What good supervision is…and what it isn’t
“I have found the supervision invaluable. I have found it helpful to work through cases in which I feel I have become a bit stuck or where I have not been sure which route to take. The supervision has also helped with increasing my confidence in my approach and with following my intuition. I have found it helpful how you talk about your own mistakes, or when things haven’t gone according to plan, as this helps me with feeling able to accept my own mistakes and to not put too much pressure on myself to have to get it ‘right’ all the time. I also value the examples that you share of your own experience when your approach has worked well and when you are able to tell me when you don’t know the answer (which is quite reassuring).”
I started in my first column by talking about the importance of giving feedback to your supervisor. The above is a supervisee’s feedback on the EMDR supervision that they had received but also serves as an introduction to what, I believe, clinical supervision should be about.
Before I proceed any further with this second column, I really need to be clear what we mean by “supervision” and, in particular, what it is and what it isn’t. Let’s start with a concise definition which was developed by Derek Milne after extensive research in this area:
‘Form’ of Supervision:
‘The formal provision by senior/qualified health practitioners of an intensive relationship-based education and training that is case-focused and which supports, directs and guides the work of colleagues (supervisees).’
‘Functions’ of Supervision:
- quality control
- maintaining and facilitating the supervisees’ competence and capability; and
- helping supervisees to work effectively.
(Milne, 2007, p. 440)
To put some flesh on these bones and get a clearer feel of what this means, let us turn to Joyce Scaife (2019) who suggests a list of “aspirations” for what clinical supervision should be, adapted from the characteristics of clinical supervision described by Cutcliffe and Lowe (2005):
- is supportive
- takes place in the context of a facilitative relationship
- is centred on developing best practices for service users
- is challenging
- is brave (because practitioners are encouraged to talk about the realities of their practice)
- is safe (because of clear, negotiated agreements by all parties with regard to the extent and limits of confidentiality)
- provides an opportunity to ventilate emotions without comeback
- is not to be confused or amalgamated with managerial supervision
- provides the opportunity to deal with material and issues that practitioners may have been carrying for many years (the chance to talk about issues which cannot easily be talked about elsewhere and which may have been previously unexplored)
- is not to be confused or amalgamated with personal therapy or counselling
- offers a chance to talk about difficult areas of work in an environment where the other person attempts to understand
- is regular
- takes place in protected time
- is offered equally to all practitioners
- involves a committed relationship from both parties
- is an invitation to be self-monitoring
- can be both hard work and enjoyable
- is concerned with learning to be reflective and with becoming a reflective practitioner
- is an activity that continues throughout one’s healthcare career
(Scaife, 2019, pp. 31-32)
I guess some of you will have been mentally checking how many of these apply to the supervision you receive and/or deliver. Let’s hope that most of the boxes have been ticked!
So, now that we have an idea of what supervision is, let’s look at what supervision isn’t:
Supervision isn’t training. Training to be an EMDR Practitioner involves an element of supervision and, as trainees, you will have started receiving supervision as soon as you completed the Part 1 EMDR training. However, “training” and “supervision” are quite distinct activities. Training is “structured education for groups of trainees… [and] involves a standardized set of steps” (Hill & Knox, 2013, p. 776). This is elaborated upon by Bernard and Goodyear (2019) who state that, “whereas teaching is driven by a set curriculum or protocols, supervision is driven by the needs of the particular supervisee and his or her clients” (p. 10). In EMDR supervision you will often be receiving some teaching, perhaps on a specific aspect of the Standard Protocol which was covered at your training. But, in this case, the teaching will be tailored to your needs as an individual supervisee. This teaching is ideally designed to be specific to your learning style and pre-existing knowledge.
Supervision isn’t therapy. There are, of course, many similarities between supervision and therapy. For example, they both involve a confidential relationship, are built on support and mutual trust to offer the safety to explore, challenge and make new connections within agreed boundaries of time, place, regularity and payment. So, let us be clear about the ways in which supervision differs from therapy. “In supervision, it is the therapy that is the ‘patient’ and the supervisee’s feelings and fantasies are examined only insofar as they may throw light on what is happening in the therapy.” (Mollon, 1989, p. 121). Page and Wosket (2013) differentiate supervision and therapy under the following headings:
- Aims: Therapy is to improve the client’s life. Supervision is to develop the supervisee’s skills as a therapist.
