CBT Supervision

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Sarah Corrie & David A Lane

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    Praise for the Book

    ‘This terrific book is comprehensive, evidence-based, and practical. Geared toward both supervisors and supervisees, it provides a number of important learning exercises to encourage active reflection. The case studies help the reader transfer what they are learning to real-life situations. I highly recommend this book to trainees, therapists who need to improve their skills in self-reflection, and to supervisors.’

    Judith S. Beck, PhD, President, Beck Institute for Cognitive Behavior Therapy; Clinical Associate Professor of Psychology in Psychiatry, University of Pennsylvania

    ‘Ever wanted some well-organised supervision for your supervision? Would you welcome some guidance in your role as a supervisee? Then this exceptionally clear and systematic book is for you! What’s more, it tackles the core tasks of CBT supervision from a well-developed understanding of the nature of CBT, continuing the reflexive tradition. For example, the reader is expected to reflect carefully on the central questions raised, while the realistic and engaging case studies are used to pose dilemmas and prompt procedural thinking. Feedback is effectively provided in the form of the authors’ responses to the dilemmas.

    This is a highly practical “nuts and bolts” guide to CBT supervision, optimistic and empowering. Unlike many competitors, CBT Supervision keeps theory and research details to an absolute minimum, sticking firmly to established supervision practices and sensible recommendations (for both supervisors and supervisees), based on the authors’ extensive supervisory experience. It is written with exceptional clarity and systematically covers all the bases. In sum, this is a highly informative, soundly based, exceptionally practical guide to CBT supervision. It is all the more welcome given the pressing need to tackle CBT supervision in a professional manner.’

    Derek Milne, PhD, retired Director of the Newcastle University Doctorate in Clinical Psychology and author of Evidence-Based Clinical Supervision

    ‘Corrie and Lane’s CBT Supervision is a well-researched, well-organized, thorough, practical workbook that will be a valuable resource for clinical CBT supervisors at all levels of experience. This volume’s supervisory case studies, chapter-by-chapter learning activities, and “tips for supervisees” make this volume ideal for a graduate seminar in learning to become a CBT supervisor. More experienced supervisors will benefit greatly from the authors’ wise suggestions in handling challenges and dilemmas in supervision, and from their emphasis on supervisor self-reflection, self-care, and lifelong professional and personal growth. CBT Supervision is at once a great asset to the field.’

    Cory F. Newman, PhD, Director, Center for Cognitive Therapy and Professor of Psychology in Psychiatry, University of Pennsylvania

    ‘The authors have produced something new, fresh and original. For the first time a book that focuses on how to effectively practise cognitive behavioural supervision. This text is an essential practice and professional development aid for both new and experienced cognitive behavioural supervisors. Each chapter takes the reader through how to prepare, undertake, refine and enhance their supervision, illustrated with examples and reflective activities – is there any other CBT supervision book that makes understandable the complexity of supervision? This book won’t just be on my book shelf it will be on my desk as I will be turning to it time and time again as a supervisor of clinicians and other supervisors and as academic responsible for the delivery of supervision workshops.’

    Michael Townend, PhD, Reader in CBT, University of Derby

    List of Learning Activities, Figures and Tables

    About the Authors

    Professor Sarah Corrie is a Consultant Clinical Psychologist, Chartered Psychologist and Visiting Professor at Middlesex University. She received her undergraduate degree in Psychology and Counselling Psychology from the University of Surrey. Recipient of the Professors Newstead and Gale Prize in recognition of ‘an exceptionally high standard of attainment in examination and course work’, she went on to obtain her doctorate in clinical psychology with Canterbury Christchurch College and completed her post-qualification training in cognitive-behavioural therapy at the University of Oxford. Among her roles for The Central London CBT Centre, Sarah is Programme Director of the Postgraduate Diploma & MSc in Cognitive Behavioural Psychotherapy offered by Central and North West London NHS Foundation Trust in conjunction with Royal Holloway, University of London; Programme Director of the Certificate in CBT Skills and joint Programme Director of the Post-Qualification Certificate in CBT Supervision. She has extensive experience in supervising, training and lecturing practitioners in the fields of psychology, psychiatry and counselling, and is an accredited therapist, supervisor and trainer with the British Association for Behavioural & Cognitive Psychotherapies (BABCP). Sarah was Chair of the British Psychological Society’s Special Group in Coaching Psychology from 2012 to 2014, is a faculty member of the Professional Development Foundation, Membership Officer for the International Association for Professional Practice Doctorates and a member of the Course Accreditation Committee of the BABCP.

    Professor David Lane has been providing services within CBT since the early 1970s. He established the first behaviour support service operating in the UK to support children and schools in 1975 for the Schools Psychological Service of the Inner London Education Authority (ILEA). Prior to this he worked directly within the school system. As part of this, programme supervision was offered to both staff at the service and to other professionals. David worked with Vic Meyer and Ted Chesser at Middlesex Hospital under their supervision for work with adults to expand his understanding of the field. He provided training in case formulation to students on the Middlesex Programme for more than 20 years. He has acted as a supervisor for almost 40 years.David was part of the group that created Counselling Psychology within the British Psychological Society and served on the governing committee of the Association for Behavioural Approaches with Children. He has been a member of BABCP for more than 30 years. He was Chair of the British Psychological Society Register of Psychologists Specialising in Psychotherapy, and has served on committees of the British Psychological Society (BPS), the Chartered Institute of Personnel and Development (CIPD) and European Mentoring and Coaching Council (EMCC). He convened the Psychotherapy Group of the European Federation of Psychologists Associations. His contributions to counselling psychology led to the senior award of the BPS for ‘Outstanding Scientific Contribution’. In 2009 he was honoured by the British Psychological Society for ‘Distinguished Contribution to Professional Psychology’. Sarah and David’s previous co-authored publications include: The Modern Scientist-Practitioner: A Guide to Practice in Psychology (Routledge); Constructing Stories, Telling Tales: A Guide to Formulation in Applied Psychology (Karnac), and Making Successful Decisions in Counselling and Psychotherapy: A Practical Guide (Open University Press).

    Acknowledgements

    There are a number of people who have contributed to the development of this book and whose interest, encouragement and support we wish to acknowledge.

    First, we would like to thank Kate Wharton, Susannah Trefgarne and Laura Walmsley, our editorial team at Sage, who have been such a solid source of support throughout the process. We are grateful to them for their guidance on the many issues encountered along the way. Our thanks also to Rachel Burrows, her colleagues in the production team, and everyone at Sage who has worked with us to bring this project to completion.

    Special thanks to Rita Woo for providing the material for the ‘Tips for Supervisees’ sections of each chapter, as well as our primary readers Anna-Maria Smit and Simon Dupont. All three provided feedback on the fledgling chapters and remained steadfast and wise guides as the manuscript gradually took shape. We are grateful also to Derek Farrell for reviewing the manuscript and for his interest in and enthusiasm for the project.

    There are a number of people and organizations who have generously given permission for us to draw upon, and in certain cases reproduce, material. We wish to acknowledge and thank the following: James Bennett-Levy for his interest in the project and for access to his materials and forthcoming publications; the British Association for Behavioural & Cognitive Psychotherapies for permission to reproduce the ‘Duties as a Member of BABCP’ from the Standards of Conduct, Performance and Ethics; Kenneth Gordon and Cambridge University Press for permission to reproduce the ‘Ten Steps for Supervision’, and Peter Hawkins for permission to reproduce the ‘Helping Roles’ table. We thank Christine Padesky for permission to reproduce the Supervision Options Grid, Anthony Roth and Stephen Pilling for permission to reproduce the outline model of the CBT Competence Framework, and Noreen Tehrani for permission to use and adapt her work on ‘Daily Rituals to Support Self-Care’.

