Introduction
Clinical supervision can be seen as playing a key role in the quality control of psychotherapies (Watkins & Milne, Reference Watkins and Milne2014). In relation to cognitive behaviour therapy (CBT) supervision is core to the delivery of training and is required as part of accreditation as a CBT therapist in the UK (BABCP, 2012). However, knowledge of what constitutes ‘optimal’ CBT supervision and the competences and skills needed to supervise effectively is limited. Relative to other areas of CBT, supervision remains a theoretically and empirically neglected domain of professional activity. As a result, there is a dearth of substantive guidance on how supervisors can best approach the task of developing their proficiency and as Milne & Reiser (Reference Milne and Reiser2016) comment in their introduction to this Special Issue, ‘we await a scientifically informed consensus on many of the core aspects of best practice’.
The apparent neglect of supervision in the literature is not just an issue for CBT. Reviewing the supervision literature more broadly, Bernard & Goodyear (Reference Bernard and Goodyear2014) note that far less attention has been paid to the development of supervisors than has been devoted to those receiving it. This is problematic for supervisors seeking to organize their professional development to best advantage, as well as for those responsible for commissioning and organizing the delivery of supervision. Moreover, in a professional climate that privileges empirically supported interventions this state of affairs is unsustainable (Milne & James, Reference Milne and James2002).
CBT supervision in the current climate
Definitions of quality and effectiveness cannot be considered in isolation from the professional contexts in which CBT supervision is provided. Training therapists to deliver competent CBT is a more complex undertaking than it was in the late 1970s when the approach emerged as a treatment for a limited number of disorders (Padesky, Reference Padesky and Salkovskis1996). Supervisors today need to ensure that they are well-versed in the theoretical and technical requirements of a range of disorder-specific treatment protocols, know how to guide their supervisees in constructing individually tailored intervention plans for diverse and atypical clinical presentations and remain informed about emerging theories, models, techniques and research in what is a rapidly expanding field. They also have a role to play in preparing junior members of the profession for the realities of delivering CBT in a target-driven climate where competitive tendering and ‘payment by results’ have become a reality (Department of Health, 2011). The latter in particular has shaped the style and delivery of CBT supervision into one that Milne terms ‘exceptional efficiency’ (Reference Milne2009, p. 107).
The need for greater ‘efficiency’ in the delivery of supervision, as well as improved understanding of how best to facilitate the development of CBT competences, has become particularly evident since the introduction of the UK Government's Improving Access to Psychological Therapies (IAPT; Department of Health, 2008). Aimed initially at enabling Primary Care Trusts to implement National Institute for Health and Clinical Excellence (NICE) guidelines for individuals suffering from depression and anxiety disorders, and more recently extended to incorporate the delivery of empirically supported psychological therapies for children and young people, older people, and those with long-term physical or mental health conditions (Department of Health, 2011), supervision has remained central in quality assuring what is essentially a new and emerging workforce.
In a climate where professional credibility has become increasingly associated with an ability to justify one's practice and decision-making, supervision has increasingly become a ‘whole career’ activity. This gives rise to questions concerning how CBT supervisors are best trained to provide supervision over the career lifespan. Moreover, the field of CBT now comprises a highly diverse group of practitioners. While some individuals become CBT therapists having first completed a core professional training in a related field such as psychology, nursing or psychiatry, others carve out alternative routes to professional status through demonstrating equivalence of knowledge, skills and attitudes (see for example the Knowledge, Skills & Attitudes route recognized by the British Association for Behavioural & Cognitive Psychotherapies; BABCP, 2013). One consequence of this is that supervisors are likely to find themselves working with professionals who are still consolidating their core clinical competences alongside experienced professionals who are seeking to hone their capabilities at a more advanced level. Different professional groups will require different supervisory skills.
In summary, for reasons that reflect both the expansion of CBT and the political and economic climate in which psychological interventions are now delivered, providing consistently high-quality CBT supervision is a challenge. In the absence of substantive guidance how, then, can supervisor development be usefully approached? In response to this question, Corrie & Lane (Reference Corrie and Lane2015) propose that there is benefit in differentiating (1) what is to be developed (that is, any specific competences and skills that are widely held as necessary for, or evidentially linked to, improved therapist proficiency) and (2) how it is to be developed (deciding how to enhance proficiency based on the supervisor's own career stage and their baseline level of supervisory skill). The ‘what’ and the ‘how’ are considered next.
