Introduction to Clinical Supervision

Introduction to clinical supervision: A TUTOR’S GUIDE

Derek Milne (October, 2008)

Contents

1 Introduction 3–4 2 Leading the workshop 5–10 3 Workshop sessions 1 ‘Orientation to supervision’ 11–13 Appendix 1 14–16 Appendix 2 17 Appendix 3 18–28 Appendix 4 29–30 2 ‘Goal-setting’ 31–33 Appendix 5 34 Appendix 6 35–45

2 3 ‘Facilitating learning’ 46–48 Appendix 7 49 Appendix 8 50–62 4 ‘The supervisory relationship’ 63–67 Appendix 9 68 Appendix 10 69–81 5 ‘Evaluation’ 82–84 Appendix 11 85 Appendix 12 86–95 Appendix 13 96–98 6 ‘The supervision system’ 99–100 Appendix 14 101 Appendix 15 102 Appendix 16 103–106 4 Acknowledgements 106–107 5 References 108 6 Appendices 109

Introduction to this guide 1 This workshop tutors’ manual introduces what I believe to be a useful technology for facilitating learning about clinical supervision amongst new supervisors. What follows is grounded in well-established and general theory (integrative; pan-theoretical: Kolb, 1984), and in a consensus about what such training should cover (Development and Recognition of Supervisory Skills group, 2006: DROSS). It is also evidence-based, both in terms of the training methods (Goldstein, 1993; Kaslow et al., 2004), and the specifics of effective supervision (Milne & James, 2000). However, the process of applying this workshop manual so as to achieve the desired changes in the workshop participants (and in the way they subsequently provide supervision) is challenging, requiring an experienced facilitator/trainer. I have therefore outlined some ways of managing the workshop in order to try to promote the appropriate experiential learning atmosphere, and generally to increase our prospects of developing effective supervisors. These ways include:

4  A collaborate style of leadership  A firm ‘platform’ on which to build the workshop  A strategy (‘hitting the ground running’) that explicitly values and builds on participants’ existing competencies  Responsivity to participants’ learning needs  Acceptance of your leadership preferences and judgements (flexibility over detailed methods, within basic experiential learning objectives of fostering the essential ‘grasping’ and ‘transforming’ functions of the workshop – see Figure 2).  Recognising the tension between support and challenge for the participants  Valuing ‘reflexivity’ as a vital metacognitive means of problem-solving within the workshops (and of promoting capability in your supervisors)  Providing a library of well-researched materials (video clips to illustrate skills and to stimulate discussion; NICE-style guidelines on supervision; professionally prepared PowerPoint slideshows; suggested learning exercises; etc.)  Adding a workshop evaluation instrument, so that you can get feedback on how all this is working I know from bitter experience how difficult it can be to lead some workshops (Milne, 1986), but have also seen how good leaders can reflect professionally on their practice in order to significantly improve their leadership (see example in Milne et al., 2000). In this collaborative, problem-solving spirit, here is my contact information. You are welcome to get in touch to discuss this workshop. With best wishes for your workshop. Derek Milne (B.Sc., M.Sc., Dip. Clin. Psych., Ph.D., F.B.Ps.S) Northumberland, Tyne and Wear NHS Trust Course Director Doctorate in Clinical Psychology 4th Floor, Ridley Building Newcastle University Newcastle upon Tyne NE1 7RU Tel: (0191) 2227925 (email: [email protected])

6 2 Leading this workshop 2.1 Style of Leadership There are several popular theories regarding how adults learn, such as the ‘shaping’, ‘moulding’ and ‘gardening’ ones. The most appropriate one for developing qualified professionals in their role as supervisors is probably that of ‘travelling’. Based on this style of leadership, the workshop leaders are analogous to mountain guides. Their role is to draw on their greater experience to help plan the learning journey, to manage the group as it travels through what is at times tricky or threatening situations, and to engage them as fully as possible in the experience (including participative decision-making and awareness-raising), etc. By contrast, the ‘gardening’ style of leadership could simply entail creating the right conditions and otherwise allowing the group to grow according to some internal/personal specification, with the odd bit of trimming and feeding (for more, see Milne & Noone, 1996, pp.3–5). This travelling style is preferred because:  New supervisors should be treated as adult learners (active participants, etc.)  The metaphor of a mountain journey is apt, treating continuing professional development (CPD) as a ‘spiral curriculum’ (Kolb, 1984).  Development is inherent in this spiral, which is consistent with the dominant model in the supervision literature (Watkins, 1997).  Leaders do not require to be experts in everything within the workshop.  Rather, in keeping with this stance, they should demonstrate competence in how material can be used, and in how problems can be solved (a collaborative, coping, or ‘good-enough’ approach).  Such a style is suitably reflexive/isomorphic – the leader consciously portrays the same identified qualities as the ‘good enough’ supervisor.  This includes respect for the participants’ needs and orientations, in relation to the journey. However, the leader has a duty of care, and so is carefully prepared (e.g. this manual) and adheres to normal professional practices/standards. Workshop platform

In addition to a travelling style, the leaders enact the workshop based on a multi-layered platform. This adds relevant history, theory, topics (and so forth), as set out in Figure 1.

Figure 1: The platform upon which the workshop is based.

2.2 ‘Hitting the ground running’  One of the more significant implications of this style of leadership is that the workshop participants are assumed to bring highly relevant prior learning with them. They are not only adults, but also highly trained clinicians and well-educated professionals, accustomed to functioning effectively in complex settings. Indeed, their daily work includes many competencies that can transfer readily to those required in supervision (Milne, 2006). These ‘common factors’ include building working alliances, goal-setting, adjusting to individual differences, collaboration, problem-solving efforts, applying general techniques, and working in context (if you are dubious, see also Norcross, 2002).  Based on this reasoning, and on the value of an explicitly reflexive approach, we can construe the participants (again, just like their supervisees) as operating within a ‘zone of proximal development’ (ZPD; Vygotsky, 1978). For the participants, their professional history implies that they will also bring other transferable factors to the workshop, helping to define their learning needs. So, far from being participants who require ‘shaping’ or

8 ‘moulding’, they are in a position to travel, to ‘hit the ground running’. The workshop strategy is based on this affirmative logic, which has several advantages, and which acknowledges a fundamental point: ‘all learning is re-learning’ (Bransford et al., 2000). 2.3 Assessment of learning needs  It follows from this logic that the participants will have a variety of well-grounded learning needs. These should be clarified at the outset (e.g. by rank ordering the workshop topics, in terms of their importance to each participant, through a show of hands) and addressed at regular intervals throughout the 3 days of the workshop (e.g. by maximising the relevance of the learning exercises, discussion, etc.). The headings in the ‘History’ panel of the platform (Figure 1, p. 7) provide prompts as to what participants bring.  Encouraging such ‘felt’ needs to be expressed is not sufficient, however, as an effective workshop leader will also relate these to their own judgements (and stakeholders’ views) on what is needed (the normative needs assessment phase), and to what the literature indicates (the comparative needs assessment: Goldstein, 1993). To illustrate, participants typically shy away from role-plays and other experiential learning methods, but the leaders may know from their own experience that such methods are necessary. This is supported by expert consensus (Falender et al., 2004) and by research (Milne & James, 2000). Therefore, experiential methods are ‘needed’ for supervisors to become effective. Based on my experience and grasp of the literature, the ‘structured learning format’ (Bouchard et al., 1980) is well suited to address this learning need. This entails a combination of learning methods, revolving around an experiential workshop episode. The present manual embodies this format. 2.4 Balancing support and challenge  The juxtaposition of the different perceptions of learning needs illustrates how tensions can arise in workshops. It brings us to one of the most challenging aspects of managing learning from experience, which is balancing your support for participants with the right degree of challenge.  According to the integrative theory of experiential learning that underpins this manual (Kolb, 1984), for adults to benefit from workshops they are required to go through some episodes of mild deskilling and perplexity, brought about by the tensions that a good workshop creates. These tensions lie at the heart of good training (the educational ‘praxis’), and typically arise from inconsistencies between the different ways of knowing about the world. For example, a workshop leader might alternately invite participants to summarise what they know about effective goal-setting (drawing on the reflection mode of knowing), then show a video clip that indicates how an experienced supervisor sets goals (or invite the participants to read a published account). Then a learning exercise, careful questioning, and other methods will typically tease out discrepancies with this ‘official’ account (i.e. the ‘conceptualisation’ mode of knowing).  The effective workshop leader will engineer such episodes and encourage (support) the participants to work through their discomfort (challenge). Too much challenge risks creating panic in the participants, too little results in boredom, so a careful balance is required. Support can take many forms, including self-disclosure by the leaders, encouragement, or acknowledgement of the inherent difficulty of mastering a new skill. As a result of an effective episode of discomfort or puzzlement, the participants will learn from the experience. Technically speaking, they will have grasped something new and transformed this into a better understanding of supervision. Following Piaget, Kolb (1984)

refers to this transformation as either assimilative or accommodative learning. Classically, this learning tends to emerge best when the tensions are created between thought and action (‘reflecting’ and ‘experimenting’), and between feeling and knowing (‘experiencing and conceptualising’). This theory of experiential learning is depicted in Figure 2 below.

Figure 2: The experiential learning theory (Kolb, 1984) that underpins this manual. The boxes are modes of learning, linked by circular arrows showing the ‘ideal’ sequence for their activation (i.e. start with something that has been experienced, like a feeling reaction to a video demonstration, leading to the participants’ reflections on that clip, etc.). Once activated in this way, these modes can facilitate learning by enabling the learner to grasp (comprehend something) and transform it (e.g. by applying it to a practical problem).

2.5 Reflexivity

10  The process of learning from experience (Figure 2) will only take place within the participants’ learning ‘zones’ (the zones above and below the ZPD are sometimes referred to as the ‘panic’ and ‘boredom’ ones). As a workshop leader, you should facilitate this process of staying in the ZPD. Leaders are part of the ‘scaffolding’ that supports learning from experience, the box around the ZPD that symbolically ‘contains’ the process. By analogy, the workshop platform (Figure 1) is the foundation for this scaffold.  In thinking about the workshop in this way, note that I am drawing on the same concepts at the level of the individual and the group of participants: what holds for the supervisor applies also to the leader. This is a reflexive stance, in that I am applying the psychological concepts that we employ to facilitate others (supervisors and their supervisees) to ourselves. Reflexivity is a form of reasoning by analogy, a metacognitive process of huge potential benefit. It can, for instance, be used to reason that research on clinical supervision can be fruitfully guided by research on psychotherapy (Milne, 2006), helping to identify promising research methods. It can also serve to enlighten the way you manage the workshop, and supervisors tackle supervision. To be concrete, the reflexive workshop leader will ask some metacognitive questions (Moseley et al., 2005): 1) Think about what you know already: how is the new problem (e.g. goal-setting) like an old/familiar one? Have you ever done anything like this before? For instance, do you ever set objectives in therapy, in your staff development work, in R& D projects (etc.)? ) What are the similarities and differences between these related activities? Put this into your own words. Which old problem is this new one like? In what sense have you encountered it before? ) Reconstruct the best available prior example – remember details and get more specific about the correspondence that exists (e.g. both therapy and supervision entail working collaboratively to agree an agenda at the outset – this is like goal-setting). ) How can an established activity transfer to a new one? Which detailed elements or general processes apply? (e.g. specifying and ranking a few, achievable goals; engaging in a working alliance). What do you have to do? ) What can be done to test out this analogy? How can the parallel be applied and tested? (e.g. by a role-play of goal-setting in supervision, as if in therapy, with a ‘blind’ observer charged with classifying it as either therapy or supervision). Which approaches might work? Can you think of any other possibilities? What will the final outcome look like? Is this approach going to get you there? ) How does the analogy break down? Have you tackled difficulties like this before? Which adjustments are sufficient to make the therapy approach viable in supervision? How good a solution will this be? How can this new learning be monitored and further developed (e.g. through regular feedback from the supervisee)? Which ideas might you be able to use in the future? This is but one example – a huge benefit of reflexive stance is that many other ways can be identified from the supervision literature and applied to the facilitation of this workshop, preferably following the above sequence. Explicitly modelling such reflexivity and drawing out these instances to the participants is an added bonus. It not only shows them how to do it, but similarly opens up this valuable ‘toolbox’ for them to draw on in their supervision.

Next: That is the end of the introductory material. We next turn to the workshop manual proper – a detailed plan for delivering the above thinking on supervisor training. But first: PLEASE NOTE: the detail in the manual’s session plans is provided in order to be as clear as possible about how this workshop can be delivered: it is by way of illustration, as it is not suggested that you follow each detail religiously (I don’t, when I deliver it!). Instead, use your judgement in order to draw on these ideas and materials flexibly, as appropriate to your local needs and practices. You should therefore modify the sessions in order to incorporate local material and to suit your style as a leader: treat the detailed sessional statements that follow as a basis for your tailored workshop. In this sense, you may wish to reduce the slideshows to a handful of slides, to use different video clips to illustrate points, do different role-plays, present the session on the supervisory relationship early on, etc. However, there needs to be a limit to such tailoring, or else this ceases to be a workshop in evidence-based clinical supervision (EBCS) and becomes something else. Therefore, I suggest that the essential aspects to retain within your tailored workshop are: ∞Aim to achieve the identified learning objectives.

12 ∞Follow the structured learning approach (i.e. the blend of methods detailed). ∞Include only evidence- based material (as per the slideshows and guidelines). ∞Monitor the sessions, to ensure that you are getting the participants using the four different learning modes (Figure 2).

∞Evaluate: are they ‘grasping’ and ‘transforming’ the material? Are the workshop objectives being achieved? If the answer is ‘yes’ and you’ve adhered to these essential aspects, then you have a suitably tailored version of the EBCS workshop! 3

Workshop Sessions

Session 1: ‘Orientation to Supervision’ (Pointers, tips & resources for leading this session in the workshop)

Learning outcomes: By the close, the novice supervisors will be able to:  Summarise at least three legal, ethical or other contextual considerations (1; 14)  Model a professional approach (2)  Summarise the structure to local placements (7)  Note how difference and diversity might affect their own placement (15). (NB. these numbers refer to the DROSS list of learning outcomes, modified slightly in the light of those generated by: Falender et al., 2004; the NHS Strategic Health Authority’s contract specification for supervision in the UK, 2006; and the relevant ‘Skills for Health’ section. The full list of these revised learning outcomes is in Appendix 1, pp.14). Materials: 1. PowerPoint slideshow (this can be found on the accompanying website (www.wiley.com/go/milne); hard copy is in Appendix 2: copy for handout 1 p.17). 2. Video clip (the ‘general example’ within the ‘Orientation’ section of the accompanying website (www.wiley.com/go/milne) is suggested, but any of the 15 video clips will potentially serve your local purpose. Or you may have some of your own material that you’d prefer to use.

Or you might enact a live demonstration. NB: This flexibility applies to all sessions. 3. Handout 2: the Participants’ guide: ‘Orientation to clinical supervision’.

14 Programme: 1. Introduction: After the initial welcome and mutual introductions, summarise the plan and start by delivering the ‘Orientation’ slideshow, being a summary of this session and an account of the whole workshop (its rationale; drawing on the knowledge-base; etc.). For this and all sessions, provide the slideshow as a handout (all such materials are appended). During and/or when finished: seek questions, clarify material. Attempt to gain an impression of what the group’s learning needs are in this area (e.g. cultural competence; awareness of supervision models). In this way, start the process of needs-led training by clarifying where the group are developmentally poised, pitching your input accordingly (e.g. by suggesting a particular perspective on the video material). 2. Video Clip: Show a video-based illustration of a typical supervision episode (Clip 1a is suggested: ‘A general example of supervision’. See Appendix 4 for the full catalogue of video clips; p.29. Remember, often an alternative tape, from a completely different session, may suit your purpose better). Seek any immediate reactions or questions (esp. can they relate to/connect with the material? What was important about the supervisor’s approach? What might you do differently? Why?). The aim is to connect the group’s experience to the material, to begin to place participants on the workshop ‘map’ and to foster ‘grasping’. Check that it served to orientate them to supervision in this way. 3. Guided Reading: NB: This material might be circulated ahead of the workshop, as preparatory reading. Alternatively, delegate sections of the handout to small groups of participants, and ask them to take about 10 minutes to read particular sections of their ‘Orientation’ handout (Appendix 3 pp.18–28), focusing initially just on their delegated section. Inform them that a learning exercise will follow in which they will be asked to discuss these delegated parts of the handout. 4. Learning Exercise: Ask the participants to break into their small groups, each group considering their delegated section of the handout. Their task is to:  Try to link the material to their own experiences, whether as supervisees or supervisors (e.g. Diversity section: an experience of struggling to relate effectively to a supervisor).  Agree on something that is a key development task for them (e.g. finding the best way to openly discuss this struggle).  Consider ways to cope with this selected episode/issue (e.g. by acknowledging the helpful way the supervisor routinely discusses relationship issues within therapy, and asking whether this might be extended occasionally to cover the supervisory alliance).  Each small group to then feedback a consensus view as to the nature of this problem, and how best to tackle it.

Alternative/supplementary exercise 1:

Ask participants to draw the outline of a person on a piece of paper, then to fold it down the middle. Write ‘best possible supervision’ above one side, and ‘worst’ above other. Then insert words/phrases, based on experience, to capture these extremes. Next, ask the participants to form small groups, and to compare their descriptions, aiming to rank order the three most popular ‘best’ and ‘worst’ lists. Back in large group, collate these lists, aiming to link to the ‘Orientation’ handout (Appendix 3 p.18). Alternative 2: Ask participants to call out examples of the ‘best’ and ‘worst’ of their supervision experiences, noting them down on a flipchart. Then form them into small groups, each allocated one of the ‘best’ examples, and one of the ‘worst’. Each group is tasked with finding something relevant in the ‘Orientation’ handout (Appendix 3 p.18). Feedback and discussion. 5. Discussion: Ask the group to now read the remainder of the handout, briefed to raise anything that is interesting or unclear (etc.). Make any additional comments that you’d like to offer (e.g. how typical are these sorts of issues? How should others, such as a course tutor, get involved?).

16 Emphasise the practice implications, including how the documentation/guidelines/CPD within courses and professions support good practice in these areas. Invite any final questions, drawing attention to what follows (remainder of 3 days, and how various related issues will be tackled. For example, note that this ‘supervision system’ aspect will be tackled more thoroughly in the final session). Seek some feedback on the methods/structure – are the group comfortable with this approach?

End of session 1

Appendix 1: DROSS learning objectives (Revised) for Introductory Supervisor Training Aims: Training should ensure that trainees receive an educationally relevant experience, through effective supervision and the assessment of their placement learning Learning Objectives: The following are the key learning objectives for Introductory Supervisor Training for clinical psychologists and related professions. It is recommended that clinical psychologists should attend this training 1–2 years post qualification. It is also recommended that the training should be for a minimum of 3 days (ideally spread over time to allow for the practical application of the training). The learning objectives include knowledge, understanding and the development of key skills, attitudes and the capability to generalise and synthesise these components.

18 It is envisaged that Programmes will use the learning objectives to develop their individual training packages. This will include specified learning outcomes tailored to each Programme.

Understanding and Application 1. Have knowledge of the context (including professional and legal) and clinical service system within which supervision is provided, and an understanding of the inherent responsibility. This context includes an onus on inter-professional learning, while the responsibilities include an agreed and timely schedule of appointments. 2. Have an understanding of the importance of modelling the professional role, e.g. in managing boundaries (inc. seeking consultation/advice when an issue arises, like multiple roles, and is outside one’s competence), confidentiality, accountability, and identifying risks to trainees on placement. 3. Have knowledge of developmental models of learning which may have an impact on supervision (in relation to both the supervisor and the supervisee). 4. Have knowledge of a number of supervision frameworks and models that could be used for understanding and managing the supervisory process. 5. Have an understanding of the importance of a safe environment in facilitating learning and of the factors that affect the development of a supervisory relationship. 6. Have skills and experience in developing and maintaining a supervisory alliance. 7. Have knowledge of the structure of placements, including assessment procedures for disciplines at different levels of qualification up to doctorate level, and the expectations regarding the role of a supervisor. 8. Have skills and experience in assessing learning needs and developmental levels, agreeing a learning contract, and in negotiating flexibly with supervisees. 9. Have an understanding of the transferability of clinical skills into supervision and the similarities and differences (the ‘common factors’, such as communication and teaching skills). 10. Have an understanding of the process of assessment and failure, and skills and experience in evaluating trainees (process and outcome evaluation). 11. Have skills and experience in the art of constructive criticism, ongoing positive (‘formative’) feedback and negative feedback (inc. summative evaluations, such as whether the trainee is heading for a ‘fail’ grade), where necessary. There should be a climate of honest feedback, both supportive and challenging. 12. Have knowledge of the various methods and modalities to gain information, assess learning on placement, and give feedback (e.g. self-report, audio and video tapes, colleague and client reports). Progress should be reviewed, identifying progress and achievements. Feedback should be written and constructive. Manage trainee progression, including poor performance and the non-attainment of competence. 13. Have skills and experience of using a range of supervisory approaches and methods, so as to provide appropriate supervision (as defined by the BPS). 14. Have knowledge of ethical issues in supervision and an understanding of how this may affect the supervisory process, including power differentials. 15. Have an understanding of the issues around difference and diversity in supervision, including diversity in all its forms. 16. Have an awareness of the ongoing development of supervisory skills and the need for further reflection/supervision training. This may include self-assessments and consultancy. 17. Have knowledge of techniques and processes to evaluate supervision, including eliciting feedback. This also includes encouraging and using evaluations of your supervision from trainees. 18. Knowledgeable about research on supervision, translating findings into practice. 19. Encourages self-assessment in the trainee.

