Supervisory Alliance Research Articles

Associations Between Supervisory Alliance, Medical Resident Distress, Burnout, and Self-Esteem.

Supervision is considered a collaboration between a supervisor and supervisee and includes perceptiveness, responsiveness of the supervisor, a state of rapport, and specific learning tasks that allow the individual to work towards a goal. The alliance in supervision has been identified as a key ingredient of effective supervision, regardless of the type of treatment, population, or supervision model being used. While it is known that the medical training environment hosts high rates of burnout, little research has examined the role of supervisory alliance in regard to burnout, distress, and self-esteem. This study aimed to apply previous models of supervisory alliance to medical education, and explore associations between educational alliance and trainee self-esteem, burnout, and distress. Participants included 108 medical trainees (response rate = 81%). Medical trainees were recruited from a rural Pennsylvanian teaching hospital and asked to complete a voluntary and anonymous electronic survey. Multiple linear regression was used to examine the association between supervisory alliance and burnout and distress, while controlling for average hours worked and slept. Results suggested that supervisory alliance was associated with burnout, distress, and self-esteem among medical trainees. Given the high rates of depression and burnout among medical providers, it may be helpful to understand the factors that may impact medical trainee's distress and esteem. Future longitudinal research might examine the role of the supervisory alliance over time, and whether strong mentorship and guidance may serve to protect trainees from burnout throughout training and into their career.

Predicting Therapeutic Alliance: Supervisory Alliance and Supervisee’s Attachment Style

The aim of this study was to investigate how attachment styles and supervisory alliance predict the therapeutic alliance. Data was collected using The Therapeutic Alliance Scale, the Working Alliance Inventory: Trainee Form, and Attachment Styles in Interpersonal Relationships Scale. The study administered measuring instruments to 361 undergraduate counseling students (i.e., supervisees) from seven different state universities who had completed at least three counseling and supervision sessions. The data was analyzed using Pearson Product Moment Correlation Coefficient and Multiple Linear Regression analysis methods. The findings revealed that supervisees’ secure attachment styles positively and significantly predicted the therapeutic alliance. While the anxious-preoccupied attachment style did not significantly predict the goal and task sub-dimensions of the therapeutic alliance, it did significantly predict the bond sub-dimension and the total score of the therapeutic alliance. In contrast, the avoidant attachment style only significantly predicted the bond sub-dimension of the therapeutic alliance. Furthermore, the supervisory alliance was significantly predictor for all dimensions of the therapeutic alliance, as well as the total score.

Supervisees’ perspectives on countertransference-focused practices and processes in clinical supervision: an exploratory study

ABSTRACT This study examined 78 counseling and psychology supervisees’ perceptions of supervision practices and processes focused on identifying and managing countertransference (CT). They reported that most supervisors paid some attention to CT. They (a) rated supervisors who neglected it entirely as lower on effectiveness and (b) rated supervisory alliance higher when CT was addressed in at least 50% of the sessions. The study also categorized respondents’ reports of (a) what cues had signaled a CT event to them (12 categories: clustered into those concerning feelings, cognitions, and in-therapy behaviors) and (b) how their supervisors had responded to that event (seven categories).

Supervisory Alliance in Medical Training: Associations with Educational Engagement and Satisfaction.

While medical education requires frequent interactions with attending physicians and supervisors, little research has explored the role of supervisory alliance in the learning process. In other learning environments, supervisory alliance, or the bond between a supervisor and trainee, is considered a key ingredient of effective supervision. Medical educators or attending physicians who aim to enhance learning and engagement in medical education may benefit from understanding specific factors that increase or decrease engagement and how those might intersect within a context that requires learning through supervision. This cross-sectional study examined associations between supervisory alliance and (a) program satisfaction, (b) educational engagement, (c) and career purpose. Participants were medical trainees from the rural Northeast (n = 108, response rate = 81%) who completed an electronic and anonymous survey. Multiple linear regression was used to examine whether total supervisory alliance independently predicted behavioral and emotional engagement in learning while controlling for hours slept, hours worked, and burnout. Supervisory alliance predicted trainees' career purpose, program satisfaction, and emotional engagement in learning. Findings from this study lay groundwork for consideration of the role of supervisory alliance in medical learning processes. Future research might explore whether targeted mentorship programs or faculty enhancement training that focuses on the supervisory relationship might positively impact learning outcomes.

The Mediating Role of Attending Rapport on Bullying and Medical Trainee Burnout.