What do CBT supervisors need to develop?
In their thorough review of the supervision literature, Bernard & Goodyear (Reference Bernard and Goodyear2014) propose that supervisory skill comprises two core domains: (1) knowledge of what the supervisee is learning to master (that is, subject-matter expertise) and (2) the ability to deliver supervision itself. Awareness of these domains provides supervisors with a broad framework for undertaking self-appraisal of practice. For example, if wishing to review their current level of subject-matter expertise, CBT supervisors might revise the established disorder-specific treatment protocols, undertake a refresher course in specific areas and evaluate their own clinical practice through seeking feedback on an established measure of competence such as the Cognitive Therapy Scale – Revised (CTS-R; Blackburn et al. Reference Blackburn, James, Milne, Baker, Standart, Garland and Reichelt2001). By contrast, honing the ability to deliver supervision effectively might lead to accessing the CBT supervision literature in order to identify core principles that inform the approach (see Padesky, Reference Padesky and Salkovskis1996; Gordon, Reference Gordon2012, for some useful, practical guidance), formal training (opportunities for which have developed considerably in recent years; see Watkins & Wang, Reference Watkins, Wang, Watkins and Milne2014) and organizing ‘supervision of supervision’ through direct observation and peer review. An additional important area to consider is the role of the supervisee as a source of development to the supervisor. To the extent that it is made possible for supervisees to provide feedback on the quality of the supervision they receive development of supervision competence is potentially enhanced (Corrie & Lane, Reference Corrie and Lane2015).
Examining the skills necessary to deliver supervision effectively, Hawkins & Smith (Reference Hawkins and Smith2006) have differentiated competences (the ability to deliver a specific intervention with technical proficiency); capabilities (knowing when and how to apply the intervention) and capacity (how the supervisor conveys that they are ‘present’ to their supervisees). Along similar lines, Falender et al. (Reference Falender, Cornish, Goodyear, Hatcher, Kaslow, Leventhal, Shafranske, Sigmon, Stoltenberg and Grus2004) have identified four distinct domains of supervisor skill:
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(1) Knowledge (e.g. of the theoretical and conceptual foundations of disorder-specific models and models of therapist development).
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(2) Skills (e.g. to assess the supervisee's baseline level of knowledge and skill; to teach specific competences and to deliver formative and summative evaluations of therapist performance effectively).
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(3) Values (being a respectful and empowering presence; behaving ethically).
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(4) Context (understanding the needs and expectations of the organization in which supervision is taking place, as well and the needs and expectations of other stakeholders who have an investment in the process and outcome of supervision).
Roth & Pilling (Reference Roth and Pilling2008, Reference Roth and Pilling2009) have contributed a more detailed description of what might underpin effective CBT supervision in the form of a supervision competences framework. Adopting a similar structure to the previously developed competence framework for therapies (Roth & Pilling, Reference Roth and Pilling2007), the authors state their aim as one of identifying those competences for which there is evidence of impact or professional consensus. Their framework grounds proficiency in the synthesis of generic supervision competences (such as the ability to gauge the supervisee's baseline level of skill and employ appropriate educational principles) with those specific to CBT.
The supervision framework ‘maps’ four domains of competence – generic, specific, model-specific and metacompetences – each of which is associated with specific supervisory activities. Thus, generic competences include the ability to form a working alliance, facilitate ethical practice and apply educational principles to foster therapist development (i.e. those that are typical of supervision across most therapeutic orientations). Specific supervision competences refer to the ability to conduct supervision in different formats, assist therapists with practising clinical skills and making use of direct observation.
The third domain – model-specific supervision competences – concerns the application of supervision to the cognitive and behavioural therapies. The CBT competences, emphasized as needing integration with the other domains, are organized under the following headings:
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(1) Supervisors’ expertise in CBT (e.g. the ability to apply the principles that underpin CBT).
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(2) Adapting supervision to the supervisee's training needs (e.g. the ability to identify the supervisee's baseline level of knowledge, skill and experience in delivering CBT).
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(3) Structuring supervision (e.g. working with supervisees to identify and prioritize items for discussion).
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(4) Specific content areas (e.g. developing supervisees’ ability to construct formulations and employing basic, specific, problem-specific behavioural and cognitive-behavioural competences in the context of collaborative working relationships with clients).
