Sandra E Stewart, PhD, Lecturer in Psychology, Monash University, Counselling and Clinical Psychologist, MAPS, and Janette G Simmonds, PhD, Senior Lecturer in Psychology, Monash University, Counselling and Clinical Psychologist, MAPS.
Introduction
Supervision has long been viewed as essential to good practice in psychotherapy and counselling (Bernard & Goodyear, 2014). Accreditation bodies require that trainees practice under supervision and many professional associations require ongoing supervision to maintain registration: for example, the Psychotherapy and Counselling Federation of Australia (PACFA) and the British Association of Counselling and Psychotherapy (BACP). In some theoretical orientations (e.g., psychoanalytic), ongoing supervision is mandated (Watkins, 2015).
Earlier substantive reviews found little evidence of the benefit of supervision for clients, calling into question the importance of supervision (Frietas, 2002; Kavanagh, Spence, Wilson & Crow, 2002; Wheeler & Richards, 2007). More rigorous research has linked quality of supervision with client outcomes (Bambling, King, Raue, Schweitzer & Lambert, 2006; Bambling, 2014) and benefits of supervision to therapists have also been reported, including increased awareness of self and others, greater capacity to cope with anxiety, improved self-efficacy, and more developed case conceptualisation and intervention skills (Ladany, Mori & Mehr, 2013; Ronnestad & Orlinsky, 2005). Such findings highlight the importance of supervision for both therapists and clients.
Despite the importance of supervision, trainees and practitioners do not always experience supervision as helpful (Orlinsky & Ronnestad, 2005). Ineffective supervision can be damaging for any therapist but for trainees in particular by increasing the stress they experience with client work and reducing their professional confidence (Orlinsky & Ronnestad, 2005). Greater understanding and delivery of effective supervision is clearly essential for both therapist wellbeing and quality of practice.
Most supervision research has employed convenience samples of therapists in training with under five years’ experience, which is not sufficient for full understanding (Skovholt, Ronnestad & Jennings, 1997). In contrast, only a few studies have focussed on experienced therapists. This situation is problematic given that most service delivery is by registered therapists in clinical settings. Findings from several survey studies indicate that most practising therapists engage in some form of supervision (group or individual) and experience at least moderate satisfaction with supervision (Ashworth, Williams & Blackburn, 1999; Grant & Schofield, 2007; Townend, Iannetta & Freeston, 2002). Beyond reports of frequency of uptake and satisfaction, important questions remain, including therapists’ commitment to supervision, regularity of supervision, engagement in supervision across the career, and the influence of supervision on professional development (Hill & Knox, 2013; Wheeler & Richards, 2007).
One approach to understanding effective supervision is from the perspective of therapists themselves. In a phenomenological study (Weaks, 2002), experienced practitioners reported viewing the supervisory relationship as “of paramount importance … to the experience of good supervision” (p. 36). Three core conditions of a good supervisory relationship were identified: safety (e.g., feeling comfortable, non-threatened); equality (e.g., an equal powerbase in the supervisory dyad); and challenge (e.g., neither too comfortable nor too paternal/maternal, providing a different perspective).
Retrospective reports from highly regarded senior therapists have been used to understand factors that influence professional development (e.g., Jennings & Skovholt, 1999; Skovholt & Jennings, 2004). In such studies, factors such as personal therapy, ongoing supervision, life experience and exposure to client work have been identified. This approach has foundations in the expert performance literature (Ericsson, 2009; Ericsson, Charness, Feltovich, & Hoffman, 2006) and is based on the premise that highly regarded senior therapists are “exemplars” of effective practice. From an expert performance perspective, highly proficient professionals with at least ten years’ or 10,000 hours experience can uniquely illuminate the factors that facilitate optimal professional development. Thus, retrospective reports of highly regarded senior therapists about influences on their practice and development across the career are likely to be an information-rich source of understanding about effective supervision.
Rationale and Study Aims
The aim of this paper is to report on research capturing highly regarded therapists’ experiences and perceptions of supervision at three points in their career using purposive, theoretical sampling (Patton, 2015) based on the expert performance framework using both experience and proficiency dimensions. Sampling along both dimensions permits greater confidence that the interviewed practitioners meet criteria for expertise in that they have sufficient experience and are deemed high quality practitioners, thereby permitting greater confidence in the conclusions that can be drawn based on the findings.