Attitudes (Value base) Respects trainees 1. Sensitive to diversity 2. Committed to empowerment of supervisees (e.g. ability to promote growth) 3. Values the ethical base guiding practice and principles. 4. Believes in balancing support and challenge, and balancing the clinical workload against the training needs. 5. Committed to a psychological knowledge-based, scientific approach to supervision 6. Recognises the need to know own limitations 7. Supports principle of life-long learning and professional growth. 8. Accepts responsibility for the supervisee and her/his patients. Capabilities 1. The capability to generalise and synthesise supervisory knowledge, skills and values in order to apply them in different settings and novel situations so as to solve problems.

20 Notes: These objectives were developed by the DROSS group in August, 2005, with additions based on the list published by Falender et. al.(2004), the NHS (SHA) standard contract for training clinical psychologists, and the Skills for Health standards. Derek Milne (9 May 2007)

Appendix 2: Session 1 (‘Orientation’), Handout 1: The PowerPoint slideshow

22 Appendix 3: Session 1, Handout 2: ‘Orientation to clinical supervision’

1. Definition: Clinical supervision can be defined as ‘the formal provision, by senior/qualified health practitioners, of an intensive, relationship-based education and training that is case/work focused and which supports, directs and guides the work of junior colleagues (supervisees) (Milne, 2006 a). Table 1 of this manuscript elaborates this definition, to distinguish it from related activities. For instance, supervision overlaps with consultancy, as both share the aim of supporting colleagues; but supervision is typically more directive, and includes a focus on competence within an individual. By contrast, consultation is typically less directive, more educational, and focuses on the whole organisation (Orchard, 2006).

2. Background: Clinical supervision is now recognised as a vital part of modern and effective health care systems. For example, the NHS policy (2004, 2005) recognises its place as a necessary element in managing and developing the workforce. Similarly, the British Psychological Society (2005) and international research findings (for example, Tharenou, 2001) underline the professional and empirical bases for supervision. Consequently, supervision is recognised within the NHS Agenda for Change framework, tends to be in all new job descriptions for suitably qualified mental health practitioners, and is deemed a core competency (Falender et al., 2004). Reflecting its complexity, supervision is recognised as a competence to be developed both within initial training and as part of CPD. Supervision emerges as probably the single most effective means of promoting professional competence and capability, as well as being regarded by peers as the most influential approach to professional development (Lucock et al., 2006).

3. Problem: However, despite its manifest importance and popularity, clinical supervision has not been developed with anything like the care and attention that it merits. According to the editor of the definitive Handbook of Psychotherapy Supervision (Watkins, 1997), ‘something does not compute’ (p.604). Perhaps the most famous illustration of this mismatch between the importance of supervision and its neglect has been provided by Michael Ellis of New York. He has published two incredibly thorough systematic reviews, which damn the empirical literature (Ellis et al., 1996; Ellis & Ladany, 1997). These two reviews have included applying 49 validity threats to 144 studies of clinical supervision. Ellis and his colleagues concluded that the literature was seriously flawed and that any strengths (such as an emphasis on realistic field studies) were ‘at the expense of conceptual and methodological rigor’ (p.48).

Does this mean that there is no reliable evidence base for clinical supervision? Fortunately, there is a seam of good quality research which does provide helpful pointers to effective supervision. Milne and James (2000) conducted a systematic review like the Ellis ones, but instead of attempting to overview the whole literature they concentrated on synthesising the best available literature (the ‘best evidence synthesis’ approach to the systematic review; see Petticrew & Roberts, 2006). In their review, Milne and James (2000) were able to scrutinise 28 sound studies of clinical supervision, and teased out several effective methods that had been successful within routine clinical settings. These methods included goal-setting, closely monitoring the supervisee in order to provide feedback, and modelling the key competencies. A subsequent review of 24 more papers has yielded similarly helpful, empirically solid information (Milne et al., 2006).

4. Working Solution: Therefore, the approach taken within this workshop is to draw on the best available evidence, whilst being mindful of the variable quality of the wider literature. Secondly, this best available research evidence has been combined with professional consensus

24 on what is considered to be the current best practice. We are grateful in particular to the guideline development group locally, an expert panel nationally, and to the DROSS group (Development and Recognition of Supervisory Skills) for their valuable work. It is this combination of complementary forms of evidence, linked to other key procedures (such as audit), that results in this workshop representing an evidence-based approach to the development of effective supervision (for more on this EBP rationale, see Milne & James, 1999; & Milne & Westerman, 2001).

5. The Workshop Itself: Learning Objectives for session 1, ‘Orientation’ (from DROSS consensus): Have knowledge of the context (including professional and legal) within which supervision is provided, and an understanding of the inherent responsibility.

This section provides a condensed account of the main legal issues and the supervisor’s prime responsibilities. References are provided to enable further study, but if this workshop is a great – and suitably ethical – opportunity to clarify any emergent issues with the facilitator and other participants. A failure to supervise adequately may result in liability. This includes liability in law, to one’s employer, or to one’s professional body (RE: one’s licence/accreditation). Failure includes not preventing a trainee from practising beyond their competence. In turn, this example implies a requirement on the supervisor to know what this competence level is (assessment), to actively monitor performance, and give direction (i.e. to seek feedback from them, to take responsibility for them, and to assume some control over them, as in giving directions/instructions). Based on this authority, supervisors are naturally held accountable (responsible) for the actions of their supervisees. In turn, the supervisor’s employer may be held vicariously responsible. Different countries have different laws, but common statutory liabilities are to:  Facilitate professional development, and to provide appropriate working conditions, timely evaluations, constructive consultation (i.e. feedback) and experience opportunities. Example: Delaware law: Masterson v Board of Examiners of Psychologists, 1995: (cited in Saccuzzo, 2002): Masterton lost her licence, due to negligence over trainee liabilities, and for allowing the trainee to exploit social relationships (counselling a friend). Note – negligence requires ‘injury’ to be proved (e.g. an inappropriate relationship needs to cause demonstrable distress).  Inform patients in writing that their treatment will be provided by a trainee, under the supervision of a suitable qualified person  Inform the supervisees in writing about the methods that the supervisor will use to monitor and evaluate their work.  Assess the patients, in order to be able to monitor treatment (inc. repeated assessments).  Document supervision (maintain a log or record) and require trainees to document their work (e.g. signing off treatment plans). The BPS has produced general ‘professional practice guidelines’ (2003a), specific supervision guidelines (2002, 2003b), and a code of ethics and conduct (2006). These provide useful advice relevant to clinical supervisors within the UK, but the advice is

essentially as above, plus considerable valuable detail. For example, specific reference to legal issues can be found in section 4.5 of the BPS’s ‘Guidelines on Clinical Supervision’ (2002): Supervisors must remember that they have clinical and legal responsibilities for their trainees throughout the training period. It is good practice for supervisors to be insured, for trainees to be aware of relevant legal boundaries (e.g. re: the Data Protection Act; the Children Act). It is essential that trainees have appropriate contracts to allow them to work in their placement (p.3) Have an understanding of the importance of modelling the professional role, including managing boundaries, confidentiality and accountability.

How should we address difficult issues in supervision, professionally and ethically? As well as guiding their own practice, displaying proper conduct and a sound value base help supervisors to model professional role performance to their supervisees. Difficulties tend to fall into three categories (Scaife, 2001): Unethical Practice (Malpractice or ‘Professional Misconduct’)

26 Breaching the rules of the organisation or of conduct (e.g. sexual relationship with supervisee or client); emotional instability (e.g. hostility / anger; lies / deception). Impairment (‘Personal Incapability’) Diminished functioning – e.g. unreliability or negligence due to stress; substance misuse; illness; lack of motivation/application, despite efforts to remedy; personal issues – e.g. low self-awareness and unwillingness to address problems) ‘Incompetence’ (‘Professional unsuitability’) Poor or absent qualities or skills that are necessary for the job (e.g. unacceptable errors). Fortunately, it appears that such difficulties are rare, in supervisor or supervisee. Falender and Shafranske (2004) summarise several surveys of psychologists. To illustrate, although breaches of confidentiality and relationship boundary problems were reported (in 18% and 17% of reported incidents, respectively), only 2% of these occurred in supervision. Also reassuring is the fact that unethical supervision has not occurred sufficiently in the USA to increase the risk of being sued. In dealing with such difficulties, it helps to bear in mind five principles that are widely accepted as a guide to ethical practice: Ethical principles: Autonomy: individuals have the right to freedom of action and choice (e.g. more autonomy with greater experience of trainee) Benificence: actions should do good, using knowledge to promote human welfare (e.g. judging actions in relation to welfare of supervisee, client, et al.) Fidelity: being faithful to promises made, and to ‘right’/proper practices (e.g. informing clients about relativeness of confidentiality) Justice: ensuring that people are treated fairly – equitably and appropriately, in light of what is due to them (e.g. providing more supervision to a struggling trainee; treating all trainees equally, regardless of diversity issues) Non-maleficence: striving to prevent harm. Major ethical issues: Confidentiality:

Inform clients: Having summarised the legal requirement to inform patients that they are being seen by a trainee with a named supervisor, it follows that patients should also be advised that the material that they bring to therapy may be shared with that supervisor. It may also be shared with others too – in relation to the public interest (e.g. information about acts of terrorism), the Children’s Act, and other circumstances surely familiar to you from the confidentiality considerations affecting your own routine work. In supervision, as in therapy, confidentiality is relative. Just as these limits of confidentiality are best made clear to patients at the outset (or anyone else involved in the supervisee’s work), so it is appropriate to make these limits explicit within supervision. For example, information from supervision might well be shared with a clinical tutor and others who have a responsibility for the smooth and ethical functioning of the overall system (e.g. course directors & external examiners).

In general, normal professional practice principles apply, such as ‘the parsimony principle’ (i.e. only disclosing the information that is necessary to address the issue) and the primacy of patient protection. For example, supervisors should not place pressure on their supervisees to provide personal information, unless this is necessary in relation to performing clinical duties competently. Accountability:

As just noted, supervisors are normally deemed to be responsible for their supervisees. It follows that they may be held accountable when things go wrong. This can create tensions, as most psychologists are wedded to ‘the cult of the positive’. This makes it uncomfortable for them to treat their supervisee (at times) as an apprentice, and to expect that they are subservient (prepared to obey orders unquestioningly), incompetent, and generally in need of firm direction. Fine and good, if you are prepared to accept the consequences! But whilst your peer group will admire the way you trust, respect and empower your trainee, such behaviour might best be seen as simply moving the tension somewhere else. This can be especially uncomfortable if things go wrong.

28 I refer to things like the way that not dealing appropriately with issues that arise in your supervision can adversely impact on the next supervisor. This typically arises on the final placement, as previous supervisors may have flagged a couple of ‘minor’ problems, leaving the next supervisor to address them. Or these issues may be placed at the door of the clinical tutor, course director, or exam board. Whilst every party should accept their share of the accountability, supervisors have perhaps the most significant role to play. In essence, a supervisor must exercise an appropriate level of authority (legitimate power), one that matches their accountability. This equates to the saying: ‘give me the tools and I’ll do the job’. A golden ethical rule is to deal with minor problems when they arise, trying to ensure that they get ‘nipped in the bud’ (apparently, Harold Shipman exhibited misconduct early in his medical career, but was allowed to continue). This advice implies that we follow an appropriate procedure, sometimes called ‘due process’. Due process: A key part of managing difficulties on placement professionally is adherence to guidelines and standards, including those dealing with how to proceed. ‘Due process’ means not ignoring or departing from accepted procedures. Therefore, consult your course’s Placement Handbook (or equivalent), discussing interpretations with a suitable colleague or clinical tutor. As per the BPS’s guidance, this may well encourage you to deal with the matter promptly and, at least initially, directly with the supervisee, in the normal professional way (e.g. recording improvement objectives in writing). This list adds some other suggestions for due process: Knowledge of codes, standards, guidelines, etc; Ability to recognise ethical/legal issues in supervisory activities; Ability to recognise and reconcile conflicts and ambiguity, and to seek convergence; Capacity to apply above to professional activities; Skill in seeking out information, including consulting with others; Skill in assertively and appropriately raising ethical/legal issues; Ability to adopt or adapt an ethical decision-making model, applying it with personal integrity and contextual sensitivity (e.g. the ‘5-step’ problem-solving cycle: Knapp & VandeCreek, 2006, p.43); Ability to build and participate in a collaborative, supportive peer network; and Capacity to self-assess; self-awareness. Have knowledge of a number of supervision frameworks that could be used for understanding and managing the supervisory process.

Conceptual models of supervision are numerous, being based either on the transfer of existing theories of psychotherapy (a particularly clear example is the CBT approach), or being developed specially for supervision (Beinart, 2004). Amongst these specifically developed frameworks there are developmental models, social role models, systems models and various mixed models. By far the most dominant of these is the developmental model of supervision. The essence of the developmental model is that supervisees progress in competence from a novice stage to become a master, proceeding from a narrow focus on concrete aspects of the job to a far more subtle, complex and problem-solving orientation to the work. Implications for the supervisor include the need to match what is done to the supervisee’s stage of development (Finklesteen & Tuckman, 1997). A particularly well-

researched and explicit example is the ‘integrated developmental model’ (IDM: Stoltenburg & Delworth, 1997). In essence, at the initial level of development, the supervisee is seen to be typically anxious and heavily reliant on the supervisor for specific guidance in different areas of competence. But motivation is high, and there is a strong desire to learn quickly and to reduce the discomfort and anxiety of perceiving oneself to be incompetent. By level 2 of the IDS model the supervisee has mastered the basic competencies and is beginning to realise that the methods used have their limitations, and so the supervisee needs to develop fresh skills in coping with these tensions. The supervisee is thought to vacillate between dependency and autonomy, but gradually to become more assertive and independent (referred to as the ‘stormy’ period). However, the supervisor is still required for advice and direction, in cases which are not straight forward. Level 3 is seen as the calm after the storm, as the fluctuations characteristic of level 2 are overcome. Supervisees at this stage of development now progress more rapidly, and start to acquire their own personal style. Anxiety persists, but it is not disabling and the commitment to the profession and its skills is now strong. Therefore, at this stage the supervisor may more often operate as a consultant, and may tend to concentrate on some of the complex issues within the profession. Supervisees

30 demonstrate more insight and are more willing to work on their weaknesses in a non- defensive manner. Supervision is also less directive and structured, more focused on helping the supervisee develop consistency and expertise, integrating different skills and taking more of an interest in monitoring outcomes. Have an understanding of the transferability of clinical skills into supervision and the similarities and differences.

Although it is important to recognise supervision as a distinct professional competence (Falender et al., 2004), this does not mean that it bears no resemblance to other competencies. At the most general level, supervision shares with therapy an emphasis on fostering individual adjustment and development through processes of learning from experience. It would therefore be surprising were supervision not to draw on related methods. To illustrate, both professional activities entail the problem-solving steps of goal-setting (usually collaboratively), the application of interventions that derive from research and theory, monitoring, evaluation and feedback. In terms of each of these steps there are more specific transferable skills. These include drawing on the ‘common factors’ of therapy (esp. methods to build a working alliance), utilising specific techniques (e.g. Socratic questioning), and ensuring that such interventions are monitored. These and other similarities are detailed in Milne (2006b). This review paper also identifies some important differences. Perhaps the two clearest examples are that, unlike therapy, supervision is normally mandatory (at least during initial training) and requires evaluation. Other instances are the related power differentials (normally more marked between supervisor and supervisee), the emphasis on education within supervision (including the regular use of feedback), the use of training-programme-prescribed methods for intervention and evaluation in supervision, and the nature of the working relationship (becoming increasingly collegial as training progresses). A key illustration of the latter point is that supervision is not therapy: its function is to develop competence, not to alleviate personal distress. In this sense, a useful dictum is that ‘supervision is of the therapy, not the therapist’ (Jackel, 1981, p.8). Have knowledge of ethical issues in supervision and an understanding of how this may affect the supervisory process, including power differentials. Have an understanding of the issues around difference and diversity in supervision.

Being an effective supervisor necessitates self-awareness and responding sensitively to the individual characteristics of your supervisee. It is this interaction between your respective personal stances that will moderate your effectiveness. Fortunately, this is an area where general professional skills are highly transferable. Regarding self-awareness, authors emphasise the need to recognise your own competence in diversity matters, such as your sensitivity to the ways that different supervisees might react to things like observation and feedback from a person like you, and your capacity to model self-awareness (Falender & Shafranske, 2004). In addition, supervisors should demonstrate the same value base and attitudes to their supervisee as they would do routinely with their patients (inc. respect, openness, and a curiosity about diversity and its contribution to our work). To illustrate, you should freely discuss your input to the diversity interaction within supervision. This remains true even amongst seemingly similar colleagues. For an amusing illustration, try reading The Wee Book of Calvin (Duncan, 2004). This pithy collection of folk stories and sayings emphasises how those raised in the cultural context of the north-east of Britain may

differ from their colleagues from other areas in such respects as their feverish work ethic, craving for responsibility, and ‘inherent sense of unworthiness’ (p.9). The devil makes work for idle hands! Ladany et al. (2005) list six such ‘multi-cultural skills’, which add to the above by recognising the supervisor’s role in facilitating the supervisee’s competencies in working with diverse groups (e.g. developing culturally sensitive ways of introducing assessments; evaluating the supervisee’s development in such areas). Hwang (2006) offers an overarching framework for thinking about and improving our approach to diversity, recognising that therapy needs to adapt if those from ethnic minorities are to receive comparable benefits. Regarding the individual characteristics of your supervisees, the acronym ADDRESSING provides a helpful summary of the main ways in which diversity might be influential (Hays, 2001): A: age and generational influences D: developmental D: disabilities

32 R: religion and spirituality E: ethnicity S: socio-economic status S: sexual orientation I: indigenous heritage N: national origin G: gender. Hays (2001) noted that each of these might interact, to create complex individual mixes of such influences, and Sue (1998) added that these influences themselves impact in highly individual ways. The upshot is to be wary of stereotyping supervisees with any particular influence (or of assuming that your individuality affects all supervisees equally), and to rather emphasise the need to recognise openly and address collaboratively the interactions that will arise between your respective influences.

6. Summary: This first session has been exceptionally wide-ranging, covering the more important dimensions that underlie supervision. It may be comforting to recognise that these are basically as per the rest of your work, and so that much can be transferred (with care). On the subject of transferability, it was stressed that supervision shares with therapy (and other activities) the same broad aim (supporting personal development through facilitating learning) and problem-solving cycle of activities. Factors common to all therapies are also relevant to supervision (esp. the working alliance). On the other hand, supervision is different in including summative evaluation and a set of mandatory interventions (e.g. observation of the supervisee’s work). Perhaps for these reasons, power differentials and relationship issues also demark supervision. Supervision was defined in such a way as to recognise the inevitable overlaps with our other professional activities, but also its distinctiveness. A key aspect is its basis in a long-term relationship that is designed to address normative, formative and restorative domains. The frameworks that inform how we practise supervision tend to be based on transferring key ideas from therapeutic models (most clearly in the case of CBT) or on developmental logic (the IDS model is a popular example). Developmental models assume that your role is to guide the supervisee’s progress on a professional journey, during which they necessarily deal with numerous challenges in order to become competent. Although the language and the metaphors of these models differ, the key implication for the supervisor is to adopt a professional stance akin to a mountain guide. To summarise the legal and ethical aspects, supervision carries with it certain liabilities, such as facilitating the supervisee’s development. In turn there are liabilities to other interested parties (e.g. to our profession and employer), which we discharge when we monitor and direct our supervisees so as to ensure that they work within their competence. In these respects and at other times, we model the professional role when we: make explicit the limits of confidentiality; observe boundaries and confidentiality conventions;

recognise and apply ethical principles; follow due process (both in preventing problems – ‘positive ethics’ – and in remediation). By behaving in these ways we model professionalism, foster competence, and improve our ability to manage clinical risk. It is worth stressing that ethical practice is a developmental process: as individuals we presumably understand and apply the guiding principles and procedures with growing skill throughout our careers (e.g. becoming more ‘positive’ and less ‘remedial’). Therefore, please treat this guideline as aiding your next step towards ethically sophisticated supervision, practised in the context of your normal attention to sound professional conduct. A further major dimension of supervision concerns diversity. Diversity can be recognised against the ADDRESSING influences, but the main implication is to treat diversity issues in supervision (e.g. cultural differences) as a result of the interaction between you both. It is a dimension of your relationship that requires your usual professionalism, particularly a willingness to discuss such interactions openly and constructively (e.g. in order to enhance your sensitivity and hence effectiveness).