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(5) Specific supervisory techniques (e.g. supporting supervisee learning and development through using a range of observational and experiential methods of learning such as clinical demonstrations, role-play and listening to audio-recordings of therapy sessions).
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(6) Monitoring the supervisee's work (e.g. using appropriate tools and procedures for assessing supervisees’ CBT competences).
The final domain – termed ‘metacompetences’ – covers a variety of supervisory skills that span the ability to modify content and process according to supervisee need, managing concerns about use of supervision, and responding effectively to complex situations such as ethical violations and fitness-to-practice issues.
Both broad categorizations of supervisor proficiency and the competence framework can provide a helpful basis for self-reflection and potentially, the organization of professional development. For example, drawing on Hawkins & Smith's (Reference Hawkins and Smith2006) distinctions CBT supervisors may begin by focusing on broad domains and listening to recordings of supervision sessions in search of examples where competence, capability and capacity were evidenced. Alternatively, after Falender et al. (Reference Falender, Cornish, Goodyear, Hatcher, Kaslow, Leventhal, Shafranske, Sigmon, Stoltenberg and Grus2004) they may seek to audit their practice over a period of time, tracking supervisory interventions that demonstrate knowledge (e.g. recommendations to supervisees based on knowledge of disorder-specific knowledge), skills (particular strategies used to deliver feedback); values (how the strengths and needs of the supervisee were honoured in the interpersonal exchanges that took place) and context (the extent to which any supervisory interventions took account of the context in which the supervisee was delivering them).
Roth & Pilling (Reference Roth and Pilling2009) propose that the supervision competence framework can be used as a basis for devising a curriculum for supervisor training and offer an illustrative example of how this might look. Additionally, at an individual level, supervisors can access the map of identified competences to explore strengths and limits of current practice in relation to specific activities. Although the competence movement is not without its critics (see Wheelahan, Reference Wheelahan2007) and competence lists need to be considered in light of a clinically informed decision-making process (Gambrill, Reference Gambrill2005), there is some evidence that these competences have high face validity for the majority of CBT supervisors (Owen-Pugh & Symons, Reference Owen-Pugh and Symons2013).
How do CBT supervisors need to develop?
Understanding the ‘what’ of development needs to be to be considered alongside the ‘how’. Optimum ways of developing, enhancing and maintaining proficiency may vary as a function of the supervisor's own career stage and context. In attempting to support self-assessment and professional development planning two areas may, therefore, prove particularly helpful to consider. These are: (1) the literature which proposes that supervisors (like the therapists they supervise) progress through specific stages in the development of their identity and proficiency and (2) understanding the expectations and needs of the context in which supervision is to be delivered.
The developmental stages through which supervisors progress
Through acquiring experience of delivering supervision across a range of therapists and contexts, CBT supervisors have the opportunity to enhance not only their knowledge and skill but also their interpersonal effectiveness. In their work examining therapist development generally and interpersonal therapeutic skills specifically, Bennett-Levy & Thwaites (Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007) identified the relevance of self-schema and self-as-therapist schema. Corrie & Lane (Reference Corrie and Lane2015) propose that these schema are just as important for understanding the development of supervisor ‘presence’, and that experience helps crystallize a unique supervisor identity. It is through this identity that the ‘human quality’ (‘capacity’) to which Hawkins & Smith (Reference Hawkins and Smith2006) refer is communicated to and experienced by supervisees.
The development of what might be termed a ‘self-as-supervisor schema’ is likely to progress through a series of stages. The supervision literature now offers a number of stage models for understanding supervisor development (see e.g. Alonso, Reference Alonso1983; Stoltenberg & Delworth, Reference Stoltenberg and Delworth1987; Heid, Reference Heid1997) with each model emphasizing different areas of change (e.g. self-efficacy, perceptions of role, and relationships with others). The work of Stoltenberg & McNeill (Reference Stoltenberg and McNeill2010) is a particularly good example as it parallels the stages of therapist development described in their Integrated Developmental Model, possibly the best known of all the stage models. The four stages they identify are as follows:
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Level 1: Supervisors (like level 1 therapists) are organized around the perceived need to deliver supervision ‘correctly’ which can result in a rigidity of approach and lack of flexibility. Nonetheless, as level 1 therapists are also concerned with ‘getting it right’ a level 1 ‘pairing’ of supervisor and supervisee can be effective (Stoltenberg & McNeill, Reference Stoltenberg and McNeill2010). An example might be a relatively recently accredited CBT therapist delivering supervision (for the first time) to a student who has started a formal training in CBT. In this type of pairing, the supervisor may be experienced as knowledgeable and effective. However, they are likely to be less able to respond to process aspects of supervision, such as how to adapt delivery to enable the supervisee to utilize supervision to optimum effect.