On the experience dimension, a beginner was a therapist with less than five years’ experience, taken from the point of entry into specialist counselling training (e.g., Master’s or Doctoral level study), a mid-career therapist was one with less than 10 years’ experience (to capture therapist experience approaching the ten year experience dimension); and a senior therapist was one with at least 15 years’ experience but preferably substantially more (to capture experience well beyond the ten year differential and across the career). Sampling three cohorts captures both ends of the novice-expert continuum, as well as the in-between experience of mid-career therapists, and also enhances trustworthiness by (a) providing an alternative perspective about participants’ experience at different career points (e.g., all three cohorts can report on experiences of being a beginner) and (b) mitigating the limitations of retrospective recall across the career, which can span decades.
On the proficiency dimension, sampling was done by peer nomination on the basis of knowledge of client work (e.g., successful referral or client report, as opposed to awards or publication record). Peer nomination has been criticised because it does not measure therapist performance by client outcomes; however, in the absence of client outcome data for therapists in the community, peer nomination is one of few methods available to identify therapists likely to be high quality.
A qualitative interview approach allows for fresh understanding and exploration of experience and can provide rich, descriptive information that can be used to develop theory; it is therefore well suited to understanding the complex influences on therapist development. The specific research question addressed was: “How do highly regarded therapists, at three points on the career path, describe the role and influence of supervision in their practice and on their development?”
Method
Participants
The sample comprised highly regarded therapists in three cohorts (N = 23): six beginners (< 5 years’ experience), six mid-career (7 – 10 years’ experience), and eleven senior ( > 25 years’ experience). Participants were practitioners who had completed accredited Australian training and had eligibility for professional registration, or were in training towards accreditation as a therapist. All participants worked primarily with individual adults, and subscribed to “therapist” as their primary anticipated or current professional role (as opposed to trainer, manager, researcher, other). Summary demographic information is presented in Table 1, including age, years of practice, full time equivalent face-to-face contact, training, highest academic qualification, professional affiliation, main theoretical orientation, and practice setting.
ID |
Cohort |
Pseud. |
Age (yrs) |
Sex |
Practice (yrs) |
% Full-time |
Professional Affiliation |
Highest Qualification |
Theoretical Orientations |
Practice Settings |
T1 |
Senior |
Sarah |
59 |
F |
35 |
90 |
Psychology Social work |
Masters |
Psychodynamic Systemic/postmodern |
Private practice Community health centre |
T2 |
Senior |
Ingrid |
63 |
F |
28 |
50 |
Social work |
Bachelor |
Systemic/postmodern |
Private practice Community welfare agency |
T3 |
Senior |
Carolyn |
59 |
F |
26 |
20 |
Psychology |
Masters |
Systemic/postmodern |
Community welfare agency |
T4 |
Senior |
Richard |
64 |
M |
24 |
60 |
Psychology |
Masters |
Cognitive-behavioural |
Private practice University counselling service |
T5 |
Senior |
Graeme |
69 |
M |
49 |
0 |
Psychology |
Masters |
Humanistic |
Recently retired (late 2011) |
T6 |
Senior |
Joanne |
57 |
F |
26 |
100 |
Psychology |
Masters |
Psychodynamic |
Private practice |
T7 |
Senior |
Amy |
57 |
F |
14 |
30 |
Social work |
Masters |
Systemic/postmodern |
Private practice |
T8 |
Senior |
Valerie |
55 |
F |
30 |
50 |
Social work |
Masters |
Systemic/postmodern Cognitive-behavioural |
Private practice Youth mental health |
T9 |
Senior |
Angela |
53 |
F |
36 |
60 |
Psychology |
Masters |
Psychodynamic |
Private practice Private consulting agency |
T10 |
Senior |
Julia |
58 |
F |
25 |
80 |
Psychology |
Masters |
Psychodynamic |
Private practice Not-for-profit organisation |
T11 |
Senior (NFT)a |
Leanne |
67 |
F |
17 |
20 |
Volunteer (none) |
None |
Eclectic |
Community welfare agency |
T12 |
Mid-career |
Leone |
47 |
F |
9 |
90 |
Counselling/psychotherapy |
Postgraduate Diploma |
Humanistic |
Not-for-profit organisation |
T13 |
Beg. |
Pamela |
29 |
F |
4 |
40 |
Psychology |
4 + 2 Internshipb |
Cognitive-behavioural Systemic/postmodern |