The aim of this study was to determine whether supervisory alliance (eg, rapport with supervisor) mediated the association between perceived bullying and trainee burnout. We administered electronic surveys to medical trainees (N=108) in a rural teaching hospital. The survey included measures of bullying, burnout, and supervisory rapport. Using Baron and Kenny's test of mediation with the Sobel test, we found that rapport with supervising attending partially mediated the relationship between bullying and burnout. This study reinforced the role of the attending physician and how perceived rapport may impact burnout. Given the high rate of bullying in medical training and the negative impact of burnout on physicians, further study is warranted to understand other factors that mediate the association between bullying and burnout.

Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies.

Exposure is an important element of treatment for many evidence-based treatments but can be challenging to implement. Supervision strategies to support exposure delivery may be an important tool to facilitate the use of exposure techniques; however, they must be considered and used in the context of the supervisory alliance. The present study examined relations between supervisory alliance and fidelity to the trauma narrative (TN; i.e., imaginal exposure) component of Trauma-Focused Cognitive Behavioral Therapy. We also examined how supervisory alliance moderated the effect of behavioral rehearsal use in supervision on TN fidelity. We analyzed data from a randomized controlled trial, in which forty-two supervisors and their clinicians (N = 124) from 28 Washington State community-based mental health offices participated. Clinicians were randomized to receive one of two supervision conditions-symptom and fidelity monitoring (SFM) or SFM with behavioral rehearsal (SFM + BR). Supervisory alliance alone did not predict delivery (i.e., occurrence) or extensiveness of delivery of the trauma narrative. Client-focused supervisory alliance moderated the effectiveness of behavioral rehearsal-as client-focused alliance increased, the odds of delivering the TN also increased significantly. Future research should further investigate how to appropriately match supervision techniques with supervisory dyads and explore the interplay of alliance with supervision techniques a supervisor might employ.

Exploring contracts and contracting within supervisor training

This article explores how to foster contracting as a process in supervision. It evaluates the teaching of contracting within a four-day supervision course at the University of Birmingham delivered over the last six years to 63 qualified Educational Psychologists. Two methods were used: a survey generating 20 responses and a focus group comprised of five participants, who elaborated on the results of the survey. The survey indicated a growth in confidence and knowledge about contracting. Helpful activities highlighted included modelling the use of a contract within the training, sharing examples of contracts and transcultural supervision activities. However, there was hesitation about the use of formal contracts to support the working relationship between supervisor and supervisee, indicating a need to support understanding of contracting as a process which enables and supports the supervisory alliance. As a result, the discussion introduces a model bringing three elements of contracting together, namely the formal contract, transcultural supervision activities and mini-contracting within sessions, as a process, with the outcome of promoting a strong supervisory alliance. The limitations to the research include the course being evaluated by those facilitating it and the limited number of respondents. The conclusions highlight the importance of being clearer about the elements of the contracting process and the need for an explicit link from the process of contracting to the quality of the supervisory relationship.

Positioning, power and agency in postgraduate primary care supervision: a study of trainee narratives

BackgroundPostgraduate supervision takes place within complex training environments, where experiences are shaped by the socio-cultural context and wider profession, and where tensions permeate. Bordin’s working alliance-based model of supervision suggests that quality relationships encompass agreement on the goals and tasks of supervision, in the context of an emotional bond. However, as trainees and their supervisors navigate the demands of providing safe clinical care, alongside educational support, disagreement on expectations for supervision may emerge. By applying a critical lens, this research draws on positioning theory to explore General Practice trainees’ experiences of supervision.MethodsIn 2017–2019 a series of narrative interviews were undertaken with 13 General Practice trainees in the United Kingdom (UK). Participants were purposively sampled based on end-of-year performance, gender, training location and training status. Interviews were analysed using Brown and Gilligan’s Listening Guide, which was adapted to incorporate an exploration of positioning, power and agency.ResultsTrainees appeared to hold variable positions, such as ‘insiders’, ‘outsiders’, ‘peers’ and ‘problem trainees’. Supervisors, through talk and the degree of access afforded, contributed to this positioning. Some trainees viewed their supervisors as brokers and guides as they navigated their training, whilst others were suspicious of the supervisor role. For trainees who raised concerns about their supervisor through formal channels, results were not often satisfactory. Others chose to navigate difficulty in supervision through informal means. This typically involved mastery of artefacts of training, such as the electronic appointment book or training portfolio.ConclusionsThis paper builds on Bordin’s model of supervision to encourage greater clarity in supervisory discussions, exploring assumptions, and recognising the influences of environment, power, positioning, and agency. We have developed a Model of the Supervisory Alliance in Postgraduate GP Training (MSA-GP) to serve as a springboard for discussion for trainees and their supervisors.

