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I recently contributed to a book about supervision in Norway edited by Freja Ulvestad Kärki and Asbjørn Kärki Ulvestad. My contribution involved four 500 word responses to the editor’s questions about my views of supervision, conceptualized more of a dialogue than a question and answer.

Reference: Asbjørn Kärki Ulvestad & Freja Ulvestad Kärki (2012). Flerstemt veiledning. Oslo: Gyldendal

The rest of the book is in Norwegian. Check it out here: http://tidsskriftet.no/article/2894303/

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  1. 1. 0000 120102 GRMAT F#5D0083.book Page 195 Friday, July 6, 2012 11:21 AM [start kap] Fra enveisspeil til løsvegger Dialog mellom Freja Ulvestad Kärki og Barry Duncan Barry L. Duncan, Dr. Psychol., er terapeut, veileder og forsker med stor klinisk erfar- ing. Han er leder for The Heart and Soul of Change Project. Duncan har publisert over hundre tekster, inkludert femten bøker. Han har vært sentral i utviklingen av Outcome Rating Scale (ORS), Session Rating Scale (SRS) og andre instrumenter for å viktiggjøre klientens stemme i den terapeutiske prosessen og for å effektivisere det terapeutiske prosjektet. Barry Duncan har tett kontakt med de norske forsknings- og kliniske miljøene gjennom veiledning, inspirasjon og bidrag på fagseminarer og – konferanser. Letter I Thank you very much for accepting an invitation to discuss the possibilities and chal- lenges around the last fortresses defending their right to lacking transparency: the supervision premises. During the last decades, the sacred atmosphere surrounding therapists and therapies has been attacked by paradigmatic reformists stating the need to open these rooms for the benefit of the clients. This development has, however, to a lesser extent been embraced by supervisors supervising the same therapies. While there has been an increased focus on the outcomes in therapy, the evaluation of the effect and effectiveness of supervision have largely been left to the supervisors in their capacity as gatekeepers to a professional career guaranteeing adequate educational qualifications. Supervision is the backbone of all professional education and career development con- sidered as part of the «package». Most of us continue to receive supervision in a number of contexts throughout our professional life, as part of advanced education, in our work place or in our organization. We are socialized to think rather uniformly about supervision and are therefore (parallel to clients) unlikely to pose too many questions about the concept or the context. Only rarely do the supervisees make chang-
  2. 2. 0000 120102 GRMAT F#5D0083.book Page 196 Friday, July 6, 2012 11:21 AM 196 fra enveisspeil til løsvegger ing the supervisor or the supervision group an issue, even if some of us might see choosing the «right supervisor» as a part of a strategic career plan. Supervision seems to be an answer – even for questions no more memorized. The benefits are taken for granted: It is considered a fertilizing, inspiring, problem-solving practice (no matter how serious the problem), and – as already stated – a quality assessment and assurance. At the same time topical questions arise: What are the implicit components on the dia- logic scene where the voice of a client is translated and edited into a narrative of a nar- rative? How can the benefits of successful supervision be more directly observed by the client, and who is responsible for amplifying the client’s voice in the supervision room? Further, what are the measures to improve the outcomes of supervision? Your continuing effort to emphasize the importance of empowering the clients, as well as your paradigmatic work for becoming a better therapist have been impressive. The former addresses the clients’ heroic role in the therapeutic partnership, making changes and setting the path for their therapeutic process. To a certain extent this new role of the client could be interpreted as a kind of supervisor to the therapist. In this first letter, I invite you to share some of your ideas about the current challenges in supervision from the point of view of your extensive professional experience. How to optimize the options present in supervision – and how to minimize the potential dis- advantages? What to do in order to «become a better supervisor»? It would also be interesting to take part of your own «turning points» in the supervision field … excel- lent examples and worst cases, equally important as learning experiences. Looking forward to your reflections! Response As you suggest, supervision is viewed as central to therapist growth. In their book, How Psychotherapists Develop, David Orlinsky and Michael Helge Rønnestad (2005) present their investigation of over 5000 therapists’ experience of their work and professional growth. What is fascinating about this study is the consistency of results across