Worth its weight in gold
Therapy Today, October 2020

I’m sitting opposite my supervisor, feeling their expectant gaze, and I sigh: ‘I don’t know where to start. I feel really stuck with this client.’ We engage in unpicking the therapeutic dynamic in a steady, thought-provoking and reflective way. An hour and a half later, I leave supervision, feeling upbeat, armed with insight and ready for my next client. I mutter that my supervisor is worth their weight in gold, and drive off.

I have had clinical supervision for 18 years, albeit for a number of professional roles and with a variety of supervisors, and I strongly believe that it is an essential ingredient of my professional practice. I expect many of you reading this agree, are likely to describe supervision as invaluable and appreciate the intrinsic link between engaging in supervision and professional, ethical practice.

In the main, my experience of supervision has been positive, encapsulating a safe space to address ethical issues, my concerns and anxieties about client work and my successes; a place where I have felt supported and inspired. Yet I have, at times, experienced less than helpful supervision. I have felt deskilled, undermined or negatively and overly scrutinised by my esteemed, more experienced supervisor. I suspect I may not be alone in this experience.

Over the years, my experience of sitting in both chairs, as supervisee and also as supervisor, has sparked my curiosity about the purpose, effectiveness and benevolence of supervision, so I have embarked on a reflective and questioning investigation into some of the more contentious issues around clinical supervision practice, and will explore some of these issues here.

An assumption of effectiveness?

Supervision has long been used in social work, nursing and the criminal justice system, among other professions, and it is used globally. Within counselling and psychotherapy, supervision has been used for more than a century. Its roots were established through extensions of counselling and psychotherapy theories, and it evolved into the supervision-specific models commonly used today.¹

Given this well-established, multidisciplinary and global use,² there may be an implicit assumption that supervision is a positive influence on practice. But I question how often we practitioners question the usefulness of supervision to our work with clients. To date, the research remains unclear as to how supervision actually impacts on practice.³

This is no small matter, given the ever-increasing move towards providing evidence-based interventions, so I am curious about how supervision fits with an evidence-based model. Can we argue that the models of supervision we use are effective? A recent systematic review of 52 models of clinical supervision suggested that there were inconsistencies and a lack of evidence regarding the efficacy of the models, and also a lack of guidance as to how to actually conduct supervision.⁴

If there remains an assumed link between supervision and positive client outcomes, the question of how that is ‘proved’ could become an issue for the profession. I query whether we supervisors truly know that our work with a supervisee is effective, and therefore ask if we can justify the need for the work we do. Despite my positive experience as a supervisee, I am cautious about asserting that supervision actually impacts on our clients. Given the available research findings, it could be argued that not only is it unclear and inconsistent as to how to conduct supervision, but also there is a current lack of evidence to support its effectiveness in improving client outcomes.⁵ As both a supervisor and supervisee, this raises questions for me about the fundamental processes and benefit of supervision.

However, supervision, like therapy, is a relational process,⁵ and it could be suggested that trying to measure the effectiveness of a relational process is a pointless task; who would we be measuring it for and why? Still, it is difficult to ignore that the funders and commissioners of services increasingly seek evidence of effectiveness as proof of value and, as with counselling and psychotherapy, supervision may be heading in that direction. And, given that, after some 30 years of clinical supervision research, there is still no evidence of its effectiveness,3 how can we continue to justify maintaining this as part of our practice, particularly beyond training, without a more stringent process of measurement of its ‘worth’?

Supervision as a business

While it seems logical and rational that trainees need clinical supervision for practitioner developmental and training purposes, the UK is unique in viewing post-qualification supervision as an undisputed ethical requirement.⁶ In most countries, including the US, proof of regular supervision is not a requirement for accreditation or registration purposes.

Supervision is big business in the UK, generating income for supervisors, training providers and, in the case of accreditation, professional bodies.⁷ The cost of training as a supervisor can be considerable, yet there is a wide variety in the qualification levels of supervision training. The lack of minimum training levels across the counselling and psychotherapy profession is echoed in supervision. I have heard of well-established supervisors practising with no ‘official’ qualification, while others have undertaken long courses. Of course, higher qualification does not necessarily equate to better-quality supervision. But perhaps there is a conflict between the lack of specific guidelines around supervisor qualification and supervision being a mandatory, ethical and professional obligation that incurs an ongoing financial commitment.

The BACP Ethical Framework is prescriptive about the amount of supervision needed when the practitioner is in training or to meet accreditation criteria.⁸ Yet I am unaware of the evidence on which the amount of supervision is calculated. Furthermore, as a supervisor, it seems that an often-overlooked keyword in the Ethical Framework in relation to supervision is ‘minimum’. The recommended 1.5 hours per month is a minimum, but in my experience many practitioners see this as the correct amount to have, not the starting point that provides flexibility for more, dependent on individual supervisee need.