7. References for Appendix 3:

34 Beinart, H. (2004). Models of supervision and the supervisory relationship and their evidence base. In I. Fleming & L. Steen (Eds.) Supervision in clinical psychology: Theory, practice and perspectives. Hove: Brunner-Routledge. British Psychological Society. (2005). DCP policy on continued supervision. Leicester: BPS. British Psychological Society. (2002). Guidelines on clinical supervision. Leicester: BPS. British Psychological Society. (2003a). Professional practice guidelines. Leicester: BPS. British Psychological Society. (2003b). Policy guidelines on supervision in the practice of clinical psychology. Leicester: BPS. British Psychological Society. (2006). Code of ethics and conduct. Leicester: BPS. DROSS (Development and Recognition of Supervisory Skills). See website: www.leeds.ac.uk/medicine/psychiatry/courses/dclin/index.html. Duncan, B. (2004). The wee book of Calvin: Air-kissing in the north-east. London: Penguin. Ellis, M.V. & Ladany, N. (1997). Inferences concerning supervisees and clients in clinical supervision; an integrative review. In C.E Watkins (Ed.) Handbook of psychotherapy supervision. Chichester: Wiley. Ellis, M.V., Ladany, N., Krengal, M. & Schult, D. (1996). Clinical supervision research from 1981–1993: A methodological critique. Journal of Counseling Psychology, 43, 35– 50. Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., et al. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771–785. Falender, C.A. & Shafranske, E.P. (2004). Clinical supervision: A competency-based approach. Washington DC: American Psychological Association. Finkelstein, H. & Tuckman, A. (1997). Supervision of psychological assessment: A developmental model. Professional Psychology: Research and Practice, 28, 92–95. Hays, P. (2001). Addressing cultural complexities in practice: A framework for clinicians and counsellors. Washington, DC: American Psychological Association. Hwang, W-C. (2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61, 702–705. Knapp, S.J. & VandeCreek, l.D. (2006). Practical ethics for psychologists. Washington, DC: American Psychological Association. Ladany, N., Friedlander, M.L. & Nelson, M.L. (2005). Critical events in psychotherapy supervision. Washington DC: American Psychological Association. Lucock, M.P., Hall, P. & Noble, R. (2006). A survey of influences on the practice of psychotherapists and clinical psychologists in training in the UK. Clinical Psychology and Psychotherapy, 13, 123–130.. Milne, D. (2006a). An empirical definition of clinical supervision. In press: British Journal of Clinical Psychology. Milne, D. (2006b). Developing clinical supervision research through reasoned analogies with therapy. Clinical Psychology and Psychotherapy, 13, 215. Milne, D., Aylott, H., Dunkerley, C., Fitzpatrick, H. & Wharton, S. (2006). Towards evidence-based training for clinical supervisors: A systematic review. Manuscript in preparation. Milne, D. & James, I. (1999). Evidence-based clinical supervision: Review and guidelines. Clinical Psychology Forum, 133, 32–36. Milne, D. & James, I. (2000). A systematic review of effective cognitive behavioural supervision. British Journal of Clinical Psychology, 39, 111–127.

Milne, D. & Westerman, C. (2001). Evidence-based clinical supervision: Rationale and illustration. Clinical Psychology and Psychotherapy, 8, 444–457. Orchard, L. (2006). The effective use of consultations: A literature review. Psychology Talk, 54, 15–17. Petticrew, M. & Roberts, H. (2006). Systematic reviews in the social sciences: A practical guide. Oxford: Blackwell. Saccuzzo, D.P. (2004). Liability for failure to supervise adequately mental health assistants, unlicensed practitioners and students. California Western Law Review, 34, 115–152. Stoltenberg, C.D. & McNeil, B. (1997). Clinical supervision from a developmental perspective: Research and practice. In Watkins (1997) (see below). Sue, S. (1998). In search of cultural competence in psychotherapy and counselling. American Psychologist, 53, 440–448. Tharenou, P. (2001). The relationship of training motivation to participation in training and development. Journal of Occupational and Organisational Psychology, 74, 599– 621. Watkins, C.E. (Ed.) (1997). The handbook of psychotherapy supervision. Chichester: Wiley.

Appendix 4:

Catalogue of 15 video clips

Menu: Session 1: ‘Orientation’ a) A general example of supervision b) Another example

38 Session 2: ‘Goal-setting’ a) Illustration Session 3: ‘Facilitating learning’ a) Informing/teaching b) The use of questions (e.g. 1) c) The use of questions (e.g. 2) d) The use of questions (e.g. 3) e) Questions and interpretation (e.g. 1) f) Questions and interpretation (e.g. 2) g) Role-play Session 4: ‘The supervisory relationship’ a) Illustration of mutual engagement in task b) Illustration of emotional bond

Session 5: ‘Evaluation and feedback’ a) Basic structured feedback b) Summary and mutual feedback Session 6: ‘Supervision system’ a) Lifelong learning – reflecting on supervisory practice

Session 2: ‘Goal-setting’

Learning objectives:

Main one: Demonstrates basic skills in contracting and negotiating goals with trainees (e.g. able to identify at least 2 needs-led learning objectives, through a role-play exercise; 8). Related one: Show understanding of the processes of assessment and failure, including skills in evaluating trainees (esp. link to learning contract; 10). Materials: 1. Slideshow (and make a copy for handout)

40 2. Video clips on the accompanying website (www.wiley.com/go/milne) Programme: 1. Introduction: Slideshow 2. Needs Assessment 3. PowerPoint Slideshow 4. Video Illustration: clip 2a: ‘goal-setting (illustration)’ 5. Guided Reading (guideline: ‘Needs assessment and the learning contract’) 6. Learning Exercise 7. Feedback on this Session 8. Discussion

1. Introduction: Stress that the topic (and LOs: Learning Objectives) should be considered within the context of session 1. That ‘orientation’ unit set the scene for this and the subsequent sessions. It might help to draw out a couple of examples, such as how the definition of clinical supervision would exclude one from setting learning objectives that correspond to therapy.

2. Needs Assessment: Get an initial idea of the group’s prior experience in contracting and negotiating goals with supervisees through a brief discussion, and then look more closely at their needs in relation to the PowerPoint slideshow and video illustration that follow. Remember that the workshop strategy of ‘hitting the ground running’ requires you to clarify repeatedly what skills and experience they already possess in relation to each session. For instance, presumably all new supervisors will have considerable skills in contracting and negotiating with patients or other staff within the NHS. In this way, eliciting and highlighting what they already know about these complex skills, in order to clarify what is specific to supervision, is a very empowering and enabling phase within each session. It can also help to distinguish how contracting and negotiating in clinical supervision differ from these established activities. This might be something to pick up in the final discussion, unless it occurs naturally beforehand.

3. PowerPoint Slideshow: Use this to outline the knowledge-base and some of the principles and practices used within the literature (Appendix 5, p.34). As ever, the key references and background material for the slideshow is to be found within the guideline (‘Needs assessment and the learning contract’). This is in Appendix 6.

4. Video Illustration: (consider showing clip 2a (‘Goal-setting-illustration’))

Stimulate engagement as necessary (e.g. ask: ‘How does this account of needs assessment differ from other familiar work examples – such as a contract for a psychology service?’ ‘Which aspects are shared?’ ‘Which are different?’). The aim is to connect with their relevant experience again, to try to ensure a good grasp of the ideas. This allows the group to ‘hit the ground running’ (and so provides reassurance and motivation).

5. Guided Reading: Now encourage the workshop participants to study the guideline, perhaps focusing their attention by asking them to relate some personally significant aspect of the slideshow or video illustration to the material within the guideline (Appendix 6, p.35). Tell them that you mean to ask them for their reflections on this comparison when they have finished reading. This helps to raise concentration and maximise benefit.

6. Learning Exercise:

42 It is suggested that you organise two or three small groups, each led by a tutor (or by a supervisee, drawn from within the local training programme). This tutor/supervisee should participate in an interview run by the workshop participants. The participants’ questions should be stimulated by the material in the guideline, and should enable them to engage in negotiated goal-setting, inc. the specification of SMARTER goals (see Appendix 6, p.35; guideline p.45). A flipchart diagram or agenda list may help the participants to structure their interview appropriately. Indeed, it may work best if they are given a few minutes before the interview, in order to translate the guideline/slideshow material into a relevant agenda.

7. Feedback on this Session: Ask each small group to let you know what learning needs they have defined and which SMARTER goals they have managed to specify. Relate their replies to the principles within the guideline. For example, did they manage to clarify anything about the supervisees’ confidence or motivation to learn from this exercise? Was there a feeling that a good working alliance was being established, and that the SMARTER objectives were developed collaboratively? You might like to extend this exercise by going into some detail on each of the SMARTER criteria for good goals. This may link usefully to the next session (facilitating learning). In closing this phase of the session, you should be on your toes when providing feedback to the participants, as any suggestions or objectives that you indicate should themselves be needs-led and SMARTER!

8. Discussion:  The general issue worth highlighting is the crucial role played by the supervisee. This is not simply in relation to such issues as needs assessment, but also in terms of sharing with the supervisee the work that needs to be done (i.e. an adult learning model). It might be interesting to reflect with the group on ways in which the supervisee can engage as a colleague in this phase of supervision.  Another general issue to note is that learning objectives tend to benefit from periodic re- examination. They should naturally fall within the regular agenda of supervision, helping to facilitate reviews of progress and refinements to the objectives. If a supervisee is progressing well, then additional or more taxing objectives would be appropriate. In essence, objectives should be seen as iterative, contributing crucially to the supervisee’s step-by-step movement up the ‘spiral curriculum’ of professional development.  The participants may be heartened to know that there is good reason to believe, from theory and research, that engaging with the learner in this collaborative way is itself a powerful method of supervision, capable of producing early benefits. As you end day one of the workshop, this is a suitably heartening message regarding the progress to date.

End of session 2

Appendix 5: Session 2, Handout 1: Slideshow

44 Appendix 6: Session 2, Handout 2: Guideline on goal-setting

Northumberland, Tyne and Wear NHS Trust

Needs assessment & the learning contract: a guideline 1. Summary: The setting of goals within a learning contract is perhaps the most widely accepted technique in clinical supervision. It is also one of the best-established ways to facilitate the supervisee’s learning, motivation and evaluation. But how should goals be set to best achieve optimal learning and motivation, and how can they enable evaluation? It appears that all learning is re-learning: there is no ‘blank slate’ within your supervisee’s head. It follows that clarifying what your supervisee already knows represents a vital basis for your supervision, and for agreeing the learning contract. As well as being developmentally informed, a learning contract should also relate to your placement platform – the learning opportunities that are available, your preferred approach, etc. (see appended example). Within this framework, the contract should contain SMARTER goals, addressing the main areas of practice (inc. specific competencies, methods of supervision, and documentation). This makes evaluation transparent and straightforward. The guidance provided within the mental health professions, expert consensus, and empirical evidence consistently underline these points. Background: This is the second of four guidelines, all designed to try to help supervisors to succeed in their efforts to facilitate their supervisees’ learning. We fully recognise that this represents only one function of supervision, the so-called ‘formative’ one. The guidelines are written on the understanding that you will naturally draw on your other professional competencies when you supervise, particularly those attitudes, values and facilitating processes that underpin good professional practice generally. Such practice will no doubt help you to achieve the other important goals of supervision, such as the provision of emotional support (‘restorative’) and the placing of supervision within its organisational and professional context (the ‘normative’ function). Given this clarity of purpose, the guideline can focus on those specific techniques and principles that seem appropriate for new supervisors, and which are based on the best- available evidence. This means that the guidelines have a strong CBT flavour. For those interested in alternative approaches, the references provided at the end suggest some complementary material.

2. Contents: 3. Key Practice Recommendations: Conduct a learning needs assessment; Agree SMARTER learning goals; Address common content areas; and Ensure regular review. 4. Guiding Principles: Psychological theory & thinking behind these recommendations.

46 5. Good Practice Suggestions: Practical ideas and examples. 6. Evidence Base: How much support is there for these guidelines? (inc. NICE quality rating). 7. Implementation: Clarification of how these guidelines are expected to be used. 8. References: Appendix: The supervision platform.

3. Key Practice Recommendations: a) Conduct a learning needs assessment: aim to gather information on the supervisee that helps to define his/her existing skills, knowledge and attitudes. This is critical to clarifying their starting place and in facilitating learning (as it builds on prior understanding). b) Define SMARTER learning objectives: specific, measurable (etc.: see below) goals tend to serve multiple important functions in supervision (e.g. giving a sense of direction and providing the basis for evaluation). Goals should normally be negotiated, to ensure that the supervisee’s learning needs (as opposed to their ‘wants’) dominate the learning contract. c) Address common content areas: learning contracts normally cover:  well-defined competencies (knowledge, skills and attitudes);  practicalities, such as the frequency of supervision;  methods to be used (e.g. mutual observation);  evaluation arrangements;  documentation plans; and  professional matters, such as confidentiality. d) Review: progress towards the learning goals should normally be reviewed regularly, using local/agreed forms and procedures.

48 4. Guiding Principles: It is important to conduct a learning needs assessment within supervision, for a number of reasons: a) Gather information: needs assessment can provide the supervisor with ‘critical information’ on the relationship between the supervisee and the workplace (Colquitt et al., 2000, p.702). Their meta-analytic review of over 250 empirical studies within the staff training literature highlighted the role played by such learner characteristics as cognitive ability, confidence, anxiety, and motivation to learn. Also significant in their path analysis was the workplace ‘climate’, including the support received by learners from peers and managers. b) Motivate : Supervisees will tend to be more motivated if they know that their needs have been considered. A needs assessment also ensures that the needs of each interested party (‘stakeholder’) are considered (e.g. the needs of supervisors and of the training course). This will tend to boost their support for your work. c) Relate: Taking the trouble to convert ‘felt’ needs into ‘expressed’ needs contributes to the learning alliance by recognising the supervisee’s past achievements. Beinart (2004) found that the quality of the supervisory relationship was perceived as more satisfying when the learning contract was prepared collaboratively, was rigorous, and was renegotiated when necessary. This is consistent with other literature, which indicates that failing to make needs explicit can contribute to failure in the supervisory relationship (Norcross & Halgin, 1997). d) Build on prior learning: A needs assessment ensures that new learning builds upon the supervisees’ existing knowledge and skill. The contemporary account of learning cited by Bransford et al. (2000) views people as constructing new knowledge based on what they already know (following Piaget, Vygotsky, and other major theorists). The needs assessment maximises learning by helping the supervisor to pitch supervision at the optimum level and, as far as possible, to match the learning styles of supervisor and supervisee. It also helps the supervisor take account of what the supervisee needs to learn at this stage in their professional development ('normative needs'). e) Evaluate: lastly, goals enable evaluation to take place: they allow supervisees to assess their own progress, and supervisors to assess progress towards passing a placement. This provides a firm basis on which to judge what to do next in supervision (e.g. degree of task difficulty/amount of support/choice of supervision method, etc.). Practical ideas on applying these principles now follow.

5. Good Practice Suggestions: Step 1: Conduct an assessment of learning needs: Assessing learning needs is regarded as a key supervisor competence (Falender et al., 2004). In assessing the supervisee's learning needs it can help to take account of at least four areas (Milne & Noone, 1996):

a) Existing skill level. This can be assessed through discussion of prior clinical work; discussion of a critical incident (‘What would you do if…?’); observation of the supervisee at work; or by consulting previous placement information. b) Existing knowledge level. Careful questioning can provide this information (e.g. prior teaching or experience of a topic). c) Motivational level. Body language and degree of engagement will provide useful information that supplements direct questioning about the learning needs, as in indicating boredom or over-arousal. d) Preferred learning style. This can be assessed through direct questioning or through discussion of past experiences of supervision (e.g.: ‘When supervision worked well for you in the past, how were you working together?’). There is some evidence that the timing of supervision relative to the next session with a client should also dictate learning style (Couchon & Bernard, 1984). For instance, if the supervisee is seeing the client in two hours' time, then concrete planning may be a more effective style than reflection or conceptualisation. Much information can also be gained by simply asking the supervisee what they need from supervision, both at the outset of the supervisory relationship and from session to session. Care should be taken to distinguish needs and ‘wants’ (wants are learner’s 50 likes or preferences, and tend not to be goal-oriented: Milne & Noone, 1996). Liese and Beck (1997) suggest that both supervisee and supervisor generate agenda items before each session. This is a practical and professional way to monitor and adjust supervision to needs. You might like to consider another practical option. This is best addressed at the start, when you each set out your learning history and expectations. If you prefer, these can be captured in the form of your respective learning ‘platforms’. This can be done by clarifying the basis of the supervisee’s approach. Which theoretical model do they prefer? What roles do they feel comfortable playing? Appendix 1 sets out a series of such questions, written from the supervisor’s perspective. This is because it may help the supervisory relationship if you first disclose your own platform to the supervisee. This can also cover qualifications and the authority that underpins your status (e.g. being a regular, accredited supervisor for a local training programme). There may also be relevant general background – what does the supervisee know about this specialty (e.g. do they have a family member who has been involved in some way, say as a carer or sufferer)? Do they have children? Did they undertake voluntary work or an Assistantship in a closely related field? Do they bring particular perspectives or values to the placement? Step 2: Set SMARTER goals: Based on the needs assessment, you should next try to agree some learning goals with the supervisee. These are often then checked by the training programme (e.g. a clinical tutor), so that they can serve as a guide to you both. A survey of 59 supervisors in Occupational Therapy and Physiotherapy supported this view, as 90% regarded the learning contract as a useful teaching tool (e.g. in highlighting strengths and weaknesses: Solomon, 1992). Trainees have been found to agree, seeing contracts as aiding self-direction, providing a clear basis for evaluation, and reducing anxiety and competition (Hardigan, 1994). These opinions are consistent with the Evaluation Process Within Supervision Inventory (Lehrman & Ladany, 2001), as the factor analysis underpinning the tool teased out goal-setting and feedback as the main factors, based on responses from 274 trainees from diverse professions. These criteria for sound goal-setting are part of the SMARTER acronym: Specific Measurable Accepted

Realistic Time-phased Evaluated Recorded. SMARTER goals should be drawn from expressed (i.e. the supervisee’s wants), normative (i.e. based on the supervisor’s judgement) and comparative needs (i.e. based on reference to other trainees’ goals; what the training programme expects). For example, a learner may express a need to ‘know more about CBT’, the supervisor and programme may support this goal, and there may also be a useful professional guide

to what constitutes initial competence in CBT (such as the Cognitive Therapy Scale). This then allows the supervisor to agree with the supervisee some specific, measurable (etc.) learning goals that suitably clarify what is to be done (a learning objective), and what will be achieved (a learning outcome). In view of the range of stakeholders in supervision, goal-setting should be both participative (where the supervisee is encouraged to suggest needs and goals) and assigned (where supervisor suggests appropriate goals, based on their experience and awareness of general standards – the normative and comparative aspects). A healthy discussion of needs will involve some negotiation (see below), which may also help the supervisee to feel more motivated. Step 3: Establish the learning contract The prioritisation of needs may require some 'win–win' negotiation. Milne and Noone (1996) suggest the following approach: Acknowledge competing needs Clarify what each stakeholder wants to achieve

52 Try to understand the basis of each stakeholder's position Generate as many options as possible for achieving the objectives Collaboratively weigh up the pros and cons of each option Through discussion, resolve which option is best. The needs assessment should be formalised, and the needs prioritised in a learning contract. Following Falender and Shafranske (2004, NB: see their Appendix A for a sample contract), and Howard (2000), this can include: a) specific competencies: the aspects of knowledge and skill determined through the above needs assessment process, as well as relevant underpinning values and attitudes (e.g.: ‘formulate three clients presenting problems collaboratively, within a CBT model’); b) practical issues, such as the scheduling, duration and frequency of supervision; c) methods of supervision (e.g. will you use mutual ‘sitting-in’ or guided reading?); d) evaluation requirements and feedback expectations; e) documentation – shared responsibilities for recording learning and supervision; and it can also include: professional matters – clarifying accountability and the legal context; confidentiality arrangements; insurance; boundaries (e.g. clarifying any dual relationship issues); fallback/cover arrangements (e.g. what to do if you are unable to help, or are absent). Step 4: Review the learning contract

The above points should be captured within the contract. Goals should then be used regularly to review progress, collaboratively. Methods might include the use of standard forms, designed to encourage mutual feedback. With regard to clinical psychology training, forms are linked to a mid-way review, though more regular review is preferable. In the Newcastle Doctorate in Clinical Psychology, for example, we use the following forms to structure reviews and evaluation: i) ‘Supervisor’s Feedback Form’ (SFF): this is designed to provide both ‘formative’ (guidance) and ‘summative’ (progress) evaluation. ii) ‘Trainees’ Feedback Form’ (TFF): this creates a variety of ways for the supervisee to feedback to the supervisor on the supervision received, and to comment on the placement facilities. iii) ‘Placement Record Form’ (PRF): a log of the learning experience. It is important that such forms exist, and feed anonymously into public review cycles (e.g. where a tutor participates in the review process with a team of supervisors, all working within a local department). Ethical practice footnote: An implication of all this effort is that you are practising positive ethics: by proactively specifying what belongs within supervision, by taking account of the supervisee’s current competencies, and by monitoring their practice (etc.) you minimise such risks as supervisees abusing supervision, or practising beyond their competence, and you increase the likelihood that their patients will benefit from their therapy.