Psychology training clinic Community welfare agency |
T14 |
Mid-career |
Andrea |
47 |
F |
8 |
90 |
Psychology |
Masters |
Humanistic |
Secondary school |
T15 |
Mid-career |
Helen |
48 |
F |
6 |
20 |
Counselling/psychotherapy |
Masters |
Humanistic |
Private practice |
T16 |
Mid-career |
Mary |
52 |
F |
8 |
90 |
Social work |
Bachelor |
Humanistic |
Not-for-profit organisation |
T17 |
Mid-career |
Sonya |
52 |
F |
10 |
40 |
Counselling/psychotherapy |
Graduate Certificate |
Eclectic |
Private practice |
T18 |
Mid-career |
Nancy |
57 |
F |
9 |
75 |
Counselling/psychotherapy |
Masters |
Systemic/postmodern |
Community welfare agency |
T19 |
Beg. |
Neil |
26 |
M |
1 |
60 |
Psychology |
Mastersb |
Cognitive-behavioural |
University counselling service |
T20 |
Beg. |
Jane |
41 |
F |
1 |
20 |
Psychology |
Postgraduate Diploma |
Humanistic |
Community welfare agency |
T21 |
Beg. |
Adam |
28 |
M |
1 |
60 |
Psychology |
Mastersb |
Eclectic |
Primary school University counselling service |
T22 |
Beg. |
Chloe |
34 |
F |
1.5 |
40 |
Psychology |
Mastersb |
Undecided |
University counselling service |
T23 |
Beg. |
Selina |
29 |
F |
2.5 |
40 |
Psychology |
Professional Doctorateb |
Humanistic |
University counselling service |
Recruitment
The target sub-sample of ten senior therapists was first recruited using peer-nomination and snowballing through the researchers’ extended professional networks. Twenty-two key informants (e.g., practice managers, supervisors, trainers, practicing therapists) nominated peers according to criteria adapted from Jennings and Skovholt’s (1999) study of master therapists as follows:
From an initial pool of approximately 90 potentially-eligible nominated therapists, ten met eligibility criteria and had two or more independent nominations (e.g., from different organisations). One highly regarded volunteer therapist was also included. Using the same criteria, the target sub-sample of six mid-career therapists was then recruited, followed by the target sub-sample of six “promising” beginners who were nominated by supervisors and course leaders at three training institutions.
Data analysis
All excerpts coded as “supervision” were then analysed as a discrete data set. Inductive content analysis was first undertaken at the level of semantic meaning, guided by the analytic question “What did this therapist say about supervision?” (Braun & Clarke, 2006). Frequency tables (Lynass, Pykhtina and Cooper (2012) were then developed to summarise the codes at a semantic level and provide a snapshot of similarities and differences in therapists’ responses from beginner to senior.
Thematic analysis was then undertaken. The entire supervision data set was read in the order the interviews were conducted. On a second pass, the data set was re-coded to reflect more detail about supervision. On a third pass, like-codes (e.g., Listening, Empathy) were grouped under provisional theme titles (e.g., “Helpful Supervision”) ensuring that the full data set was incorporated. Themes were then refined using an iterative process of checking against the source text and code names to better represent therapist responses. Disconfirming codes were incorporated to capture the complexity of the data set (e.g., the provisional theme “Helpful Supervision” was changed to “Helpful/Unhelpful Supervision”). Themes were developed taking into account both frequency of mention (i.e., how often therapists mentioned certain codes) and importance (i.e., how much weight therapists attributed to certain codes). Theme names were finalised by reading the entire supervision data set to check that themes fully captured therapists’ responses. Finally, excerpts were chosen to illustrate each main theme.
A codebook was developed to ensure that code definitions were sufficiently comprehensive and clear for another rater to code the text similarly. Inter-rater reliability was calculated with a practicing psychologist with experience in qualitative research and found to be acceptable (r = .78) (Guest, MacQueen, & Namey, 2012).
Ethical considerations
University ethical approval and written, informed consent were obtained. Pseudonyms are used for participants with identifying details removed.
Findings
Four themes were identified: Essential to Good Practice; Reflective Space; Relational Influence; Helpful/Unhelpful Supervision. Each are discussed in turn.
Theme 1: Essential to Good Practice
Supervision was viewed as essential to good practice by all but one therapist, and was described as a privilege rather than an obligation.
Theme 2: Reflective Space
Therapists’ perceptions of the role of supervision are presented in Table 2.