profes- sion, nationality, gender, and theoretical orientation. Part and parcel of our identity appears to be striving to get better at what we do – we believe that clients are the best teachers, but we value supervision as a close second in helping achieve the pinnacle with our clients, what Orlinsky and Rønnestad call healing involvement. But how do we know we are achieving anything? According to research, we are not very good judges of outcomes, client deterioration, or the quality of the alliance. More- over, what we value so much has never been shown to increase our success – the super- visory literature is almost exclusively about process, not whether it helps attain client benefit. Pontificating about clients in their absence seems to invite second-hand narra- tives and incomplete stories – clients become cardboard cutouts of our favorite theories
  3. 3. 0000 120102 GRMAT F#5D0083.book Page 197 Friday, July 6, 2012 11:21 AM fra enveisspeil til løsvegger 197 and caricature-like descriptions of why therapy goes awry. Without the client’s voice to keep us in the space of client privilege, we are left with our love affair with models and tendencies to place failed therapy squarely on the client’s shoulders. I believe that supervision can improve outcomes if it is focused on the client’s perspec- tive of benefit. Measuring outcomes allows us and our supervisors to wade through the ambiguity and discern both our outcomes and our growth from the perspective outside of our own that matters the most. Soliciting client feedback allows us to examine our effectiveness and development, as well as the benefits of supervision without falling prey to pitfalls of a therapist-centric view of success. It enables us to learn from whom most of us see as the best teachers of psychotherapy – our clients. Placing clients in the position of «super supervisor» ensures that supervisors stay on track and use clients’ voices to guide us through the uncertainties of working in tough circumstances. From client reac- tions, we receive information that we can use in figuring out the next step to take in ther- apy. Tracking outcomes enables clients – especially those who aren’t responding to our therapeutic business-as-usual – to teach us how to work better. In fact, clients who aren’t benefiting offer us the most opportunity for learning by helping us to step outside our comfort zones. Supervision can help capture these important lessons. The routine collection of outcome data permits us to determine our effectiveness over time, as well as a base for trying out and evaluating new strategies and input from supervision. If we can review and assess our clinical work over the years, we can actu- ally learn from experience, rather than simply repeating it and hoping for the best. Highlighting clients as supervisors and appreciating the moments of insight they inspire, opens the helping process to ideas outside of the culture of «mental health.» This is a good thing. Letter II Thank you very much for your reflections about the necessity of extending the clients’ influence to supervision. The current trend in therapy in Norway seems to be leaning towards an increasing pressure for the use of standard measures to present evidence on different methods and tools. The hierarchies of evidence effectively regulate the con- tents of recommendations, clinical guidelines and normative expectations from the health authorities. The clinical practice tends, however, to demonstrate a remarkable resistance toward these «good intentions» – mostly due to the individual practitioner’s preferences, competence and theoretical frame of reference. And, as you indicate, we are not very good at judging our own outcomes. Despite this (and the fact that client involvement is enforced by law and included in all policy documents) the paradigmatic change seems to indicate a new rise of EBM as proof of best practice. But as you are well aware, science can be utilized in a number of different settings to generate diverse/con-
  4. 4. 0000 120102 GRMAT F#5D0083.book Page 198 Friday, July 6, 2012 11:21 AM 198 fra enveisspeil til løsvegger tradictory findings, putting the independence of research and researchers to the test. Still, when we allow ourselves to expect improved clinical outcomes, we usually ignore the aspect of supervision. True, in some contexts we do include supervision in the evi- dence-based approach, namely in settings with method-specific supervision, for instance parent management training (PMTO) and other imported certification pro- grams for the clinicians. What is your opinion about the current trend from the context you’re working in? Has the realization of the importance of the common factors in therapy had any influ- ence on supervision, and if so, how? What do you think will be the next major steps: Where do we go from here? In Norway, the developmental trend leans strongly toward clinical pathways not very different from