- Presentation: Client presents information verbally. Supervisee presents through a variety of media.
- Timing: Client may choose the pace. Supervisee focuses on what needs to be covered to work effectively with their clients.
- Relationship: The client is held emotionally and can regress and act out emotions. The supervisory relationship is professional and collaborative.
- Expectations: Client is not expected to prepare for the session. Supervisee is expected to come prepared and with necessary materials.
- Responsibilities: Therapist’s responsibility is to the client. The supervisor’s responsibility to the client can take precedence over their responsibility to their supervisee.
There is another important difference between therapy and supervision that is not included in Page and Wosket’s list. Beinart (2004) points out that supervision is primarily an educative process which involves evaluation of the supervisee.
And finally, “what is the actual point of having supervision?” Aha! Well, this is a tricky question to answer. There are three questions to consider:
- Does supervision increase treatment fidelity?
- Does supervision affect therapeutic outcomes for the client?
- What other benefits might supervision have?
Does supervision increase treatment fidelity?
One published study specifically examines the extent to which clinical supervision can directly increase treatment fidelity with an evidence-based therapy. Bearman, Schneiderman, and Zoloth (2017) looked at the effectiveness of clinical supervision upon clinicians trained in CBT: “Specifically, those who received supervision that included skill modeling, role-play, and corrective feedback based on session review showed a pattern of incremental improvement … on cognitive restructuring fidelity, CBT expertise, and global CBT competence. These participants were rated as proficient or near proficient on all three outcomes by the final assessment.” (Bearman et al., 2017, p. 12). In contrast, the participants whose supervision did not include these specific components did not improve following the assessment immediately post-training. Other studies have also supported these findings (Martino et al., 2016; Webster-Stratton, Reid, & Marsenich, 2014).
To what extent does EMDR supervision increase the skills of the EMDR therapist and enhance their adherence to the Standard Protocol? To date, there is no specific research to answer this. However, the experience of those trained in EMDR is that supervision is necessary in order for them to continue to use EMDR beyond their basic training (Dodaj & Dodaj, 2021). In an American study, EMDR therapists regarded ongoing supervision as the most important factor for the continued use of EMDR with 40 percent of respondents ranking its importance high on their lists (Grimmett & Galvin, 2015). I wish to add my own anecdotal evidence from my work as a trainer: Those individuals who have attended my Part 1 training and have been unable to access EMDR supervision, for whatever reason, are unlikely to have actually started using EMDR with their clients. It is therefore likely that trainees will simply not use EMDR after they have been trained if they have not received specific supervision in EMDR.
Does supervision affect therapeutic outcomes for clients?
Thinking specifically about EMDR therapy, we have a clear protocol and there is evidence that sticking to the protocol achieves better therapeutic outcomes. Farrell and Keenan (2013) found that EMDR therapists who had achieved accreditation were generally reporting better outcomes from EMDR therapy than those who had not been accredited. This offers some evidence that EMDR supervision may improve treatment outcomes. This is confirmed by Maxfield and Hyer (2002) whose study found a correlation between treatment fidelity and clinical outcomes with EMDR.
But supervision’s impact on actual client outcome is not so clear. “Scholarly opinion —based upon the supposed weight of empirical evidence – is that supervision contributes to supervisee competence development and skill transfer, but any impact on client outcome has yet to be proven” (Watkins Jr, 2020, p. 14). These were broadly the same conclusions of a review by Tugendrajch et al. (2021) who concluded that supervision enhances therapist self-efficacy, therapist competence, and therapist alliance with their clients but there is no clear effect on actual client therapeutic outcomes.
What other benefits might supervision have?
In a review of studies, Watkins Jr (2020) concluded that supervision is positively associated with job satisfaction, job retention and the ability to manage workload. It is seen as helpful by supervisees and may even benefit their therapeutic competence. One study has shown that supervision reduces burnout and stress (Wallbank, 2013) whilst another showed its value in improving staff well-being and productivity (Hyrkäs, Lehti, & Paunonen‐Ilmonen, 2001).
