Evidence-Based CBT Supervision

Principles and Practice

Derek L. Milne

• Publisher: Wiley-Blackwell
• Year: 2017
• ISBN:
  9781119107606
• Edition: 2
• Topic: Psicologia
• Subtopic: Psicologia clinica

New edition of a distinctive guide to clinical supervision, for all who work in the mental health field

Evidence-Based CBT Supervision offers an evidence-based perspective of particular interest to CBT supervisors working within mental health. It integrates the author's extensive professional experience with relevant theories, empirical knowledge derived from the latest research, and guidance from other leaders in the field. First published as Evidence-Based Clinical Supervision, the Second Edition puts the emphasis more firmly on a cognitive-behavioral approach, clarifying as never before a CBT orientation to the subject. It also incorporates more information on the restorative function of supervision (supporting supervisors emotionally), and draws on findings and methods for developing professional expertise.

Founded on the author's long-term involvement in painstaking programmatic research, this book offers an original, scholarly, systematic, and constructive guide for fostering evidence-based supervision in mental health care. It features a manual with video demonstrations and supervision guidelines, and includes many useful ideas and recommendations for all those involved in supervision, not just trainers and supervisors. The author also spells out how the evidence base informs his companion book, the more practical and training-focused Manual for Evidence-Based CBT Supervision (Milne & Reiser, 2017).

Bringing applied science to supervision, Evidence-Based CBT Supervision offers an expert's guide to the critical business of making clinical supervision work within modern mental health services.

1
Recognizing Supervision

Introduction

Sitting squarely at the crossroads between professional development and professional practice, clinical supervision continues to cry out for study and enhancement. Clinical supervision is defined as the formal provision, by approved supervisors, of a relationship-based education and training that is work-focused and which manages, supports, develops and evaluates the work of colleague/s (Milne, 2007b). This definition is described later in this chapter.

Supervision merits scholarly attention because it helps to ensure safe and effective practice (Falender & Shafranske, 2004), partly by fostering treatment fidelity (Inman et al., 2014), which in turn helps to maximize the outcomes for clients (Callahan et al., 2009). It also offers support to supervisees (Knudsen et al., 2008) and represents the foremost ‘signature' method and most critical part (Watkins & Milne, 2014) of teaching clinical skills to mental health practitioners. Duly perceived as the main influence on clinical practice amongst qualified staff and their trainees (Lucock et al., 2006), it also helps to address the growing emphasis on clinical accountability (Wampold & Holloway, 1997), is required for the accreditation of initial professional training (e.g. British Psychological Society: BPS, 2002), is necessary for continuing professional development and regulation (e.g. British Association for Behavioural and Cognitive Psychotherapies: BABCP, see Latham, 2006) and is an accepted defence against litigation (Knapp & VandeCreek, 1997). Not surprising, then, that Britain's Department of Health (1998) should regard effective staff training that subsumes supervision as one of the ‘ten essential shared capabilities' of mental health practitioners (Department of Health, 2004a). For such reasons, supervision has now achieved international recognition as a distinctive and essential professional role (Watkins & Milne, 2014).

Yet, in spite of its critical and valued role, the development of supervisors has long been a neglected research area, one that has ‘generated only a modicum of research' (Holloway & Poulin, 1995, p.245), research that has been judged inadequate scientifically (Ellis et al., 1996; Ellis & Ladany, 1997) and narrow in focus (Milne & Reiser, 2016a). Russell and Petrie (1994, p.27) found this neglect ‘alarming', and Watkins (1997) noted how this neglect simply ‘does not compute' (p.604) with the important role supervision has in professional life. Since 1997 the number of papers on supervision has increased dramatically, but unfortunately the methodological weaknesses remain marked (Inman et al., 2014). For example, there appear to have been five studies of supervision within the otherwise impressive Improving Access to Psychological Therapies (IAPT) programme: McFadyen et al. (2011); Newman-Taylor et al. (2013); Richards et al. (2013); Green et al. (2014); and Waller et al. (2015). This is disappointing, given that the cognitive-behaviour therapy (CBT) model that underpins IAPT is devoted to an empirical approach. But more worrying is the unsystematic nature of this research. Table 1.1 provides an illustration of the omissions within this small literature. By applying some important questions about these five studies (from the fidelity framework: see Chapter 8), and doing so leniently (see key to Table 1.1), it appears that none of these studies has conducted a thorough evaluation of supervision. In two cases there was reason to believe that supervision had even been implemented in a faulty manner. For example, in the McFadyen et al. (2011) study supervision only seemed to include one feature of IAPT supervision (agenda-setting); in the Waller et al. (2015) study there was poor attendance at group supervision. Furthermore, only one of these studies utilized a controlled research design (Richards et al., 2013), and none of these studies manipulated supervision or employed direct observation. Indeed, the controlled study (Richards et al., 2013) was focused on patients' clinical outcomes, with only passing mention of supervision (clarification that IAPT style supervision was included was only obtained by personal correspondence between the author and Professor Richards on 16 April 2015).