taylorism and the principles of «product units», i.e. standard treatment provided by standard combinations of professionals in standard settings. We must, however, quickly remind ourselves of the individuality of each client knocking at our door – something of a paradox if you start thinking about it. Looking forward to hearing your thoughts on these matters. Response Once again you nail the issue when you speak of «product units» in reference to EBM. The idea that change primarily emanates from the model wielded, is a siren call des- tined to smash us against the jagged rocks of ineffective therapy and supervision. A treatment for a specific «disorder,» from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalk- ing the client. In its most unfortunate interpretation, clients are reduced to a diagnosis and therapists defined by a treatment technology – both interchangeable and insignif- icant to the procedure at hand. This product view of psychotherapy is most empirically vacuous because the treatment itself accounts for so little of outcome variance, while the client and the therapist – and their relationship – account for so much more. You mention PMTO, and it provides a great illustration in terms of EBM and super- vision. In a Norway study, Ogden and Hagen (2008) reported that PMTO was more effective than TAU with children exhibiting serious behavioral problems. The initial analysis found a difference favoring PMTO on only 4 out of 16 outcome measures. The secondary analysis looked at treatment differences by age. Once again, they got a supe- rior finding for PMTO on 4 out of 16 measures for children aged 7 and younger only. No differences between TAU and PMTO on 15 out of 16 measures for children aged 8 and older; 1 measure favored TAU over PMTO. PMTO therapists received 18 months of training and ongoing support/supervision during the study, while the TAU thera- pists received no additional training, support, or supervision. The meager results com-
  5. 5. 0000 120102 GRMAT F#5D0083.book Page 199 Friday, July 6, 2012 11:21 AM fra enveisspeil til løsvegger 199 bined with the differential training and support of the two therapist groups cast signif- icant doubt on this study’s conclusions. In addition, it offers sad commentary on the benefits of model specific supervision given it did not make much of a difference. Iron- ically, attaining client feedback will soon be an EBT, providing an empirically justified way to operationalize user involvement. After attention to client feedback, it makes more sense to focus supervision on the factors of change commensurate to the amount of variance they account for – the client is the heart, and the alliance is the soul. This doesn’t mean that technique isn’t impor- tant. Technique is the alliance in action, carrying an explanation for the client’s difficul- ties and a remedy for them – an expression of the therapist’s belief that it could be help- ful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and the therapist to understand how change can happen. I believe that supervision that provides the relational context to explore the factors that most lead to change in combination with the client’s feed- back about the benefit of services, provides the best possibilities for supervision. Letter III It is indeed interesting to discuss how the evidence is cultivated and interpreted in dif- ferent contexts, although it is a never ending debate, with no immediate cathartic con- sensus in view … In this third letter I invite you to reflect upon the relational aspect of supervision that you are emphasizing in your response. As we know, it might some- times prove an overwhelming task for a supervisor to create a fruitful interaction as a basis for relational (leading to professional) development. Different explanations apply: personal references, differences in theoretical preferences, group dynamics in group supervision, diverging or sometimes contradictory goals (for example supervi- sors who replace mutual professional exploration by indoctrinating the supervisees with their own favourite paradigms). Division of power is an additional aspect, partic- ularly if the supervision includes gatekeeper components in supervisees’ education or career development. It happens but rarely that a supervisee chooses to quit the scene to ask for another supervisor, and second opinions are not frequently requested even if there exists little coherence between the supervisees’ investments and the outcome of the supervision. I was educated in a tradition where you could only receive supervision in its real sense from a colleague in your own profession. Consultation with related pro- fessions would be used in order to learn a specific method or to work in an interdisci- plinary setting (as in family therapy with a co-therapist). There are pros and cons to this, especially in contemporary interdisciplinary environments, where collaboration
