accounts, conform to the requirements for evidence-based practice but some definitions do encompass clinical experience and intuition as falling under its umbrella. I think this is often overlooked. ‘Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values’ (University of Toronto Libraries, 2000). Clinical expertise and patient values often seem to be missing. In addition, I believe that practitioners’ assumptions, beliefs and values determine how they judge the evidence from these sources and so the personal qualities, thinking and reflecting skills that they bring also need to be included in the equation of effective clinical practice. The challenge of including such factors within an evidence- and competency-based approach has been acknowledged (Falender, 2014a). Many professions, including clinical psychology, have moved towards encompassing this perspective by acknowledging the importance of reflective practice in addition to scientific practice (British Psychological Society, 2017; Practice Guidelines).

John Steinbeck concluded that the two kinds of ‘truth’ (derived from the experience of the pickled fish and from the pulsing being on the end of a line) could be complementary and that neither need detract from the evidence provided by the other. Jan Horwath (2007) distinguishes between technical-rational activity which emphasises traditional views of knowledge, standard procedures and empirical research, and personal-moral activity, which recognises that individuals do not fit neatly into boxes and that personal and professional values and beliefs influence judgements. My concern is that the evidence-based mantra of professional practice appears to privilege the technical-rational over the personal-moral to the potential detriment of the accomplishments that our discipline is capable of helping people to achieve. Peter Cropper of the Lindsay String Quartet argued that technique is useful (essential even) to the extent that it opens up the possibility for creativity. What I want from my therapist and from my supervisor is someone who is involved with me and who minds about what happens to me. I want to work with someone who thinks about what they are doing and uses their experiences to reflect upon and develop their practice. I do not want to work with a technician, but rather with someone who is happy to wade with me in the murky swamp, making discoveries as we go, using the research literature as a map which helps me to plan but does not constrain me from taking interesting and informative detours as my intuition and experience dictate. And this means broadening the definition of evidence to include those things that do not readily lend themselves to measurement.

In writing the article I wanted to emphasise the value of what might be regarded as two different kinds of evidence in which one kind tended to be underrepresented in the debate about the efficacy or effectiveness of supervision (Lambert, 2013). The two kinds come from different underlying worldviews or paradigms: ‘worldview (and the theories which are generated by it) determines what gets studied, how it gets studied, how the data gets interpreted, and what counts as valid findings’ (McMillan, 2015: 16).

Worldview reflects underlying beliefs, values and foundational assumptions which determine our perspectives on life and which guide actions. It has been argued that these beliefs, ‘must be accepted simply on faith,’ irrespective of how well argued they may be because, ‘there is no way to establish their ultimate truthfulness’ (Guba and Lincoln, 1994: 107). Jon Scaife (2018) summarised the differences between three different worldviews in the following table:

Table 1.1 Worldviews

	Positivism	Constructivism	Criticalism
Ontology (assumptions about the nature of Reality or reality)	• There is a Reality ‘out there’, and it can be known. • Laws and mechanisms govern the workings of that Reality.	• There is an underlying Reality ‘out there’ but its nature cannot be known. • Each individual constructs their own experienced reality. • Research can produce rich accounts of people’s realities.	• Reality may be objective or subjective, but truth is continually contested by competing groups.
Epistemology (assumptions about the nature of knowledge)	• Knowledge, if carefully found, describes aspects of Reality. • The researcher and the object under investigation are independent entities. This is known as an ‘objectivist’ view. • Good research aims to reduce or eliminate any influence on the objects of study by the researcher.	• Knowledge is constructed from each person’s unique history and ways of constructing. • Knowledge is a resource that we use to navigate through our life experiences. • Perceptions and experiences of both the researcher and the research participants affect what is seen and conceptualised.	• Power relations determine what (and whose) knowledge counts. • Power is implicated in the relationship between the researcher and the researched. • What can be known is inextricably intertwined with the interaction between the researcher and the researched.
	• Researchers find, collect or discover data in the world. The same data is available for others to collect.	• Researchers generate or produce data from their experiences. • The outcome of research is the researcher’s story of the participants’ stories.
Methodology and methods (decisions the researcher needs to make about how to carry out an inquiry)	• Hypotheses and/or questions are specified in advance and rigorously tested under controlled conditions. • Main methods are more likely to be quantitative than qualitative.	• Multiple modes of inquiry are employed and synthesised in pursuit of a rich, trustworthy story. • Qualitative methods are likely to be used but quantitative methods may also be used.	• A dialogic approach may be taken, with dialogue aiming to raise participants’ and researcher’s awareness and bring about transformation. • Qualitative and quantitative methods may be used.
Example of a research question, hypothesis or line of inquiry	• Hypothesis to be scientifically tested: ‘Musical training enhances children’s second language learning’	• Constructivist research explores people’s realities through research questions, e.g. ‘What skills are needed for students to succeed in inquiry-based learning?’	• Value-rich area of inquiry and potential transformation: ‘How are behavioural sanctions in primary schools used with students from different ethnic groups?’
Related ideas	• Science • Scientific method • Realism • Behaviourism • Objectivity	• Interpretivism • Subjectivity • Relativism • Diversity • Pluralism	• Ideology • Critical theory • Critical realism • ‘Race’/class/gender theory • Feminist theory

Source: Scaife, 2018

From a positivist worldview it is assumed that with very careful and controlled studies it is possible to generate absolute, universal ‘true’ descriptions of Reality or a ‘God’s-eye view’. From a constructivist worldview, it is assumed that each person create...