Psychometric evaluation of a pragmatic measure of clinical supervision as an implementation strategy

BackgroundValid and reliable measurement of implementation strategies is essential to advancing implementation science; however, this area lags behind the measurement of implementation outcomes and determinants. Clinical supervision is a promising and highly feasible implementation strategy in behavioral healthcare for which pragmatic measures are lacking. This research aimed to develop and psychometrically evaluate a pragmatic measure of clinical supervision conceptualized in terms of two broadly applicable, discrete clinical supervision techniques shown to improve providers’ implementation of evidence-based psychosocial interventions—(1) audit and feedback and (2) active learning.MethodsItems were generated based on a systematic review of the literature and administered to a sample of 154 outpatient mental health clinicians serving youth and 181 community-based mental health providers serving adults. Scores were evaluated for evidence of reliability, structural validity, construct-related validity, and measurement invariance across the two samples.ResultsIn sample 1, confirmatory factor analysis (CFA) supported the hypothesized two-factor structure of scores on the Evidence-Based Clinical Supervision Strategies (EBCSS) scale (χ2=5.89, df=4, p=0.208; RMSEA=0.055, CFI=0.988, SRMR=0.033). In sample 2, CFA replicated the EBCSS factor structure and provided discriminant validity evidence relative to an established supervisory alliance measure (χ2=36.12, df=30, p=0.204; RMSEA=0.034; CFI=0.990; SRMR=0.031). Construct-related validity evidence was provided by theoretically concordant associations between EBCSS subscale scores and agency climate for evidence-based practice implementation in sample 1 (d= .47 and .55) as well as measures of the supervision process in sample 2. Multiple group CFA supported the configural, metric, and partial scalar invariance of scores on the EBCSS across the two samples.ConclusionsScores on the EBCSS provide a valid basis for inferences regarding the extent to which behavioral health providers experience audit and feedback and active learning as part of their clinical supervision in both clinic- and community-based behavioral health settings.Trial registrationClinicalTrials.gov NCT04096274. Registered on 19 September 2019.

Exploring the Relationship Between the Supervisory Alliance and the Development of Reflexive Self-Awareness: A Mixed Methods Approach

Exploring the Relationship Between the Supervisory Alliance and the Development of Reflexive Self-Awareness: A Mixed Methods Approach

The changing face of telesupervision and digital training in response to COVID-19.

The COVID‐19 pandemic has rapidly changed the ways in which marriage and family therapists (MFTs)/couple and family therapists (CFTs) engage in clinical supervision. Traditional face‐to‐face supervisory relationships have transitioned to telesupervision, which refers to supervisors using the internet as a training medium for their supervisees. Supervisors and supervisees alike are necessarily adapting to telesupervision relationships in an evolving world. As emergency protocols begin to give way to more routine procedures, it is important for supervisors to engage in meaningful conversations around the benefits, the challenges, and the future of telesupervision. This article discusses the various facets of telesupervision, including ethical implications, supervision modalities, the virtual supervisory alliance, the impact of telesupervision upon self‐of‐the‐therapist work, and the potential benefits of telesupervision.

Therapists' experiences of a brief case formulation and alliance focused pre‐treatment training session (CALL)

AbstractObjectiveA general lack of supervision outcome studies and new advancements within therapist training methods inspired us to develop a randomised controlled trial, Case formulation and ALLiance (CALL), testing the efficacy of a brief pre‐treatment training session. CALL combines generic case formulation and alliance principles with the supervision of a specific client. This qualitative study acts as a preliminary to the randomised controlled trial and aims to explore psychologists' experiences of participating in CALL.MethodSemi‐structured interviews were conducted with seven psychologists in private practice, who participated in CALL between January and May 2020. The transcribed interviews were analysed using thematic analysis.ResultsThe psychologists described CALL as a clinically useful and collegial experience but simultaneously conveyed a lack of recollection of the training session and doubts as to its enduring utilisation.ConclusionCALL has the potential to positively influence the process and outcome of therapy through the fostering of case formulation and alliance management skills, as well as a strong supervisory alliance. However, the familiar content or brief format of the session, and participants' memory bias, may have limited the utilisation and recall of the intervention.