  6. 6. 0000 120102 GRMAT F#5D0083.book Page 200 Friday, July 6, 2012 11:21 AM 200 fra enveisspeil til løsvegger between the different professionals is necessary to address the different needs of the cli- ents and their families. Learning the trade still usually happens in uni-professional set- tings (to some extent unimportant as long as we don’t want to be «jacks of all trades – masters of none», and not only due to protectionism on the part of the key profes- sions). However, central players in the therapy field sometimes seem to pull in different directions – and struggle with interpreting each other’s «languages». What are your views on this? How can we achieve a more holistic approach in serving our clients? What does it take to make an interdisciplinary supervision/consultation group truly (co)operative? Another issue I would like to address is the client’s position / impact in the supervi- sion room from the point of view of the therapeutic research communities. Do you know if any studies have been carried out in this area? And if not: In your opinion, what are the next steps? Where should we put the effort? Response First, while there will be no cathartic group hug regarding the evidence, the data don’t lie, although proponents of models often do. Clinicians should look at the studies and draw their own conclusions. Next, I know of no supervisory process that includes the client’s voice, other than the one described below. Regarding interdisciplinary supervi- sion, Orlinsky and Rønnestad’s massive study of over 11,000 therapists from a variety of disciplines and orientations demonstrated that regardless of how fragmented the field is reputed to be, psychotherapy seems to be a profession united in the one, true cause, the quest for healing involvement – the meaningful connection between client and therapist for a common purpose to make a difference in the client’s life. This tran- scends discipline and specific model and is isomorphic to a supervisory process that values the creation of connections that matter in the lives of those we serve, and the supervisee’s development. Healing involvement is enhanced by therapists’ cumulative career development, their sense of mastery and clinical growth over the course of their careers. But an even more powerful factor promoting healing involvement is the thera- pists’ sense of currently experienced growth – the feeling of learning and deepening our understandings from our day-to-day work. A focus on outcome highlights these two central elements and provides a client-based hierarchical view that allows for a super- visory relationship that supersedes both discipline and model. It begins with an identi- fication of clients who are not benefiting, relying not on the therapist’s judgement of what should be discussed, but rather on the client’s voice reflected in the data. Here both therapist and supervisor discuss each at-risk client and develop options to present to clients, including consultation and referral to another counsellor or service. Next, the supervision shifts to therapist development, effectiveness, and ways to improve.
  7. 7. 0000 120102 GRMAT F#5D0083.book Page 201 Friday, July 6, 2012 11:21 AM fra enveisspeil til løsvegger 201 This is a transparent discussion that ultimately co-evolves a plan for improvement, fol- lowed by the ongoing evaluation to see if the plan is working. In addition, supervision can enhance the therapist’s sense of currently experienced growth. Tracking outcomes takes the notion that «the client is the best teacher» to a different, higher, and more immediately practical level. By encouraging client reactions and reflections, tracking outcomes enables clients – especially those who aren’t responding well to therapeutic business-as-usual – to teach us how to work better. Supervision helps us take advantage of those clients who force us to step outside our comfort zones. In summary, having supervisees track their cumulative career development is isomorphic to therapists engaging clients to monitor benefit. In addition, collaborating with therapists about potential plans to enhance their development is parallel to the egalitarian conversation that is hoped for with clients regarding the tasks of therapy. Finally, supervisor curios- ity about the lessons that clients teach, the therapist’s sense of currently experienced growth, helps the therapist make the best of their continued reflections while enhanc- ing therapist appreciation of what can be learned from clients. Letter IV In this last letter I would like to address the issue of personal experiences. We have been exploring the components adding up to therapists’ currently experienced growth, as you call it, as well as the clients’ position. Those who have been participating in confer- ences and seminars where you have presented some of your best «teachers» on video (among those, 9-year-old Molly) can hardly forget the sudden moments of insight. It requires a