Supervision and Clinical Psychology

Theory, Practice and Perspectives

Ian Fleming, Linda Steen, Ian Fleming, Linda Steen

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136650710
• Edition: 2
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

What are the developments influencing supervision in clinical psychology?

Supervision is crucial to good professional practice and an essential part of training and continuing professional development. This second edition of Supervision and Clinical Psychology has been fully updated to include the recent developments in research, policy and the practice of supervision.

With contributions from senior trainers and clinicians who draw on both relevant research and their own experience, this book is rooted in current best practice and provides a clear exposition of the main issues important to supervision. New areas of discussion include:

• the impact of the recent NHS policy
• developments in supervisor training
• practical aspects of supervision
• a consideration of future trends.

• 
  
  

Supervision and Clinical Psychology, Second Edition is essential reading for clinical psychology supervisors as well as being invaluable to those who work in psychiatry, psychotherapy and social work.

Chapter 1

Introduction

Ian Fleming and Linda Steen

Welcome to the second edition of Supervision and Clinical Psychology. The first edition was written largely in 2002 and published in early 2004. This revised edition incorporates new knowledge and utilises the experience of supervision gained from both within and outside clinical psychology since 2002.

What has changed since the first edition?

Superficially, it might seem as if not a lot has changed since 2002 in the practice of clinical psychology in the UK. The vast majority of clinical psychologists – over 8000 – remain working in the public health system, the National Health Service (NHS); see Chapter 3. There has been some increase in the numbers of people working independently (either directly for themselves, or for private employers or so-called third-sector organisations) and this may be accounted for in part by the policy of outsourcing certain NHS services to the ‘independent’ sector.

There have been some changes to the organisation of clinical psychologists in the NHS, most apparently the dissolution of psychologist-managed psychology departments that cross specialisms. Moreover, as for all nonmedical NHS staff, the career structure for clinical psychologists has changed since the introduction in 2004 of the NHS salary structure, Agenda for Change (AfC; DH, 2004). A clear career structure remains intact and it is still common to find unfilled posts that are hard to recruit to, although there is a tendency for a smaller proportion of posts to exist at Consultant grade (see, for example, Turpin and Llewelyn, 2009).

There has continued to be an expansion in the number of clinical psychology training places, with 623 places having been commissioned in the UK in 2009, although this increase has slowed. To illustrate, from 2000 to 2005 there was an increase of 198 training places; from 2005 to 2009 the number of places increased by 35 and, as noted by Graham Turpin in Chapter 3, far from expanding, in some regions of England there has been a reduction in training places since 2005 due to financial stringencies. Nonetheless, there continue to be very high numbers of well qualified applicants for each place; the 2010 data for applications to UK clinical psychology training programmes show a 27% increase in applications as compared with 2009. Once qualified, most individuals appear to quickly find full-time employment, usually in a clinical area of their choice; the exception to this was in 2006 following the introduction of the AfC pay structure, when there were fewer full-time posts available within the NHS and, unusually, a significant number of trainees had to take locum or part-time jobs or seek employment within the private sector.

This picture of relative stability may be illusory, however, and significant changes to the organisation of clinical psychology services in the NHS may be in the offing. One example of this is the Improving Access to Psychological Therapies (IAPT) initiative. For many years the psychology profession has worked to be better recognised by the government, and within the past few years this has taken place. Lord Layard, Labour Life Peer and Emeritus Professor of Economics at the London School of Economics, through reading the research on psychological treatment for anxiety and depression championed clinical psychology as the key to therapy that would enable numbers of people to throw off their psychological distress and as a result be able to return to employment. Whatever the range of beneficial reasons underlying the practice of clinical psychologists, the basis of the Layard Report was firmly in the economic realm, with an emphasis on the overall gains for the exchequer when offset against the finances needed for new therapists. This was crystallised in the policy document entitled Improving Access to Psychological Therapies (IAPT; DH, 2009b). This contained an emphasis on therapists rather than clinical psychologists per se, because the understanding of the research demonstrating the effectiveness of cognitive behaviour therapy presumed a need for a limited form of uni-linear training as necessary to provide effective treatment – as opposed to the training in different psychological models required of clinical psychologists. There may be significant implications contained in IAPT for the continuing use of trained clinical psychologists.