The association between political climate and trainees’ supervision experiences and needs

ABSTRACT This study examined whether political climate influenced trainees’ clinical work, supervisory experiences, and supervisory alliance. Data were collected from 366 trainees in a nationwide survey. Most trainees believed that the political atmosphere has affected clients to some degree. Over half reported political dialogue with supervisors, more often when political affiliation was similar. Supervisory alliances were most positive when trainees were aware of their supervisors’ political beliefs, regardless of agreement. Trainees wanted supervisors to provide greater awareness of multicultural issues and political climate in their clinical work. We recommend that supervisors invite trainees to discuss political effects on their clinical work.

Supervisor self-disclosure, the supervisory alliance, and trainee willingness to disclose.

Supervisor self-disclosure, the supervisory alliance, and trainee willingness to disclose.

CREATING THE PSYCHOTHERAPIST’S IDENTITY IN THE TRAINING AND SUPERVISION PROGRAM

Psychotherapists are humans, and humans have different personalities and identities. So not all psychotherapists are the same, they develop differently; they have different perspectives in life and go through different training programs. Psychotherapists discover during training what motivates them in their practice, what they need to accomplish, how they need to behave with clients, with colleagues, with supervisors. Identity is also shaped in training being challenged by development both in theory and in practice, but also in supervision being challenged by the supervisory alliance and by the therapeutic relationship with the client.

Narrative Philosophy of Supervision: Isomorphic Journey of Discovery and Identity

The collaborative process of supervision supports discovery of clinical identity and skill for the trainee and supervisor. It affords a bare space for both to explore self-of-the-therapist in and out of session by bringing to light their narratives. Also, it provides room to remedy their meaning making. Supervision unearths the essence of equafinality interwoven through the supervisory alliance relationship, which highlights that there is more than one way to learn and/or supervise. This notion of relationship grounds the writers research, clinical and supervisory skills, and role as a family therapist attempting to serve from a narrative framing. Within the writers journey of discovery and identity as a supervisor, she shares a framework on having a collaborative, compassionate, and contemplative lens that includes the voice of the family system and scaffolds the development of the trainee. Her therapeutic practice guides and gives room for trainees to lead in their identity growth.

The good, the bad, and the less than ideal in clinical supervision: a qualitative meta-analysis of supervisee experiences

ABSTRACT . With qualitative studies increasingly published on different aspects of supervision, this qualitative meta-analysis synthesized existing qualitative research and explored what aspects therapy trainees find helpful and unhelpful in individual supervision. A sample of 29 studies (755 participants) was selected by conducting a systematic literature search and a critical appraisal process to ensure a suitable level of methodological rigor. Data analysis followed a descriptive and interpretative framework. Results yielded 6 main meta-categories: three in the helpful aspects domain (i) Supervisor establishes a secure learning environment, (ii) Supervisor demonstrates ability to facilitate learning, and (iii) Supervisor demonstrates willingness and ability to acknowledge and negotiate differences; and three in the unhelpful aspects domain (i) Supervisor demonstrates behaviour that lacks sensitivity, accountability, and ethical consideration, (ii) Supervisor fails to create a safe and supportive environment, and (iii) Supervisor demonstrates limitations in the appropriate maintenance and sharing of knowledge and skills. Influenced by the quality of the supervisory alliance, supervision can be helpful, but it may also be experienced as unhelpful and potentially harmful. Issues of power and diversity need to be negotiated in a manner that maintains ethical and professional standards of practice and care. Implications for supervision training, practice, and research are discussed.

Group clinical supervision for nurses: process, group cohesion and facilitator effect