    Beyond those directly connected with this project, we are deeply grateful to all those who, over the years, have shaped our understanding of both cognitive-behavioural therapy and supervision. A particular mention goes to the many supervisors with whom we have had the good fortune to work and from whom we have learned so much. Our gratitude also goes to our colleagues at the Professional Development Foundation, Middlesex University, and our students and clients who have influenced our thinking in profound ways.

    Sarah Corrie wishes to acknowledge the talented team of supervisors, trainers and students at The Central London CBT Centre, who have provided the inspiration for many of the ideas presented in this book. It has been a privilege to work with all those who have chosen to study with us over the years and who courageously share their practice in an attempt to master this complex activity called CBT. Particular thanks go to Michael Worrell for permission to reproduce the Supervisor Evaluation Scale, for our many discussions about supervision over a ten-year period, and in conversation with whom the idea of writing this book was born. In developing my knowledge and skills as a supervisor and trainer, special thanks must also go to Don Baucom, whose approach to training others has been an inspiration.

    David Lane wishes to acknowledge colleagues at University College Hospital, particularly the late Ted Chesser and Vic Meyer for their inspiration and Mary Watts and Michael Bruch. Colleagues at the Islington Educational Guidance Centre and other Behaviour Support Teams throughout the UK have supported him through their active participation as he explored various approaches to supervision.

    Finally, special thanks go to Peter Hoy for proof-reading the manuscript and to Ian Lacey for his encouragement, critique and unfailing belief in the project and its authors.

    Confidentiality

    The case scenarios and case material included in this book have been inspired by dilemmas encountered in the context of either providing CBT supervision or providing consultation to those who are providing supervision. However, care has been taken to ensure anonymity and the supervisors and therapists in all of the case scenarios provided are fictitious.

  • Appendices

    Appendix 1: Recommendations for Case Study 1

    One way of conceptualizing the dilemma that Patrick and Jen are experiencing is as a scenario in which supervisor and supervisee have (apparently unacknowledged) different ideas about what effective CBT comprises and how it should be optimally delivered. Both Jen and Patrick appear to have well-formed beliefs, based on prior experience of delivering CBT in specific contexts, as to how CBT ‘should’ proceed from the earliest stages of assessment, formulation and intervention planning, including the amount and type of information necessary to develop an intervention plan.

    Without an explicit acknowledgement of these differences, there is a risk of rupture in the working alliance. For this reason, we would recommend that Patrick raises his concerns with Jen, conveying a desire to explore this dilemma with her, and a wish to hear her perspectives on both CBT generally and supervision with him specifically. By conveying clearly his commitment to forging a positive working relationship that can support her clinical work to best advantage, Jen may feel sufficiently safe to share her concerns.

    One possible way forward would be for Patrick to draw on the three- step method outlined in Chapter 1. Specifically:

    Step 1:

    We would recommend that if he has not done so already, Patrick spend some time clarifying his own beliefs and values about CBT as well as the ‘brand’ of supervision he both seeks to offer and is best-placed to offer. It will be important for him to ensure that the type of supervision he is able to provide will meet Jen’s needs and also to be clear about how his approach relates to the context in which he is working. Assuming this is the case, and having clarified his own beliefs and values:

    Step 2:

    Patrick could spend some time talking with Jen to gain a clearer understanding of her beliefs and values, both about therapy and about CBT. How does she conceptualize this undertaking? What are her views about how CBT is best applied in contexts where clients have difficulties that could give rise to stigma and shame? In this example, Jen may have a view that ‘good’ CBT practice is protocol-driven and therefore looks to Patrick to ensure that she remains ‘on model’. She may not, however, have fully considered how some of the essential tasks of CBT (such as assessment and formulation) need to incorporate issues that are relevant to clients living with hepatitis B.

    Step 3:

    By encouraging Jen to articulate her beliefs and values about CBT, Patrick can gain a clearer sense of what is driving Jen’s preferred way of working. Through sharing his own beliefs and values, both parties can identify areas of similarity and difference and anticipate where differences could create disruptions in the working alliance.

    Patrick may find it helpful to acknowledge the value of Jen’s approach and to communicate his respect for her excellent track record as a trainee CBT therapist. However, as her supervisor, he also needs to communicate that Jen can have confidence in him to support her work and that while he is encouraging a different approach from her previous supervisor, it can be understood as just as rigorous, thoughtful and systematic. To achieve this, he might find it helpful to consider with Jen the broad field of CBT and how each tradition encompasses the expression of diverse worldviews. He could then apply this to the current context and the way in which protocols might need to be adapted to the needs of a client living with a medical condition such as hepatitis B. This way, Jen has a clear rationale for Patrick’s recommendations.

    In presenting his beliefs and values clearly and non-defensively, and sharing how they underpin his way of working, Patrick can invite Jen to explore with him the advantages and disadvantages of approaching therapy in a different way. Would she be willing to suspend certain assumptions she might hold about effective CBT in order to try a new approach? If she were willing to embrace this as a behavioural experiment, there is the potential to gather information about alternative ways of thinking about CBT and its delivery that may enrich her professional skills and the range of clients with whom she can work. Agreeing to revisit the outcome of her behavioural experiment at a specific future date (for example, in three months) might also reassure Jen that Patrick welcomes her feedback and is committed to working in partnership with her.

    As a recently trained therapist, Jen is making a transition in identity from student to qualified professional. It would be helpful for Patrick to be aware of some of the developmental issues arising from her stage of development and to consider how he might wish to tailor his style and choice of intervention accordingly (he might benefit from some of the material we cover in Chapter 4, for example). There is an opportunity for Patrick to model an openness to diverse ways of conceptualizing and delivering CBT, and also to act as a mentor for enabling Jen to clarify her own emerging ‘brand’.

    Appendix 2: Recommendations for Case Study 2

    In this scenario, it would seem that Patrick feels torn between prioritizing Ben’s needs as a trainee CBT therapist and his manager’s needs to enhance the image of the service.

    One way of conceptualizing the dilemma that Patrick and Ben are experiencing is as a scenario in which both parties are being unduly influenced by a range of local, national and global level influences. Because he does not yet appear to have reflected upon these influences, it is difficult for Patrick, who holds ultimate responsibility for the supervisory engagement, to formulate a more helpful response.

    In this context, a first step would be for Patrick to ensure that he is able to recognize, and take appropriate action to modify, any unhelpful thoughts, assumptions or beliefs about himself, Ben and his own forthcoming appraisal. He needs to be attentive to his reactions to Ben and the client which stem from cognitions about pleasing his manager or proving his worth, as these may undermine his ability to problem-solve effectively. Currently, his own anxieties about his forthcoming appraisal appear to be infecting his clarity of thinking in supporting Ben’s work. It is also possible that Ben is aware of this and, carrying the unacknowledged burden of Patrick’s anxiety, feels under pressure to produce results. Hence, he externalizes blame for lack of progress on to his ‘resistant’ client.