The September 2009 report of the NHS Workforce Review Team ‘suggests that there is room for growth on the clinical psychologist workforce over the next 5 years’ and specifically refers to the ‘increased requirement for clinical psychologists in both a training and service delivery capacity’ resulting from IAPT (Workforce Review Team, 2009: 1). However, it should be noted that the data set (from the NHS Information Centre) that underpins the report includes within the category ‘clinical psychology’ all applied psychologists and some trainees and assistants. At the time of writing this is generating more heat than light amongst the profession. It also must be recognised that IAPT in its original incarnation applies to only one of the client areas in which clinical psychologists now practice, although in mid-2009/10 there had been an expansion of IAPT to working with children and their families, and some consideration of its application to working with other groups, including people who have learning disabilities. It is unclear in this case where any economic benefits may lie. These issues will be discussed at more length in Chapter 3.

This development has important implications for supervision and there are a number of strands to this. First, within the IAPT strategy – and indeed inseparable from the different levels (‘intensities’) of therapeutic input – there is an explicit reference to the use of supervision to ensure the quality of therapeutic delivery. Second, it is clear that there are differences between the approach to supervision envisaged within IAPT and the more inclusive form of supervision being developed in supervisor training. Here the priority would appear to be adherence to a manualised approach to treatment combined with problem-solving within that model. This ‘“high volume” and outcome-linked’ (Milne, 2009: 51) case-based supervision has quite a different feel from clinical supervision; in the former, the emphasis is on client outcome, whilst the latter focuses on ‘the personal and professional development of the individual’ (BPS, 2006a: 4). In Chapter 5 David Green debates the issues involved in model-specific and more general forms of supervision. The first indicates the widespread presence of supervision, although the second has implications for the content and breadth of these skills.

It remains unclear whether we will continue to see greater demands for supervisor training as part of the organisation of professional training. Whatever the outcome, it is hoped that the momentum that has developed over the past decade will continue to press for better training and supervisory arrangements.

Supervision developments

It is interesting to reflect that a 2000 survey of clinical psychology trainers (Milne and Oliver, 2000) found little support for developing formal procedures such as supervisor certification, due largely to ‘a cautious approach to a finite and fragile placement/supervisor resource’ (ibid.: 300). In 2009 accreditation of clinical psychologist supervisors became a reality, with the introduction of the BPS Register of Applied Psychology Practice Supervisors (RAPPS). Although membership of the Register will not be a requirement for supervising, it will certainly act to focus attention on the content and form of effective training, the subsequent transfer of training into practice and research into supervision and supervisor training. Accreditation is discussed further alongside the training of supervisors in Chapter 6, where similar developments in other professions are also considered.

The introduction of the aforementioned AfC pay and grading structure and, more recently, the publication of New Ways of Working for Applied Psychologists (BPS, 2007b; Lavender and Hope, 2007) appear to have had a positive impact on clinical psychologists’ attitudes towards supervision as well as their supervisory practice. Whilst the majority of clinical psychologists have always had a favourable approach to supervision, particularly towards supervising trainee clinical psychologists, they could opt out of supervising if they so chose. Now, there is a clear expectation that all clinical psychologists will supervise others from an early stage in their career. Moreover, as the capacity to provide supervision is a key factor within the Knowledge and Skills Framework and is thus one of the criteria for career progression within AfC, it is not unusual for clinical psychologists to seek training in supervision as soon as they qualify, whereas previously it was much more usual for them to wait at least 2 years before training to take on the supervisory role.

The implication of the above is that in future there will be increasing demands on clinical psychologists to receive and provide supervision, both to members of their own profession and to others. This will place pressure on the traditional model of one-to-one supervision, and in Chapter 10 Linda Steen considers different supervision formats and those that might develop in the future.

Also, the introduction of the IAPT programme has led many clinical psychology trainers to have concerns about its potential impact on the supervisory resource for clinical psychology trainees, fearing that those clinical psychologists involved with IAPT training and supervision would have little additional time for supervising clinical psychology trainees. To date, this does not seem to have had a significant impact, although it remains to be seen what will happen in the immediate future.

Another important issue is that of preparedness for supervision, especially when a member of one profession supervises a member of another. Within the NHS, interprofessional learning and working are priorities for both education providers and healthcare organisations, and it is not unusual for clinical psychologists to both supervise and be supervised by other professionals. There does not appear to be a single view of supervision, however, and, for example, clinical and managerial supervision can be confused or seen as interchangeable. Moreover, as outlined in Chapter 10, some terms are used by different professionals to describe similar activities; notable amongst these are consultation, support, mentoring and coaching. In this book the emphasis is on clinical supervision, and particular models are discussed. Rarely does the process take on a didactic form, and yet this is sometimes what people in other professions receive and expect in their supervision. This misapprehension is not an insurmountable problem, but at a service level it does suggest increased clarity about the purpose of supervision, and at an individual level honest communication through the means of a supervision contract. This is highlighted in a number of the chapters in this book, for example Chapters 4, 10 and 11.