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Level 2: As for therapists, level 2 is associated with conflict and ambivalence. For level 2 supervisors there is an emerging understanding of the complexity of supervision. Motivation varies, and there can be a tendency to locate any obstacles to the smooth-running of supervision in the supervisee. This can result in frustration and blame and hinder a more impartial formulation of the difficulties encountered. At level 2, obtaining ‘supervision of supervision’ is particularly recommended in order to support the supervisor in remaining a consistent interpersonal presence.
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Level 3: Level 3 supervisors have acquired consistent motivation in the supervisor role and are able to function more autonomously. They are increasingly able to evaluate their own practice including their own contribution to any potential challenges.
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Level 3 Integrated: Level 3 Integrated describes those ‘master supervisors’ who are capable of supervising effectively across the career lifespan and who bring to their work a highly personalized approach. At this level, supervisors are often approached to provide consultation to less experienced supervisors. They might also be sought out as external supervisors and consultants (see Lane's ‘process model’ in the next section).
Developmental models have been criticized on the grounds that they are yet to be empirically substantiated (see Russell & Petrie, Reference Russell and Petrie1994). Nonetheless, they can support a more systematic approach to supervisor development. For example, supervisors might usefully reflect upon their own stage of development, the evidence used to arrive at this evaluation, and particular learning needs typically associated with the stage in question (such as being overly attached to structure at level 1 or needing to work on being a more consistent interpersonal presence at level 2). This can help clarify specific supervisor competences that may need targeting or broad domains (e.g. specific educational principles that must be incorporated alongside discipline-specific knowledge) that need addressing.
Vygotsky referred to a zone of proximal development (ZPD) that denotes, ‘the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers’ (Vygotsky, Reference Vygotsky, Cole, John-Steiner, Scribner and Souberman1978, p. 86). The way that learners progress through this zone has been described by Tharp & Gallimore (Reference Tharp, Gallimore and Pollard2002).
The concept of ZPD can be used to help supervisors think about skills that a therapist can deliver either independently or with optimal supervisory assistance (James et al. Reference James, Milne, Blackburn and Armstrong2006). Corrie & Lane (Reference Corrie and Lane2015) propose that this is equally relevant for understanding the development of CBT supervisors. For example, a level 1 supervisor may be relatively dependent on others for their development. Activities likely to be helpful to supervisors at this level include observing experienced supervisors, obtaining feedback on recordings of sessions and role-playing challenging scenarios (such as giving corrective feedback or managing ruptures). In contrast, there is a transition away from instructor-led guidance towards self-reflection and self-regulation as a basis for learning at level 2 which can be supported in ‘supervision of supervision’. Complementing live observations with reflective practices through which supervisors can articulate their formulations and choice of intervention may be useful (see Corrie & Lane, Reference Corrie and Lane2015, for examples of these kinds of exercises).
As performance becomes more automatic effective practice might be undermined by habitual responding (Tharp & Gallimore, Reference Tharp, Gallimore and Pollard2002). This risk is considered to be greatest at level 3. At this stage, the need for direct observation of practice takes on a new significance with supervisors needing to remain open to critiquing their practice to prevent what Vygotsky (Reference Vygotsky, Cole, John-Steiner, Scribner and Souberman1978) terms ‘fossilization’. Finally, the automatic comes back under conscious control and again can be subjected to reflection and modification. At this level, supervisors are able to draw effectively on multiple sources of feedback to hone their approach. Such high level supervisors may also find a demand for their services in parallel fields such as cognitive behavioural coaching.