    Having taken steps to address his own potentially unhelpful cognitions, Patrick could usefully expand his focus beyond the outcome measures in order to take a broader perspective on the extent to which the client is progressing: What are the objectives and goals of therapy? Has the client made progress in relation to these or not? How can any lack of progress be understood (for example, does the formulation need updating)? How does Ben understand what is occurring? Can the dilemma be understood by Patrick returning to his formulation of Ben’s career stage and specific learning needs?

    There is also evidence of local level pressures as the clinical lead seeks to ‘rehabilitate’ the reputation of the service in order to bring it in line with a national agenda for delivering evidence-based interventions, and retain staff. It is worth Patrick considering whether his reactions are being influenced by the anxiety of the clinical lead. It might be helpful for him to consider the pressures that this individual is facing in their more senior role, and the stakeholders who may not be immediately obvious to Patrick but who are exerting pressure. By considering these factors, Patrick would be in a better position to understand the extent of, and limits to, his responsibility and develop a clearer understanding of the actual (as opposed to the feared) expectations of him as a CBT supervisor. In relation to his appraisal, he needs to ensure what criteria are being used to evaluate his performance. (It would be unlikely, for example, that the outcome of Patrick’s appraisal would be determined by the score profile of a single client of a single supervisee.)

    Patrick is a relatively new supervisor and is eager to demonstrate his own competence. While he is appropriately focused on the clinical outcomes achieved by his supervisees, he is perhaps not yet sufficiently able to consider the boundaries between service development, service policy and therapist development. It would be helpful for Patrick to consider the combination of local, national and global level influences that are impacting on his reactions. (Engaging in Learning Activity 2.2 might help him identify the factors at work in this scenario.) We would also recommend that Patrick enlist the support of a more senior colleague or mentor outside the service to talk over his concerns about how he might be appraised. The guidance of a more experienced colleague would help him identify which of his concerns about Ben’s performance might be reasonable and which might reflect his doubts about his own competence.

    Appendix 3: Recommendations for Case Study 3

    The dilemma that Nina and Jas have encountered can be conceptualized principally as one relating to the contracting phase of supervision. There are three principle issues arising in this scenario which we can consider in turn:

    • Confusion about what was, and was not, agreed at the outset.
    • Differences of opinion concerning Jas’s readiness to apply for accreditation as a CBT therapist.
    • Jas’s career progression within his service and the need to be accredited to support this.
    1. Confusion about what was, and was not, agreed at the outset

    Nina ensured that her work with Jas is supported by a written supervision contract. This enables both she and Jas to refer to a specific document to confirm what was explicitly agreed. Nonetheless, Jas maintains that there was tacit agreement to work towards accreditation and that he commissioned supervision on this basis.

    We would recommend that Nina explains her approach to developing learning agreements and clarifies that any objectives need to be explicitly agreed to become a basis of supervision. We would also recommend that Nina suggests taking this opportunity to revisit the contract, discuss the learning agenda (inviting Jas to express any previously unarticulated hopes for supervision and his career) and develop a revised plan for moving forwards. Jas is new to both CBT and structured forms of supervision and is not familiar with the use of written contracts to formalize the aims, objectives, roles and responsibilities that will underpin the approach taken. Therefore, it may have been difficult for him to participate in this process fully when Nina introduced it. It will be helpful for Nina to recommend that she and Jas revisit, and if necessary revise, the contract periodically to ensure that it remains fit for purpose.

    2. Differences of opinion concerning Jas’s readiness to apply for accreditation as a CBT therapist

    Nina can describe her commitment to helping Jas develop his knowledge and skill as a CBT therapist while also outlining her responsibilities as an accredited CBT therapist and supervisor. Ethically, she cannot support an application for accreditation if she does not believe that the therapist concerned has demonstrated the necessary level of competence. What she can agree to is the facilitation of a learning process that will support Jas in working towards this. Given that he is a skilled therapist, this should, with time and training, be an option for him.

    Nina could suggest undertaking a skills audit of Jas’s proficiency, drawing on Roth and Pilling’s (2007) competence framework (see Chapter 5) as a basis for identifying priority areas. She also needs to make explicit what she would need to see evidence of (Chapter 6) in order to be comfortable about providing a reference for accreditation purposes. It will be important that Jas fully understands Nina’s thinking, so that he can make an informed decision about whether he wishes to continue commissioning supervision from her.

    3. Jas’s career progression within his service and the need for accreditation to support this

    Although there may well be outside pressures on Jas to become accredited as he indicates, the existing contractual arrangement does not involve Jas’s employer and their interests are not included in the learning agreement. Nor has Jas indicated specific career objectives as part of the contract. If career progression, or the needs of the service, are to be included, a new contract should be negotiated which will require further conversations with those stakeholders who have an investment in the outcome. Specifically, Nina and Jas will need to understand what is expected by whom, how information about Nina’s evaluations of Jas’s competence and readiness for accreditation will be shared and with what implications.

    Nina is an experienced supervisor and so has plenty of experience to draw upon and in which to have confidence. However, possibly because of this, she may have assumed that a contract developed for one supervisee will automatically generalize to another and she has been insufficiently attentive to the cognitive adjustment that Jas was having to make in contracting supervision in this new, more structured way. If working with a therapist in a similar situation to Jas in the future, it would be preferable to work towards excavating any hopes for supervision and career goals that are not automatically offered up by the supervisee.

    This is likely to be a difficult conversation and Nina will need to manage the process carefully. By indicating her commitment to Jas’s development and making use of the restorative function, empathizing with Jas’s disappointment, she may be able to prevent a rupture in their working alliance. Through this, a clearer contract that is fit for purpose can be negotiated and a better outcome ultimately achieved for all concerned.

    Appendix 4: Recommendations for Case Study 4

    Nina is supervising a newly formed supervision group of three mid-career professionals, two of whom appear ambivalent towards Nina and/or the approach she is offering.

    Because she is an experienced professional and confident in her own ability, Nina is able to maintain a curiosity about (as opposed to feeling undermined by) the situation. As a result, possible ways forward can be focused on the situation rather than the management of the supervisor’s feelings. (For a less experienced supervisor it may be important to seek consultation with a colleague so that the supervisor can manage any personal material arising.)

    A first step would be to formulate the dilemma occurring and each individual’s contribution to it, as well as the needs that may be expressed through each member’s conduct. Assuming that Nina took time at the outset to develop a formulation of each supervisee’s idiosyncratic preferences, abilities and needs (see also Chapters 1 and 2), she is well placed to plan a response to this situation. If she has not done so, this would be a good place to start.

    Nina might then benefit from considering the stage of therapist development relevant to each member of the group. One of the therapists is engaged in supervision and appreciates directive input. It is possible that this supervisee is at level 1 in her stage of development, motivated to learn, wanting to progress rapidly through the anxiety that comes from being relatively inexperienced in CBT and appreciating clear guidance from a position of relative dependence. As Nina is happy to provide this, it would seem that there is a match between what the supervisee needs and what Nina is providing.

    For the other two therapists, it is possible that Nina is encountering a loss of confidence and ambivalence that characterizes level 2. Although the members of the group are mid-career professionals, their experience of, and skill in, delivering CBT may not yet be at the same level as their skills in other domains. For mid-career professionals it can feel exposing to have to share their practice, and the exchange of looks as well as the subtle resistance to Nina’s input may indicate poorly managed anxieties about being evaluated and found wanting.