certain degree of humility to open oneself to the mutual learning experience in the therapy room –as long as we don’t have that kind of approach as an integral part of the basic education in health professions (as the case is at present). Moving from the clients to the supervisors, we all have experienced supervisors in our professional careers who – more or less consciously – have been shaping and moulding us. Some of them we heartily applaud, others may serve as a reminder of what we do not wish to repeat in our role as supervisors. I would like to invite you to reflect upon your own turning/learning points and influential mentors in supervision. What kind of processes can be traced behind your current working model and paradigmatic thinking? Who were the supervisors representing an approach you wanted to develop further and what was the background? I’m referring to moments of change here, also including poten- tially negative experiences, as influential as learning experiences as are the positive ones. One of the interesting factors here is personality, and how to increase the value of supervision despite differences in personal styles between the supervisor and the super- visees in individual settings as well as in groups. Learning style and learning speed vary a lot among supervisees – as among supervisors. It would certainly be beneficial to have
  8. 8. 0000 120102 GRMAT F#5D0083.book Page 202 Friday, July 6, 2012 11:21 AM 202 fra enveisspeil til løsvegger a similar approach to begin with, as well as an ability to «tune in» to each other’s mind- sets. And sometimes the message, as important as it may be, can get lost in translation – or communication. The more inexperienced supervisees are likely to have a tendency towards a non-critical adaptation of a supervisor’s model, and some of the supervisors quite obviously want to pass their model to their bona fide-adepts. It goes without say- ing that we here deal with an issue that no professionalization of the supervision field can transform. The change must come from within. The role of professional supervision must be reinterpreted and redefined if we want to improve our practice on all levels. In your previous letters you outlined a model for the added value of supervision. How should we proceed to bring about a change in the supervisor role? How could a systemic reformation process be initiated, and who should be in charge? Response Over thirty years ago, I began my mental health career at a state hospital. I experienced first hand the facial grimaces and tongue wagging that characterize the neurological damage caused by antipsychotics, and sadly realized that these young adults would for- ever be branded as grotesquely different, as «mental patients». I witnessed the dehu- manization of people reduced to drooling, shuffling zombies, spoken to like children and treated like cattle. Shortly thereafter, to make ends meet as a graduate student, I worked in a residential treatment center for troubled adolescents. So «disturbed» were these kids that every one «required» at least two psychotropic medications despite their protestations. These experiences forever shaped my viewpoints and led to my commit- ment to challenging mental health business as usual and partnering with clients in all decisions that affect their care. After these quite negative encounters, a mentor appeared on my career horizon – Scott Fraser, a Mental Research Institute trained supervisor who provided a radically different framework to viewing clients and the therapeutic process. He directed a crisis / brief therapy unit of an inner city hospital emergency room, and I learned that regardless of where a client started – in spite of the dire circumstances faced – that at the end of just one hour, many futures are possible. It was a continual parade of people facing the worst of times, including violence and suicide. I participated in weekly live supervision via the one way mirror, and later met with other talented staff for addi- tional support and supervision. I was infused with the belief that clients can overcome any obstacle, a belief that I still maintain and am forever grateful for. Scott exposed me to the MRI and Jay Haley – which have proven invaluable – and embedded a passion for the work that has never left me. Although I had negative supervisory experiences that were troublesome, conten- tious, and even one in which I was fired for my client-directed values (see Duncan