Formats of CBT supervision
Methods to support the development of practice may also vary as a function of supervision format. Traditionally CBT supervision has been understood as a role played by experienced practitioners who pass on knowledge and skill to the next generation. The underlying assumption is that if a supervisor is a suitably skilled and experienced therapist, then this individual will be well-placed to supervise more junior members of the profession. However, seen as a ‘whole career’ activity, supervision may take a variety of additional forms. In examining this issue, Lane (Reference Lane, Bachkirova, Jackson and Clutterbuck2011) has identified four possible formats of supervision which have implications for how proficiency is understood and developed. These are the (1) expert-apprentice, (2) continuous professional development (CPD), (3) peer mentoring, and (4) process formats.
In the expert-apprentice format, the supervisor has both content and process expertise and mentors a more junior partner to develop their practice through an apprenticeship-style relationship. An example of this would be where an experienced CBT supervisor works with a small group of therapists in the context of a CBT training course.
In the context where both parties possess content and process expertise it is possible for them to work together to support each other's CPD. In this format, they may work across areas of practice, service or disciplinary boundaries. Here the emphasis is on refining practice through a negotiated process of mutual support. An example might include two accredited CBT therapists from different backgrounds (such as nursing and psychology) who also work within different specialisms (mental health and cancer services).
In some disciplines, and certainly in industry, a peer mentoring approach to professional development is common, even where those peers are relatively inexperienced. In the context of a CBT training course, trainee therapists may meet in self-directed learning groups to support the development of one another's knowledge and skill. In this type of supervision peers play the role of thinking partners (Lane, Reference Lane1994) or create with others a time and space to think (Kline, Reference Kline1999).
Finally, there is increasing interest in the idea of supervision as a professional practice area. It is argued by groups such as the Association of National Organizations for Supervision in Europe, and the European Association for Supervision that supervision is a professional practice in its own right. It is possible, therefore, to be an expert in the process of supervision. Using this expertise, practitioners can work across multiple areas. There are a number of examples of this (i.e. working with refugees, in mental health, psychosocial care, process consultancy and peer counselling) where supervisory support is provided outside of content expertise (Stern et al. Reference Stern, Lane and McDevitt1994; Lane, Reference Lane, Bachkirova, Jackson and Clutterbuck2011). Within CBT this approach has not been endorsed by bodies such as BABCP where content expertise is still a requirement. We need to be clear that the different approaches to supervision are not equivalent. Whereas peers can helpfully support each other in a learning set, an expert-apprenticeship framework is necessary for trainees to ensure that they develop appropriate competences for the work. The boundaries between the approaches and the purpose they serve have to be managed.
Different skills and combinations of competences may be required for effective delivery of each format. If a supervisor is working from the expert-apprentice model, they will require a high level of subject matter expertise and would benefit from CBT-specific measures of supervisory competence.
There are a number of CBT-specific supervision measures that would be helpful in this context. These include:
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• The Supervision: Adherence and Guidance Evaluation Scale (SAGE; Milne et al. Reference Milne, Reiser and Raine2011). This is based on the Dreyfus (e.g. Dreyfus & Dreyfus, Reference Dreyfus and Dreyfus1986) taxonomy of competence that underpins the CTS-R, using the seven-point rating scale of ‘absence of feature’ through to ‘expert’.
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• The Supervisor Evaluation Scale (SES; Corrie & Worrell, Reference Corrie and Worrell2012). This is also informed by Dreyfus’ taxonomy, and assesses a supervisor's proficiency in a specific supervision session by evaluating performance on the four domains of (a) Session Structure and Planning, (b) Facilitation of Supervisee Learning, (c) Development of CBT-Specific Competences and (d) Management of the Session.
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• The STARS (Supervision Training Assessment Rating Scale; James et al. Reference James, Blackburn, Milne and Freeston2005). This also assesses competence in the delivery of CBT supervision.
Generic measures can complement CBT-specific measures to good effect. Again, there is an increasing number which have been developed including those that focus on the identification of supervisee needs (Muse-Burke & Tyson, Reference Muse-Burke and Tyson2010); supervisory styles (Friedlander & Ward, Reference Friedlander and Ward1984); the supervisory working alliance (Efstation et al. Reference Efstation, Patton and Kardash1990) and a group supervision scale (Arcinue, Reference Arcinue2002).
