History and context

Clinical supervision emerged from classical psychoanalysis and has been recognised as such since at least the 1920s. It has been integrated to at least some degree, with varying levels of success and in multiple forms, into the practice (or the espoused practice) of all of the professions using psychotherapeutic or counselling frameworks. Substantial reference to clinical supervision can thus be found in the literature of psychotherapy, counselling, mental health nursing, social work, psychology, occupational therapy and medical psychiatry.

The literature is vast. A simple search of the mainstream literature databases will produce approximately 20,000 references to the subject spread across the literature of the various disciplines, with a predominance in the psychotherapy/counselling literature. It is difficult to accurately categorise such a wealth of writing, but areas of focus include ethical issues, practice examples, descriptions of models, issues around the specific characteristics of supervision (particularly as it interacts with management), and the effects or outcomes of supervision.

Definition and focus

While supervision is variously defined, and as Rich (1993) points out "no single definition or theory exists by which to describe its meaning, methods or purpose uniformly", there are common core threads to the definitions. Platt-Koch (1986), warning of the misconceptions that abound, pointed out that "one cannot learn how to interact with a patient solely by reading a book" and identified the goals of supervision as developing the therapist's knowledge base, clinical proficiency and professional autonomy.

With due deference to the wise epithet that the whole is always greater than the sum of the parts, some appraisal of the functions and purpose of supervision is necessary to justify its existence and to guide inquiry and evaluation, especially as we enter an era in which co-location of the supervisor and supervisee is not guaranteed, and thus the supervisor's knowledge of the context of the supervisee's work is likely to be entirely based on the reports of that supervisee.

Description of clinical supervision is, not surprisingly, varied, but it is possible to marshal much of the salient descriptive literature under an adaptation of the widely accepted headings proposed by Proctor (1986).

Regulatory (Normative)

This aspect of clinical supervision is perhaps prone to the most intense debate, involving as it does the boundaries between organisational/managerial, professional and 'clinical' supervision. Cottrell (2002), drawing upon the supervision rhombus proposed by Ekstein and Wallerstein (1972), points to the suspicion and mistrust that can accompany perceived managerial influence in supervision or collusion between the supervisor and management. Nevertheless fostering adherence to some code of conduct is a legitimate aspect of supervision and, furthermore, is the aspect most likely to engender organisational support (Butterworth & Woods, 1998).

Developmental (Formative)

The imparting of information and the development of expertise are recognised as key components of supervision by the majority of authors, although contributors differ as to the importance placed on these functions. The work of Consedine (1994), which has been hugely influential in New Zealand for well over a decade, focuses on the role development of the supervisee.

Supportive / restorative

This aspect of supervision is perhaps closest to the original intent inherent in its psychodynamic origins (Faugier, 1992) - supervision developed to assist psychotherapists to work through issues arising from their work with patients and the nature of the relationship between supervisor and supervisee, with particular focus on issues of transference and countertransference. The work of Ekstein and Wallerstein (1972) elucidated, in this context, the important notion of parallel process.

Integral to the concept of clinical supervision is the notion that the patient must be the focus of the exercise. In reinforcing the importance of that focus, Yegdich (1999) emphasises that the supportive aspect of supervision is, and must remain, distinct from therapy.

Caveats and difficulties

In parallel to the therapeutic relationship, there are potential pitfalls in the supervisory relationship. Salvendy (1993) draws attention to inherent power differentials between supervisor and supervisee and the consequent potential for abuse in such relationships. More recently, Cottrell (2002) draws attention to potentially problematic implementation issues in organisational contexts.

Evaluation and assessment of supervision

There is strong support in the literature that supervision is beneficial for the supervisee. Authors including Hallberg (1994) and Butterworth, Carson et al (1997) have used measures such as the Maslach Burnout Inventory to demonstrate effectiveness of clinical supervision in improving staff morale and attitude. With the exception of the recent work of Bambling and King (2001), however,which demonstrates improvements in therapeutic alliance (the most robust indicator of therapeutic outcome) related to clinical supervision, little has been done to effectively demonstrate that clinical supervision produces benefits for patients.

On-line supervision

The growing popularity of on-line psychotherapy and its accompanying literature has yet to give rise to a substantial study of on-line supervision. Indeed, the field of on-line supervision is in its infancy and has yet to acquire agreed parameters.

One of the more established groups, the International Society for Mental Health Online, has done considerable work under the mantle of on-line case study and consultation (Fenichel, Suler et al. 2002). Goss and Anthony (2003) include comprehensive accounts of supervision via discussion board and email (Fenichel, 2003) and supervision via video and telephone (Armstrong & Schnieders, 2003) in their edited book "Technology In Counselling and Psychotherapy: A Practitioners Guide". Others have provided various forms of supervision as part of counselling-related courses, generally as complementary to face-to-face supervision (Stebnicki and Glover, 2001; Stofle, 1998).

It is worth noting that opportunities for what could be described as peer supervision have been available and utilised for some time in the form of individually or service-initiated email exchanges and the various email lists. An example of the latter is the International Psychiatric Nursing Email List, started by Prof. Len Bowers in 1994. (Bowers, 1997; Davidson, 1998a, Davidson 1998b).