    Level 2 is recognized as a turbulent stage in therapist development and Nina would do well to consider how she might adjust the style of supervision to balance structure with encouraging autonomy. This might include suggesting that supervisees take turns in setting the agenda and organizing the session, and encouraging the sharing of ideas about each other’s cases (that is, fostering peer supervision). This would help the supervisees ‘test out’ their emerging skill within a framework that enables Nina to maintain a consistent and structured approach.

    Finally, it would be worthwhile Nina reflecting on each supervisee’s motivations for undertaking CBT training at postgraduate level. Are they willing participants in the process? Or is at least one individual in the group coming because they believe they have no choice in the current professional climate? The behaviour of the supervisees may reflect the felt pressure of some of the local and national level influences examined in Chapter 2 and may be important to explore further.

    Nina will need to remain attentive to the emotional climate within supervision and monitor the situation carefully. If difficulties continue, it will be necessary for her to address directly with the supervisees what is occurring to ensure that supervision remains a safe and productive learning environment for all concerned.

    Appendix 5: Recommendations for Case Study 5

    In this scenario, Nina has concerns about Sandra, a newly qualified clinical psychologist who is avoiding sharing recordings of her sessions in supervision and tends to ask concrete questions such as ‘What should I do?’ or ‘What would you do in this situation?’ The uneasiness that Nina experiences is due to a perceived discrepancy between Sandra’s performance in supervision and Nina’s expectations of a therapist who has completed doctoral level training and previous CBT-oriented placements. Additionally, by failing to present live examples of her work, Nina is unable to form a clear impression of the quality of Sandra’s work and the methods of learning that might be optimal for her development.

    Nina is correct that she now needs to understand precisely what Sandra is, and is not, competent to deliver and she needs to adopt a respectful but direct approach.

    As a first step, it would be helpful for Nina to share her dilemma with Sandra and explain that withholding direct access to her work is undermining her ability to evaluate Sandra’s competence and support her in her learning. Nina can frame this in terms of her responsibilities as a supervisor, reminding Sandra of the normative, formative and restorative functions of supervision.

    Assuming that Sandra can acknowledge Nina’s position, a number of options then present themselves. Nina could ask Sandra how she experiences supervision, what enables her to learn effectively and how she self-assesses her practice currently. She can also revisit what occurred in supervision during her CBT placements and how Sandra responded to a structured learning environment in the context of clinical psychology training.

    Nina can acknowledge Sandra’s apparent preference for case discussion and ask her to share her understanding of the benefits and limitations of this approach. Drawing on Bennett-Levy’s DPR model, as well as Padesky’s Supervision Options Grid, Nina can share her understanding of why CBTS emphasizes a multi-method approach to learning and the ‘must’ and ‘can’ interventions that follow from this. She can seek Sandra’s views on this, remaining attentive to what Sandra says (and doesn’t say) that may provide clues about any underlying obstacles.

    If Nina senses that Sandra’s reluctance to bring recordings to supervision stems from heightened anxiety, it will be helpful to enable Sandra to express this directly. Anxiety is a response with which Nina can empathize and if problematic cognitions are identified, they can consider together whether these can be appropriately addressed in supervision, modified through self-practice of CBT strategies, or need to be addressed through some other means, such as therapy. Nina could also normalize ‘therapist imperfection’ (particularly if Sandra is hampered by catastrophic beliefs about the consequences of imperfect performance) by sharing some of her own recordings of sessions and asking Sandra to rate these on the measure of therapist competency used by the service (such as the CTS-R).

    Given that Sandra tends to ask concrete questions, Nina could encourage better preparation for supervision by asking her to generate three possible answers to her own question, derived from the client’s formulation and any relevant reading, for discussion in supervision. This way, Nina can begin to enhance Sandra’s capacity for autonomous decision-making and see where specific limitations lie.

    Nonetheless, however facilitative Nina wishes to be, to fulfil her responsibilities as a supervisor, the situation needs to change. If Sandra’s conduct in supervision contravenes what has been specified in the supervision contract, this needs to be addressed. Nina may decide to identify targets and timeframes for the presentation of recordings, formulations and intervention plans and to identify these as clearly the ‘must’ rather than ‘can’ components of supervision. If these targets are not met, then Sandra needs to understand the implications.

    As Nina considers how to respond to this dilemma, it will also be necessary to consider whether she is best placed to supervise Sandra at this time. Given that she is both Sandra’s CBT supervisor and line manager, there is a dual relationship in operation. This may be implicated in what is occurring and Nina will need to reflect on whether Sandra’s needs, and the needs of her clients, may ultimately be better met by another supervisor.

    Appendix 6: Recommendations for Case Study 6

    In this scenario, Patrick harbours doubts about Leanne’s competence despite her obvious progress, diligence in seeking feedback and now consistently passing assessments on the CTS-R. His concerns reflect the fact that any assessment of competence has a present and a future focus. Leanne is able to demonstrate competence in the present (at least with some clients, as evidenced by her scores on the CTS-R). However, Patrick harbours doubts about her ability to work with future clients based on her interpersonal skills.

    In considering how to respond to this dilemma, there are two main questions to consider:

    • What should Patrick do in response to his concerns?
    • How should he prepare himself to respond to Leanne’s anticipated request for a reference?
    1. What should Patrick do in response to his concerns?

    Given that Patrick is a relatively inexperienced supervisor, it would be useful for him to discuss this situation with a more experienced colleague. It is possible that, in the early stages of supervision with Leanne, he omitted to ensure that he had a clear operational definition of competence and has been working with an under-developed set of evaluation criteria. The benchmark criterion of whether or not he would feel comfortable referring a member of his own family to Leanne may enable him to qualify a ‘hunch’ but is insufficiently specified to be useful for addressing the dilemma in hand, or indeed for arriving at an impartial judgement about her overall competence.

    In considering his options and in discussion with his own supervisor, it would be useful to clarify whether the service has any protocols in place for addressing such concerns. Additionally, he needs to think through whether there might be some advantage to sharing his concerns with a member of the Programme Team (Leanne is shortly due to finish her Master’s degree). In sharing his doubts, Patrick needs to anticipate the potential implications – for himself, for Leanne, and for any other stakeholders with an investment in the outcome of Leanne’s placement. For example, in approaching the Programme Team, is there the option for a confidential discussion, or will his doubts be shared with the Programme Director? Will Leanne be notified of the conversation and what implications might this have for their working relationship? Will sharing his concerns influence whether or not Leanne passes the course?

    Patrick could also give further thought to what underpins his concerns. In elaborating his evaluation criteria, he needs to consider both which competences Leanne lacks (see Chapter 5) and whether he has used a sufficiently broad range of assessment methods to form a sound judgement. He also needs to consider Leanne’s ability to apply feedback. Given that she has progressed well and is diligent in her approach, it is possible that through further exposure to supervised therapeutic practice, her current limitations will resolve.