Table 2. Therapists’ perceptions of the role of supervision
Response |
Senior. |
Int. |
Beg. |
Total. |
Enhance self-awareness |
7 |
6 |
6 |
19 |
Understand and manage dynamic processes |
6 |
6 |
7 |
19 |
Reflection |
5 |
4 |
3 |
12 |
Encouragement, support and validation |
2 |
3 |
2 |
7 |
Assess capacity for work |
3 |
1 |
2 |
6 |
Deal with difficult clients |
2 |
2 |
1 |
5 |
Self-care |
2 |
2 |
4 |
|
Discuss ethical concerns |
3 |
3 |
||
Challenge and extension |
3 |
3 |
||
Balance caseload |
1 |
1 |
2 |
|
Devise alternatives |
1 |
1 |
2 |
|
Staying open |
1 |
1 |
||
Discuss end of career issues |
1 |
1 |
||
Gain knowledge |
1 |
1 |
||
Navigate training |
|
|
1 |
1 |
Note. Figures reported refer to the number of therapists mentioning a particular response. |
GRAEME: I know that [dynamic processes] are reciprocal as well, and that I constantly gotta be reflecting on my own processes to deal with the transferential elements…. I was in both therapy and supervision during virtually all the time I worked as a therapist…. And with my therapist it had more of a direct therapeutic focus, and in my supervision we’d be talking more about this client and your relationship with that client and stuff. (Humanistic, Senior)
To a lesser extent, supervision was valued for encouragement, support and validation; self care; discussing ethical concerns; challenge and extension; managing caseload and devising alternatives. Mid-career and senior therapists valued supervision that was less technical than for beginners and more focused on understanding the impact of “self” on the therapeutic process.
LEONIE: I’m more interested in supervision that’s not just about content, it is a lot about you … a “supervisory-therapy” is what perhaps I’m looking for now, rather than it just being “Tell me about your cases.” (Mid-career).
Conversely, role modelling and support was more highly valued by beginners.
CHLOE: … having a good working alliance with a supervisor or mentor is unbelievable … having somebody that you respect, somebody experienced, open, [who] embodies a lot of the elements about the good therapist … somebody who’s got empathy, … [can] be supportive in your learning, just as a therapist is supporting somebody learning about themselves and their behaviours (Beginner).
Theme 3: Relational Influence
Participants reported being highly interconnected through past or present group or individual supervisory relationships. Not only did therapists perceive supervision as the cornerstone of effectiveness, they also reported it as highly formative in their professional development. Supervisory relationships were described with reverence, reflecting a level of appreciation much deeper than collegial respect. To conceptualise the nature and extent of the influence of supervisory relationships in this sample, Figure 1 was developed.
Figure 1. Web of influence and connection
INGRID: …my lifelong supervisor – I’ve had lots of supervisors of course, which has been great – but the one I chose was someone who had a lot to teach me about the part that was lacking in me … it feels like it was pretty unconscious then … but I couldn’t have made a better choice. (Senior)
Two of Ingrid’s supervisees (also participants) spontaneously described the formative experience she had provided them, an experience that appeared to mirror her own as a supervisee:
LEONIE: I can’t imagine who I’d be if I hadn’t had the supervisor I did to start with… I just know she was absolutely the right person for that starting out, because she was so encouraging. She was just perfect (Mid-career).
Theme 4: Helpful/Unhelpful Supervision
Although not prominent in the analysis, there were some descriptions of what was helpful and unhelpful in supervision. In particular, beginners reported that a lack of validation was undermining.
NEIL: Sometimes supervision of [complex] clients has been overwhelming … you think “I did pretty well today” and then you’ll have your supervision and it’s like, “that wasn’t validated … and now I feel like crap.” (Beginner)
Finally, the ideal supervision was seen as balancing challenge and support:
MARY: Having [a supervisor] ask questions that prompt me to really reflect and think about what’s actually going on … Helpful supervision helps me to get more clear about what I’m feeling, what the client might trigger in me … my feeling of inadequacy or “stuckness” or whatever. (Mid-career)
Discussion
This research explored 23 highly regarded therapists’ experiences and perceptions of supervision at three points in the career. Four themes were identified: Essential to Good Practice; Reflective Space; Relational Influence; and Helpful/Unhelpful Supervision.
Overwhelmingly, participants perceived supervision as essential to good practice; conversely, that lack of supervision risked unethical practice. This finding is consistent with survey data of Australian therapists in which 80% of respondents reported that personal therapy and supervision were important influences on their development (Schofield & Roedel, 2012), although participants in the present study described supervision as their most valued developmental influence. Participants’ perspectives were also consistent with the view that supervision is foundational to ethical practice (Barnett & Molzon, 2014).
Supervision was described primarily as a reflective space for deepening one’s self-awareness, with the aim of better understanding relational dynamics between therapist and client. Most participants assumed the ubiquity of dynamic processes in the therapeutic encounter, despite their explicitly-stated theoretical orientations. Although such a view of the role of supervision has psychodynamic foundations (Watkins, 2015), participants reported various theoretical orientations (see Table 1), indicating an implicit integrative approach (see Norcross & Goldfried, 2005).