Another clear illustration is how the learning contract can help to set down appropriate boundaries. For example, a supervisee might want supervision to resemble therapy (boundary violation), or expect that only you will see the feedback you provide (confidentiality misunderstanding). The negotiation of the learning contract normally reflects appropriate power differences between you and the supervisee (e.g. you have the authority to assign goals, and the responsibility to evaluate their progress, etc.). You are also explicitly basing your supervision on established standards, and participating within the structure of a training system. This provides the supervisee with a good model, and also means that your own practice can be more readily reviewed and guided. Suggestion: To involve your supervisees explicitly in this positive practice, why not let them read this guideline too, then discuss the ethical aspects?

6. Evidence Base: The major supervision texts all stress the importance of supervision goals (for instance, Falender and Shafranske’s text [2004, pp.22–23]; and Fleming and Steen, 2004,

54 pp.214–216). This is repeated in general texts on learning (e.g. Bransford et al., 2000). To illustrate, the Bransford text notes: There is a good deal of evidence that learning is enhanced when teachers pay attention to the knowledge and beliefs that learners bring to a learning task, use this knowledge as a starting point for new instruction, and monitor students’ changing conceptions as instruction proceeds. (p. 11) Needs assessment and goal-setting also appear to be a fully accepted parts of professional practice (see, for example, the BABCP’s ‘supervision supplement’: Townend, 2004; BPS, 2003). Most of the relevant research studies incorporate goal-setting within a package of interventions used to promote learning in the supervisee. Illustrations follow: Methot et al. (1996) found that a supervisory training intervention that comprised feedback followed by a blend of participative and assigned goal-setting led to improved outcomes for supervisees and their clients. Fleming et al. (1996) evaluated a supervisory training programme that included providing a rationale, instruction, modelling, feedback, and participative and assigned goal-setting. The programme was associated with an increase in or maintenance of targeted skills in supervisees. In a rare analysis of goal-setting alone, Talen and Schindler (1993) studied the learning plans of 26 psychology trainees. Results indicated that concrete, observable and theory-based goals were perceived as most helpful by these trainees, and were associated with positive improvements in their learning. QUALITY RATING: B (i.e. there are well-conducted clinical studies, but no randomised clinical trials; there is a good degree of professional consensus)

7. Implementation: This guideline is designed for use by all mental health professionals, and should be used within the practitioners’ professional practice guidelines and management/supervisory arrangements. In this context, supervisors should consider the principles and practice suggestions made above, forming their own judgement about their appropriateness, in relation to their individual supervisees. This guideline should also be used in liaison with their local professional training programmes, in the case of trainees. In the case of CPD supervision, practitioners are encouraged to refer to the relevant guidance on CPD within their profession. Additionally, scientific journals and professional texts can help to guide effective supervisory practice (e.g. see attached reference list). The guideline draws on the training and supervision literature, including four systematic reviews (Milne & James, 2000; Milne et al., 2007), conducted to support the present, closely related guidelines. All four guidelines were drafted by an experienced supervisor and a senior journalist-turned-trainee clinical psychologist, following the NICE(R) approach (Dunkerley et al., 2005). They were then shaped through discussion in a local guideline development group; improved by drawing on the views of a national group of experts; and made more feasible by building a consensus on the best approach with supervisors attending local CPD workshops.

There is no charge for using this guideline, all costs having been met through a grant from The Higher Education Academy Psychology Network to Derek Milne in 2005. It can therefore be copied for use within supervisor training workshops. We do ask, however, that we are duly acknowledged. Comments, relevant research literature, and any other ideas that might improve this guideline are welcome. Derek Milne and Chris Dunkerley, Doctorate in Clinical Psychology, 4th Floor, Ridley Building, The University of Newcastle, Newcastle Upon Tyne, England NE1 7RU. ([email protected]; [email protected]; 0191-2227925).

8. References Beinart, H. (2004). Models of supervision and the supervisory relationship, and their evidence-base. In I. Fleming & L. Steen (Eds.) Supervision and clinical psychology. Hove: Brunner-Routledge. Bransford, J.D.., Brown, A.L. & Cocking, R.R. (Eds.) (2000). How people learn. Washington DC: National Academy Press.

56 Colquitt, J.A., LePine, J.A. & Noe, R.A. (2000). Toward an integrative theory of training motivation: A meta-analytic path analysis of 20 years of research. Journal of Applied Psychology, 85, 678–707. Couchon, W.D. & Bernard, J.M. (1984). Effects of timing of supervision on supervisor and counsellor performance. The Clinical Supervisor, 2, 3–20. Dunkerley, C., Milne, D. & Wharton, S. (2005). A NICE(R) systematic review of the clinical supervision literature. Annual conference of the European Association for Behavioural and Cognitive Psychotherapy, Manchester. Falender, C. & Shafranske, E. (2004). Clinical supervision: A competency based approach. Washington, DC: American Psychological Association. Fleming, I. & Steen, L. (2004). Supervision and clinical psychology. Hove: Brunner/Routledge. Fleming, R.K., Oliver, J.R. & Bolton, D.M. (1996). Training supervisors to train staff. Journal of Organizational Behaviour Management, 16, 3–25. Hardigan, P. (1994). Investigation of learning contracts in pharmaceutical education. American Journal of Pharmaceutical Education, 58, 386–390. Howard, F. (2000). Supervision. In I. M. Evans, M. O’Driscoll, and J. J. Rucklidge, (Eds.) (2007) Practice Issues Handbook. Wellington: New Zealand Psychological Society. Lehrman-Waterman, D.E. & Ladany, N. (2001). Development and validation of the evaluation process within supervision inventory. Journal of Counseling Psychology, 48, 168–177. Liese, B.S. & Beck, J.S. (1997). Cognitive therapy supervision. In C.E. Watkins (Ed.) Handbook of psychotherapy supervision. Chichester: Wiley. Methot, L.L., Williams, W.L., Cummings, A. & Bradshaw, B. (1996). Measuring the effects of a manager-supervisor training program through the generalized performance of managers, supervisors, front-line staff and clients in a human service setting. Journal of Organizational Behaviour Management, 16, 3–34. Milne, D. (2007). An empirical definition of clinical supervision. British Journal of Clinical Psychology (in press). Milne, D., Dunkerly, C., Aylott, H., Wharton, S., Falender, C., Shafranske, et al. (2007). Systematic reviews of clinical supervision: a) A basic model; b) Competence in clinical supervision; & c) Training clinical supervisors. All in preparation, available from Derek Milne at address on page 4. Milne, D. & James, I.A. (2000). A systematic review of effective cognitive-behavioural supervision. British Journal of Clinical Psychology, 39, 111–127. Milne, D. & Noone, S. (1996). Teaching and training for non-teachers. Leicester: BPS. Norcross, J.C. & Halgin, R.P. (1997). Integrative approaches to psychotherapy supervision. In C.E. Watkins (Ed.) Handbook of psychotherapy supervision. Chichester: Wiley. Talen, M.R. & Schindler, N. (1993). Goal-directed supervision plans: A model for trainee supervision and evaluation. The Clinical Supervisor, 11, 77–88. Townend, M., Ianetta, L. & Freeman, M.H. (2002). Clinical supervision in practice: A survey of UK cognitive-behavioural therapists accredited by the BABCP. Behavioural and Cognitive Psychotherapy, 30, 485–500.

Towened, M. (2004). Supervision Contracts in CBT. Accrington: BABCP

58 Guideline appendix 1:

THE SUPERVISION ‘PLATFORM’

Definition: the base of your practice. Best clarified at outset (mutually) and used as the foundation for the learning contract. ‘ Layers’ of the platform:

Supervision Practice Platform a) Supervision style or ‘stance’ (relationship qualities – e.g. support v challenge) b) Supervision methods and techniques (e.g. use of feedback and experiential methods; formats – e.g. group; 2:1) c) Supervision goals/agenda (including topics, settings, links, admin) d) Supervision roles (e.g. consultant; teacher; model; colleague) e) Supervision model/orientation (e.g. ‘tandem’/integrative) f) Supervision philosophy: Personal core beliefs and values (e.g. assumptions arising from own training – e.g. own theory of learning); rationality; freedom – e.g. as ‘adult learner’; respect; trust; collaboration; compassion: personal & professional (PPD)

Session 3: ‘Facilitating Learning’

Learning outcomes:

Main ones: Demonstrates competence in using a range of supervisory approaches and methods (13); employs reports and tapes effectively (e.g. competent within learning exercise; 12). Related ones: Draws on transferable skills (9; e.g. able to question, in order to clarify a learning objective), provides constructive criticism and feedback competently (11). Programme:

1. Introduction: slideshow; Q&A (questions and answers)

60 2. Illustration (1): video clip (select from the 7 options on the accompanying website (www.wiley.com/go/milne) (e.g. ‘Informing and teaching’) 3. Guided Reading: ‘Methods of facilitating learning in supervision: A guideline’ 4. Illustrations (2): another video clip (e.g. ‘role-play’) 5. Learning Exercise 6. Discussion

1. Introduction: Show slideshow, referring to key parts of the guideline.  Ensure participants have their handout (i.e. hard copy of this slideshow: Appendix 7 p.48).  Encourage questions and general engagement.  In particular, aim to encourage the use of multiple methods of supervision, ones that are likely to encourage the supervisees to move around the experiential learning cycle. So, try to ensure that the participants strike an appropriate balance between talk (e.g. recounting details of a case, employing the ‘reflection’) and action (e.g. trying to ‘conceptualise’ the case better, as in reformulating). 2. Illustration (1): Play your selected video clip (e.g. to show how questioning can be used: respond to groups’ needs). 3. Guided Reading: Ask the group to read all or part of ‘Methods of facilitating learning in supervision: a guideline’ (Appendix 8, p.50). Encourage the usual needs-led focus on those aspects of particular relevance to participants (e.g. prime with ‘please try to list something that is easily transferable to supervision, and something new’). Elicit questions/comments/reactions, and try to link with the guideline material (e.g. to the slideshow or initial illustration). 4. Illustration (2) (optional): Select another clip, perhaps based on a vote amongst the group (See Appendix 3, pp.18–28, for the full catalogue, or simply go to the ‘Methods’ menu page). 5. Learning Exercise: a) Introduction: Objective: rehearse an appropriate method, with feedback. Learning objective: more competent/confident in using a range of methods.

b) TASK: Option 1:  Participants to work in pairs, alternately role-playing supervisor/ee.  Each to select an aspect of the video material just viewed that is personally relevant and which falls in their ZPD (if people struggle, you might revert initially to session 2 – i.e. get them to help each other to define a suitable learning objective).  Ask group to rehearse the method, as realistically as possible (i.e. ‘simulation’, rather than role-play).  Provide feedback to as many pairs as possible – by informal observation and by encouraging feedback to group, on which you can comment (or demonstrate).

c) TASK: Option 2: See slideshow. 6. Discussion: Usual efforts to promote learning. For example, some relevant questions to the group are:

62  (Ethical) ‘How did your method differ from therapy? What needs to happen to ensure that supervision does not become therapy?’  (Learning from experience) ‘How difficult should it be for the supervisee to learn from your selected method? How would you know whether it had been difficult?’ (to engage in a discussion about the need for an optimal degree of ‘perplexity’/fascination/destabilisation, at times).  See general (metacognitive) questions, as per earlier in this manual (p.9).  As ever, refer back to the session’s LOs, trying to verify success.

End of session 3

Appendix 7: Session 3, Handout 1: The ppt

64 Appendix 8: Session 3, Handout 2: The ‘methods’ guideline

Northumberland, Tyne and Wear NHS Trust Methods of facilitating learning in supervision: a guideline 1. Summary: Supervision methods are used to facilitate the supervisee’s learning, such as providing corrective feedback. The supervisor should draw on these methods to address the supervisee’s learning needs (see the guideline on ‘Developing the supervision contract’). The aim is to achieve the objectives set out within the learning contract, efficiently and professionally, which should be verified through evaluation (see the guideline on ‘Evaluation’). Numerous methods are used in supervision, but the most widely used ones are listed below. For convenience, we class them under the three traditional headings of symbolic, iconic and enactive methods. Of course, techniques need to be embedded in a good supervisory alliance (see the guideline on the supervision relationship). Many supervision methods are similar to those used in other kinds of professional activity, such as research supervision, staff training, and therapy. Just like those activities, it is important to try to create a supportive, safe and facilitating learning process. We do recognise that there are other important processes within supervision (esp. relationship-enhancing qualities, such as emotional support and the other ‘core conditions’). However, this guideline is primarily about the basic, discrete techniques that help to promote learning in supervision, and are mainly drawn from a CBT perspective, to be used by novice supervisors. This recognises supervision as a competence, reflects the evidence-base, and responds to the kind of concrete guidance that novices prefer. Background: This guideline draws on the training and supervision literature, including four systematic reviews (Milne & James, 2000; Milne et al., 2007a–c), conducted to support the present, closely related guidelines. All guidelines were drafted by an experienced supervisor and a senior journalist, following the NICE(R) approach (Dunkerley et al., 2005: we recognise that this means that the organisation of the material can be unfamiliar and off-putting to some. If so, feel free to rearrange the contents to suit). The guidelines were then shaped through discussion in a local guideline development group, improved by drawing on the views of a national group of experts, and made more feasible by building a consensus on the best approach with supervisors attending local CPD workshops. However, these guidelines will remain open to further development from new findings in the literature and through input from supervisors, tutors and others. Please send any comments to the authors:

2. Contents: 3. Key Practice Recommendations: Take account of the learning contract; vary supervision methods, use them in combination (symbolic, iconic and enactive); monitor mini-outcomes; offer supportive feedback. 4. Guiding Principles: Draw on a coherent model; contextualise and personalise; blend methods, pace carefully; monitor and adjust. 5. Good Practice Suggestions:

66 Symbolic methods: case presentations, questioning, etc.; Iconic: video material; sitting in/modelling, etc.; Enactive: joint working & role-play, etc. 6. Ethical Aspect: Pause to reflect critically. 7. Evidence Base: 8. Implementation: 9. References:

3. Key Practice Recommendations: a) Try to take account of the learning contract: select methods that you feel comfortable with, and which help you to work in the supervisee’s ‘zone’ (zone of proximal development: the area that defines the next step). The zone is normally defined by agreeing on objectives together, clarifying exactly what is to be achieved (i.e. working towards SMARTER goals (the ‘learning contract’ guideline details these points)). As well as the micro episodes of learning within a supervision session, it can help to think of the journey from the start until the end of the placement/supervision contract: what steps need to be taken to successfully reach the end? b) Aim to vary your use of supervision methods: this is likely to produce the best results, by helping to ensure that the supervisee uses the different learning modes (see c). It also creates variety and stimulation, promoting the supervisee’s motivation to learn. One important consideration is the kind of learning that the supervisee is engaging in when not in supervision. The available methods can be thought of as being based on words (‘symbolic’ methods, such as case discussion), images (‘iconic’ learning, through watching a video, for instance), and actions (‘enactive’ methods, like role-plays). This reflects an ancient Chinese proverb: ‘I hear and I forget, I see and I remember, I do and I understand’ ‘Symbolic’ methods mainly help the supervisee to report, reflect, conceptualise and plan. ‘Iconic’ methods help the supervisee to ‘see’ the desired skill as demonstrated by the supervisor (or through video recordings, etc), so these will tend to achieve outcomes like enhanced proficiency and theory – practice integration. ‘Enactive’ methods help the supervisee to rehearse and try out relevant skills. The combination of methods that a supervisor uses will vary with theoretical orientation. It will also vary with the extent to which each part of the session is led by the supervisor or by the supervisee. c) Using these different supervision methods will help to supervisees to learn. For example, they may recount important events from their recent work, and by careful questioning you may increase their awareness of important affective aspects (e.g. why they feel anxious about meeting a new client). This can lead to

helpful reflections and a fresh understanding, helping them to move round the experiential learning cycle, and to plan for next time. d) Just as in therapy, a ‘package’ or combination of methods normally works best. Aim to use two to three methods in a 60-minute supervision session. Some methods (such as case presentation, questioning and planning) may be more appropriate for a novice supervisee. Other methods (such as challenging and the use of more than one model) may be more suitable for a supervisee with two or three years of experience. e) The different methods are likely to promote different learning outcomes. These include the ‘mini-outcomes’ that help the supervisor to recognise progress, such as when the supervisee grasps something or can demonstrate a skill competently. It is therefore important for the supervisor to monitor these mini- outcomes, and to use the information to guide what is done next. f) Provide corrective, supportive feedback: the different methods can provide a lot of useful information on a supervisee’s competence and learning. Feedback should be used to guide the acquisition of competence, and to consolidate this learning. It is important to relate feedback to the learning contract, so that there is

68 an agreed point of reference (for other aspects of high-quality feedback, see the FEEDBACK acronym in the box below). An example: Jensen et al. (1998) provide a useful protocol that might be used to guide how you provide feedback: 1) Open with a positive or empathic statement 2) Identify and praise correctly performed skills 3) Identify incorrectly performed skills 4) Demonstrate correct performance 5) Solicit feedback 6) End with a positive statement Mutual feedback is important too – see the appended ‘Helpful Aspects of Supervision Questionnaire’. This is a simple but effective way to encourage the supervisee to contribute to mutual feedback.

4. Guiding Principles: a) Use a model: The methods of supervision should be drawn from within a coherent model, as this fosters a clear and consistent approach. It also aids problem-solving (‘Nothing as practical…’). For the supervisee a coherent model provides a credible rationale, aiding understanding and predictability. b) Relate your approach to the context: Methods need to be considered within their context, including the supervisee’s learning needs, the working alliance that you have established, respective professional styles, biases and preferences, etc. That is, any method will have an element of personal and situational specificity, making its use conditional (and therefore something to monitor closely). Of course, much useful learning occurs outwith supervision, and this should be factored into your use of methods. It is important both to adjust your choice of methods to the work context (e.g. to ensure compatibility), and to use methods in supervision that help to strengthen and support the ‘natural’ learning that takes place (e.g. feedback from a team member). c) Personalise supervision: Aim to reflect the supervisee’s (and your own) needs in your approach, to aid effectiveness and motivation. This includes drawing on your respective strengths and weaknesses. Respecting what the supervisee brings to the learning situation not only strengthens the working alliance, it also helps to define where to start, aiding learning. Remember that all learning is re- learning, so always try to clarify the relevant link to prior understanding. Good questions may include ‘what is this like, in terms of your experience to date?’ and ‘how does this differ from your previous approach?’ d) Blend supervision methods: This helps to provide stimulation and increases the likelihood that the supervisee will learn from the supervisory experience. In particular, first modelling or demonstrating how you would tackle something, like an initial clinical interview, indicates an openness to learning and provides a concrete illustration. e) Pacing: A key task for the supervisor is to judge how fast to progress learning (‘developmentally-informed’ supervision – a strong value: Kaslow et al., 2004). Too little challenge can invite boredom and stagnation. Too much stimulation and there is the likelihood of confusion and deskilling. The optimal pace and depth of

development is that which energises and enthuses, but which also causes some puzzlement and perplexity. This should help supervisees to deepen their understanding, and to become better able to integrate new material (e.g. relating how they learn in supervision to the kind of ‘spontaneous’ learning that occurs whilst working with patients). f) Monitor and adjust: Creating this challenge to the optimal degree requires a fine balance, indicating the need for careful monitoring of these supervisee reactions. There may also be an effect on the supervisory relationship. Joint reflection is therefore indicated, which might usefully refer to the supervisor’s model and personal experiences of such learning, to aid the supervisee’s acceptance and awareness of the learning experience. Provided that it works, give choice and control to the supervisee, building on what is familiar. Check understanding and seek feedback. Continue to respect and value the supervisee’s contribution, as part of your efforts to build confidence and a clinical identity. Recognise explicitly that this is just one way of working, and that all methods should be reviewed critically (Including the material in this guideline!).

