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The problem we have with supervision
Mentioned no less than 26 times in BACP’s Ethical Framework, supervision has a central place in our professions. Its role in facilitating our professional development and promoting the welfare of clients almost goes without saying. Most of us value supervision, find it helpful, and wouldn’t countenance being without it.
Given the almost unquestioned place held by supervision, therefore, it’s easy to overlook a rather central problem. That problem concerns the lack of evidence to support its impact on client outcomes. Given that a recent study has concluded that “the evidence supporting supervision impact of any type is weak at best”, is it time to ask the question “Is supervision working?”
Two papers have roused my interest recently, both on the theme of the impact of psychotherapy supervision. Although they differ somewhat in their focus and findings both agree on one key issue. That is, that evidence for therapy supervision having any material impact on client outcomes is pretty much non-existent.
The first paper, published in 2020, is a summary of reviews of research into psychotherapy supervision in the last 25 years. Authored by C. Edward Watkins Jr. and titled What do clinical supervision research reviews tell us? Surveying the last 25 years, it explores what reviews of psychotherapy supervision research have to say about its impacts.
The second paper, by Jason Whipple and colleagues in the US, is a replication of a study published in 2014 by Rousmaniere et al, exploring supervisor effects on client outcomes in routine practice. The original study found no differences in client outcome between supervisors, and few differences in client outcome due to either degree level or experience as a supervisor.
What do reviews of clinical supervision research tell us?
So, what do reviews of psychotherapy supervision over the past 25 years tell us about the impact of supervision? C. Edward Watkins Jr.’s meta-review identified a total of 20 reviews published between 1995 and 2019. They span several mental health disciplines and include representation from from social work, counsellor education, nursing and psychology.
The review covers five broad areas of supervision research study: (a) supervision effects on client outcomes; (b) supervision effects on the supervisor–supervisee interaction; (c) supervision’s direct effects on supervisee competence; (d) factors that mediate and moderate supervisor impact on supervisee competence; and (e) supervisor and supervisee characteristics.
The review finds that supervision is “found to be positively associated with job satisfaction, job retention and ability to manage workload, appears to be seen as helpful by supervisees and may even benefit their therapeutic competence.”
Beyond this, however, there is little evidence of supervision’s favourable impact on worker outcomes, which is described as “weak at best.”
It goes on to say that “Furthermore, the client has been, and continues to be, summarily neglected in supervision research: supervision’s impact on client outcome has yet to be proven.”
Summarising the evidence presented in the 20 reviews, the author concludes that: “The question ‘Does supervision work?’ still seems to be a wide open question, not answered affirmatively and conclusively on any front across these reviews.”
What is supervisors’ impact on therapy outcome?
As Whipple and colleagues point out, clinical supervision has two related yet distinct goals: (a) facilitating the professional development of supervisees and (b) protecting/enhancing the welfare of psychotherapy clients. It would seem reasonable to assume that if supervision is effective, we would expect to see this reflected not only in the practice of therapists, but in the outcomes of their clients.
Evidence for the impact of supervision on client outcomes is conflicting. As highlighted in the Whipple et al paper, a handful of studies (both controlled and naturalistic) have found evidence for its positive impact. The study by Rousmaniere, using hierarchical linear modeling (HLM), however, came to a different conclusion. Using five years of data from 23 supervisors, 175 supervisees and 6,521 clients, it concluded that supervisors accounted for a vanishingly small degree (0.04%) of the variance in client outcomes.
The replication study by Whipple et al, again using HLM, was based on an archival dataset from 3,030 clients, seen by 80 different therapists and supervised by 39 different supervisors. It concluded that the contribution of supervisors to client outcomes was 0.00%. Zero.
With customary academic tact the authors conclude: “The contribution of supervisors to client outcome in routine practice settings should be further examined to determine the effect supervisors have on client outcome, especially given that supervision in this study appeared to have a similar effect on outcome across all clients of supervisees.”
Does therapy supervision need a fresh direction?
I’m no statistician, but my reading of the Rousmaniere and Whipple studies is that the impact of supervisors on outcomes is more or less uniform. But uniformly what, exactly? Uniformly potent, or uniformly non-existent? Given also the conclusions of the C. Edward Watkins Jr. review, it might be argued that supervision makes little or no demonstrable contribution to therapy outcomes.
I’m no statistician, and neither am I a supervisor. But if I were, I would want to make sure that the approach of my supervisees to their client work was solidly grounded in evidence.
Not evidence relating to therapy models, but to those aspects of the therapeutic relationship that are trans-theoretical and have been shown to have a demonstrable impact on the outcomes of therapy. For example, the therapeutic alliance, goal consensus and collaboration, obtaining client feedback, working with client preferences, clients expectations of therapy and motivation, and hope.
If I were training supervisors, I’d probably take a similar approach. In therapy, these relationship factors work across orientations. I see no reason why they would not also work across different supervision models.
I can think of no better resource to draw upon than the excellent Psychotherapy Relationships That Work.: Evidence-Based Therapist Contributions, edited by John Norcross and Michael Lambert.
Supervision: what difference in your practice?
Is the scarcity of evidence to support the impact of supervision on outcomes the result of a lack of impact, or a lack of evidence? Is it that there is impact which has not yet been sufficiently demonstrated because of methodological challenges? Is the impact so minimal that it’s barely discernible? Or is there no impact that we can measure in standard outcome terms?
I’m not quite sure of the answer to those questions yet. My own experience of supervision is that while it doesn’t alter the basic way I practice, it does often bring phenomenally useful perspectives which enhance my work. How my outcomes would look were I to be without it, it’s hard to say.
In conclusion I’m mindful of the words of a former colleague who reminded me that “Not everything that is useful can be measured, and not everything that can be measured is useful.” How true.
What’s your experience? Do let us know in the comments section below.
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