The CPD format of supervision may require a different combination of skills. Corrie & Lane (Reference Corrie and Lane2015) propose that a useful approach for obtaining and providing feedback for this format is the ‘ORCE’ method (Psychological Testing Centre, 2012). ORCE is a trans-theoretical process commonly applied in occupational psychology (Seegers, Reference Seegers and Heriot1989) that can be usefully adapted to the assessment of supervisory skill as there is no pre-determined competence framework. This method involves a number of specific steps. The starting point is an agreement about the area that the individual seeks to explore. This might include a competence, behaviour or process. A means of observing the individual performing the agreed activity, such as a video-recording of a supervision session, is then established. The observer notes from that session what they have observed. The key is that they record what happened rather than look for examples of the competence in question. (Tools used in traditional behavioural approaches to observe and record behaviours are helpful here, such as event recording and timed observations.) Once the record is obtained, it is reviewed for evidence of the competence, behaviour or process being demonstrated. It is then classified as an example. The final step is to evaluate the evidence to see if the competence was effectively or ineffectively delivered (e.g. a positive of negative example of the behaviour).
An example of the application of the ORCE method would be a supervisor who seeks to refine their approach to eliciting feedback from supervisees (a supervisory technique identified in the supervision competence framework). From a recording of a supervision session, it proves possible for an observer to classify a piece of behaviour as an example of eliciting feedback. A positive example might be where the supervisor asked explicitly for feedback and summarized carefully what the supervisee was saying. A negative example would be where this was implemented in a rushed manner at the end of the session, without allowing the supervisee sufficient time to share their reactions and consider the implications of the feedback for their future practice.
ORCE can be a powerful tool for enhancing skills in assessment. It is often used in occupational practice as a means of training colleagues in how to evaluate one another's performance (Seegers, Reference Seegers and Heriot1989). It has also been proposed as a potentially valuable development for supervision training in CBT (Corrie & Lane, Reference Corrie and Lane2015).
Peer supervision can be used to add value to the expert-apprentice model. This approach can occur amongst a self-selecting group of peers on a CBT training course as a means of exploring areas of learning in addition to more formal supervision arrangements. The New Zealand Coaching and Mentoring Centre (2012) has developed a process for group peer supervision which entails the supervisee selecting one from a number of peer supervision ‘tools’ to match their supervision need. (These tools comprise structured approaches for examining successes, asking for ideas; reviewing a piece of work that did not go well; reviewing challenging incidents and ‘rehearsing’ forthcoming events.) The facilitator in the group ensures adherence to the chosen tool and the time-frame. The function of the tools is to enable peers to balance support and challenge, and also to offer a framework through which critical reflection is enhanced by the sharing of multiple perspectives.
Finally, there may be occasions when a supervisor may not need content expertise in the specific form of CBT being delivered but possesses expertise in process consultation (Lane's process model). This is still relatively unusual in the field of CBT and the boundaries would need to be carefully managed so that supervision remains fit for purpose. Nonetheless, it may become increasingly common as the field of CBT expands. An example that is relevant to, but goes beyond, CBT supervision is the use of process consultation in development work. In this scenario, the consultant does not possess the local knowledge and so must rely on the participants (or supervisees) for the expertise on their unique context (Schein, Reference Schein1997).
Lane's (Reference Lane, Bachkirova, Jackson and Clutterbuck2011) identification of these four types of supervision provides an additional lens through which CBT supervisors can consider their professional development needs. Understanding the different formats in which supervision can be delivered and received enables reflection on the different forms of knowledge, skill and competence that might be particularly important for each of the types practised.
Translating general principles into a personalized approach to supervisor development
The scholarship on supervision is progressing (Watkins, Reference Watkins2012 a,b; Barker & Hunsley, Reference Barker and Hunsley2013; Goodyear et al. Reference Goodyear, Lichtenberg, Bang and Gragg2014). Nonetheless, as Barker & Hunsley (Reference Barker and Hunsley2013) point out the evidence-base is still limited and more research that explicitly applies and evaluates models of supervisory development is needed. Emerging studies examining the training of supervisors (see for example, Milne & Dunkerley, Reference Milne and Dunkerley2010; Watkins & Wang, Reference Watkins, Wang, Watkins and Milne2014) are promising (although conclusions on the extent to which it better prepares novice therapists can be no more than tentative; Watkins, Reference Watkins2012 b). Equally promising are the models that attempt to plot the stages of supervisor development and the frameworks identifying the broad domains and specific competences that underpin effectiveness. Nonetheless, if they are to fulfil their potential as aids to learning and development, these frameworks need to be translated into a form that makes sense for the needs of the individual supervisor.
