Supervisors’ experience of delivering individual clinical supervision to qualified therapists: a meta-ethnographic synthesis

Publication Date03 May 2019
AuthorGemma Forshaw,Rachel Sabin-Farrell,Thomas Schröder
SubjectHealth & social care,Mental health
Supervisorsexperience of delivering
individual clinical supervision to qualified
therapists: a meta-ethnographic synthesis
Gemma Forshaw, Rachel Sabin-Farrell and Thomas Schröder
Purpose The purposeof this paper is to systematicallyidentify, appraise and synthesisequalitative literature
exploring the experience, both positive and negative, of clinical supervision from the supervisors perspective.
Design/methodology/approach A systematic search of three databases, grey literature, reference lists
and citations was conducted. Six articles met the inclusion criteria and their quality was critically appraised by
using a modified version of the Critical Appraisal Skills Programme tool. Data extracted from the articles were
synthesised using meta-ethnography.
Findings Four key themes were identified: experiencing difficulties in clinical supervision, responsibility,
similarities to therapy and capabilities as a supervisor. These demonstrated that the role of a supervisor has
the potential to be both beneficial and harmful to personal and professional development.
Research limitations/implications The quality of the studies was variable. Further research is required to
explore how supervisors manage difficult experiences to ensure personal development and growth.
Practical implications Clinical implications include the need for employers to consider the additional
pressure associated with providing clinical supervision and to ensure that appropriate support is available.
Results complement previous research on the bi-directionality of parallel process in clinical supervision.
Originality/value This review presents an original synthesis of the supervisors experience of delivering
clinical supervision to qualified therapists. This is achieved by utilising a systematic methodology and
appraising the quality of the studies included. The review highlights how the effects of clinical supervision are
not limited to the supervisee, but also experienced by the supervisor. The competing demands and
responsibilities associated with clinical supervision impact upon the supervisors experience, both positively
and negatively. When beneficial, delivering clinical supervisioncan lead to personal and professional growth in
addition to the acquisition of new skills.
Keywords Qualitative research, Qualitative synthesis, Meta-ethnography, Supervisor perspective, Supervision
Paper type Literature review
The Division of Clinical Psychology (BPS, 2014) defines supervisions primary purpose as
safeguarding the service-user, ensuring they receive quality treatment and care. Secondary
objectives include: professional development, acquiring additional skills, facilitating reflection and
individual support. Elaborating upon the primary objective, supervision serves to ensure
supervisees are adhering to good practice and receive assistance for their formulation,
re-formulationand delivery of intervention.Whilst frequently confused with managerial supervision,
clinical supervision does not involvea managerial agenda (Adams etal.,2003).Clinicalsupervision
is defined as the formal provision by senior/qualified health practitioners (or similarly experienced
staff) of an intensive, relationship-based, education and training that is case-focused and which
supports, directs and guides the work of colleagues (supervisees)(Milne, 2007, p. 440).
For this review, the term supervision will refer to clinical supervision.
Supervision can occur both individually and in group settings. Group supervision has the
advantage of generating richer sources of feedback, reflections and contributions, provided by
Received 6 September 2018
Revised 11 February 2019
Accepted 26 February 2019
Gemma Forshaw,
Rachel Sabin-Farrell and
Thomas Schröder are all based
at the Division of Psychiatry and
Applied Psychology, The
University of Nottingham,
Nottingham, UK.
DOI 10.1108/MHRJ-09-2018-0028 VOL. 24 NO. 1 2019, pp. 51-68, © Emerald Publishing Limited, ISSN 1361-9322
PAG E 51
multiple clinicians, reducing dependency or over-influence of a supervisor (Hawkins and Shohet,
2006). However, providing supervision in a group format may hamper a supervisors ability to
deliver best practiceas group processes can be detrimental to supervisory processes: feelingsof
shame may be exacerbatedwhen revealing shortcomings, and rivalrymay occur when discussing
successes (Borders, 2014; Gautier, 2009; Hawkins and Shohet, 2006). Hence, individual
supervision has been found to facilitate deeper reflection and learning (Ögren et al., 2014).