A complex web of interconnectivity amongst participants through supervisory relationships was evident. Interconnectivity is an inevitable consequence of peer-nomination and snowballing within a specific geographical region; nevertheless, connections were via supervision (e.g., “She was my supervisor”) rather than collegial acquaintance (e.g., “We worked together”). Consistent with Australian survey data (e.g., Grant & Schofield, 2007), this finding points to a strong culture of supervision within this therapeutic community, within which the acquisition and maintenance of therapeutic competence occurred via valued supervisory relationships (as opposed to via professional development or training events, for example). Similar findings regarding the influence of supervision relationships within therapeutic communities on professional expertise were reported in New Zealand (Annan & Ryba, 2013).
Formative, long-term supervisory relationships were reported by half of the senior therapists in the present sample. Although long-term supervision might be expected to be more likely for psychodynamically-oriented therapists (Watkins, 2015), participants’ theoretical orientations included postmodern and humanistic, within which long-term supervision might not be expected. This finding was not due to a single, highly influential supervisor because three highly influential supervisors were described.
The value of ongoing mandated supervision has been questioned in the literature (e.g., McMahon & Patton, 2002), particularly for therapists with relatively light caseloads. In contrast, the present findings indicate that a successful supervisory relationship, similar to that described by Bordin (1983), can support career longevity and professional growth. The findings are thus consistent with previous studies highlighting the primacy of the supervisory relationship (Ladany et al., 2013; Weaks, 2002) and underscore the importance and desirability of supervision.
The present findings are reassuring in that they demonstrate that supervision can be experienced as beneficial when supervisors with positive experiences offer the same to their supervisees. The descriptions of developmentally-appropriate supervision in which beginners were provided with relatively more support and encouragement, with a balance of support and challenge, are largely consistent with previous literature (e.g., Bernard & Goodyear, 2014).
Limitations and contributions
These findings must be considered in light of inherent methodological limitations; primarily, that a qualitative paradigm does not allow generalisation beyond the sample. This research adds to the supervision literature about post-training supervision, and specifically about the role and influence of supervision in one Australian therapeutic community. Rich, descriptive information is provided about highly-regarded therapists’ perceptions of and engagement with supervision, for both their long-term growth and their immediate therapeutic work. The study also provides a novel contribution by capturing the perspectives of both members of a number of supervisor/supervisee dyads.
Future Research
Although the therapists in this sample valued supervision, the extent to which therapists in general engage in and value supervision remains uncertain; particularly regular, planned, individual, supervision as described in this study. Present survey research is limited in the number of studies conducted and the response rates reported. It is also likely that therapists who complete surveys may be those who value supervision (Grant & Schofield, 2007). Further research to establish rates of engagement in supervision is clearly required, and the question of whether it is possible to practice competently and ethically without supervision remains of key interest.
Given the powerful influence of the practice community on practitioner development reported in this study, further examination of the role of practice communities appears warranted. Furthermore, given that this community was located within a metropolitan area, questions about developmental influences for rural and remote practitioners not in close physical proximity particularly are raised: are those practitioners disadvantaged?
Numerous dissatisfactions with workplace supervision were raised by the therapists in this sample. Given that supervision can be costly when compared with weekly income, particularly for counsellors, on the basis of the present findings, organisations may be well advised to invest in non-evaluative supervision provided by qualified supervisors with clinical expertise. This would likely improve wellbeing and engagement of mid-career therapists, in particular, as they reported the highest demands of all therapists in this sample.
Supervision could be viewed as paralleling the role of coach or mentor in high performance domains (McMahan, 2014). Much has been learned about effective coaching in the acquisition of expertise (e.g., Farrow, Baker & MacMahon, 2008) and many world-class performers employ individual coaches (e.g., swimming, tennis). Research along these lines could inform understanding of “good” supervision.
Recommendations
The present study describes how highly-regarded therapists and promising beginners engage with supervision to their benefit. Participants’ descriptions may therefore serve as a model for practitioners wishing to optimise their own supervision. On the basis of the present findings, the following recommendations are made.
For practitioners
- Engage in regular supervision, regardless of level of experience, through to retirement.
- Actively seek supervision that meets your needs if the provided supervision is lacking, including external supervision in addition to workplace supervision.
- Seek supportive yet challenging versus evaluative supervision.
- Find a supervisor who themselves had a positive experience of supervision, values supervision, and desires to provide a formative experience for their own supervisees.
For organisations
- Provide in-house supervision by qualified, clinically experienced staff.
- Avoid the dual role of manager/supervisor.
- Offer or pay for external supervision where employed staff are not suitable or available.
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