Seeking to contribute to the professional development literature in CBT supervision Corrie & Lane (Reference Corrie and Lane2015) have developed a framework – the PURE Supervision Flower – to help supervisors navigate the different tasks, processes and competences of CBT supervision and to self-assess their proficiency in relation to these (see Fig. 1).
The PURE Supervision Flower.
The PURE Supervision Flower is offered as a decision-making aid for assisting supervisors (and those who train and develop them) in identifying specific areas of skill that may warrant development. Choosing the concept of the flower on the basis that this is commonplace in CBT as a means of illustrating maladaptive (‘vicious flower’) and adaptive (‘virtuous flower’) maintenance cycles, the PURE Supervision Flower has 12 petals. Each ‘petal’ highlights a particular activity or domain of activity, derived from the supervision literature, in which CBT supervisors need to be proficient in order to create an effective learning experience. The 12 activities or domains are grouped into four classes of activity, indicated by the acronym, ‘PURE’:
Prepare (for CBT supervision): excavating the personal and professional beliefs and values that shape the approach taken; understanding the context in which supervision is provided, and using this information to devise a supervision contract for the work that is to take place.
Undertake (CBT supervision): the activities undertaken to foster therapist development in terms of structure, specific supervisory interventions and the assessment of competence.
Refine (CBT supervision): management of the supervision process through working with the supervisory relationship, balancing managerial, educational and mentoring functions, using power effectively and ethically and knowing how to manage resistance and ruptures in the working alliance.
Enhance (CBT supervision): developing competence in working with ethical issues, knowing how to self-assess supervisory skill and planning professional development activities that accommodate both learning needs and self-care.
Corrie & Lane (Reference Corrie and Lane2015) propose a series of exercises that enable individuals to make decisions about where to direct their professional development activities at a given point in time. They suggest that if relatively new to the role, it may be particularly advantageous for supervisors to focus on the preparation and undertaking aspects, whereas if experienced, working more explicitly with the refine and enhance aspects may be preferable. Additionally, they propose that the PURE Supervision Flower can be used to identify specific domains of activity that require development (it may be that a supervisor is confident supporting CBT skills development in the context of an expert-apprentice format, but less skilled at managing process issues that arise in the supervisory relationship).
Developing supervisors within organizations: building a successful knowledge culture
The current work climate places increasing emphasis on individuals managing their own learning, professional development and employability. However, although professional development is still predominantly conceptualized as a personal process organized around individual models of learning and development, many aspects of our work no longer take this form. We work, learn and develop in teams within organizations where our knowledge exists not just as individual intellectual capital but also as social capital (Lane & Corrie, Reference Lane and Corrie2006). This is echoed in the Department of Health's (2001) paper, ‘Working together-learning together: a framework for life-long learning for the NHS’, where there is recognition of the need to equip supervisors with a variety of resources for learning and development. Corrie & Lane (Reference Corrie and Lane2015) also make the case that choices concerning professional development need to be holistic and contextualized.
By broadening our understanding of the supervisor as a ‘one-to-one mentor figure’ and considering supervision as providing a means for promoting a knowledge culture, new ways of approaching supervisor development may present themselves. Rajan et al. (Reference Rajan, Lank and Chapple1999) propose that the elements comprising a successful knowledge culture include:
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• Communities of practice reflecting self-organized groups to exchange ideas and thoughts on practice within specific contexts.
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• Virtual teams brought together across service locations, organizations or countries.
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• Cross-functional team working to break up silos of thinking and generate innovative ideas and approaches for practice-related dilemmas.
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• Toleration of mistakes to create a culture which acknowledges that innovation will, at times, result in mistakes.
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• Action learning whereby work is arranged and supported in ways that promote experiential learning.
Using these elements as a basis for expanding collective understanding of how to optimally support supervisor development, we offer the following questions – both for organizations who may be seeking a clearer understanding of the principal factors involved, and for individuals wanting to negotiate and plan their professional development needs in a specific organizational context:
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• What opportunities are available for formal training in supervision? Whose responsibility is it to source these (the individual supervisor or the organization responsible for mandating and delivering supervision)?
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• How are supervisors supported to transfer formal learning (such as that acquired through formal training programmes) into practice?