5. Good Practice Guidelines:

70 ‘ Symbolic ’ methods: (i.e. based on the use of words) 1. Case presentation (asking supervisee to update you on a case, describing what has happened and then jointly considering issues like re-formulation and alternative strategies: the most popular supervision method) 2. Questioning and challenging (e.g. ‘What would you do next?’ or ‘Would that bring about the desired outcome?’ Might also include supervisee accessing supervisor's knowledge-base, or supervisor checking supervisee's knowledge- base) 3. Discussion (e.g. of therapy notes, letters; see ethical discussion points below – it is appropriate to review these kinds of judgements regularly) 4. Instruction/teaching/informing/suggesting (use teaching methods to convey the relevant knowledge-base effectively) 5. Planning (e.g. prioritising; discussing in detail how to tackle something – e.g. a teaching session; agreeing exactly what to do in next session) 6. Facilitating reflection (e.g. ‘What might you have done differently?’ Aim to draw out the similarities/differences with what is already understood or practised by the supervisee; what are the action implications?) 7. Tips and examples from the supervisor's clinical experience (e.g. what to do when things go wrong; ‘good enough’ practice) 8. Feedback/evaluation (e.g. what worked, what didn't, what needs more work: see Appendix 1 for a user-friendly questionnaire, which the supervisee can use occasionally to reflect on your supervision).

This box summarises the main functions of feedback, together with some methods:

‘ Iconic’ methods: (based on images) 9. Modelling by the supervisor, or demonstration on a video (e.g. agenda setting during co-working) 10. Observation by the supervisee (via one-way mirror, or by sitting in on your work) 11. Both parties observing and commenting on supervisee's performance recorded on audiotape or video

‘ Enactive ’ methods: (based on actions) 12. Role-play (e.g. have the supervisee practise Socratic questioning, with you playing the patient) 13. Behavioural experiments and tasks (e.g. supervisee trying things out, testing beliefs; agreeing a task/project; simulated practice) 14. Live supervision (supervisor observes and actively advises during session) 15. Learning exercises (e.g. supervisee studies video of own or supervisor's clinical work, using a coding tool, and presents analysis at next supervision session) We now illustrate how these principles can be enacted, using a specific example of each of the three broad methods.

SYMBOLIC METHODS OF FACILITATING LEARNING

Case Presentation: Case presentation enables the supervisee to bring problems to supervision and it enables the supervisor to assess competence. The supervisor can facilitate case presentation first and foremost by establishing a good learning alliance. Active encouragement, support, praise and reassurance may be used. Case presentation can be aided with clear and detailed questioning about content and process, as well as conceptualisation. Case presentation also provides an opportunity to assess and facilitate understanding of the supervisee's personal reactions to the case. Where appropriate, probing can be used to elicit more information. Typical questions or statements to use during case presentation might include:

72 ‘Tell me what happened in last week's session.’ ‘How did you feel at that point?’ ‘Why did you do that?’ ‘Why do you think they said that?’

ICONIC METHODS OF FACILITATING LEARNING

Modelling: Modelling takes place when the supervisor asks the supervisee to observe them demonstrate the correct (or deliberately incorrect) performance of a skill, or to watch a video demonstration. Skills modelled might include agenda setting, circular questioning, downward arrow technique, Socratic questioning, and so on. Modelling helps supervisees to visualise the extension of a specific skill and aids them in integrating theory and practice. The BPS (2003) recommends that modelling should grow directly out of the supervisee's learning needs and the goals set in that supervision session. It should also develop naturally from the material discussed in the session. A needs assessment may have indicated that the supervisee has a preference for this or another learning method.

ENACTIVE METHODS OF FACILITATING LEARNING

Role-play: Role-play typically takes place when one party plays the part of the client and the other the therapist. The supervisor might ask the supervisee to demonstrate how they did something in therapy (for example, opening a session or setting homework), or perhaps to prepare for therapy by practising the correct performance of a skill in a safe and nurturing environment. For the supervisor, role-play provides rich information on the supervisee’s approach and learning needs. Indeed, the BPS (2003) recommends that role-play should grow directly out of the supervisee’s learning needs and the goals set in that supervision session. It should also develop naturally from the material discussed in the session. The role-play itself should have learning goals that are acceptable, specific and achievable. The

supervisor should also be sensitive to the anxiety that often accompanies role-play, and so should conduct it in a considerate and thoughtful manner. It should have a clear beginning and end, and be followed by a de-role period, including reflection and feedback.

6. Ethical Aspect: Once or twice we have mentioned the importance of adjusting your supervision to its context. We now want to pause to illustrate one dimension – ethics. Just as in therapy, supervisors should follow good practice guidelines. One of these is ‘positive ethics’, the constructive consideration of ways to foster highly ethical practice. Ethical guidance and codes should help us to reflect critically on our work, as they represent a wealth of accumulated wisdom on how to deal with difficult situations. Rather than being rigid rules, they require judgement at every turn – hence the frequent use of such qualifiers as ‘appropriate’ and ‘reasonable’ (Donner, 2007). So, in this spirit, consider the following:

74 Is it fair to ask supervisees to expose themselves to the kind of embarrassment that role-play can evoke? Are there any circumstances under which a supervisor can reasonably ask a supervisee to make a tape of some of their work? Would it ever be appropriate to treat a supervisee like a patient? What kind of risk would justify your insisting on providing the feedback that the supervisee consider another profession? Does it ever make sense to treat supervision as an art? Can we be held responsible for the incompetence of our supervisees? These questions are intended to infuse the fascinating business of facilitating learning with the necessary ethical colouring. If you are unsure about ‘the answer’ then that’s probably a good thing, as ethical dilemmas should trigger uncertainty and careful reflection, drawing on those codes of conduct, peer discussion, and other processes that aid critical professional thinking. Given the importance and complexity of ethical practice, ethics (preferably the positive kind) should form a regular part of your reflection work with the supervisee.

7. Evidence Base: Textbooks agree on the need to use a blend of supervision methods, closely related to the learning needs of the supervisee. Bernard and Goodyear (2004), for instance, urge the supervisor to take account of the perceived needs, interests and experience of the supervisee. They are less adamant about the specific methods, stressing instead the importance of monitoring processes and outcomes. Citing surveys, Falender and Shafranske (2004) note that discussing videotapes of therapy has been found to be the most popular method, followed by live supervision and then co-working. Discussion of casework and demonstrations by the supervisor were intermediate in popularity (with both parties), with the least popular methods being reviewing verbatim transcripts of the supervisee’s work, and ‘sculpting’ (forming body positions to represent relationships within family therapy). However, they note that such lists do not necessarily reflect the frequency with which methods are used, as case discussion tends to occur most often. They conclude by noting that a supervision competence is ‘knowledge of multiple formats of supervision’ (p. 58) within a strong relationship, endorsing specifically the importance of respect, facilitation of learning, and the use of live/video material. Norcross and Halgin (1997) add an emphasis on having a clear guiding model, needs-led and customised learning, and using a blend of methods. Watkins (1997) stresses a systematic, well-structured approach (inc. shared goals and tasks, guided practice, and constructive feedback). However, all of these authors note the lack of rigorous research on the effectiveness of the different methods, noting the greater tradition of analysing supervision ‘styles’. Therefore they suggest the kind of care noted above (see next paragraph too). Consensus statements tend to be more decisive, an American one noting ‘the value of modelling, role-plays, vignettes, in-vivo experiences, supervised experience, and other

real-world experiences as critical instructional strategies’ (Kaslow et al., 2004, p.706). The BPS’s (2003) policy guidelines strongly echo this consensus statement, and also the main points in the above paragraph (inc. the benefits of using a combination of methods). A useful and shared emphasis is also placed on adopting an empirical approach to supervision, that is, of judging the worth of these methods by studying their impact on the supervisee’s learning. Turning to the primary literature, a systematic review of 28 successful supervision studies by Milne and James (2000) found that systematic methods were used (aided by manuals, in some cases). They cited the example of Fleming et al. (1996), who began with a brief presentation of the relevant knowledge-base, then used a video to model the correct performance of a skill before asking the supervisee to rehearse this, concluding with corrective feedback. Overall, this review also found that the most frequently used methods were the symbolic ones (feedback and discussion most popular), followed by enactive ones (e.g. role-play and behavioural rehearsal), then iconic methods (live and video models). In a more recent review of 24 successful studies, Milne et al. (2007) found that a wide range of methods were used (26 in total), the most common being training/educational

76 methods (18 studies), feedback (16) and observing/monitoring (10). Bearing out the above emphasis on using a well-structured approach, the surveyed authors used an average of over 6 methods per study. This was associated with high levels of supervisee experimenting (reported in 15 of these studies), followed by planning (4), reflection (3) and conceptualising (2). An Australian review of supervision across four professions concluded that a supportive, well-structured approach is preferred, even by the more experienced clinician (at least when learning new skills: Spence et al., 2001). The notion of ‘developmentally informed’ (needs-led) supervision is widely endorsed, as in the consensus statement by Kaslow et al. (2004).They noted the desirability of providing supervision that becomes gradually more complex and sophisticated over time. An illustration is the use of role-play. The research literature suggests that role-play, when incorporated smoothly in a sequence of needs assessment, instruction, demonstration, and feedback, can be effective in facilitating supervisee learning. For example, Harchik et al. (1992) found that this combination was associated with improved supervisee performance and behaviour change in the client. Schepis and Reid (1994) reported that a similar sequence resulted in improved supervisee performance. Feedback stands out as one of the most frequently used methods in supervision, typically linked to other high-frequency elements within supervision, such as goal- setting. Jensen et al. (1998) are typical of the literature, finding that the combination of systematic observation and contingent feedback was associated with strong gains in supervisee competence. As another example, Fleming et al. (1996) defined nine effective supervision skills from the Industrial/Organizational psychology literature, applying them to the clinical field. Two of these were feedback on the correct and incorrect performance of a particular competence by the supervisee. This feedback included qualitative information, such as noting how well a skill worked in relation to the patient, and quantitative information (such as rating this skill as demonstrating competence, and meriting a ‘pass’ mark). Their study indicated that four of the five supervisors in their study were able to provide these two forms of feedback successfully, after five hours of training. Feedback also plays a central part within the psychology of learning. According to Komaki (1986), literally hundreds of experimental studies have shown substantial improvements in performance when desired performance was clarified and then contingent, frequent consequences were provided. Strength of evidence: B

Box 1: Strength of evidence key The suggestions in this guideline are based on evidence. An attempt has been made to indicate the strength of this evidence. Gradings offered are provisional, and are based on the grading scheme of the National Institute for Health and Clinical Excellence (NICE):

A = ‘At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific

recommendation… without extrapolation.’ B = ‘Well-conducted clinical studies but no randomised clinical trials on the topic of recommendation… or extrapolated from level-I evidence." C = ‘Expert committee reports or opinions and/or clinical experiences of respected authorities… This grading indicates that directly applicable clinical studies of good quality are absent or not readily available.’

8. Implementation: This guideline is intended for qualified mental health practitioners, in their role as clinical supervisors. It is designed for use by all professional groups and is considered compatible with most theoretical orientations. The guideline should be used within the practitioners’ professional practice guidelines and

78 management/supervisory arrangements. In this context, supervisors should consider the principles and practice suggestions made above, forming their own judgement about their appropriateness in the case of their individual supervisees. There is no charge for using this guideline, all costs having been met through a grant from The Higher Education Academy Psychology Network to Derek Milne in 2005. We do ask, however, that the use of the guideline is duly acknowledged. Comments, relevant research literature, and any other ideas that might improve this guideline are welcome (see address on p.4).

9. References: Bernard, J.M. & Goodyear, R.K. (2004). Fundamentals of clinical supervision. New York: Allyn & Bacon. British Psychological Society. (2003). Policy guidelines on supervision in the practice of clinical psychology. Leicester: BPS. Donner, M.B. (2007). Myths, the ethics code, and professional life. The California Psychologist, 40, 31. Dunkerley, C., Milne, D. & Wharton, S. (2005). A NICE(R) systematic review of the clinical supervision literature. Annual conference of the European Association for Behavioural and Cognitive Psychotherapy, Manchester. Falender, C.A. & Shafranske, E.P. (2004). Clinical supervision. Washington, DC: APA. Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., et al. (2004). Defining competency competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771–785, Harchik, A.E., Sherman, J.A., Sheldon, J.B. & Strouse, M.C. (1992). Ongoing consultation as a method of improving performance of staff members in a group home. Journal of Applied Behavior Analysis, 25, 599–610. Kaslow, N.J., Borden, K.A., Collins, F.L., Forrest, L., Illfelder-Kaye, J., Rallo, J.S., et al. (2004). Competencies conference: Future directions in education and credentialing in professional psychology. Journal of Clinical Psychology, 60, 699–712. Milne, D., Dunkerly, C., Aylott, H., Wharton, S. & Fitzpatrick, H. (2007). Systematic reviews of clinical supervision: d) An empirical definition; e) Models; & f) Methods and outcomes. All in preparation, available from Derek Milne at address on page 4. Milne, D. & James, I.A. (2000). A systematic review of effective cognitive- behavioural supervision. British Journal of Clinical Psychology, 39, 111–127. Norcross, J.C. & Halgin, R.P. (1997). Integrative approaches to psychotherapy supervision. In C.E. Watkins (Ed.) Handbook of psychotherapy supervision. Chichester: Wiley. Schepis, M.M. & Reid, D.H. (1994). Training direct service staff in congregate settings to interact with people with severe disabilities: A quick, effective and acceptable program. Behavioural Interventions, 9, 13–26.

Spence, S.H., Wilson, J., Cavanagh, D., Strong, J. & Worrall, L. (2001). Clinical supervision in four mental health professions: A review of the evidence. Behaviour Change, 18, 135–155. Watkins, C.E. (1997). Handbook of psychotherapy supervision. Chichester: Wiley.

80 ‘Methods’ guideline: Appendix 1:

HELPFUL ASPECTS OF SUPERVISION QUESTIONNAIRE (H.A.S.Q.)

Your Name (optional): ______Date of supervision: ______1 Please rate how helpful this supervision was overall: Very unhelpful Fairly unhelpful Neither helpful nor unhelpful Fairly helpful Very helpful 1 2 3 4 5 2 Of the events which occurred in this supervision, which one do you feel was the most helpful for you personally? It might be something you said or did, or something the supervisor said or did. Can you say why it was helpful? 3 How helpful was this particular event? Rate this on the scale: Neither helpful nor unhelpful Fairly helpful Very helpful 3 4 5 4 Did anything else of particular importance happen during this supervision? Include anything else which may have been helpful, or anything which might have been unhelpful.

Session 4: ‘The supervisory relationship’

Learning Outcomes:

Main ones: Demonstrates competence in understanding, developing and maintaining a supervisory alliance (e.g. able to clarify collaboration over specific activity; 6); and in creating a safe learning environment (e.g. can summarise own contribution, and expectations of supervisee; 5). Related ones: Models professionalism (including stating specific boundaries and confidentiality standards); summarises assessment/evaluation practice; manages ethical/power issues (e.g. negotiates for recordings of therapy to be used in supervision; 2, 10, 11, 14, 17).

82 Programme: 1. Introduction: slideshow; Q&A 2. Reflective Exercise: Experiences of positive and negative relationships 3. Guided Reading: ‘Enhancing the supervisory relationship: a guideline’ 4. Illustration: Use this session’s video material (clips of ‘mutual engagement’ and ‘emotional bond – but note: this is very brief) 5. Learning Exercise: Specific guideline development (from Helen Beinart and Marina Palomo) 6. Discussion

1. Introduction: Show slideshow.  Ensure participants have their handout (Appendix 9, p.68).  Encourage questions and general engagement.

 In particular, aim to connect this material to their existing competencies in forming a learning alliance, one that provides a ‘safe base’ for experimentation. 2. Reflective Exercise: Ask the group to take a few minutes to reflect on the supervisory relationships that they have had as a supervisor (or supervisee). Choose a specific example that they think demonstrates aspects of either effective or ineffective supervision. Write down brief notes that specify what they did to make the supervision work well/less well. What was the contribution of the other party? Did contextual any issues impact? Then invite feedback, taken on flip-chart. For example, list: (a) things that contribute to effective supervision; (b) things that contribute to ineffective supervision; (c) contextual issues. 3. Guided Reading:  Ask group to read all or designated sections of the guideline, ‘Enhancing the supervisory relationship’ (Appendix 10, p.69).  Again, attempt to energise/focus/connect (e.g. ‘After you’ve finished, I’ll ask how this material relates to therapy/your existing activities/competencies’). 4. Illustration:  Consider showing the two ‘relationship’ video clips. They are meant to illustrate mutual engagement (clip 4a) and an emotional bond (4b – NB this is an exceptionally brief clip). Invite reactions and clarify issues, like the difference between these phenomena within

therapy versus supervision. But, as with the other video material, you or they may see other helpful uses. 5. Learning Exercise: Distribute the ‘Background Information’ sheet (below, p.66–67) alternately to participants, delegating them the role of either supervisor or supervisee. TASK:  Ask the respective groups to form into small groups (4–6).  Each small group should generate a specific and personally feasible guideline for dealing with the situation that is summarised within the ‘Background Information’ sheet.  This must refer to the provided ‘relationship’ guideline (e.g. to the ‘rupture and repair’ material).  Groups should prepare to summarise their emergent, specific guideline to the large group.  Summaries presented (alternating supervisors/ees).

84 6. Discussion:  Comment on these specific guidelines, in terms of how similar they are to ‘best practice’ locally (recent examples can help), and/or to the profession’s policy/guidelines.  This is a good point at which to draw out the systemic/general nature of the supervisory relationship/learning alliance. For example, from the ‘platform’ and learning contract stages there are important implications for the alliance. More significantly, supervisors (like authors of related texts) will probably view the relationship as the basis/vehicle of everything else in supervision.

Alternative Learning Exercise (for Session 4):

Role-Play Exercise:

Form groups of 3, each containing one supervisee (who receives only their background information – see below, p. 26), one supervisor (who receives only their background information – see below), and an observer (who receives no background information). To be followed by group feedback/discussion.

Work on developing and negotiating a contract item to address the supervisory relationship (about 1 month into placement).

86 BACKGROUND INFORMATION:

(A) Supervisor

You are beginning to have concerns about your current supervisee, although you have not pinpointed the issues as yet. The supervisee has recently joined the service and you are still getting to know them. Signs that have made you begin to question the situation are: having to repeat advice/suggestions when actions do not appear to be followed through (for example, arranging visits during induction), and a slight lack of enthusiasm and initiative on the part of the supervisee. Although the supervisee appears to be pleasant and seems to get on well with the team, you have not yet had the chance to observe any client work (initial joint appointment was cancelled and your diary is full). You wonder whether the slight lack of enthusiasm you have picked up may impact on client engagement. However, you are conscious that you have been very busy lately and perhaps have not given the supervisee sufficient guidance or attention. There are financial constraints on your service, which have taken a lot of your time and have added to an already busy workload. (B) Supervisee

You like and respect your supervisor, but feel your supervisor is very busy, and somewhat over- committed, and you do not want to make demands. You are quite experienced, but new to this area of work. You are feeling low on confidence, although keen to develop your practice (you had looked forward to the placement and heard good things on the trainee grapevine). You have had a stressful time at home recently and although you have tried to share this, your supervisor does not seem very interested in you as a person. Indeed, your supervisor seems a bit rushed in supervision sessions, often making suggestions before you have had a chance to express your view (for example, suggesting that you visit a service during induction that you had worked in as an Assistant). You have started seeing clients, but your supervisor has not observed you: the initial joint appointment was cancelled, and it has been difficult to fit in another. You are quite confident that you can engage people, but feel a bit unclear about the next step and feel you have not been offered enough direction or feedback. You are beginning to feel deskilled, but are also feeling confused about why things seem not to be going as you had hoped. You have quite a bit of experience working in teams and feel you have established good working relationships with the other team members. Your supervisor seems to wish to spend valuable supervision time discussing broader issues, when it is actually the clinical work that you feel you need help with. End of session 4 Acknowledgements: With special thanks to Helen Beinart and Marina Palomo: the reflection and learning exercises above are based on a workshop that they delivered in Newcastle in 2006, as helpfully recorded by John Ormrod.