I regard working with individual need as a cornerstone of the supervisory relationship. But there are also concerns about the dynamics in the supervisory relationship that are worth exploring.

The nice factor

There is a great deal of anecdotal and empirical evidence that supervisees find the process of clinical supervision useful. I have heard colleagues describe ‘getting on well’ with their supervisor, but a ‘nice’ supervisor does not necessarily equate to good supervision. As with any other therapeutic relationship, the research is clear that the quality of the relationship is a key factor in establishing a supervisory rapport that is beneficial.^9,10 However, there is potentially a risk of supervisory complacency or collusion, hiding poor practice behind the veneer of a ‘nice’ supervision relationship.

If we agree that supervision, like therapy, is a relational process, I question why many organisations that offer counselling placements insist on using their own supervisors. Often counsellors get assigned an in-house supervisor for their clinical practice while on that placement. How this fits with a relational model, if the supervisory relationship is one that is obligatory, remains unclear. I am also curious about how this aligns with ethical thinking around client autonomy, as surely the supervisees are also clients? Many trainees and those accruing hours towards accreditation are so grateful to have a clinical placement that they may not feel able to challenge a placement-imposed supervisor, even if the relational fit is not good enough.

I am also aware of placement organisations that insist on only using supervisors that have trained at the same organisation. It seems that these organisations have a rather blinkered view that any training other than their own is somehow invalid. How these imposed supervisor arrangements impact on the supervisee is a further point of concern, as potentially this power dynamic within the supervision relationship may also influence supervisee non-disclosure.

To tell or not to tell?

‘I know I should tell my supervisor, but I’m worried they will think badly of me.’ Non-disclosure in supervision has been the subject of numerous studies. The research around the issue highlights the need for a good supervisory relationship, so I am curious as to how having a forced supervisory relationship in many trainee placements may exacerbate supervisee non-disclosure. Whether the issues of non-disclosure remain present for those qualified therapists is worth reflecting on; how often do experienced practitioners omit aspects of clinical work from the supervision session and how, as supervisors, do we tackle the issues of non-disclosure in our supervisees?

Non-disclosure can include clinical mistakes, concerns about competency, and reticence about personal issues that may be impacting on the supervisee’s practice. Supervisees may ultimately find themselves in a cycle of non-disclosure.¹¹ Both the supervisor and supervisee have a responsibility to acknowledge and unpick the power dynamics that may be impacting on the supervisee’s ability and willingness to disclose.

This may be a relatively simple process if the supervisory relationship is mutually respectful and balanced. However, challenging the supervisory process can be fraught with difficulty, particularly if the supervisory relationship is experienced as harmful.

Helpful or harmful?

My own experience of harmful supervision came at a time of considerable development as a practitioner. I had recently completed core training and sought independent supervision with someone established in the field who had a good reputation. Over the course of a year, I became increasingly despondent and unsteady about my practice. The supervisor in question would rigorously and ruthlessly challenge my theoretical stance, understanding, assessment and work with my clients, to the point where I became unsure whether I was able to practise, despite having good feedback as a trainee and in my placement.

While I was still a novice practitioner, the relentless doubt cast over my abilities severely damaged my confidence, but I took their critique as correct and strove to be ‘better’. Yet I would often leave the appointments feeling confused and unsure. It was only their rigid and ignorant views about diversity issues that finally resulted in my decision to stop working with them. At no point did I feel able to discuss my experience of supervision with them. It is said that supervisor humility is an essential foundation for good supervision practice.¹² I am not convinced that I experienced that supervisor as being humble, and nor did I feel in a position to challenge them.

Research into harmful supervision makes for alarming reading in respect to the prevalence of supervisees reporting current inadequate or harmful supervision. One study¹³ of 300 supervisees suggested more than 70% were currently experiencing inadequate supervision and more than 30% were categorised as currently having harmful supervision. While this means that a significant amount were not experiencing harmful supervision, the study recognises that negative experiences of supervision are often hard to identify and so are likely to be under-reported.^13,14

Engaging with these contentious issues around supervision has not been easy for someone who is a staunch advocate of the professional, personal and ethical value of supervision. But to be unquestioningly accepting of a core element of my practice is equally uncomfortable. I’m left wondering to what extent supervision is a consistently safe place for supervisees and, in turn, effective for clients. At worst, supervision may discourage the disclosure of issues pertinent to clients’ needs and the supervisee’s own wellbeing, as the supervisory dyad may be fraught with power dynamics that result in an unhelpful relationship. The relationship may be imposed rather than chosen, and it remains unclear how supervision actually benefits clients’ outcomes. The time has come for us to pay more attention to some of the assumptions around supervision, however challenging this may be for us.