    2. How should he prepare himself to respond to Leanne’s anticipated request for a reference?

    Before Patrick decides how to respond, it is vital that he has thought through the points raised above. If he is to provide a clear and helpful response to Leanne’s anticipated request, he needs to be able to communicate what the contents of his reference might be and what evidence this would be based upon. He would benefit from using the CORBS approach to organizing his feedback as follows:

    • Clear: About the feedback that needs to be given to Leanne about what a reference from him would and would not include.
    • Owned: Presented in a way that indicates recognition that the feedback is based on perception rather than truth (e.g. ‘‘In my opinion…’’ versus ‘’You are…’’).
    • Regular: Hopefully, Patrick’s feedback will resonate for Leanne based on the formative and summative feedback that she has received throughout supervision.
    • Balanced: Balancing positive and negative feedback so that Leanne is clear about her strengths as well as development needs.
    • Specific: Patrick needs to be clear about the evidence upon which he would be basing his reference, and able to supply particular instances upon which he is basing his evaluation.

    Although it is important to avoid forming impressions about a therapist’s competence too early in supervision (some areas of competence can only be adequately assessed over time), it is possible that Patrick failed to reflect on his concerns early enough. He may lack confidence in providing feedback, possibly falling into the common trap of providing insufficient feedback, and is now facing a dilemma as a result. Using role-plays to hone his skills in giving feedback to supervisees might, therefore, be a useful approach in his own supervision.

    Appendix 7: Recommendations for Case Study 7

    Nina is a participant in a monthly peer supervision group and is also the manager of the service. She has responsibility for the trainees who attend the group. The trainees are unable to raise questions, another individual is supporting a friend within the group and Nina experiences conflict between her role as manager and member of the peer group.

    One way of conceptualizing this dilemma is that the relationships in the group are being experienced as increasingly unsafe for the participants. It is important, therefore, to explore how to establish a sense of safety. The pointers for good practice provided by Beinart (2004; see Chapter 7) might enable Nina to reflect on this issue. In particular, she would benefit from considering:

    • What steps she has taken to establish a sense of safety (a safe base) in the group.
    • How much time she devoted to establishing the relationship between members in the early stages.
    • How she has contracted to clarify responsibilities, expectations, objectives and methods of evaluation.

    Through this exploration, Nina may discover that the group has evolved in a haphazard way, rendering its purpose somewhat unclear. For example, originally it may have been a vehicle to encourage staff to share their formulations so that Nina could assess the quality of their work. However, as the staff became more experienced, she may have delegated the role of chairing the meetings as a means of developing members of her team. Later, it may have been decided that the trainees would benefit from hearing how experienced therapists present their cases. Without a clearly thought through rationale, this ‘organic’ evolution may have contributed to the group feeling unsafe. If this is so, then it will be important for Nina to discuss with her colleagues how they set up the group and determine its functions, and how it might need to operate differently in future. One approach to this task would be to seek the group’s permission to review what is, and is not, working well for each member. Sharing Beinart’s principles of good practice as a means of reviewing the work, and using each of the questions as a prompt for discussion, may make it easier for members to share more openly where their concerns lie.

    As part of this process of exploration, Nina could usefully introduce models that seek to understand different relationships, experiences and learning styles and to identify methods and processes of learning that might better meet the needs of trainees and experienced therapists. (It is unlikely that the needs of all the members will be adequately met by the same methods.)

    Once a sense of safety has been sufficiently restored to enable collaborative decision-making, members will need to revisit the function of the supervision group and decide whether it should continue in its current form. It is important that while Nina maintains a collaborative approach to resolving this dilemma, she also accepts her role as the leader of the service in order to manage both the process of discussion and any solutions identified. If, following discussion, it emerges that Nina unwittingly allowed an ‘unsafe base’ to emerge, her willingness to take responsibility for her role in shaping an unhelpful learning environment will be important as a means of engendering a sense of trust.

    It will be helpful for Nina to remember that supervisory relationships need to be continually renewed and that not all colleagues value, or benefit from, the same approach. Nina should also remember that in order for supervisory relationships to flourish, it is essential to create a safe learning environment which will require clear contracting between all members of the group.

    Appendix 8: Recommendations for Case Study 8

    In this scenario between Patrick and Seiko, there are a number of factors in operation. The five recommendations in Table 6 (Chapter 8) on how to make power visible provide a possible way to progress. To recap, these are:

    • Discuss power openly when you are establishing the supervision contract.
    • Discuss the different forms of power, how they might manifest in supervision and what represents the ethical use of these.
    • Anticipate ways in which the unhelpful use of power could manifest in supervision and any unhelpful reactions that could emerge from this.
    • Ensure that you have adequate time for self-reflection when maladaptive power issues begin to emerge.
    • Ensure you have consultation in place to provide you with ‘supervision on your supervision’ when you suspect that power issues are manifesting in unhelpful ways.

    Given their past relationship, an initial consideration of role dilemmas could have usefully occurred in setting up the supervision contract. A standardized approach to contract setting would not necessarily address concerns where a previous line management relationship existed. Patrick could have drawn upon his ambivalence about becoming Seiko’s supervisor to initiate a discussion with her. This would have given Seiko an opportunity to express any concerns that she harboured.

    Recommendations 1–3 above would have assisted that original discussion and can now be reintroduced. Seiko’s request for a change of supervisor provides an opening to revisit the contract, acknowledge their inauspicious beginning and consider how to take things forward. It will be important for Patrick to acknowledge openly that Seiko is not experiencing the supervision as helpful. He could highlight that the way the contract was set up originally failed to take account of their previous relationship and any concerns she might have had about this.

    There is also the issue of Patrick’s own prior perspectives. He sees Seiko as ‘diligent’ and ‘rigid’, whereas she sees staying true to the protocol as a matter of fidelity and integrity. Patrick, in questioning Seiko’s approach, may be tapping into a belief about the importance of fidelity. In undermining this belief, a potential vicious cycle may come into play (fuelled by the cognition ‘‘Why is my supervisor treating me like this?’’). Any perceived injustice may also be experienced by Seiko as the exercising of coercive power. Patrick needs to address this quickly before Seiko seeks remedies to correct any perceived injustice. He needs to work with Seiko to acknowledge the importance of fidelity to the model, but also to consider occasions when it operates as guidance rather than as a mandate. This step needs to precede any attempt to ask Seiko to explore the current case material differently.

    Patrick could also provide examples of where he has worked within a protocol and where he has felt the need to move outside it. He needs to be sensitive, though, to cultural issues at play between him and Seiko. She may well have particular views on what a supervisor should do and what she can expect of that relationship, including what can, and cannot, be shared. Nonetheless, opening a full discussion around the role of protocols in CBT can enable a discussion about when moving away from a protocol is, and is not, helpful. To support this process, it might be useful to examine the current case from different perspectives, with Patrick adopting the role of committing to follow the protocol and Seiko the role of exploring deviations from it to discover what new perspectives might emerge.

    Patrick needs to consider how he may be playing a role in setting up difficulties for Seiko through his prior perception of her as ‘rigid’. Recommendations 4 and 5 above would be helpful at this point. In the same way that he might ask a trainee to consider positively connoting a client’s negative behaviour, he could do the same for himself in relation to Seiko. What is positive in the challenge she is making? How might this be important feedback to him? There may also be a parallel process in operation. Specifically, Seiko may be experiencing some element of discrimination from Patrick that he is not aware of, just as Patrick views Seiko as being unaware of the client’s sense of discrimination.

    It will be important to explore openly the issue of the role of power in this relationship and to establish a new contract in which Seiko is given explicit permission to feed back to Patrick any concerns. Equally, it will be necessary for Seiko to acknowledge Patrick’s responsibility to raise legitimate concerns and that these are designed to be helpful rather than an attack on her integrity.