Appendix 9: Session 4: Handout 1: The ppt

88 Appendix 10: Session 4: Handout 2: The ‘relationship’ guideline

Northumberland, Tyne and Wear NHS Trust

Enhancing the supervisory relationship: a guideline 1. Summary: The supervisory relationship represents the foundation for success, providing a sense of working together with the supervisee on shared objectives. It can be thought of as providing a safe, structured space for development. In turn, this alliance facilitates the methods used in supervision, and allows individual differences to be accommodated. Although the direct evidence to support these claims is surprisingly weak in relation to the supervision literature, what we know about similar relationships (esp. therapeutic ones), together with general professional conventions, suggests that we should attend closely to the alliance. Background: This is the third of four guidelines, all designed to try to help supervisors to succeed in their efforts to facilitate their supervisees’ learning. We fully recognise that this represents only one function of supervision, the so-called ‘formative’ one. The guidelines are written on the understanding that you will naturally draw on your other professional competencies when you supervise, particularly those attitudes, values and facilitating processes that underpin good professional practice generally. Such practice will no doubt help you to achieve the other important goals of supervision, such as the provision of emotional support (‘restorative’) and the placing of supervision within its organisational and professional context (the ‘normative’ function). Given this clarity of purpose, the guideline can focus on those specific techniques and principles that seem appropriate for new supervisors, and which are based on the best- available evidence. This means that the guidelines have a strong CBT flavour. For those interested in alternative approaches, the references provided at the end suggest some complementary material. The guideline is part of the manual: ‘A CPD workshop for new clinical supervisors’, written by Derek Milne. Even if not used as part of that workshop, it should be used in a context where you can discuss these guidelines with peers and clinical tutors. Copyright © by Derek Milne and Chris Dunkerley (for address see p.4)

2. Contents: 3. Key Practice Recommendations:

Collaborate closely; provide support; ensure clear and consistent structure; model; facilitate reflection; be sensitive to anxieties; give feedback. 4. Definition: Bond, mutual engagement and agreement about the goals (plus a recent elaboration) 5. Guiding Principles: The supervision or learning alliance acts in concert with other factors to promote learning. The alliance includes: emotional bond; structure; commitment; role model; reflective education; and feedback 6. Good Practice Suggestions: Work on building the alliance (inc. empathy & support); ensure structure and collaboration; regular review and feedback (and see Table 1) 7. Evidence Base: How much support is there for these guidelines? (inc. NICE quality rating) 90 8. Implementation: Clarification of how these guidelines are expected to be used 9. Acknowledgements: 10. References:

3. Key Practice Recommendations: a) Collaborate closely: Supervisors should work closely with their supervisees in order to establish the ‘facilitative conditions’ for a learning alliance; take account of the work context (e.g. team/service arrangements) to ensure a good ‘fit’. b) Provide support: Be trustworthy and responsive to the trainee’s learning needs. The acid test of this ‘safe base’ is that the supervisee will feel valued, respected and safe. c) Create a clear and consistent structure and show appropriate interest in supervision, and the supervisee will also contribute to this alliance. d) Model: To build on that relationship, supervisors should take every opportunity to demonstrate the skills and respectful relationships that are expected of professionals. e) Facilitate reflection in supervisees through questioning and other developmentally appropriate methods, so as to facilitate learning. f) Be sensitive to the spoken and unspoken anxieties that will naturally occur, and try to match your supervision to the supervisee’s stage of development. g) Give feedback: Constructive, regular and open feedback (i.e. positive and negative comments, made sensitively) maximises the alliance and its effective contribution to the supervisee’s development and clinical effectiveness. Remember, differences in your respective experience will result in differing perceptions of progress. Elaborations on these points, together with additional ideas, can be found in section 6, and in the table in section 7. However, the lack of convincing evidence to date means that supervisors should monitor their alliances carefully, looking for evidence of effectiveness (especially in terms of the supervisee’s learning trajectory), and for evidence that the supervisee feels valued, respected and safe.

4. Definition: The alliance can be defined as: ‘Feelings and attitudes that the supervisor and supervisee have towards one another, and the manner in which these are expressed’ (Palomo, 2004, p.9). That is, the personalities of the two parties, related to their respective input (skills, experience, etc.) and their joint working, result in an interactional pattern called the alliance (Binder & Strupp, 1997). This alliance is considered to be integral to the success of the endeavour, as per therapeutic relationships (Safran, 1993). In short, the learning alliance can be viewed as a ‘collaboration to change’ (Bordin, 1979, p.73).

According to Bordin (and later researchers – see p. 464 of Ellis & Ladany, 1997), the alliance is made up of three main things: a) An agreement about goals (usually a caseload focus); b) Jointly undertaking the tasks necessary to achieve those goals (mutual engagement); c) The emotional bond that develops between supervisor and supervisee (rapport). Recent research in the UK suggests an elaboration of this definition – see Table 1 below.

Specifying the opposite: Definitions like this are aided by also specifying what something is not. As noted in the Bernard and Goodyear (2004) text, this can be done by outlining ‘how to be a lousy supervisor’! This includes breaking all the rules of both good clinical practice and the

92 findings from relevant research. Examples include not revealing any of your own shortcomings as a supervisor, not providing a sense of safety or emotional support, and placing the importance of service delivery way above the supervisee’s learning needs (p.151). To these can be added negative personal qualities, such as rigidity, uncertainty, exploitation, criticism, and distance and distraction in the supervisor (Falender & Shafranske, 2004, p.99).

5. Principles: As per the general literature on effective working relationships, particularly the research on therapy, the importance of the relationship appears to be paramount, acting in concert with the interventions used, the characteristics of the participants, etc. (Norcross, 2002). The bond is thought by Bordin to develop as a result of either working together on these tasks, and/or on the basis of shared emotional experiences. It is thought to centre around the feelings of liking, caring and trusting that are shared by these participants in the alliance. Bernard and Goodyear (2004) note the general acceptance of this alliance logic within the literature on supervision. They also helpfully summarise a range of research that has attempted to understand how different supervisor behaviours influence supervision processes and lead to different outcomes. Figure 3 summarises their account. Note that this includes ‘negative’ behaviours that have been found to weaken the bond (e.g. unethical supervisory activities). These are marked as negative (-) in the figure.

Figure 3: A summary of some of the positive and negative factors that have been found to contribute to the ‘learning alliance’ in supervision (based on Bernard & Goodyear, 2004, p.147)

94 6. Good Practice Suggestions: How can supervisors adhere to these principles in their work? Here are some suggestions: a) Relationship building: Because the elements of the supervisory and the therapeutic relationships are so similar, one key practice ingredient is to draw on therapy methods within supervision. This includes an open, expressive stance, warmth, respect for the supervisee’s position, and mutual engagement in the required work. Bernard and Goodyear (2004) also stress the importance of facilitating the supervisee’s exploration of interests, to aid in solving problems collaboratively (inc. discussion of the supervisee’s ideas, elicited and clarified through reflection). A complementary concrete focus can enable the supervisee, as in goal-setting, then agreeing practical, step-by-step actions. Once clarified, trust the supervisee to enact these plans. Self-disclosure can help the supervisee to see how you have managed these issues in your own time, as well as giving some historical perspective to your relationship. A good example is dealing with the cycle of relationship ‘rupture and repair’. This is viewed by some as a natural iteration within healthy relationships (i.e. where impasses and awkward issues are addressed appropriately, rather than being a trigger for dissociation: Falender & Shafranske, 2004). Most supervisors will be able to illustrate how such repairs can be made from their own experiences of crises (e.g. significant disagreements over the goals of supervision; mutual misunderstandings). Probably the main source of tension and rupture relates to the power differential between the parties, particularly where the supervisee is a trainee. This should be acknowledged as a fact of life in supervision, a reasonable arrangement, given that the supervisor is accountable for the trainee’s actions (see session 1 of the manual). b) Social support: Like a good friend or parent, the supervisor should be trustworthy and reliable. Other elements of effective friendships include sharing the work, providing needed information, offering practical assistance and (most prized of all) unconditional emotional support (Milne, 1999). This textbook reviewed the role of social support and indicated that, as a result of such relationship conditions, we can infer that the supervisee may develop a sense of safety, belonging, personal validation, and receive assistance with their coping efforts. In turn, the supervisor may find their supervisee more willing to disclose things (e.g. recounting something that went wrong), showing more enthusiasm, ability, etc. c) Organization: A clear, consistent but flexible approach to the supervision sessions helps with these tasks and processes. It also signals a professional commitment to the endeavour, and enables the two parties to do the required work. Therefore, agree regular supervision times, and structure them properly (e.g. referring regularly to the learning contract and to future evaluations). Record these as per other appointments, and treat these meetings as you would a clinical or any other appointment (e.g. preparing carefully; no interruptions; fill the available time). A related task is to create the right workplace climate. After all, this is the environment that will help or hinder a systematic approach. For instance, cultivate the support of your peers (e.g. through being collegial and professional) and of your manager (e.g. by emphasising the contribution that the supervisee makes to the department).

d) Engage fully: Having set aside the required time, ensure that it is used effectively. Depending on their theoretical orientation, supervisors will naturally emphasise different methods. However, a common denominator of these is to work in an ‘internally consistent’ manner – that is, one aims to work with the supervisee as one would wish to work with the patient. At this basic level, then, the supervisor is modelling good professional practice to the supervisee. To illustrate, let’s return to the issue of a relationship rupture. The fully engaged supervisor will address this thoroughly, as in trying to jointly clarify why it arose. A neutral stance will be taken, and perspectives examined (e.g. asking the supervisee to imagine how the rupture episode might appear to others). A further important perspective is thought to be meta-communication. This entails attempting to step outside an incident, so as to be able to reflect more effectively, and to discuss it more objectively (Safran & Muran, 1996). For instance, negative material from the supervisee needs to be ventilated and heard, or at least removed as a barrier to resolution. Such a process stands to teach the supervisee several important lessons, but the main one to highlight here is that the supervisor is fully committed to the supervisee’s development.

96 e) Review: It is a good plan to have regular opportunities to reflect jointly on progress. This should include eliciting feedback on your supervision, as this helps to facilitate effective collaboration (and to share responsibility, acknowledge the supervisee’s input, etc.). The evaluation guideline offers the Helpful Aspects of Supervision Questionnaire as a simple but useful way to foster such mutual involvement. The supervisor can again demonstrate first, showing the supervisee different ways to give feedback in a supportive, non-threatening way. f) Other: Table 1 (below) lists similar and additional practice options.

7. Evidence Base: Authorities unanimously agree that the supervisor needs to form an effective working relationship with the supervisee (Falender et al., 2004; Watkins, 1997). Indeed, the assumption that strong parallels exist with the therapeutic relationship has been supported (Beinart, 2002; Palomo, 2004). This includes the notion that any such alliance requires the active collaboration of the supervisee (Stambor, 2005). To illustrate, the Association of Directors of Psychology Training Clinics in the USA has produced a summary of key competencies in the supervisee (Stambor, 2005). This includes the general ability to interact collaboratively and respectively with colleagues. They specifically recognise the competence of ‘the ability to use supervision’. They note that this is partly dependent on a relationship competence, namely the ability to work collegially and responsively with supervisors (p.14). On the supervisor’s side, a parallel consensus statement noted that the ‘the ability to build a supervisory... alliance’ was a key competence (Falender et al., 2004, p.778). Empirical analyses of the supervisory relationship support this emphasis, though with caution (Ellis & Ladany, 1997). Summarising this literature, Bernard and Goodyear (2004) state that ‘a positive and productive relationship is critical to successful supervision’ (p.101). Next, some of the key findings that lead to this conclusion are noted. Qualitative research on the alliance: In the UK, a qualitative examination of both ‘lousy’ and effective supervisory relationships has been carried out by Helen Beinart (2002), the Clinical Director to the Oxford clinical psychology course. Drawing on Bordin’s (1983) thinking about the working alliance, she surveyed supervisees and supervisors in the UK about their most recent supervisory relationships within clinical psychology training. All of the supervisees in her sample (N = 48) had experienced relationships both high and low in effectiveness. Their satisfaction with the support provided in supervision appeared to distinguish between the effective and ineffective relationships. Beinart (2002) concluded that the key elements of an effective supervisory relationship were that it was:  Boundaried  Supportive  Open  Respectful  Committed

In terms of the process, she stressed the value of a collaborative, sensitive (to needs), educative and evaluative approach. Quantitative research on the alliance: Palomo (2004) drew on Beinart’s work to develop a quantitative measure, the ‘Supervisory Relationship Questionnaire’ (SRQ). The SRQ was administered to 284 trainee clinical psychologists in the UK and the results submitted to principal components analysis. The result was a six-factor solution (Table 1).

98 Table 1: The six factors in the ‘Supervisory Relationship Questionnaire’ (SRQ; Palomo, 2004)

Components: Definitions & examples: Possible actions:

A. Facilitative Conditions (variance accounted for in SRQ scores):

1. ‘Safe base’ (52%) Supervisee feeling Empathise and connect emotionally (e.g. valued, respected and through self-disclosure). safe. Supervisor Seek understanding and consensus (e.g. supportive, trustworthy shared expectations); offer warmth and and responsive. respond to learner’s needs. Avoid hostility, criticism and being judgemental.

2. ‘Structure’ (4.5%) Maintaining practical Be clear about duration and purpose (inc. boundaries, like time. shared goals/joint agenda-setting); regular & structured supervision.

3. ‘ Commitment’ (2.9%) Supervisor interested in Show interest and enthusiasm; be supervision and approachable and attentive; offer supervisee. constructive feedback; address and repair alliance ruptures

B. Goals and Tasks:

4. ‘Role model’ (2.2%) Supervisor perceived as Draw on experience within system; skilled, knowledgeable provide practical support; demonstrate and respectful. your approach and key skills, especially respect for patients and colleagues.

5. ‘Reflective education’ (1.9%) Facilitating learning Draw on multiple models flexibly; through supervisee’s encourage reflection; foster theory– reflection; sensitive to practice integration; promote interesting supervisee’s anxieties. discussions of techniques; focus on the process of supervision (including acknowledging the power differential).

6. ‘Formative feedback’ (1.8%) Constructive & regular, Encourage interest in feedback from the inc. positive & negative supervisee, adapting it to fit his/her feedback; tailored to understanding & level of confidence; stage of supervisee’s provide feedback regularly, including development. positive and negative comments, made in a balanced, constructive way.

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This breakdown of the supervisory relationship agrees with but elaborates the original Bordin definition. Palomo’s study also gives relative weight to each of the components – it can be seen that a ‘safe base’ was three times as important as all the other factors put together. The ‘possible actions’ column above draws on Palomo’s SRQ items and the general therapy literature on alliance (Agnew-Davies et al., 1998) to suggest how the supervisor might promote the alliance. If used in supervision, it would be important to monitor their impact, since there may be significant individual differences in how these methods are perceived by the supervisee. Palomo (2004) established that the SRQ was psychometrically sound and related these components of the relationship to the supervisee’s ratings of a number of supervision outcomes. These included the impact on their learning and on their clinical effectiveness. Highly significant positive correlations were found between these components of a good supervisory relationship and the ratings of desirable outcomes. An illustrative study of the relationship and its impacts on the supervisee was provided by Rabinowitz et al. (1986). They had 45 trainees at different stages of development

100 rate their ‘most important’ processes and outcomes from each week’s supervision for 12 weeks. They found that the supervisees' most frequent rating of the supervision process was ‘supporting, reassuring & nurturing’. This was also judged to be the second most important factor, after the business of gaining competence. Conversely, least endorsed were ‘challenging, confronting & disagreeing’. These findings were surprisingly constant across the different stages of supervisee development, leading the authors to suggest that they were ‘universal elements of the supervision process’ (p.298). Although these findings agree with the reviews and consensus statements above (e.g. Bernard & Goodyear, 2004; Falender et al., 2004), there is a need for caution: a meticulous systematic review that included the role of the alliance found only two rigorous studies and only modest support (Ellis & Ladany, 1997). These authors also noted a myriad of other relationship variables within this research field, such as expertise, ‘client-centred’ relationship conditions, and roles. Bernard and Goodyear (2004) agreed, referring to the ‘complex’ nature of the supervisory relationship (p.157). The systematic reviews by Milne and James (2000) and Milne et al. (2006) also found few manipulations of the supervisory relationship as such in their sample of 25 successful interventions, although many of the above-noted elements of the relationship were reported as constituent methods (e.g. collaborating; modelling; feedback). Strength of evidence (provisional) for guideline: B

Box 1: Strength of evidence The suggestions in this guideline are based on evidence. An attempt has been made to indicate the strength of this evidence. Gradings offered are provisional, and are based on the grading scheme of the National Institute for Health and Clinical Excellence (NICE): A = ‘At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation… without extrapolation.’ B = ‘Well-conducted clinical studies but no randomised clinical trials on the topic of recommendation… or extrapolated from level-I evidence.’ C = ‘Expert committee reports or opinions and/or clinical experiences of respected authorities… This grading indicates that directly applicable clinical studies of good quality are absent or not readily available.’

8. Implementation: This guideline is intended for qualified mental health practitioners, in their role as clinical supervisors. It is designed for use by all mental health professionals groups and is considered compatible with most theoretical orientations. The guideline should be used within the practitioners’ professional practice guidelines and management/supervisory arrangements. In this context, supervisors should consider

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the principles and practice suggestions made above, forming their own judgement about their appropriateness, in relation to the case of their individual supervisees. This guideline should also be used in liaison with their local professional training programmes, in the case of trainees. In the case of CPD supervision, practitioners are encouraged to refer to the relevant guidance on CPD within their profession. Additionally, scientific journals and professional texts can help to guide effective supervisory practice (e.g. see attached reference list). The guideline draws on the training and supervision literature, including four systematic reviews (Milne & James, 2000; Milne, 2007; Milne et al., 2007), conducted to support the present, closely related guidelines. All four guidelines were drafted by an experienced supervisor and a senior journalist-turned-trainee clinical psychologist, following the NICE(R) approach (Dunkerley et al. 2005). They were then shaped through discussion in a local guideline development group; improved by drawing on the views of a national group of experts; and made more feasible by building a consensus on the best approach with supervisors attending local CPD workshops. There is no charge for using this guideline, all costs having been met through a grant from The Higher Education Academy Psychology Network to Derek Milne in 2005. It

102 can therefore be copied for use within supervisor training workshops. We do ask, however, that we are duly acknowledged. Comments, relevant research literature, and any other ideas that might improve this guideline are welcome. Derek Milne and Chris Dunkerley, Doctorate in Clinical Psychology, 4th Floor, Ridley Building, The University of Newcastle, England NE1 7RU. ([email protected]; [email protected]; 0191-2227925).

9. Acknowledgements: This guideline was initially drafted by Derek Milne and Chris Dunkerley, and re-drafted with the help of the Newcastle Guideline Development Group: Daria Bonanno, Alisdair Cameron, Kate Cavanagh, Lesley Clarke, Joanne Cunningham, Lorna Gray, Caroline Leck, Ian James, & John Ormrod. Helpful comments on a draft were made by Marina Palomo.

10. References: Agnew-Davies, R., Stiles, W.B., Hardy, G.E., Barkham, M. & Sahapiro, D.A. (1998). Alliance structure assessed by the Agnew Relationship Measure (ARM). British Journal of Clinical Psychology, 37, 155–172. Beinart, H (2002). An exploration of the factors which predict the quality of the relationship in clinical supervision. Unpublished top-up doctorate, Oxford Doctorate course. Bernard, J.M. & Goodyear, R.A. (2004). Fundamentals of clinical supervision (3rd edn). London: Pearson. Binder, J.L. & Strupp, H.H. (1997). ‘Negative process’: A recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice, 4, 121–139. Bordin, E.S. (1979). The generalizability of the psychodynamic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Bordin, E.S. (1983). A working alliance model of supervision. Counselling Psychologist, 11, 35–42. Dunkerley, C., Milne, D. & Wharton, S. (2005). A NICE(R) systematic review of the clinical supervision literature. Annual conference of the European Association for Behavioural and Cognitive Psychotherapy, Manchester. Ellis, M.V. & Ladany, N. (1997). Inferences concerning supervisees and clients in clinical supervision: An integrative review. In C.E. Watkins (Ed.) Handbook of psychotherapy supervision (pp.447–507). Chichester: Wiley. Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., et al. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771–785. Falender, C.A. & Shafranske, E.P. (2004). Clinical supervision: A competency-based approach. Washington, DC: APA. Hawkins, P. & Shohet, R. (2004). Supervision in the helping professions. Milton Keynes: Open University Press.

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Milne, D., Dunkerly, C., Aylott, H., Wharton, S., Falender, C., Shafranske, E., et al. (2007). Systematic reviews of clinical supervision: g) Models; h) Methods and outcomes; & i) Training clinical supervisors. All in preparation, available from Derek Milne at address on page 4. Milne, D. & James, I.A. (2000). A systematic review of effective cognitive- behavioural supervision. British Journal of Clinical Psychology, 39, 111–127. Milne, D.L. (1999). Social therapy: A guide to social support interventions for mental health practitioners. Chichester: Wiley. Milne, D.L. (2007). An empirical definition of clinical supervision. British Journal of Clinical Psychology (in press). Norcross, J.C. (2002). Psychotherapy relationships that work. Oxford: Oxford University Press. Palomo, M. (2004). Development and validation questionnaire measure of a supervisory relationship (SRQ). Unpublished doctoral dissertation, available from the clinical psychology course at Oxford University. Proctor, B.M. (2000). Group supervision: A guide to creative practice. London: Sage.