There are documented discrepancies between different disciplines in using supervision, e.g.
practice guidelines regarding format, duration, and frequency (British Association for Counselling
and Psychotherapy, 2010; BPS, 2014; Inman et al., 2014).
The effects of supervision extend beyond supervisees to their clients; beneficial effects for clients
include symptomreduction and increased ethicalpractice of their therapist (Bradshaw et al., 2007;
Lichtenberg,2007; Watkins, 2011). Supervisionhas been found to promote skill development and
enable therapiststo explore their emotionalresponses to clients, increasingtheir ability to effectively
manage therapeutic processes without distraction (Ögren and Jonsson, 2004; Vallance, 2005).
Negative experiences of supervision have been found to contribute towards poor therapist-client
relationships, an alliance shown to highly correlate with client outcome (Lambert and Barley,
2001; Ramos-Sánchez et al., 2002). Much of the literature has received criticism for lack of
follow-up and methodological flaws (Freitas, 2002; Watkins, 2011). Nonetheless, it highlights the
potential sequalae of difficulties in supervision towards clients.
The theory of parallel process provides one explanation of the importance of supervision for client well-
being. It is based on the psychodynamic concept of transference, where the dynamics of one
relationship are unconsciously mirrored into a different relationship (Bernard and Goodyear, 2009).
Thus, the superviseeclient relationship in therapy is reflected within supervision ( Jacobsen, 2007), in
turn, affecting both supervisees and supervisors experience of process. To prevent supervisory and
consequent therapeutic ruptures, it is critical that supervisors identify such incidents (Koltz et al., 2012;
Rubinstein, 1993). Parallel process can occur bi-directionally, bottom-up (client-therapist-supervisor)
and top-down (supervisor-therapist-client), and the point of origin can occur with any participant within
the supervisory triad (Ekstein and Wallerstein, 1958; Searles, 1955). Whilst the notion of parallel
process originates from psychodynamic theory (Morrissey and Tribe, 2001), the phenomenon has
been identified within other orientations (Raichelson et al., 1997) and has been described as
supervisions most influential concept (Binder and Strupp, 1997). By understanding a parallel process,
supervisees can better comprehend their work with clients and parallel treatment-supervision
difficulties can be explored and addressed (Carroll, 1996; Watkins, 2017). As this phenomenon is not
limited to supervisees, supervisors experiences are also of interest.
The current literature predominantly relates to trainees; however, supervision is governed by the
supervisees career stage (Wheeler and Richards, 2007). Trainee therapists must act as clinical
subordinates; however, the consequent power imbalances can be damaging to the supervisory
relationship (Kilminster and Jolly, 2000; Nelson and Friedlander, 2001; Worthington, 1987).
In addition, supervisors contribute to decisions about traineesprogression on their training
courses (BPS, 2007). Once such dominant evaluative roles are absent, power imbalances should
reduce (Aryee et al., 2008). Thus, the current literature exploring supervision cannot be
generalised to qualified staff (Green and Youngson, 2003).
To summarise supervisors have multiple tasks withinsupervision, requiring them to adoptan array
of roles whichcan be influenced by numerous factors:first, whether their superviseeis qualified or in
training; in the latter case, the supervisors role incorporates being an evaluator (BPS, 2007).
Second, supervisors are expected to govern and assure the quality of their superviseestherapy
delivery (Flemingand Steen, 2013). Third, supervisorsare required to provide a reflectivespace for
their supervisees, exploring the emotional experience of working therapeutically with clients
(Wheeler, 2007). In addition, the supervisor must also manage the dynamics of the supervisory
relationship (Pearson, 2000). Furthermore, whilst supervision is for the superviseesbenefit,
providing it may have implications for the supervisor (Wheeler, 2007). Yet a minority of research
pertaining to supervision considers supervisorsexperiences (Nelson and Friedlander, 2001).
Understandingtheir perspective would generatea greater knowledge of the componentsrequired
to deliver quality supervision and the potential difficulties or obstacles faced (Trede et al., 2014).
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VOL. 24 NO. 1 2019

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