    Appendix 9: Recommendations for Case Study 9

    Patrick is supervising Jason, who brings a case that is concerning him. Jason finds that his client wants to talk about his childhood experience of foster care whereas Jason believes he needs to treat the client’s PTSD. Jason is angry with Patrick for not providing the supervision he believes he needs. Patrick in turn is starting to dread supervising Jason, labelling him as narcissistic.

    In attempting to understand this scenario, it is clear that a pattern of resistance has been established. As this has not been addressed, a rupture in the working alliance is increasingly likely and needs to be managed before any effective client-related decision-making can occur.

    At this point, we would strongly advise Patrick to draw on the support of a colleague who can provide ‘supervision on his supervision’; strong reactions have been evoked within him which will hamper his ability to engage in more impartial decision-making and increase the risk of ‘retaliation’ against Jason’s perceived attack on his supervisory skill. With this in mind, we consider how Patrick might work with his supervisor using Hersted and Gergen’s (2012) approach to de-escalating the emerging animosity and restoring productive relations. This could be approached as follows.

    De-construct the realities

    Patrick is tending to locate the problem in Jason, labelling him as ‘superior’, ‘entitled’ and ‘narcissistic’. A good starting point, therefore, may be to ask Patrick to tell the story from Jason’s perspective to see what this might reveal. It is probable that Jason feels under pressure to complete the work and is ‘running out’ of allocated sessions. He is relatively new to therapeutic practice and encountering resistance from his client is likely to have evoked anxiety. In the context of his career stage, Jason may be looking to Patrick as a ‘saviour’ (see Chapter 9), expecting him to provide a solution, whereas Patrick is not really responding to the dilemma that Jason presents (‘I am running out of time and getting nowhere’).

    De-polarize the differences

    Having ‘heard’ the story from Jason’s perspective it might be possible for Patrick to consider some potential benefits in Jason’s view and acknowledge that there are different interpretations of the same event. If Patrick can do this for Jason, then it may also become possible for Jason to reflect on the story from the client’s perspective (‘Here is a client who was abandoned at the scene of an accident by his friends; he took the blame for them. He also describes being placed in foster care and may have experienced feelings of abandonment then which have been triggered by the current situation’). Jason is not letting his client discuss this so perhaps the client feels let down again – first his parents, then his friends and now his therapist. He may also believe that he is being blamed by Jason for his lack of progress in therapy.

    Search for commonalities

    Having worked through this process with his supervisor, Patrick might now be able to ask Jason to work with him in order to identify possible shared goals, values or outcomes. If this occurs, Patrick could then ask Jason to do the same with his client.

    Avoid using power

    If these conversations happen, exploration of the power position becomes possible. How might Jason experience Patrick? Does he believe that Patrick is using his power to determine what happens in supervision? How might Patrick be experiencing a sense of powerlessness in responding to Jason? This exploration, if successful, could open up a further conversation between Jason and his client on the issue of power.

    Focus on the ‘we’

    Jason is new to the CBT community and part of Patrick’s role is to initiate him into that culture. This includes how to manage sessions where resistance appears to be present. Helping Jason to recognize why resistance might occur could help him see its value in providing feedback that he is not fully hearing the client. This outcome is more likely where Patrick models that behaviour by ensuring Jason feels fully heard. Helping Jason to recognize when it may be necessary to re-contract both with clients and the sponsors of the intervention is an important lesson. It is possible that the service cannot help this client because it is too restrictive in its time limits. If so, understanding other referral options may be necessary and Jason can learn how to make a referral without further reinforcing the client’s sense of abandonment.

    Appendix 10: Recommendations for Case Study 10

    In this scenario, Moses has completed an effective piece of work focused on his client’s low mood and symptoms of depression. However, the client has raised a new issue, which is well beyond what was contracted. Surprised by this, Moses is unsure how to respond and may have been overwhelmed by the distress he witnessed. He has indicated that he will not tell the school or the client’s parents about her fears, although he has made it clear that he must talk to his supervisor.

    There are a number of dilemmas here that map on to the Supervision Flower. In Petal 1 we have a possible clash of values and beliefs. In Petal 2 there is the context of work, which now involves child protection issues, relationships with the client, her parents and the school, and the training programme. In Petal 3 we have the nature of the contract negotiated. This matter is beyond the original contract and it is important to consider what was negotiated about disclosures.

    It is clear that there are external frameworks that would apply here – a possible forced marriage may raise child protection issues. The client’s intent to run away also raises concerns of a child protection nature. Additionally, there is the matter of confidentiality. A child aged 15 would almost certainly be considered by the courts as competent to make her own decisions to seek professional help without disclosure to her parents (see Gillick competency and Fraser guidelines: Gillick v West Norfolk and Wisbech Area Health Authority, 1985). There are a number of universal principles in play relating to respect and responsibility which are owed to several parties in this case.

    There is also the matter of ethical maturity. Moses is a trainee and his supervisor and training programme owe him a duty of care. His ability to negotiate the issues involved needs to be considered and some clear learning is possible once the immediate concerns are resolved. Such cases can sometimes prompt an over-reaction – a rush to turn a situation into a child protection matter (and therefore another’s responsibility) rather than a response to the evidence presented (for example, how real are the threats of forced marriage or running away?).

    A number of courses of action are possible here. First, we would recommend that Patrick re-examines the nature of the relationship between the training establishment and the placement setting and the requirements concerning disclosures. Using Epstein’s List (see Chapter 10), he can then support Moses in thinking through the nature of the contract he has with his client.

    Assuming that Moses had established a therapeutic contract that had clarified the limits of confidentiality, Patrick could direct Moses’ attention to who should now be included in a wider circle of participation and what would seem right to him, ethically, in managing this. The possibility of exploring this further with the client, while also making it clear that the matter falls beyond the remit of the original contract and Moses’ own area of competence, should also be considered. The purpose of any discussion would then become one of helping the client identify and approach an appropriate person in the school with whom to discuss her concerns. If Moses is prepared to attend this meeting, he is able to sensitively hand over the case to someone who has the necessary expertise. (NB: Forced marriage is illegal. In making the referral to the school all parties will need to take account of the current legislative position; see www.gov.uk/forced-marriage.)

    By avoiding directing Moses to a particular stance, Patrick can avoid coming across as imposing a unilateral authority and work with Moses to arrive at a thoughtful plan which respects the client’s position and his own ethical values. Moses could be encouraged to affirm the client for raising her concerns and at the same time respect his own position and his client’s by stating clearly that this is not an area in which he has the necessary competence to provide support or advice.

    Finally, Patrick could help Moses prepare for his next meeting with the client by role-playing the conversation and various scenarios, including helping her take the matter to someone appropriate within the school. During the meeting, it would be containing for Moses if Patrick agreed to make himself available to be called upon, if needed.

    Following this, it would be important for Patrick to encourage Moses to reflect upon what he had learned from this situation. Patrick could helpfully affirm both the anxiety that this situation must have caused Moses and his ability to remain focused on the needs of his client, as well as validating the positive work that has been accomplished.

    Appendix 11A: Recommendations for Case Study 11

    This scenario brings together our two fictitious supervisors, with Patrick seeking Nina’s services in order to refine and enhance his skills as a CBT supervisor. Through reading Chapters 111, you will have become familiar with their practice, as well as their individual strengths and needs.