104 Rabinowitz, F.E., Heppner, P.P. & Roehlke, H.J. (1986). Descriptive study of process and outcome variables of supervision over time. Journal of Counseling Psychology, 33, 292–300. Safran, J.D. (1993). The therapeutic alliance as a transtheoretical phenomenon: Definitional and conceptual issues. Journal of Psychotherapy Integration, 3, 33–49. Safran, J.D. & Muran, J.C. (1996). The resolution of therapeutic ruptures in the therapeutic alliance. Journal of Consulting and Clinical Psychology, 64, 447–458. Stambor, Z. (2005). Prepare for practicum. Monitor on Psychology, 36, 70–71. (This is a summary of a report on the work of the association of the directors of psychology training clinics in the USA, chaired by Hatcher, R.L. and Lassiter, K.D., 2004). Watkins, C.E. (Ed.) (1997). Handbook of psychotherapy supervision. Chichester: Wiley.

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Session 5: ‘Evaluation’

Learning outcomes:

Main ones:  Demonstrates skills (and gains experience) in using a range of supervisory approaches and methods (e.g. able to carry out the learning exercise competently; 13).  Understand the transferability of clinical skills into supervision, and the similarities and differences (e.g. can list three shared skills, and two important differences; 9). Related ones:  Models the professional role (2).  Utilises knowledge of development (3).

106  Draws on models/frameworks for managing process (4).  Creates a safe learning environment and develops an alliance (5; 6). Materials: You will need these items for this session: 1. The Guideline on evaluation (Appendix 12, p.86) 2. Video clips for same, plus (optional) a general clip (see learning exercises) 3. PowerPoint slideshow (handout in Appendix 11, p.85) Programme: 1. Introduction: slideshow; Q&A 2. Needs Assessment 3. Guided Reading: ‘Enhancing the supervisory relationship: a guideline’ 4. Illustration 5. Learning Exercise 6. Discussion

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1. Introduction: As part of the slideshow presentation, invite participants to reflect on their evaluation experiences as supervisees. For example, ask them to reflect on their best and worst experiences (with their workshop neighbour), selecting strongest examples for large group feedback and summary on flipchart. Aim to clarify, from these experiences and from the slideshow, the skills that are involved in providing effective evaluations of supervisees’ progress. 2. Needs Assessment: Using discussion and a flipchart, get an idea of what the group already know about local processes of assessment, and any skills that they have in both supportive and challenging feedback (e.g. in terms of communicating bad news). Refer to the learning objective 10: ‘Have an understanding of the process of assessment and failure, and skills and experience in evaluating trainees’ (alternatively, video clips are also a good primer: invite the participants to comment on what they see as the strengths and weaknesses of an illustrative episode).

108 This needs-assessment information should guide your approach to the workshop material (inc. your pace and depth), and you might wish to check explicitly as to whether you are indeed working in their ZPD zone (a reflexive use of feedback).  Use the slideshow (Handout version is in Appendix 11, p.85), taking questions. 3. Illustration:  Show the video clip/s on the accompanying website (www.wiley.com/go/milne) (number 5a or 5b, but note that these may have been used in session 3, so may require a different slant. For example, there is little within either of these clips concerning evaluation (as opposed to feedback), so participants could be invited to suggest when and how to add this (evaluation), appropriately. Another slant would be to invite participants to say how the video material could be made to represent a more challenging evaluation).  Alternatively, omit this material in favour of a demonstration or some other video material (e.g. The Leeds University video: ‘Ethical issues in Clinical Supervision’. Media Services, Leeds University, c 2000; Access too via Dave Green at Leeds – [email protected]; or through the DROSS website). Encourage participants to consider how their own approach compares with these recordings or demonstrations; request examples. 4. Guided Reading:  Ask the group to read the ‘evaluation’ guideline (Appendix 12, p.86). 5. Learning Exercise:  Use the fictitious Supervisor’s Feedback Form (within the participants’ handout, Appendix 13, p.96) and demonstrate the role-play (e.g. enact the positive–negative– positive sequence of feedback points: see the example in the ‘Feedback’ section of the ‘Methods’ guideline, p.132). The aim is to illustrate supportive and challenging feedback, so that the group know what is expected of them in the role-play. Next, ask the group to work in pairs, following your example and the instructions in their Guide. Alternative/supplementary learning exercise: The participants can be encouraged to stop the role-play as soon as they disagree with anything (e.g. the absence of any reference to the learning objectives – guideline 2a). Indeed, they might have the guideline open at section 2 (the ‘Key practice recommendations’) to bring these into the frame, and to prompt them to spot sub-standard performance. 6. Feedback: Circulate during the role-play, trying to offer tips and praise. After the role-play, encourage the group to complete the form in their Guide, inviting some feedback to the large group (e.g. points of agreement between supervisors and supervisees within the role-play). 7. Discussion: Provide a summary of the session, linked explicitly to the learning objectives; invite questions/comments; draw conclusions (inc. link to other sessions).

End of session 5

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Appendix 11: Session 5: Handout 1: The ppt

110 Appendix 12: Session 5: Handout 2: The ‘evaluation’ guideline

Northumberland, Tyne and Wear NHS Trust Evaluation in clinical supervision: A guideline 1. Summary: Evaluation can be an uncomfortable duty for the supervisor to perform, but it is an absolutely vital one. It can be made easier by drawing on the tools, procedures and guidance that training programmes usually provide (and the professional good practice guidance from employers and professional bodies). There is also considerable overlap between general professional practice and evaluation in supervision (inc. effective communication; e.g. skills in breaking bad news). Using these established devices and skills to foster an adult learner dialogue with the supervisee helps to ensure that supervisees know where they stand, and that only those who are fit to progress do so, safeguarding patient care and professional standards. The guidance provided within the mental health professions, expert consensus, and empirical evidence consistently underline these points. Background: This is the last of four closely related guidelines, all designed to try to help supervisors to succeed in their efforts to facilitate their supervisees’ learning. We fully recognise that this represents only one function of supervision, the so-called ‘formative’ one. The guidelines are written on the understanding that you will naturally draw on your other professional competencies when you supervise, particularly those attitudes, values and facilitating processes that underpin good professional practice generally. Such practice will no doubt help you to achieve the other important goals of supervision, such as the provision of emotional support (‘restorative’) and the placing of supervision within its organisational and professional context (the ‘normative’ function). Given this clarity of purpose, the guideline focuses on those specific techniques and principles that seem appropriate for new supervisors, and which are based on the best- available evidence. This means that the guidelines have a strong CBT flavour. For those interested in alternative approaches, the references provided at the end suggest some complementary material. The guideline is part of the manual: ‘A CPD workshop for new clinical supervisors’, written by Derek Milne. Even if not used as part of that workshop, it should be used in a context where you can discuss these guidelines with peers and clinical tutors.

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2. Contents: 3. Key Practice Recommendations: Set goals, enabling evaluation; have regular, scheduled meetings; use multiple evaluation methods; address inherent tensions around evaluation; review progress regularly 4. Definitions: Formative (corrective feedback) and summative evaluation (gatekeeping) 5. Guiding Principles: Consistency and coherence; communication; measurement; supervisee involvement and system support 6. Good Practice Suggestions: Observation; using measures of the supervisee’s satisfaction and clinical effectiveness; referring to learning contract

112 7. Evidence base: How much support is there for these guidelines? (inc. NICE quality rating) 8. Implementation: Clarification of how these guidelines are expected to be used 9. References:

3. Key Practice Recommendations:

a) Refer to the learning objectives: the SMARTER (specific, measurable, achievable, realistic, time-phased and recorded) goals agreed within the learning contract should provide the basis for evaluation. The criteria should be clear at this stage (e.g. by using a standard form from within a local training programme).

b) Provide timely, scheduled evaluations: these should take place at least at the mid- and end-points of a supervision episode (‘evaluation’ is a judgement about passing or failing the supervisee within the assessed work of a training programme).

c) Utilise multiple methods, in order to guide evaluation judgements (inc. supervision logs/records, direct observation, written material, self-reports and clinical discussion). Measurement of patient satisfaction and clinical outcomes are important external criteria, as they permit some perspective on your supervisee’s ‘fitness for practice’.

d) Conduct evaluations in a professional way: a balance between positive and negative comments (strengths and weaknesses) is usually appropriate, identifying specific improvement goals and agreeing a plan. Be clear, timely, objective, and so forth, as per normal professional practices. Seek feedback from the supervisee (e.g. does the evaluation seem feasible? acceptable? fair?), and regularly encourage self- evaluations by the supervisee.

e) Acknowledge and address inherent problems over evaluation: recognise the power imbalance and professional discomfort that usually accompany evaluation, and try to engage the supervisee in the evaluation process in an appropriate way, esp. as an adult learner developing a vital skill (e.g. self-monitoring). Try to ensure consistency, with the normal conventions (e.g. adhere closely to the course’s procedures).

f) Review your approach regularly: Ensure that you have opportunities for formal and informal reflection and guidance on your approach (e.g. through departmental meetings; attendance at supervisors’ workshops; reading the profession’s guidance documents). A good reason is to reflect on your management of the ethical and legal aspects of supervision. For example, are you managing boundaries between the dual roles of supervisor and colleague effectively? How is evaluation helping you to be

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confident that your supervisees are not practising beyond their competence? See the handout from workshop session 1 for more on these sorts of issues.

4. Definitions: Two forms of evaluation are distinguished in the literature. ‘Formative’ evaluation focuses on giving corrective information to the supervisee on a regular basis (e.g. every supervision session), to foster development. It also represents a way of determining if supervision is being provided as planned (i.e. mutual feedback). ‘Summative’ evaluation is about outcomes and the attainment of a required standard of competence. It has been described as the ‘moment of truth, when the supervisor steps back, takes stock and decides how the supervisee measures up’ (Bernard & Goodyear, 2004, p.20). Summative evaluation is therefore a judgement made by the supervisor, one which concerns the extent to which the supervisee demonstrates the attainment of the learning objectives, and is perceived to be fit to ‘pass’ an episode of

114 training. This is sometimes referred to as the supervisor’s ‘gatekeeping’ role, reflecting how a supervisee is or is not permitted to enter a profession). These types of evaluation are regarded as basic aspects of a supervisor’s competence (Falender et al., 2004). Not surprisingly, they occur frequently in professional practice. For example, the UK survey of 170 members of the BABCP by Townend et al. (2002) indicated that they took place in around 75% of supervision sessions. However, a survey of 232 clinical psychologists in the USA reported only a 17% figure. This marked difference may be because of different definitions of feedback/evaluation, or because the UK survey covered both types of evaluation, while the US survey considered only summative evaluation. Either way, it is safe to assume that evaluation represents a cornerstone of supervision (e.g. see Bernard & Goodyear, 2004; Falender & Shafranske, 2004). From here on, we use the term evaluation to refer solely to the summative aspect. See the ‘Methods’ guideline for more on feedback.

5. Principles of Evaluation: a) Coherence: Evaluation should be linked explicitly to the rest of the supervision cycle. That is, it should figure in the learning needs assessment; be stated as an objective (for supervisor and supervisee); and the learning methods used should relate to the relevant part of an evaluation (e.g. behavioural methods for behavioural objectives, such as the use of modelling, rehearsal and feedback for acquiring the skills of interviewing). b) Consistency: The criteria for evaluation need to be very clearly defined. They should conform to practices and procedures that are used within the relevant organisational system, as in using the standard evaluation forms for a supervisee on a given training course. These criteria should clarify what is to be evaluated, and how this will be accomplished. For example, Overholser and Fine (1990) defined their training as encompassing these areas of supervisee performance: Factual knowledge General clinical skills Specific technical skills Clinical judgement Interpersonal qualities If supervision is supposed to address such areas, then there should exist a standard form with which to evaluate them (like a competence checklist), and the supervisee should have a copy from the outset. There would normally be a parallel form, with which the supervisee evaluates the supervision (e.g. against a set of standards evolved by the training programme). c) Communication: A formal but constructive, consistent and generally professional approach should be adopted in relation to evaluation. According to Bernard and Goodyear (2004), evaluation is a ‘major problem’ (p.23) in the helping professions, as supervisors’ judgements are often intuitive and heavily influenced by the supervisee as a person. There is also the sense that evaluation is inconsistent with the typically non-judgemental approach that therapists take.

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An example of the kind of problem that can arise is that of collusion, where the parties conspire to avoid the business of evaluation, including ignoring expected practices, like mutual observation. This can lead to the situation where the supervisee has had no formal evaluation, even up to the halfway stage (often coinciding with the time when a tutor visits). Typically, they say that they assume that they are doing OK, because nothing has been said by the supervisor! This is poor practice, and should be replaced by positive ethical practices, ones that promote the supervisees capacity to do good. In order to minimise such problems, evaluation activities should encourage a dialogue between supervisor and supervisee (as well as the training programme representatives, such as tutors), conducted in a well-bounded space, designed to aid the supervisee’s development (Juwah et al., 2004). For instance, mutual engagement in evaluation should be seen in agreements about the next learning steps, or in special arrangements to cover poor progress. d) Measurement: Choose evaluation tools and procedures to suit their purpose, to foster variety, and to promote engagement. As in clinical work, there are many available evaluation tools and methods. Most commonly, these are locally

116 developed self-report instruments, such as rating scales or checklists. Tape recordings, direct observation (through sitting in, role-play, joint work, or live supervision), and written material (e.g. the supervisee’s case notes, letters, reports) are also popular. However, discussion of case work is probably the most widely used approach to gathering information for an evaluation. To give another common example of the kind of difficulty that can arise, supervisors who have concerns about a supervisee’s competence may be acting in an ethically positive way (e.g. trying to protect patients from harm), yet fail to ensure that their evaluation criteria have wide acceptance, or that their competence standards are properly benchmarked. This reliance on subjective and private criteria for an evaluation makes for problems, for the supervisee and for the tutor (or any other third party, such as an external examiner). Having a sample tape of the supervisee’s application of the relevant competencies can be a huge help in converting this stressful situation into a more neutral, professional one. Similarly, making reference to published criteria and accepted standards can lead to much greater confidence that the right judgement is being made. Another thought is to consider the timing of such reviews, with the onus being on tackling the issue at the earliest practicable moment. e) Supervisee involvement: As already noted, although the supervisee is usually the main focus for evaluation (being the one who can formally pass or fail), it should have a two-way element. The example form that is appended (HASQ) is an easy way to socialise the supervisee into the business of evaluation. But perhaps the key thing to encourage in the supervisee is self-evaluation (Bernard & Goodyear, 2004). This helps to develop autonomy, lifelong learning skills and short-term capability. It should motivate supervisees, raising their self-esteem. An example of how this can be done is by viewing a recording of the supervisee’s work jointly, but encouraging the supervisee to initiate any evaluation (e.g. regarding processes and results within the observed sample). f) Support and guidance: Finally, a strong and clear administrative system should underpin your evaluation work, in the wider context of the employer, the training organization, and professional guidelines/policy (e.g. the Code of Conduct and Professional Practice Guidelines within Clinical Psychology: British Psychological Society, 2000, 2001). When conducting summative evaluations, it is particularly important to draw on the expertise and objectivity of tutors, course leaders, or others whose job involves supporting supervisors. This relates to the ethical business of ‘due process’. 6. Good Practice Suggestions: How can supervisors adhere to these principles in evaluating their supervisees? Here are some suggestions: Observe: In addition to discussing the supervisee’s work, it is essential that supervisees and supervisors have opportunities to observe each other at work. The supervisee can learn much from this, and it is essential in order for the supervisor to give the supervisee a fair evaluation. Some supervisor/supervisee dyads may use joint clinical work of some kind; others may prefer audiotape, videotape or a one-way screen. The available facilities and respective theoretical orientations will influence the form that observation takes. The literature suggests that, where possible, observation should be

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systematic and objective (e.g. using data charts). This should then be followed with contingent feedback (BPS, 2003). An example: See the combined example that now follows. Measure: In evaluating their supervisees, supervisors tend to restrict themselves to the measures used within the relevant local training programme. These are of course necessary, but they may not be sufficient. There are at least two other options: published instruments specific to supervision; and those of general relevance, such as therapy outcome instruments. Although there are numerous supervision-specific instruments, they are generally of questionable quality (Ellis & Ladany, 1997). However, some serviceable examples can be found appended to the Bernard and Goodyear (2004) text, and in Falender and Shafranske (2004). These collections include measures of: general satisfaction with supervision; the working alliance; competence of supervisor and of supervisee; role conflict; and supervision outcomes.

118 As regards other general instruments, supervisors may wish to encourage their supervisees to assess aspects of their work (e.g. the therapeutic alliance) or their clinical outcomes (patient satisfaction; symptom change; coping profile; etc.). It is important that these are consistent with your approach. Such criteria provide an important external reference point: sometimes within supervision it is difficult to decide about the supervisee’s competence, but some data back from their work can greatly assist. For example, you may feel uncomfortable about the supervisee’s interpersonal style during supervision, but patient satisfaction data may persuade you to give the supervisee the benefit of the doubt (i.e. evidence of the supervisee’s competence and fitness for practice). Ideally, these contrasting impressions should be discussed, with the aim of drawing your impression to the supervisee’s attention (awareness-raising; feedback), and encouraging a dialogue (respective perceptions of interpersonal effectiveness; importance of adjusting styles to situations). An example: Jensen et al. (1998) observed and measured how well their supervisees (teaching assistants in the learning disabilities field) enacted a series of procedures, such as the use of verbal prompts, teaching steps, reinforcement and evaluation of their patients’ progress. They used a direct observation tool for this purpose, yielding a percentage correct performance profile for these supervisees. Seven of the eight supervisees became more proficient in these skills following supervision. Communication: Another contributor to the supervisee’s development is effective communication: being consistent, objective, referring to the agreed forms/criteria, minimising bias, being timely and specific, etc. (Lehrman-Westerman & Ladany, 2001). The supervisor should be empathic towards the supervisee's negative and positive emotional responses to any evaluation. With regard to the identification of incorrectly performed skills, this is often best managed when the supervisor first questions the supervisee, to elicit self-appraisals. Alternatively, the supervisor can verify that the supervisee understands and agrees with their own evaluation of their performance by asking them to describe what they would do next, as a result of the feedback. The supervisor should clarify any discrepancies, and agree a review date and method (BPS, 2003). An example: Gillam et al. (1990) analysed how four supervisees communicated with their patients, finding that their therapy work was dominated by ‘therapist talk’. The authors therefore introduced ‘supervisory conferences’, which included patient progress data (provided by the supervisee – an example of self-monitoring), supplemented by discussion, action-planning, and goal-setting (note the typical use of multiple methods of supervision). Multiple baseline data indicated that all four supervisees improved significantly in these communication skills, following this form of supervision.

7. Evidence Base: As per the material regarding the learning contract in the 'Developing the Supervision Contract' Guideline, the major texts consistently place a major emphasis on evaluation. For instance, Bernard and Goodyear (2004), like most authors, dedicate a chapter of their text to evaluation, concluding that it is both the most challenging and most

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important supervisory responsibility (p.48). Similarly, Falender and Shafranske (2004) refer to evaluation as ‘central’ (p.225) and list several competencies (including providing formative and summative feedback). However, the systematic review of Ellis and Ladany (1997) notes that, while some sound evaluations exist, there is a great need for better measures (p.485). They reach a similar conclusion regarding the evaluation of clinical outcomes in relation to the supervisee’s work. They recommend only two measures (inc. the Barrett–Lennard Relationship Inventory), listing several more that they would not recommend. The systematic review by Milne and James (2000) draws similar conclusions, adding a note on the need to apply multiple measures in a stepwise manner (i.e. evaluating each stage in the supervisory enterprise: reactions, learning and transfer). This is as opposed to basing evaluations of supervisees on their clinical outcomes (as they found in 79% of their 28 studies). However, evaluation was nonetheless a major element in these studies, indicating the important role that evaluation plays. Strength of evidence (provisional) for guideline: B

Box 1: Strength of evidence

120 The suggestions in this guideline are based on evidence. An attempt has been made to indicate the strength of this evidence. Gradings offered are provisional, and are based on the grading scheme of the National Institute for Clinical Excellence (NICE): A = ‘At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation… without extrapolation.’ B = ‘Well-conducted clinical studies but no randomised clinical trials on the topic of recommendation… or extrapolated from level-I (i.e. grade A) evidence.’ C = ‘Expert committee reports or opinions and/or clinical experiences of respected authorities… This grading indicates that directly applicable clinical studies of good quality are absent or not readily available.’

