Can supervision improve therapist competence?

A systematic review of evaluations of supervision in psychotherapy completed by Alfonsson and colleagues (2018) could find only one randomised controlled trial that demonstrated an effect of supervision on therapist competence and no studies that showed an effect on client outcomes. This week, these same authors (Alfonsson et al., 2020) published the results of their efforts to develop a structured CBT supervision program and evaluate its effects on therapist competence.

The study involved 6 therapists (2 counsellors, 4 psychologists) in a single-case experimental multiple baseline design. All therapists were involved in the study for 12 weeks and were randomised to a baseline phase without supervision of between 3-6 weeks, resulting in a weekly supervision phase of 5 to 8 weeks. Each therapist recruited two clients who agreed to have sessions recorded to evaluate the therapist’s competence.

The supervision intervention was guided by a structured manual consisting of 13 modules (an Introductory module and 12 topic modules). The topic modules corresponded to the different skills on the CTS-R (e.g., Agenda setting, Feedback, Collaboration, Pacing). Each module provided a rationale and description of the CBT skill, examples of how a supervisee might struggle with the skill, suggestions for how the supervisor might discuss and model the skill, and how role-plays could be used to practice the skill. Before the first supervision session, the supervisor listened to an audio recording of the supervisee’s session, and rated their strengths and weaknesses on the CTS-R. In session 1, the supervisor and supervisee agreed on the three priority areas from the CTS-R that supervision would work on. The supervisor listened to an audio recording of one of the supervisee’s sessions prior to each supervision session throughout the intervention. The supervision sessions focused on modelling and rehearsal and included setting homework for the supervisee for the following week.

The supervision phase was associated with significant differences of medium effect size in the areas of the CTS-R that were targeted in supervision. Areas that were not the focus of supervision did not significantly change. Participants reported high satisfaction with the supervision, finding concrete feedback and practical training the most helpful parts. Negative supervisee feedback concerned increased self-criticism and additional workload.

The study highlights that therapist skill improvements can be facilitated by targeted supervision incorporating direct feedback, modelling and rehearsal. It also demonstrates the intensity of training that may be needed to have broad effects on therapist competence; the improvements after 5-8 weekly sessions were moderate and restricted to three target microskills of CBT. Therapists’ experience of providing CBT ranged from 1 – 7 years (M = 2.8 years) so these were not beginner therapists, although only 3 of the 6 therapists’ average total competence scores on the CTS-R were in the competent range at baseline. It may be more realistic to expect that 20-30 supervision sessions might be needed to increase CBT competence across all foundational skills.

For those who might consider joining my study or referring a colleague to it, there are some similarities with Alfonsson et al.’s study: the first supervision session begins with a collaborative discussion of strengths and weaknesses to produce goals for the supervision and negotiates the balance of time to be spent between three key activities. My study also promotes the use of recording review and feedback, however admittedly not to the extent that Alfonsson et al. incorporate it. In my study, participants are required to produce video recordings for review prior to session 2 and 9 and invited to bring as many other recordings to other sessions as they wish which often results in only two video reviews occurring. Similarly, the session structure has some similarity with therapy sessions, beginning with agenda setting and ending with homework setting. However, there are some big differences between the studies. In my study, the primary dependent variable is change in client anxiety and depression symptom scores, rather than therapist competence. This is the first study to my knowledge to employ this design. Secondly, supervision in my study is less concerned with adherence to CBT fidelity than ensuring supervisees’ practice is internally consistent. That is, supervisees are free to formulate their cases using whatever framework they think is most apt, however, the process of supervision is designed to ensure the supervisee can explain their formulation and how their treatment plans derive logically from it, and that their experiences and knowledge of the client support their working formulation. Furthermore, therapists’ therapy-interfering beliefs and rules are usually a common component of supervision in my study (although this is part of what is negotiated in session 1). Unlike Alfonsson et al’s study, the supervision in my study is not intended to train supervisees: I assume supervisees have the skills to deliver good therapy, but usually busyness and therapy-interfering thoughts create blind spots and stuck points which once untangled, usually suggest clearer paths forward. However, one area that people usually benefit from rehearsal with is empathic confrontation of client therapy-interfering behaviour, so this is another common component. Finally, an important structural difference is that the supervision in my study occurs once per month for 10 months to approximate a typical supervision dose for those in Australia seeking to meet their AHPRA requirements.

Take home: Clinical Implications

supervision involving feedback on therapist audio recordings, modelling and rehearsal increased therapist competence in targeted CBT skills

• the effects of 5-8 weekly supervision sessions were moderate and limited to the areas targeted, even in therapists with 1-7 years experience of CBT

• to take part in a similar study looking at supervision as a means to improve client outcomes, go to: https://www.drmatthewsmout.com/supervision-intervention-study

For the original article, go to:
https://www.tandfonline.com/doi/full/10.1080/16506073.2020.1737571

REFERENCES
Alfonsson, S., Lundgren, T., & Andersson, G. (2020). Clinical supervision in cognitive behavio/r therapy improves therapists' competence: a single-case experimental pilot study. Cognitive Behaviour Therapy, 49, 425-438.

Alfonsson, S., Parling, T., Spannargard, A., Andersson, G., & Lundgren, T. (2018). The effects of clinical supervision on supervisees and patients in cognitive behaviour therapy: a systematic review.