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Introduction and Overview of EvidenceāBased CBT Supervision
What a State Weāre in
We are not the first to be concerned by the gap that exists between the vital role of supervision in professional practice and the means by which clinical supervisors are prepared and developed. The phrase āsomething does not computeā sums it up succinctly (Watkins, 1997, p. 604). Although Watkins was referring to the neglect of supervisor training, his phrase applies just as well to the way that many advocates of CBT supervision have neglected evidence, failing to create an evidenceābased approach to their supervision practice, despite the impressive commitment to evidence in therapy (Milne, 2009; Reiser, 2014). We recognize this is a timely moment to bridge that gap, in recognition of the increasing international status of clinical supervision (Watkins & Milne, 2014). This manual makes things compute by providing both a wealth of researchābased evidence, which will improve CBT supervisorsā training, and robust support for supervisors in their everyday supervision practice.
Now Youāre Talking!
The gap becomes even more apparent when one considers the value of supervision, which is rightly regarded as the signature method of training in the mental health professions (Bernard & Goodyear, 2014). Our interventions are called talking therapies, but CBT places special emphasis on taking the correct action (Waller, 2009). This principle applies equally well to CBT supervision in that the role of experiential learning, which involves repeated cycles of reflection, experiencing, conceptualizing, planning, and experimenting, is viewed as the primary mechanism of development (Reiser, 2014). Our preferred summary of experiential learning is provided by Kolb (1984), who noted that humans are primarily adapted for learning: we are effectively āthe learning species.ā It follows that ālearning is an increasing preoccupation for everyone ā¦ and an increasing occupationā (pp. 1ā2). This underscores the importance of action and helps us understand why clinical supervision is such a marvelous and quintessentially human activity. Not only is it deeply satisfying, it is also highly effective. Although research on clinical supervision ā CBT supervision in particular ā has been sparse and of variable quality, there is reason to believe it is the single most effective method for helping supervisees (therapists) to develop the competence, capability, and professional identity they need (Falender & Shafranske, 2004; Callahan et al., 2009; Milne & Watkins, 2014). Supervision is also perceived by supervisees as the main influence on their practice (Lucock, Hall & Noble, 2006), and is currently recognized by governments as an essential component of mental health services. In the United Kingdom the Care Quality Commission (2013, p. 6) states that āclinical supervision is considered to be an essential part of good professional practice,ā and a clear example of the UK governmentās investment in supervision can be found in the Improving Access to Psychological Therapies program (IAPT: Department of Health, 2008). In addition, supervision has strengthened its status internationally in recent years (Watkins & Milne, 2014), and CBT supervision has developed significantly (Reiser, 2014). Therefore, this is a timely moment to attempt to tackle the longāstanding gaps and build a bridge for CBT supervision as a professional specialization (Milne, 2008).
Getting Our Act Together
How, then, can we bridge the gap between how training and supervision are conducted and the evidence base, so that we better realize the great potential of CBT supervision? Consistent with the IAPT approach, Dorsey and colleagues (2013) claim that the gold standard for supervision in clinical trials is:
- Assessing the fidelity of therapy
- Developing competence through behavioral rehearsal
- Reviewing therapy through direct observation (usually audiovisual recordings)
- Monitoring clinical outcomes
Training CBT supervisors in these methods, and supporting them so that they maintain the standards and continue to develop expertise, are as challenging as supervising therapy, but have been afforded far less interest and attention (Although we refer throughout this manual to therapy, we recognize that supervision should embrace all professional activities). Even less is known about supervisor training than supervision itself and the gaps in our knowledge base are even wider when it comes to organizational support for supervisors (see chapter 9). Although Watkinās (1997) concern that something does not compute has been eased by what he regards as a sea change in supervisor training, his review concludes that we are still in the formative stage and know little about structuring, timing, covering, delivering, or evaluating supervision training (Watkins & Wang, 2014). Milne and colleagues (2011) reached a more optimistic conclusion, based on their systematic review of 11 controlled evaluations of supervisor training, which they believed provided enough empirical support to recommend the following training methods:
- Roleāplaying and use of simulations
- Observational learning (competence modeled live, or by a video recording)
- Corrective feedback, ideally based on direct observation
- Teaching (verbal instruction, discussion, and guided reading)
- Written assignments (e.g., learning exercises, quizzes, and homework)
Note how similar these methods are to the gold standards for supervision itself, not to mention CBT. This suggests a fundamental role for experiential learning (Kolb, 1984) in mental health interventions (see chapter 4). This manual reflects this status and draws attention to relevant commonalities.
How Can We Act Together?
Inspired by the potential of CBT supervision to improve competence in supervisees through experiential learning, this manual addresses the gaps in supervisor training and evidenceābased supervisory practice. Our approach has been to develop an accessible, stateāofātheāart product, designed to enhance supervisory training in CBT in a way that is consistent with evidenceābased practice, including relevant competence frameworks. This manual, together with associated internet content (e.g., video demonstrations of competent practice), has been developed in six userāfriendly modules, reflecting the popular and logical training cycle, starting with goals and ending with evaluation. Each module includes a guideline, condensing the essential information found in the chapters. We also tested the guidelines and other materials at supervisorsā workshops, paying close attention to feedback and retaining only the material rated as clear and accurate. To ensure that the manual was stateāofātheāart we reviewed the latest ideas from the best available supervision manuals and guidelines (Milne, 2016). We also studied the wider literature for evidence, such as controlled studies and systematic reviews of staff training (see chapter 3). Finally, we learned important lessons about effective dissemination and uptake through experiences with a prior manual that showed promise (Milne, 2010; Milne & Dunkerley, 2010). It is for these reasons that we are confident that our current effort will further enhance supervisorsā training.
Our project is ambitious in at least two ways: it addresses the shortage of suitable training resources and fosters successful dissemination. When we surveyed the current supervisor training manuals we found that most were restricted to academic discussions of supervision, but provided minimal interactive content, limited internetābased connectivity, and, with very few exceptions (Milne, 2009; Sudak et al., 2016), had minimal enactive, DVDāsupported content. While these manuals are excellent for restricted, classroomābased teaching or as a reading assignment, they are neither userāfriendly nor accessible across disciplines and countries, and none appeared to be easily adaptable to the highly enriched, complex experiential and procedural learning required for the effective training of clinical supervisors. This last shortcoming seemed especially egregious, as experiential learning lies at the heart of our method in CBT therapy and supervision. In short, most manuals offer limited practical support and do little to advance supervision in practice.
We have addressed dissemination by studying what works and then incorporating useful ...