Issues with on-line supervision

Many of the potential advantages and disadvantages of on-line supervision parallel those of on-line therapy. The emerging literature and experience in on-line forums point to the following issues:

Advantages

• Email communication provides a permanent record, to which all parties can refer.
• there is considerable potential saving in costs associated with face-to-face supervision, such as travel.
• Communication can be asynchronous, giving both supervisor and supervisee the opportunity to consider questions and responses.
• Potential choice of supervisor is wider.
• Offers supervision opportunities to isolated practitioners.

Disadvantages

• Email communication is notoriously open to misinterpretation and requires some care with language which is not modified by facial expression or body language. Idiom and usage vary internationally
• Because of the permanence of the record, the nature of electronic communication and the likelihood that supervisory relationships will be formed outside service boundaries, particular attention to confidentiality is required.

There is no doubt much to be discovered in both the pitfalls and potential of on-line clinical supervision. While it may in fact appeal to many for some of the reasons outlined above, it should be noted that on-line communication is not of course limited to typed email text. Use of videoconferencing may appeal to some users and may resolve some of the problems of email communication.

References

Armstrong P and Schneiders L (2003). Video and Telephone Technology in Supervision and Supervision in Training in Goss & Anthony (2003) op cit

Bambling M and King R (2001). "Therapeutic alliance and clinical practice." Psychotherapy in Australia 8(1).

Bowers L (1997). "Constructing International Professional Identity: What psychiatric nurses talk about on the internet." International Journal of Nursing Studies 34(3): 208-212.

Butterworth T and Woods D (1998). Clinical Governance and Clinical Supervsion; working together to ensure safe and accountable practice, School of Nursing, Midwifery and Health Visiting, University of Manchester.

Butterworth T Carson J White E Jeackock J Clements A Bishop V (1997). It is good to talk. An evaluation of clinical supervision and mentorship in England and Scotland. Manchester, School of Nursing, Midwifery and Health Visiting, University of Manchester.

Cohen, J. (1992) A Power Primer. Psychological Bulletin 112(1)155-159

Consedine M (1994). Taking the next step; The selection, development and training of nurses to provide supervision for role development in mental health nursing. 20th Annual Conference of the Australian and New Zealand College of Mental Health Nurses, Brisbane.

Cottrell S (2002). "Suspicion, resistance, tokenism and mutiny: problematic dynamics relevant to the implementation of clinical supervisionin nursing." Journal of Psychiatric and Mental Health Nursing 9: 667-671.

Davidson B (1998a). "Using the internet forum: a case study." Mental Health Practice 1(7): 25-29.

Davidson, B. (1998b) The Internet and the Large Group Group Analysis 31[4] pp.457-471

Ekstein R & Wallerstein R (1972). The teaching and learning of psychotherapy. New York, Basic Books.

Faugier J (1992). The Supervisory relationship. Clinical Supervsion and Mentorship in Nursing. B. T. a. F. J. London, Chapman and Hall.

Fenichel M, Suler S , Barak A, Zelvin E, Jones G, Munro K, Meunier V, Walker-Scmucker W. (2002). "Myths and realities of on-line clinical work." Cyberpsychology and Behaviour 5(5): 481- 498.

Fenichel M (2003). The Supervisory Relationship On-line in Goss & Anthony (2003) op cit

Goss, S & Anthony, K. (2003) Technology In Counselling and Psychotherapy: A Practitioners Guide. Basingstoke, Palgrave.

Hallberg IR (1994). "Systematic clinical supervision in a child psychiatric ward: Satisfaction with nursing care, tedium, burnout and the nurses' own report on the effects of it." Archives of Psychiatric Nursing VIII(1): 44-52.

Platt-Koch L M (1986). "Clinical supervision for psychiatric nurses." Journal of Psychosocial Nursing 26(1): 204-208.

Proctor B (1986). Supervision: A co-operative exercise in accountability. Enabling and Ensuring. Marken M and P. M. Leicester, National Youth Bureau for Education in Youth and Community Work.

Rich P (1993). "The form, function and content of clinical supervsion." The Clinical Supervisor 11(1): 137-198.

Salvendy J T (1993). "Control and Power in Supervision." International Journal of Group Supervision 43(3): 363-375.

Stebnicki M A and Glover N M (2001). "E-supervision as a complementary approach to traditional face-to-face clinical supervision in rehabilitatiob counselling: problems and solutions." Rehabilitation-Education 15(3).

Stofle G (1998). "On-line Supervsion for Social Workers." The New Social Worker 5(1).

Winstanley J (2000) Clinical Supervision: development of an evaluation instrument. Unpublished PhD thesis, Faculty of Medicine, Dentistry and Nursing, University of Manchester

Winstanley J and White E (2002) Clinical Supervision: models, measures and best practice.

White E, Butterworth T, Bishop V, Carson J, Jeacock J and Clements A (1998) Clinical Supervision: insider reports of a private world. Journal of Advanced Nursing, 8:1, pp85-192

Yegdich T (1999). "Lost in the crucible of supportive clinical supervision: supervision is not therapy." Journal of Advanced Nursing 29(5): 1265-1275.

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online-supervision.net research team
20 July 2003