Objective: This qualitative research project set out to explore how, and by what means, participation in group clinical supervision might impact nurses. It aimed to describe participant perceptions of the processes within a long running reflective practice group for intensive care nurses and explore these in relation to relevant theory. Background: Interpersonal aspects of care are central to the nursing role, however, the associated emotional labour can develop into moral distress, compassion fatigue and burnout. Australia’s peak nursing and midwifery bodies have released a joint position statement on the importance of supervision for nurses. Group supervision interventions, such as reflective practice groups, mitigate stress, promote learning and support interpersonal aspects of nursing. Method: Twenty-two intensive care nurses from a reflective practice group that had been running for 10 years, participated in focus groups convened by an independent researcher. Thematic analysis identified key perceptions relating to process and outcomes. Results: Group identification, voluntary participation and skilled facilitation created an enabling environment for nurses to self-disclose. The sense of universality experienced by participants, along with increased empathy, enabled reflection and self-evaluation relevant to the group prototype of the ideal nurse. Authentic emotional expression was seen to provide respite from emotional labour, thereby regenerating resources for nurses to cope with job demands. Discussion: Key themes can be aligned to social psychology constructs of group identity, task interdependence and homogeneity, supporting earlier studies that suggest group cohesion is comprised of measurable factors. By developing and aligning with these constructs, the facilitator assists the group to establish a safe space whilst conceptualizing and aspiring to a model for the professional and compassionate nurse. Conclusion: Social psychology constructs can help develop practice and research of group supervision for nurses. In clinical nursing settings, group identity is particularly salient and facilitator interventions should aim to strengthen this. The development of a sense of universality, when combined with voluntary participation and a focus on intra-group process, can enhance cohesion and create a safe space for self-disclosure. This enables nurses to examine actions and responses to clinical situations and explore emotions incongruent with the ideal nurse prototype, thereby promoting restorative and formative benefits. Implications for research, policy, and practice: This study adds to our understanding of processes in group clinical supervision for nurses and suggests that it is appropriate to apply social identity theory to improve practice and research. It will be of interest to nurses and nursing leaders who wish to develop supervision programs. What is already known about this topic? Compassion fatigue, emotional labour and moral distress contribute to nurse burnout. Group Clinical Supervision can help mitigate stress, enhance learning and support interpersonal aspects of nursing care. The supervisory alliance is an important factor in effective clinical supervision whilst group cohesion is an important factor in the effectiveness of group work. What this paper adds: Reflective Practice Groups (RPG) are defined as a form of Group Clinical Supervision that utilize social support as a resource. RPG facilitation principles are aligned with social psychology constructs of group identity, task interdependence and homogeneity. Alliance with the facilitator and cohesion within the group, enhanced by voluntary participation and facilitation techniques, allow group members to access restorative and formative benefits whilst prompting self-evaluation against the group ideal nursing prototype.

Version française de l’échelle d’alliance thérapeutique entre le supervisé et le superviseur (BSWAI-fr) : une étude pilote

Supervision in the field of behavioral and cognitive therapies has long been neglected in France. However, the little research on this subject highlights the positive effect of supervision on the psychotherapist (improvement of his skills, reduction of compassion fatigue) and on the patient (improvement of his well-being). It would seem to increase the effectiveness of therapy. The combination of supervisory work could be a major ingredient in these positive effects. Therefore, we have adapted and validated in French a 6-item tool, the Supervisory Working Alliance Questionnaire (SWAQ), to increase research on this subject and allow for a rapid and systematic evaluation of the supervisory alliance. After conducting a back-translation, we conducted an exploratory factor analysis and a confirmatory factor analysis. These analyses validate the bifactorial design of the model with “relationship” and “patient focus”. This model explains nearly 73 % of the total variance. The SMRM, TLI and CLI fit indices are very good. The analysis of the internal consistency of each subscale is excellent. One of the main limitations of this French-language validation is the population composed solely of behavioral and cognitive therapists. On the other hand, it opens up research perspectives in the little-studied field of supervision despite the obvious psychosocial risks present in psychotherapists.

Deepening the Group Training Experience: Group Cohesion and Supervision Impact in Alliance-Focused Training.

The aim of the current study is to explore experiences of trainees engaged in alliance-focused training (AFT), a group supervision modality with an explicit focus on awareness of ruptures and implementation of repair strategies. Using Cognitive Behavioral Therapy (CBT) group supervision as a point of comparison, the study examines supervisory alliance, ruptures, group cohesion and safety, and supervision impact. Eighty-three trainees (clinical psychology interns, advanced-level psychology externs and psychiatry residents) at a metropolitan medical center in New York City who received supervision in CBT (N = 38) or AFT (N = 45) reported on their group supervision experience. Participants had a mean age of 29.5 (SD = 4.9); 77% were women; 84% of participants identified as White, 7% as Multiethnic, 6% as Hispanic/Latinx, 1% as Black, and 1% as Asian. Participants reported on occurrence of ruptures with their supervisor, supervisory alliance (Working Alliance Inventory-Short), group safety, supervision depth and smoothness (Session Evaluation Questionnaire), and group cohesion (Group Climate Questionnaire). Mixed and general linear models, and correlation analyses were used for analysis. All trainees reported equally low incidence of ruptures with their supervisor alongside high ratings of supervisory alliance. Trainees in AFT reported experiencing less safety, smoothness, and greater intergroup conflict than trainees in CBT supervision; however, they also reported stronger group engagement and a deeper supervision experience. Results suggest that AFT may provide a rich environment to foster a certain level of discomfort and risk-taking that may facilitate an engaging and meaningful learning experience.