So, in conclusion, whilst we cannot yet prove that clinical supervision improves client outcomes, it does help us to stick to the Standard Protocol and it does improve our wellbeing as therapists. But most important, however, is the likelihood that clinical supervision increases the prospect that therapists will continue to actually use EMDR after they have been trained. This must be one of the most compelling rationales for EMDR therapists receiving regular supervision.
Bearman, S. K., Schneiderman, R. L., & Zoloth, E. (2017). Building an evidence base for effective supervision practices: An analogue experiment of supervision to increase EBT fidelity. Administration and Policy in Mental Health and Mental Health Services Research, 44(2), 293-307.
Beinart, H. (2004). Models of supervision and the supervisory relationship. In I. Fleming & L. Steen (Eds.), Supervision and clinical psychology (pp. 47-62). Hove, East Sussex: Routledge.
Bernard, J. M., & Goodyear, R. K. (2019). Fundimentals of clinical supervision (6th ed.). New York, NY: Pearson.
Cutcliffe, J. R., & Lowe, L. (2005). A comparison of North American and European conceptualizations of clinical supervision. Issues in mental health nursing, 26(5), 475-488.
Dodaj, A., & Dodaj, A. (2021). Experience of an EMDR Practitioner in EMDR Education: Case Report. Psychiatria Danubina, 33(Suppl 1), 100-102.
Farrell, D., & Keenan, P. (2013). Participants’ experiences of EMDR training in the United Kingdom and Ireland. Journal of EMDR Practice and Research, 7(1), 2-16.
Grimmett, J., & Galvin, M. (2015). Clinician Experiences With EMDR: Factors Influencing Continued Use. Journal of EMDR Practice and Research, 9(1), 3-16.
Hill, C., & Knox, S. (2013). Training and supervision in psychotherapy. In M. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change, 6th ed (pp. 775-811). New York: Wiley.
Hyrkäs, K., Lehti, K., & Paunonen‐Ilmonen, M. (2001). Cost–benefit analysis of team supervision: the development of an innovative model and its application as a case study in one Finnish university hospital. Journal of nursing management, 9(5), 259-268.
Martino, S., Paris Jr, M., Añez, L., Nich, C., Canning-Ball, M., Hunkele, K., . . . Carroll, K. M. (2016). The effectiveness and cost of clinical supervision for motivational interviewing: a randomized controlled trial. Journal of Substance Abuse Treatment, 68, 11-23.
Maxfield, L., & Hyer, L. (2002). The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD. Journal of Clinical Psychology, 58(1), 23-41.
Milne, D. (2007). An empirical definition of clinical supervision. British Journal of Clinical Psychology, 46(4), 437-447.
Mollon, P. (1989). Anxiety, supervision and a space for thinking: Some narcissistic perils for clinical psychologists in learning psychotherapy. British Journal of Medical Psychology, 62(2), 113-122.
Page, S., & Wosket, V. (2013). Supervising the counsellor: A cyclical model: Routledge.
Scaife, J. (2019). Supervision in clinical practice: a practitioner’s guide (3rd ed.). Milton Park, Abingdon, Oxon: Routledge.
Tugendrajch, S. K., Sheerin, K. M., Andrews, J. H., Reimers, R., Marriott, B. R., Cho, E., & Hawley, K. M. (2021). What is the evidence for supervision best practices? The Clinical Supervisor, 40(1), 68-87.
Wallbank, S. (2013). Maintaining professional resilience through group restorative supervision. Community Practitioner, 86(8), 26-28.
Watkins Jr, C. E. (2020). What do clinical supervision research reviews tell us? Surveying the last 25 years. Counselling and Psychotherapy Research, 20(2), 190-208.
Webster-Stratton, C. H., Reid, M. J., & Marsenich, L. (2014). Improving therapist fidelity during implementation of evidence-based practices: Incredible years program. Psychiatric Services, 65(6), 789-795.