8. Implementation: This guideline is intended for qualified mental health practitioners, in their role as clinical supervisors. But it is recognised that the guideline is primarily written for clinical psychologists, from a broadly CBT perspective. This is because of the background of the authors, their own orientation, and the available evidence. Also, we recognise that the emphasis is mostly on the facilitation of learning (the ‘formative’ function of supervision). The reader should be aware of these biases, and should form a judgement about the best use of this guidance. The guideline should be used within the practitioners’ professional practice guidelines and management/supervisory arrangements. In this context, supervisors should consider the principles and practice suggestions made above, forming their own judgement about their appropriateness, in relation to their individual supervisees. This guideline should also be used in liaison with their local professional training programmes, in the case of trainees. In CPD supervision, practitioners are encouraged to refer to the relevant guidance on CPD within their profession. Additionally, scientific journals and professional texts can help to guide effective supervisory practice (e.g. see attached reference list). The guideline draws on the training and supervision literature, including four systematic reviews (Milne & James, 2000; Milne, 2007; Milne et al., 2007), conducted to support the present, closely related guidelines. All four guidelines were drafted by an experienced supervisor and a senior journalist-turned-trainee clinical psychologist, following the NICE(R) approach (Dunkerley et al., 2005). They were then shaped through discussion in a local guideline development group; improved by drawing on the views of a national group of experts; and made more feasible by building a consensus on the best approach with supervisors attending local CPD workshops. There is no charge for using this guideline, all costs having been met through a grant from The Higher Education Academy Psychology Network to Derek Milne in 2005. It can therefore be copied for use within supervisor training workshops. We do ask, however, that we are duly acknowledged.

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Comments, relevant research literature, and any other ideas that might improve this guideline are welcome. Derek Milne and Chris Dunkerley, Doctorate in Clinical Psychology, 4th Floor, Ridley Building, The University of Newcastle, England NE1 7RU. ([email protected]; [email protected]; 0191-2227925).

9. References: British Psychological Society. (2000). Code of conduct, ethical principles and guidelines. Leicester: BPS. British Psychological Society. (2001). Professional practice guidelines (DCP). Leicester: BPS. British Psychological Society. (2003). Policy guidelines on supervision in the practice of clinical psychology. Leicester: BPS.

122 Dunkerley, C., Milne, D. & Wharton, S. (2005). A NICE(R) systematic review of the clinical supervision literature. Annual conference of the European Association for Behavioural and Cognitive Psychotherapy, Manchester. Ellis, M.V. & Ladany, N. (1997). Inferences concerning supervisees and clients in clinical supervision: An integrative review. In C.E. Watkins (Ed.) Handbook of psychotherapy supervision. Chichester: Wiley. Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., et al. (2004). Defining competency competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771–785. Fleming, R.K., Oliver, J.R. & Bolton, D.M. (1996). Training supervisors to train staff: A case study in a human service organisation. Journal of Organisation Behaviour Management, 16, 3–25. Juwah, C., McFarlane-Dick, D., Mathew, B., Ross, D. & Smith, B. (2004). Enhancing student learning through effective formative feedback. York: Higher Education Academy. Lehrman-Waterman, D. & Ladany, N. (2001). Development and validation of the evaluation process within supervision inventory. Journal of Counseling Psychology, 48, 168–177. Milne, D., Dunkerly, C., Aylott, H., Wharton, S. & Fitzpatrick, H. (2007). Systematic reviews of clinical supervision: j) An empirical definition (in press: British Journal of Clinical Psychology); k) Models; & l) Methods and outcomes. All in preparation, available from Derek Milne at address on page 4. Milne, D. & James, I.A. (2000). A systematic review of effective cognitive- behavioural supervision. British Journal of Clinical Psychology, 39, 111–127. Watkins, C.E. (Ed.) (1997). Handbook of psychotherapy supervision. Chichester: Wiley.

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Appendix 13: Session 5: Handout 3: Learning exercise Session 5 – ‘Evaluation’ Guide to the learning exercise for participants 1. Introduction Aims: This session enables you to be effective in providing both supportive and challenging feedback in supervision; and to be aware of pass and fail processes. Learning Outcomes: 10. Have an understanding of the process of assessment and failure, and skills and experience in evaluating trainees (process and outcome evaluation).

124 11. Have skills and experience in the art of constructive criticism, providing ongoing positive feedback and negative feedback where necessary (create a climate of honest feedback, supporting and challenging). 12. Have knowledge of the various methods to gain information and give feedback. For example, self-report; video tapes; colleague and client reports (use different modalities). 17. Have knowledge of techniques and processes to evaluate supervision, including eliciting feedback (encourage and use feedback from the trainee).

2. Learning Exercise Watch the workshop leaders’ demonstration of this exercise. In an abbreviated way, s/he will try to work with a role-played supervisee to illustrate the aims/this exercise. Based on that demonstration, work in pairs to: a. Agree a suitable focus for an imaginary preparation for a mid-point ‘three-way’ meeting with a clinical tutor. b. Either draw on the illustrative and fictitious ‘case study’ material (see slideshow/handout, headed 'Newcastle Supervisor's Feedback Form (example)’, OR draw on your own relevant material. c. Try to provide both supportive and challenging feedback. d. Role reversal – swap round roles. e. Seek feedback from your ‘supervisee’. What worked well? What might be done more effectively? How? f. To enhance your feedback, please now complete the paper and pencil assessment below, together with your supervisee, focusing on one of your turns (role-plays): Instructions: Please reflect jointly on the role-play you’ve just completed and assess it with these items, using the following rating scale:

Not Moderatel Very at y much all so

1 The supervisor helped the supervisee to 1 2 3 4 5 6 7 identify areas where he/she needs to continue to develop, by identifying strengths and weaknesses.

2 The supervisor’s feedback encouraged the 1 2 3 4 5 6 7 supervisee to keep trying to improve.

3 Supervision helped the supervisee to see 1 2 3 4 5 6 7 mistakes as learning experiences.

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4 The supervisor welcomed comments about 1 2 3 4 5 6 7 his or her style as a supervisor.

5 The appraisal from the supervisor was 1 2 3 4 5 6 7 impartial.

6 The supervisor’s comments about the work 1 2 3 4 5 6 7 were understandable.

7 The supervisor balanced his or her feedback 1 2 3 4 5 6 7 between positive and negative statements.

8 The feedback from the supervisor was based 1 2 3 4 5 6 7 on his or her direct observation of supervisees work.

9 The feedback was directly related to the 1 2 3 4 5 6 7

126 goals established.

Note: These feedback items are drawn from the ‘Evaluation Process within Supervision Inventory’ (Lehrman-Waterman & Ladany, 2001), and the ‘Supervision Outcomes Survey’ (Worthen & Isakson, 2000). g. Agree a suitable focus for an imaginary preparation for a mid- point ‘three-way’ meeting with a clinical tutor: Item: 11. ‘my supervisor’s criteria for evaluating my work were not specific’ 14. ‘I got mixed signals from my supervisor and I was unsure of which signals to attend to’ 18. ‘the feedback I got from my supervisor did not help me to know what was expected of me (in my work)’ 23. ‘my supervisor gave me no feedback and I felt lost’ 27. ‘the supervisor gave no constructive or negative feedback and as a result I did not know how to address my weaknesses’. h. Final step – feedback/discussion within the large workshop group.

3. References: Lehrman-Waterman, D. & Ladany, N. (2001). Development and validation of the evaluation process within supervision inventory. Journal of Counseling Psychology, 48, 168–177. Olk, M. & Friedlander, M.L. (1992). Trainees experiences of role conflict and role ambiguity in supervisory relationships. Journal of Counseling Psychology, 39, 389– 397. Worthen, V.E. & Isakson, R.L. (2000). Unpublished scale, reproduced in appendix J of Falender, C.A. & Shafranske, E.P. (2004). Clinical supervision: A competency-based approach. Washington, DC: APA.

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Session 6: ‘The Supervision System’

Learning outcomes:

Main ones: Participants: are able to summarise how placements are structured (inc. assessment forms and procedures; visits by tutors); to list three expectations of the supervisor’s role (7); and to state three ways that ongoing supervisor’s development is organised (16). Related ones: Participants: are aware of relevant context (1); can specify roles and accountability (2); can list three factors affecting supervisory relationship (5); know main evaluation processes (10); recognise ethical practice (14); demonstrate appropriate attitudes and value base (e.g. DROSS attitudes list, No 8 – lifelong learning principle supported), and ‘capability’ (using one’s

128 understanding of supervision and psychology to address problems requiring improvised solutions). Programme: 1. Introduction: ‘six honest serving men’ slideshow; Q&A 2. Illustration: ethical practice video (a: Leeds Doctorate: 3-way meeting; b) lifelong learning: Chris’s reflections on supervision) 3. Demonstration: show how you would lead a placement review meeting 4. Discussion 5. Workshop Evaluation: HAWQ

1. Introduction: Show slideshow (note – the provided one was designed for the Newcastle University Doctorate in Clinical Psychology course, Appendix 13, p.96: you should adapt this as necessary/replace this with your local material). Q&A (‘critical incidents’ might be used to prompt clarification of this material – e.g. recent issues around forms/procedures, etc). The aim is to ensure that participants can locate their role as a supervisor within the organisational context. Good questions to check this include: ‘Who is clinically responsible for the supervisee’s work?’; and (reference to the preceding session) ‘What procedure would you follow in the case of considering a “fail” grade? Such questions, general discussion, and possibly a fictitious ‘case study’ (such as the one depicted in the Leeds University video on ethical practice – see below) should be used to ensure that supervisors understand how they are supported and linked to the training system. 2. Illustration: Show the Leeds University video ‘Ethical Issues in Clinical Supervision’. Prime the group by indicating that you’ll be seeking comments on the appropriateness of the procedure used in the video (or similar, as appropriate to the needs of the participants, at this stage). 3. Demonstration: Try to model how you would prefer to address a group-selected aspect of the video material (or similar – e.g. a local issue, such as how you would discuss a provisional borderline ‘fail’ recommendation from a supervisor). 4. Discussion:  Q&A.  Summary of your supervision (esp. future learning/system support events).  Pull together whole workshop, perhaps by referring back to the workshop aims?  Commence workshop evaluation by inviting comments on how well these aims were satisfied.

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 Administer the ‘Helpful Aspects of Workshop Questionnaire’ (HAWQ: Appendix 14, p.101), the more thorough ‘Training Acceptability Rating Scale – TARS’ – Appendix 15, p.102), or your preferred alternative.  Inform the group about how their feedback will be used, and thank them for participating. End of session 6 Evaluation:  Ask participants to complete HAWQ, TARS, or similar. END OF WORKSHOP

130 Appendix 14: Session 6: Handout 1: The ppt

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Appendix 15: Session 6: Helpful Aspects of workshop questionnaire (HAWQ)

WORKSHOP FEEDBACK FORM, OPTION 1

HELPFUL ASPECTS OF WORKSHOP QUESTIONNAIRE (H.A.W.Q.) Your Name (optional): ______Date of workshop:…………………… 1 Please rate how helpful this workshop was, overall: Very unhelpful Fairly unhelpful Neither helpful nor unhelpful Fairly helpful Very helpful 1 2 3 4 5 132 2 Of the events which occurred in this workshop, which one do you feel was the most helpful for you, personally? It might be something you said or did, or something the facilitators said or did. Can you say why it was helpful? 3 How helpful was this particular event? Rate this on the scale; Neither helpful nor unhelpful Fairly helpful Very helpful 3 4 5 4 Did anything else of particular importance happen during this workshop? Include anything else which may have been helpful, or anything which might have been unhelpful.

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Appendix 16: Session 6: Workshop evaluation, option 2: Training Acceptability Rating Scale (TARS)

TRAINING ACCEPTABILITY RATING SCALE (TARS)

Training Course:……………………………………………………………………….. Date:……………………………………………………………………………………. Instructions: please rate your agreement with the following statements on this scale: 1 = strongly disagree 2 = moderately disagree 3 = slightly disagree 4 = slightly agree 5 = moderately agree 6 = strongly agree

134 The first set of six statements concerns the content of the ‘introduction to supervision’ workshop that you have just completed.

CIRCLE YOUR LEVEL OF AGREEMENT

1 General acceptability: this approach to supervision would be 1 2 3 4 5 6 appropriate for a variety of staff

2 Effectiveness: this approach will be beneficial for supervisees 1 2 3 4 5 6

3 Negative side-effects: this approach will result in disruption or 6 5 4 3 2 1 harm to clients

4 Appropriateness: most supervisees would not accept that 6 5 4 3 2 1 this approach to supervision provided an appropriate basis for client care

5 Consistency: the workshop was consistent with common 1 2 3 4 5 6 sense and good practice in helping supervisees to work effectively

6 Social validity: in an overall, general sense, most supervisees 1 2 3 4 5 6 would approve of training in this method (e.g. would recommend it to others)

The next 12 questions focus on your impressions of the teaching process and outcomes (i.e. how competently you think the training was conducted and whether it was helpful or not. For each question please circle the statement that best expresses your opinion. PLEASE CIRCLE ONE ANSWER:

7 Did the workshop improve your understanding?

Not at all A little Quite a lot A great deal

8 Did the workshop help you to develop work-related skills?

9 Has the workshop made you more confident?

10 Do you expect to make use of what you learnt in the workshop in your workplace?

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11 How competent were the workshop leaders?

12 In an overall, general sense, how satisfied are you with the workshop?

13 Did the workshop cover the topics it set out to cover?

14 Did the workshop leaders relate to the group effectively? (e.g. made you feel comfortable and understood)

136 Not at all A little Quite a lot A great deal

15 Were the leaders motivating? (e.g. energetic, attentive and creative)

16 What was the most helpful part of the workshop for you personally?

…………………………………………………………………………………….. …………………………………………………………………………………….. ……………………………………………………………………………………..

17 What change, if any, would you recommend? (e.g. to the content or teaching)?

…………………………………………………………………………………….. …………………………………………………………………………………….. ……………………………………………………………………………………..

18 Please make any other comments that you would like to offer.

…………………………………………………………………………………….. …………………………………………………………………………………….. ……………………………………………………………………………………..

End of manual Derek Milne, 6 June 2007

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Acknowledgements:

This manual has its own historical platform. The ancestry of my own involvement included formative early experiences with inspiring supervisors and managers, leaders who saw more to clinical psychology than the provision of therapy. In Leicester (where I trained, and undertook a part-time MSc & then a PhD on staff development), I was supported primarily by Charles 4Burdett and Keith Turner. I then wrote up the PhD in a new post in Wakefield (supported by Iain Burnside). Links with the local clinical psychology training courses allowed me to be influenced by Tony Carr and Stephen Morley, respectively. They and many others helped me to take training and supervision seriously, within a scientist-practitioner approach. I started out as a supervisor myself in 1983, travelling to London to undertake a supervisors’ workshop then taking trainees from the Leeds University Masters course in clinical psychology. This led into some part-time clinical tutoring for the course, which was my main introduction to the material and issues addressed within this manual.

138 In 1986 I took up my first proper supervisor development job, as Senior Clinical Tutor to the Newcastle clinical psychology course. My interest in the topic inevitably grew, thanks largely to the numerous, highly motivated local supervisors (within supervision workshops, but also when I visited them on placement). These visits were also a regular source of inspiration, as they provided a privileged view of how supervision could be practised, and of the clear benefits that accrued to the trainees. At supervisors’ workshops we challenged the current orthodoxy, debated developments (we were probably the first UK clinical psychology course to introduce a formal competence model), and evolved ways of grasping supervision. For example, John Bell, a participant at one of these events, is credited with ‘Bell’s mountain’, providing me with my first significant grasp of the developmental model of supervision. Thanks to them all for such inspiration and guidance.

The contents for this present phase of personal development included another inspirational manager (Roger Paxton), a facilitating Course Director (Peter Britton), several clinical tutor colleagues (including Lesley Clarke, Paula Heath, John Ormrod and Alison Robertson), and a priceless network of colleagues nationally. I particularly want to thank Dave Green, Ian Fleming, Jan Hughes and the DROSS-ers (Development and Recognition of Supervisory Skills project, based at Leeds University) for providing me with a sense of teamwork over aspects of this manual (e.g. as noted above, the objectives for the workshop are largely a DROSS product).

During these productive Newcastle years I have engaged in a range of pragmatic and more explanatory research projects (see the annotated bibliography, linked to my home page: http://www.ncl.ac.uk/nnp/staff/profile/d.l.milne). I am especially indebted to Ian A. James for his collaboration on several of these initial projects. Caroline Leck has continued this tradition, helping me to develop the approach set out within this manual. Many others have also contributed significantly, as can be seen from the authorship of these papers, and from the acknowledgements therein. A related example is the Guideline Development Group, which is acknowledged within the four guidelines (appended). This guideline work was made possible primarily by Chris Dunkerley, John Ormrod and Helen Aylott. More specific input to this manual was gratefully received from: Christina Blackwell (feedback on a drafted section on diversity); Steve Bradwell and his colleagues at the Newcastle University TV Studio (video clips); the supervisors and supervisees who were good enough to carry on their routine supervision in front of the cameras (with the exception of Chris Baker, who improvised with assistants Helen Aylott and Bryony MacGregor, plus trainees Petra Carlsson-Mitchell and Tom Christodoulides). They are acknowledged individually at the end of the video clips. Others helped me to produce additional recordings, which were not ultimately used within this draft of the manual. The PowerPoint slideshows were designed by Judy Preece (graphic artist at Newcastle University) and prepared by Nasim Choudhri (assistant psychologist). General secretarial support was provided by Karen Clark, Kathryn Mark and Barbara Mellors, led by our Doctorate course’s Administrator, Lynn Armstrong. A big ‘thank-you’ to them all, for making this manual possible. This guide was prepared with the help of a grant from the Higher Education Academy Psychology Network to Derek Milne.

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References

Bernard, J.M. & Goodyear, R.A. (2004). Fundamentals of clinical supervision. London: Pearson. Bouchard, M.A., Wright, J., Mathieu, M., Laloude, F., Bergeron, G. & Tompin, J. (1980). Structured learning in teaching therapists social skills: Training, maintenance and impact on client outcome. Journal of Consulting and Clinical Psychology, 48, 491–502. 5Bransford, J.D., Brown, A.L. & Cocking, R.R. (2000). How people learn: Brain, mind, experience and school. Washington, DC: National Academy Press. Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., et al. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771–785. Falender, C.A. & Shafranske, E.P. (2004). Clinical supervision: A competency-based approach. Washington, DC: APA. Goldstein, I.L. (1993). Training in organisations: Needs assessment, development, and evaluation. Pacific Grove, CA: Brooks Cole. Kaslow, N.J., Borden, K.A., Collins, F.L., et al. (2004). Competencies conference: Future directions in education and credentialing in professional psychology. Journal of Clinical Psychology, 60, 699–712.

140 Kolb, D.A. (1984) Experiential learning: Experience is the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall. Komaki, J.L. (1986). Toward effective supervision: An operant analysis and comparison of managers at work. Journal of Applied Psychology, 71, 270–279. Milne, D.L. (1986). Training behaviour therapist: Methods, evaluation and implementation with parents, nurses and teachers. London: Croom-Helm. Milne, D.L. (2006). Developing clinical supervision research through reasoned analogies with therapy. Clinical Psychology and Psychotherapy, 13, 215–222. Milne, D.L. & James, I. (2000). A systematic review of effective cognitive behavioural supervision. British Journal of Clinical Psychology, 39, 111–127. Milne, D.L., Keegan, D., Westerman, C. & Dudley, M. (2000). Systematic process and outcome evaluation of brief staff training in psychosocial interventions for severe mental illness. Journal of Behaviour Therapy and Experimental Psychiatry, 31, 87–101. Milne, D.L. & Noone, S. (1996). Teaching and training for non-teachers. Leicester: British Psychological Society. Moseley, D., Baumfield, V., Elliott, J., Gregson, M., Higgins, S., Miller, J., et al. (2005). Frameworks for thinking. Cambridge: Cambridge University Press. Norcross, J. (Ed.) (2002). Psychotherapy relationships that work. Oxford: Oxford University Press. Vygotsky, L.S. (1978). The mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press. Watkins, C.E. (Ed.) (1997). Handbook of psychotherapy supervision. Chichester: Wiley.

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Appendices

6Appendix No. Title 1 DROSS Learning Objectives (revised) 2 Session 1 (‘Orientation’), handout 1: the PowerPoint slide show (ppt) 3 Session 1, handout 2: ‘Orientation to clinical supervision’ 4 Catalogue of video clips 5 Session 2 (‘Goal-setting’), handout 1: the ppt

142 6 Session 2: handout 2: the guideline (‘Needs assessment & the learning contract’) 7 Session 3: handout 1: the ppt 8 Session 3: handout 2: ‘Methods of facilitating learning’ (Guideline) 9 Session 4: handout 1: the ppt 10 Session 4: handout 2: Guidelines on ‘Enhancing the supervisory relationship’ 11 Session 5: handout 1: the ppt 12 Session 5: handout 2: the ‘evaluation’ guideline 13 Session 5: handout 3: Learning exercise 14 Session 6: handout 1, the ppt 15 Session 6: Helpful Aspects of Workshop Questionnaire (HAWQ) 16 Session 6: Training Acceptability Rating Scale (TARS)