Table 1.1 An illustration of the methodological weaknesses of supervision research.

Study	Right thing?	Right thing done?	Done right?	Right receipt?	Right outcome?
Green et al. (2014)	?	?	?	✓	✓
McFadyen et al. (2011)	×	?	✓	✓	?
Newman-Taylor et al. (2013)	✓	✓	✓	?	?
Richards et al. (2013)	✓	?	?	?	✓
Waller et al. (2015)	?	×	?	✓	✓
Key: ✓, clear claim or demonstration (any measure or qualitative data); ×, not right (some evidence of low fidelity); ?, not known: no data.

In relation to Table 1.1, it should be acknowledged that these studies had other important foci, and made an impressively rigorous job of analysing one or more of the fidelity criteria. For example, Richards et al. (2013) provided very rare and interesting information on the economics of therapy, including estimating the cost of supervision (£40.50 per patient). However, the overall conclusion I draw is that we still do not know if IAPT supervision works. Whilst there are rigorous clinical outcome evaluations that indicate that IAPT is an effective approach (e.g. Clark et al., 2009; Richards & Suckling, 2013), as far as I know it has not been shown that IAPT supervision contributes to these outcomes. In short, the ‘modicum of research' decried by Holloway and Poulin (1995) appears to still hold true more than 20 years later, even for a ‘flagship' development like the IAPT programme.

It should not be surprising, then, to learn that supervision models do not correspond to the complexities of professional practice (Cleary & Freeman, 2006), and that the adequacy of supervision has been rated as ‘very poor' in 20–30 per cent of cases, according to a national inquiry concerning junior doctors in the UK (see Olsen & Neale, 2005). In the presence of such damning views, and in the absence of a well-developed toolkit of psychometrically sound instruments, long-standing concerns that the practice of clinical supervision may generally be poor are difficult to dispel (Worthington, 1987; Binder, 1993). To illustrate the validity of such concerns from my own experience, N = 1 observational analyses of experienced CBT supervisors have always indicated surprisingly low levels of competence at baseline assessments.

An Evidence-Based Framework for CBT Supervision

In order to address some of these concerns and to introduce a systematic approach, the present book adopts the evidence-based practice (EBP) approach and applies it to supervision, using an evidence-based clinical supervision (EBCS) framework to guide the development of CBT supervision (i.e. the best-available research, expert consensus and theory). In this sense, EBCS is a research and development rationale or practice development philosophy, similar to ‘Best Evidence Medical Education' (Harden et al., 1999), in that both treat professional development in a systematic way, based on the highest quality and most relevant research. It differs most markedly from intensively personal (humanistic) approaches to the development of supervision, which assert, for instance, that ‘good supervision, like love…cannot be taught' (Hawkins & Shohet, 2000, p.195). As described in the next chapter, the EBCS framework is based on the use of a range of research activities, expert consensus and relevant psychological theories which address the development of ‘good supervision' through the applied science of training.

The EBCS framework is therefore a specialized example of EBP (see Parry et al., 1996), a prominent objective in health services, and part of an international effort to ensure that patients have access to the best-available care. For example, in the USA, the American Psychological Association (APA) has developed a policy for EBP (APA, 2006), and international scientific journals published in the USA have carried special issues to foster understanding and to promote EBP (e.g....