This book contains unambiguous recognition of the importance of the supervisory relationship and this is succinctly explored by Helen Beinart in Chapter 4. It is interesting to consider which elements are sufficient for effective supervision and how this relationship can be both established and maintained within different supervision formats, especially the distal ones such as telephone and email supervision. There is evidence that, where possible, participants who engage in some forms of remote supervision, such as on-line supervision, prefer to meet face-to-face initially in order to establish an alliance; this theme is developed further in Chapter 10.

We closed the first edition of our book by quoting Milne and James (1999), who were of the view that we were at an ‘exciting stage’ (ibid.: 36) in the development of supervisory practice. It is satisfying to report that since the first edition was published the increased interest in all aspects of supervision has been maintained. This is the case at all levels: research grows in strength, as exemplified by the work of Derek Milne and colleagues in Chapter 9; there is a keen emphasis on the reflection on supervisory practice, for example in the work of NHS Education for Scotland (NES), referred to in Chapter 6; there is a huge demand for training in supervisory skills from newly qualified clinical psychologists; and there is a recognition that at best supervisor training should commence in pre-qualification and extend to post-qualification continuing professional development.

There has been an increased focus on the evaluation of both supervision and supervisor training and there are a number of assessment tools that can be used. The issue of evaluation is discussed in a number of chapters alongside a call for the evaluation of the transfer of training into practice, although this is in its early stages.

Developments in clinical psychology training

At the time the first edition of this book was written, the BPS had just introduced a new, competence-based framework for clinical psychology training. This involved moving from an experiential model of training, in which trainees were required to have pre-defined experience on ‘core’ placements, to one that emphasised achievement of the competencies required for the roles and responsibilities of newly qualified clinical psychologists. The competencies were expressed as learning outcomes and transferred into the new Standards for Doctoral Programmes (BPS, 2010), which guide all aspects of clinical psychology training from the design of the curriculum, through placement experience, to the methods of monitoring progress and assessment. The particular relevance of the competence framework to this book is two-fold. First, it has given training programmes much more flexibility in the pathways through training, enabling the use of a much wider variety of clinical placements than previously, thereby maximising the supervisory resource. Second, three of the learning outcomes directly concern the practice of supervision, namely: ‘using supervision to reflect on practice, and making appropriate use of feedback received’ (ibid.: 2.3.7); ‘understanding of the supervision process for both supervisee and supervisor roles’ (ibid.: 2.3.8); and ‘providing supervision at an appropriate level within own sphere of competence’ (ibid.: 2.3.9). Whilst the practice and quality of supervision have always played a large role in pre-qualification clinical psychology training, the focus had mainly been on the supervisors’ practice. The introduction of the competence framework, with its explicit focus on the aforementioned learning outcomes, has undoubtedly raised the profile of the practice of supervision as a two-way endeavour and has led to an increased emphasis during the pre-qualification period on training in how to receive and provide supervision.

Another important development within clinical psychology training has been the increased emphasis in recent years on trainees’ personal and professional development (Hughes and Youngson, 2009) and their development as reflective practitioners (Stedmon and Dallos, 2009). In both of these areas, supervision plays a crucial role in helping the practitioner to reflect on self, other and process, and this is developed further in Chapter 2.

Professional developments

As mentioned previously, a desire amongst clinical psychology trainers to recognise the increased attention being paid to supervisory practice in clinical psychology has led to significant developments towards the accreditation of supervisory skills for clinical psychologists; these are described in detail in Chapter 6. It is pleasing to be able to report that agreement has been reached on a core set of learning outcomes for introductory supervisor training and that a process has been agreed whereby the acquisition and practice of these skills are validated by the body that professionally represents UK Psychologists, the British Psychological Society (BPS).

In 2010, the vast majority of UK Clinical Psychology training programmes were engaged in supervisor training and there appears to be a great deal of agreement about the content and organisation of this training. In addition, there is an increasing interest in a requirement for participants to demonstrate the transfer of this training into practice, although this has not been made a specific requirement of accreditation.

In addition to the potential pressures resulting from the wider service policies mentioned earlier, another potential influence on supervision and supervisor training derives from the changing role of the BPS, clinical psychology's professional body. In July 2009, the Health Professions Council (HPC) took on responsibilities for the regulation of practitioner psychologists. Whereas previously the BPS was responsible for accrediting clinical psychology training programmes, this approval role has also been taken on by the HPC. At the time of writing, the role of the Committee on Training in Clinical Psychology (CTCP), the BPS body that formerly took the lead for accreditation vis...