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• What opportunities are provided for ‘supervision of supervision’ so that supervisors and the stakeholders of the supervision provided can be assured of its quality?
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• In light of Rajan et al.'s (Reference Rajan, Lank and Chapple1999) recommendations above, what communities of practice, virtual teams or ‘hubs’ are available or could usefully be established within the organization to encourage critical reflection on practice?
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• In order to enhance transparency and facilitate learning how can organizations promote a culture of tolerating mistakes (in much the same way that supervisors need to support therapist learning through ‘safe to fail experiments’)?
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• How will new supervisors be mentored? What systems need to be in place?
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• Given the very real possibility of supervisor burnout (Tehrani, Reference Tehrani2011) what needs to be in place to support the well-being of supervisors who may well be providing supervision to therapists who are themselves highly stressed?
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• How can CBT supervisors come together as a community to inform and support research activity aimed at clarifying how best to supervise a highly diverse and emergent CBT workforce?
Conclusion
Supervision is one of the most critical and frequently described forms of therapist development. However, it is a complex and multifaceted activity that requires a balancing of managerial, educational and supportive functions (Proctor, Reference Proctor, Marken and Payne1988) and adaptations in method and style as a function of the type of CBT being practised and the context in which supervision takes place. Robiner et al. (Reference Robiner, Fuhrman and Ristevedt1993) have observed that clinical competence is a ‘moving target with an elusive criterion’ (p. 5). This could equally be said of supervision given that supervisors are operating in a professional climate involving unprecedented levels of uncertainty, unpredictability and volatility where expectations can rapidly change and evaluation of competence serves multiple agendas.
While supervision is deemed to play a central role in therapist development opportunities for supervisor training and development have remained limited – a paradox that Watkins (Reference Watkins1997) has described as ‘staggering’. Despite progress, there remains a lack of formal guidance on how supervisors can acquire and then refine their capabilities and a virtual absence of standardized methods of assessment for providing supervisors with meaningful feedback on their work (Corrie & Lane, Reference Corrie and Lane2015). There is a hiatus between what is required and the knowledge-base available to meet that requirement. This disadvantages those wishing to deliver and receive effective CBT supervision, as well as services that seek to commission a high-quality resource capable of steering the development of proficiency amongst clinical staff.
As Drake (Reference Drake2009) observes, it can often be a challenge for practitioners to know which domain of knowledge to prioritize, let alone identify methods of learning that will optimally assist development. Nonetheless, until evidence-based guidelines emerge, supervisors will continue to have to make individual choices about their professional development needs and be proactive in sourcing opportunities for further learning. This article has attempted to offer some ideas and approaches to enable CBT supervisors to create context-sensitive and effective approaches. However, the field can only be confident that it has truly taken strides when the emerging picture of what underpins effective supervision is embedded within organizations for the purposes of supporting the learning and well-being of supervisors and the therapists whom they seek to develop.
Summary of main points
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• Supervision is one of the most critical and frequently described forms of therapist development.
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• While supervision is deemed to play a central role in therapist development, opportunities for supervisor training and development have remained limited.
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• Until evidence-based guidelines emerge, supervisors will continue to have to make individual choices about their professional development needs and be proactive in sourcing opportunities for further learning.
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• Definitions of quality and effectiveness cannot be considered in isolation from the professional contexts in which CBT supervision is provided.
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• Supervision has increasingly become a ‘whole career’ activity. This gives rise to questions concerning how CBT supervisors are best trained to provide supervision over the career lifespan.
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• Methods to support the development of practice may also vary as a function of supervision format based on career stage.
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• We must pay attention to how we prepare for and undertake our supervisory practice as well as how we refine our activities in response to dilemmas that arise and over time seek to enhance our practice and well-being through self-care.
Acknowledgements
The authors acknowledge the contribution of their supervisory colleagues and supervisees who have helped shape the authors' work in this field over a number of years.
Declaration of Interest
None.
Having read this article, the reader should be able to:
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(1) Understand and describe the impact of context on the CBT supervision they provide.
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(2) Describe the broad domains of knowledge and skills, and specific supervision competences widely regarded as underpinning effective CBT supervision.
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(3) Describe the PURE Supervision Flower.
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(4) Identify their own stage of supervisor development.
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(5) Make decisions about how best to plan their own professional development.
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