    Based on recent dilemmas that she has encountered (see Chapter 3), Nina would be well advised to attend carefully to contracting so that she can be clear about what Patrick needs and wants from ‘supervision on his supervision’. Since she has no connection with his place of work, and this is a private arrangement for the purpose of development, she will need to explore how he sees his skills before establishing a contractual basis for any work that follows.

    A good place to start would be to ask Patrick to undertake a self-assessment of his supervisory knowledge and skill, which could provide the basis for a subsequent discussion about areas of development need. One option is to introduce Patrick to models which describe the stages of supervisor development and then ask him to consider his own stage in relation to this. Nina could also ask him for specific examples from his practice that he believes are indicative of this stage of development (including examples where he has been most and least effective in his supervisory practice). She might also usefully draw on some of the exercises in Chapter 1 in order to better understand Patrick’s ‘brand’ of CBT and CBTS.

    Nina could then request some samples of his supervisory practice, clarifying any formal arrangements for recording supervision sessions in his service. Assuming this is possible, she might propose that they both rate the session according to the criteria specified by a particular measure. This will not only give Nina a sense of Patrick’s work as a supervisor, but also enable her to establish his capacity for accurate self-assessment as a basis for determining objectives for their work together. Corrie and Worrell’s Supervisor Evaluation Scale (see Appendix 11B) would be a useful instrument for gaining an initial sense of Patrick’s style and level of performance. Rating a specific supervision session will also enable Nina to gauge Patrick’s reaction to feedback. Does he, for example, welcome this or react negatively to perceived challenges to his practice?

    Based on how Patrick has conducted himself in the previous chapters, we might anticipate that he is keen to learn. We might also anticipate that he is able to identify himself as a Level 1 supervisor (see Stoltenberg and McNeill, 2010; Chapter 11), who tends to treat aspects of the task separately rather than seeing them holistically. As a result, he can be inconsistent in his judgements (his work with Seiko and Jason in Chapters 8 and 9 suggest this) and can struggle with feedback that appears hostile or challenging to his own sense of competence. As Nina becomes aware of these areas of need, she may decide that in addition to the general terms of the contract she wants to specify that the supervision process will include ongoing access to recordings of his practice. In determining learning objectives for supervision, Nina might also suggest honing their focus to one or two particular areas that could be subjected to observational analysis, such as examining samples of recordings of supervision sessions using the ORCE process. Furthermore, she might seek to include an agreement from Patrick that he will consider all feedback from her as formative for his development rather than as an attack on him. Where she senses a negative reaction, she then has permission to share what she is sensing, with Patrick agreeing in advance to step back from the emotion and explore what is giving rise to his reaction.

    If these initial conversations progress well, it would be useful for Nina and Patrick to formalize their agreement, in writing, for a specified period of time, following which they agree to review their work together with the option to continue if both agree.

    Appendix 11B: The Supervisor Evaluation Scale (Corrie and Worrell)

    The Supervisor Evaluation Scale (SES) tracks the development of a supervisor’s abilities as delivered in the context of a specific supervision session. It is intended as a tool for self-monitoring of professional development as well as for more formal evaluation. For this reason, it is important to use the SES on a regular basis to ensure both familiarity with the dimensions being assessed and the self-tracking of competence development.

    Because CBT is now widely regarded as comprising a broad and diverse range of scientifically grounded approaches, rather than a single unified approach, CBT supervision is equally likely to include a variety of practices and approaches as a function of the type of CBT being practised and the context in which supervision is provided. For example, effective CBT supervision for a supervisee who is reasonably new to therapeutic practice and is learning CBT as part of an IAPT training would look very different from schema-focused supervision for an experienced therapist delivering their interventions in a personality disorder unit. For this reason, the SES avoids a narrow, prescriptive approach to competence in favour of a series of broad domains in which the supervisor is afforded considerable flexibility in how the competence is demonstrated.

    How competence is assessed

    The SES scale has incorporated Dreyfus and Dreyfus’s model of skill acquisition, which is described in detail in their book Mind over Machine (Dreyfus and Dreyfus, 1986). The way in which this has been adapted to assess supervisor competence is outlined in the table below. Please note that the highest marks (i.e. near the ‘expert’ end of the continuum) are reserved for those supervisors demonstrating highly effective skills, particularly in the face of difficulties (e.g. significant process issues that are impacting on the supervision session, performance management issues, or situations where the supervisor needs to manage and repair ruptures in the supervisory alliance).

    It is important to note that any score awarded is not intended as a comment on the general skills, competences or abilities of the supervisor. Rather, it is a statement about the extent to which specific skills were demonstrated within a particular session.

    The pass mark is 36 or above. To account for the fact that it is possible to provide a competent and effective supervision session without securing a minimum score on each dimension, there is no minimum score required for each of the 12 dimensions assessed.

    Dreyfus & Dreyfus Competence LevelScoreTranslation of Competence Level into Features of Supervisor Performance
    0The skill or feature is not displayed in this session.
    Incompetent (0–1)1The supervisor commits significant errors and displays poor and/or unacceptable behaviour, resulting in negative consequences for the supervision session. The supervisor’s performance is highly problematic, and major problems with the supervisor’s style, approach or choice of intervention are evident.
    Novice (1–2)2The supervisor displays a rigid adherence to taught rules and is unable to take account of situational factors. The session is characterized by a lack of discretionary judgement about how to adapt the content and process of the session in light of contextual factors, such as the supervisee’s developmental stage and service setting. Effective use of pacing and timing, as well as the management of the session are not evident.
    Advanced beginner (2–3)3The supervisor demonstrates evidence of competence, but this is inconsistent. The supervisor treats all aspects of the task separately and gives equal importance to each aspect, rather than prioritising. There is evidence of some degree of situational perspective and discretionary judgement but this is inconsistent and at times, the supervisor appears to be more attached to their own agenda than fostering supervisee learning.
    Competent (3–4)4The supervisor is able to link the tasks of supervision to a specific conceptual framework. He/she makes plans within this framework and uses standardized and routinized procedures appropriately. The session demonstrates a good degree of competence despite minor fluctuations in performance.
    Proficient (4–5)5There is evidence that the supervisor sees the supervisee’s needs holistically, is able to prioritise tasks and make ‘on the spot’ decisions that are responsive to the supervisee’s needs. The supervisor is clearly skilled and able, and demonstrates a highly effective degree of competence at a number of points during the session.
    Expert (5–6)6The supervisor demonstrates excellent performance. He/she evidences a well-developed, tacit understanding of key issues and is able to use novel problem-solving techniques and creative interventions to facilitate supervisee learning. The skills are demonstrated consistently even in the face of difficulties (e.g. performance management issues, ruptures in the supervisory alliance, supervisee avoidance).

    © Corrie and Worrell, 2012

    Domains of supervisor competence assessed by the SES

    The measure assesses four broad categories, or domains, of supervisor competence. These are as follows:

    • A.Session Structure and Planning (three questions)
    • B.Facilitation of Supervisee Learning (three questions)
    • C.Development of CBT-Specific Competences (three questions)
    • D.Management of the Session (three questions)

    These are described below.

    Category A. Session Structure and Planning (Questions 1–3)

    Session Structure and Planning is concerned with those factors that enable the supervisor to structure and plan the session in order to meet the educational and support needs of the supervisee to best advantage. The supervisor is expected to: (1) display an awareness of and sensitivity towards the context in which the supervisee is delivering their therapy; (2) negotiate appropriate session aims; (3) structure the session appropriately in light of this; and (4) plan the content of the session to facilitate the needs of the supervisee and their client/s.

    Category B. Facilitation of Supervisee Learning (Questions 4–6)

    Facilitation of Supervisee Learning examines the supervisor’s ability to accommodate the generic learning needs of the supervisee as an adult learner at a particular stage of their career development. The questions in category B are concerned with the ‘goodness of fit’ between the style and content of supervision and the supervisee’s development needs. As such, this category taps into the supervisor’s ability to formulate their supervisee’s competence level and learning needs, and to adapt their approach accordingly. For example, attempting to use guided discovery to instruct the therapist in a skill of which they do not have prior knowledge and where direct instruction would be preferable would be considered an example of poor competence on this category. A balance between guided discovery, direct instruction and supervisor ‘modelling’ of specific CBT competences needs to be demonstrated here, as does the use of supervisee feedback (direct and indirect) to modify the approach taken. The supervisor’s use of any specific CBT models of supervision to inform choice of supervision strategy (such as Padesky’s Road Map or Bennett-Levy’s Declarative-Procedural-Reflective model) is also assessed in questions 4–6.

    Category C. Development of CBT-Specific Competences (Questions 7–9)

    Development of CBT-Specific Competences is the skill with which specific supervision interventions are delivered that would be recognizable as CBT-informed (e.g. the supervisor’s use of questioning techniques that encompass the Socratic style of questioning, use of particular interventions such as setting up a behavioural experiment, setting homework, etc.). Unlike Category B which is concerned with demonstrating generic supervisor competences, Category C is concerned with the extent to which the learning opportunities provided in the session are consistent with the style of CBT being supervised (i.e. fidelity to the model), the use of specific methods of change to foster specific CBT competences and the methods used to foster reflective practice.

    Category D. Management of the Session (Questions 10–12)

    Management of the Session examines the skill with which the supervisor manages process issues arising in the session and adapts the pacing, structure or content of the session in light of this. As such, the supervisor creates the potential for any process issues to become valuable sources of learning and development. The supervisor’s effectiveness in providing feedback, appropriate use of humour to aid learning, interpersonal effectiveness and management of any ruptures, as well as management of the pacing and timing of the session, are considered under this category.

    Appendix 12: Recommendations for Case Study 12

    In this case study the primary purpose was to help you to think about your own CPD and we have suggested ways to do so. We also asked you to consider how you might advise Patrick and Nina based on knowledge of their casework.

    Patrick’s needs

    Throughout the book, we have seen examples of Patrick being keen to do the right thing but at times becoming defensive when challenged. In this situation he tends to take a stand on his own position rather than explore the other’s point of view. On several occasions we have seen a need for him to collaborate more. A mentor to support him at this stage of his development has been suggested.

    Looking at his casework we might help him reflect upon:

    • How he ‘Prepares’

    For example, in case study 1 with Jen, the issue ‘is he best placed to support?’ was raised. He needed to have spent more time in the Preparation stage thinking about how to set up the working alliance. We saw Patrick’s tendency to become defensive when challenged rather than seeing Jen’s reactions as valuable feedback. This could come across as failing to value the other’s position.

    These issues were further elaborated in case study 2 with Ben. Patrick clearly wanted to support Ben and the service in which he operates, but had not sufficiently thought through the context for the work.

    • 2. How he ‘Undertakes’

    An issue arose in case study 6 with Leanne where there was insufficient clarity on the definition of competence. Patrick also appeared to lack confidence in giving feedback. Greater familiarity with both competence models and methods for giving feedback would be helpful to him. Possibilities might be to spend more time using the range of competence tools available (referenced in the text). He perhaps could also spend some time setting up opportunities to create ‘safe to fail’ experiments on giving feedback using tools such as CORBS.

    • 3. How he ‘Refines’

    The work Patrick undertook with Seiko raised issues about how he had set up the contract initially – there were clearly gaps that, based on their past relationship, should have been addressed. Each came with assumptions which were neither explored nor tested. However, we also saw in Patrick a tendency to blame Seiko when things started to go wrong, with his attributing the cause to her ‘rigidity’. He struggled with the issue of power and needed to consider his own role in setting up difficulties. A similar issue was raised in his work with Jason where he quickly labelled Jason’s resistance as ‘narcissistic’ rather than seeing it as feedback. A mentor was suggested to help him deal with his own reactions and de-escalate the potential rupture. There is perhaps an opportunity for Patrick to begin to use tools such as OCRE to explore specific reactions in his case work and build into his CPD plan opportunities to get feedback on specific patterns in his behaviour.

    • 4. How he ‘Enhances’

    Case study 10, working with Moses, encapsulates the range of difficulties that can emerge if the Preparation, Undertaking and Refinement of the work are not attended to fully. Patrick was faced with a dilemma of how to support Moses without directing him to a solution at the same time as dealing with his responsibilities to the client, Moses and the service setting. Reflection on this case would enable Patrick to enhance his practice on each of these issues and to be sure he pays attention to his own needs as part of his CPD Plan.

    Nina’s needs

    We have seen examples of Nina getting into some bad habits. She has shown that she can deal with complex material and is dedicated to supervision. Nonetheless, her experience has led her on several occasions to be less than careful with the basics in terms of how she sets up supervision contracts.

    Looking at her casework, we might help her reflect upon:

    • How she ‘Prepares’

    An issue arose in case study 3 with Jas where there was insufficient clarity on the definition of what was included in the contract. Assumptions were made by Nina that did not sufficiently take account of the fact that Jas was new to this process; his assumptions needed to be fully explored. A similar issue arose in case study 7 in the supervision group, where matters were allowed to drift to the point where supervision became unsafe. Helping her to reflect on the basics of brand, context and contract might be difficult given Nina’s experience. Nonetheless, with experience come shortcuts. Since she is committed to supervision, recognizing when her shortcuts need to be challenged would be helpful.

    • 2. How she ‘Undertakes’

    In case study 4 we saw how Nina needed to pay attention to the ongoing relationships. Issues of sensitivity to the emotional climate in the group and how to monitor the ongoing psychological safety of the supervisees were raised. This issue was also featured in case study 5 with Sandra. The dual relationship was not sufficiently explored in the preparation and attention to how she assessed Sandra’s work and the development of the ongoing relationship became problematic.

    • 3. How she ‘Refines’

    Case studies 4 and 5 raised questions about how Nina seeks to refine the work as it progresses. Issues of power in case study 5 and resistance and potential rupture in case study 7 were important points for reflection.

    • 4. How she ‘Enhances’

    Case study 11 with Patrick encapsulates Nina’s need to be really clear about how she contracts with her supervisees. Setting this work up carefully would be central to ensuring an effective arrangement for the future.

    A useful approach for Nina across all the cases would be to set up opportunities to undertake a STAR analysis of her casework. In particular, she could usefully pay attention to how issues emerge, not just what emerges. It seems that problems can emerge in her work because she is not sufficiently prepared and it would be important for Nina to understand this tendency in order to avoid drift. This might enable her to enhance her practice as well as ensure appropriate self-care and the care of her supervisees.

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