  9. 9. 0000 120102 GRMAT F#5D0083.book Page 203 Friday, July 6, 2012 11:21 AM fra enveisspeil til løsvegger 203 et al., 2004), I’d prefer to use this space to describe two other people who have made a difference for me. First, Steve McConnell, a humanistic/existential therapist who for- ever made the impression upon me about the power of authenticity and the therapeu- tic alliance. Steve introduced me to Carl Rogers and James Bugenthal and, more impor- tantly, was the most genuine person I ever met. Our interactions about therapy and life in general taught me that what I really have to offer to my clients is me – that I am the most powerful medium of any message that therapy has. This notion has been rein- forced by clients many times and has served me well. The second is Joe Rock, who after supervision, became my best friend and has been ever since. Joe was a cognitive-behav- iorally oriented supervisor who had many useful ideas for clients, but more impor- tantly, was never limited by theories in his understanding of people or therapy. Joe had a refreshing humility about the work and never took theory or the work itself too seri- ously – he taught me to laugh with my clients and always value what they said over what any model suggested. He regularly supported me in stepping outside the bounds of my comfort zones to be useful with clients. One time he encouraged me, in response to a client request, to meet the client in a bicycle shop to help him follow his biking passion after a long hiatus. This outside of the box encounter proved very helpful for the client (see Duncan, 2010). This client and Joe’s encouragement led to the develop- ment of the idea of the client’s theory of change. Supervision can be a real game changer – made so by the authenticity of the super- visor and his/her desire to be helpful, much like therapy can really make a difference based on similar qualities. Such relationships are only enhanced by the formal inclu- sion of client voice and perspective about the benefit and fit of services, the use of out- come and alliance measures. I believe the next step is to put a supervisory process based in model and technique on the back burner and instead make supervision unabashedly about outcome, or what I call supervision for a change, in both clients and therapists. Supervision focused on outcome defined by the client makes us accountable to those who matter most and provides a definitive standard for therapists to monitor their development. For system change to occur, the field needs only to operationalize its highest ideals about client welfare and truly put the user in charge of service delivery, a true partner in all decisions that affect care and supervision. Frejas ettertanker Dialogen med Barry Duncan løfter frem en rekke refleksjoner og problemstillinger. Det er interessant å lese om prosessen der ideen om reell brukermedvirkning gradvis mate- rialiserer seg i en svært empirisk forankret teori, som man kanskje også kunne kalle en ideologi på grunn av de sterke humanistiske innslagene. En grunnholdning skapes, for- met av egne møter med pasienter og forsterket av andre møter underveis. I disse
  10. 10. 0000 120102 GRMAT F#5D0083.book Page 204 Friday, July 6, 2012 11:21 AM 204 fra enveisspeil til løsvegger møtene er det kollegaene og veilederne som blir de viktige andre som gir næring til en vei Barry allerede har begynt å utforske, og som han er overbevist om er den rette. Det er interessant å reflektere over hvor viktig timing er her – det å finne de rette fagperso- nene til riktig tid. Samtidig søker man seg uansett til dem man anser har noe å bidra med, eller tar til seg det som passer til ens egne teoretiske ståsteder. Nettopp det sist- nevnte vil også kunne fungere som en buffer i lite konstruktive møter mellom en vei- ledningskandidat og en veileder: Den som mottar veiledning vil sortere ut de elemen- tene i veiledningen som ikke passer sammen med det som allerede finnes hos henne/ ham. Særlig gjelder dette for terapeuter med noen års erfaring bak seg, og de som har en sterk faglig overbevisning uavhengig av fartstid. Den tilnærmingen som Barry Duncan representerer, vil utfordre både ekspertrollen og den ordinære, mer systemisk- strukturelt orienterte brukermedvirkningen med sine regelmessige brukerundersøkel- ser. For profesjoner som vanligvis assosieres med ekspertrollen og spisskompetanse innen feltet psykisk helse, fremstår tolkninger (om pasientens utsagn, psykiske status, prognose etc.) som noe helt elementært. Slike tolkninger (eller forståelser) tar eksper- ten med seg til veiledningsrommet, der en annen ekspert på nivået over bidrar med en tolkning/forståelse fra sitt faglige ståsted. Dersom man ikke skal tolke eller «forstå» – hvor skal man da plassere sin faglighet, utviklet med det for øyet å bidra til en forståelse som kan kanaliseres i gode, nøyaktige kategorier? Det er grunn til å tro at det faller ekspertveldet tungt for hjertet å omskolere seg til å spille en helt annerledes rolle i møte med pasienter eller kandidater. Til tross for at den valgte terapeutiske metoden som sådan ikke representerer det sentrale i dialogens tilnærming, skriver Barry Duncan at «dette ikke betyr at teknikken ikke er viktig». «Teknikken er alliansen i aksjon og innebærer både en forklaring på kli- entens vansker og botemiddelet for dem», med andre ord at det er viktig for både kli- enten og terapeuten å forstå hvordan endringer kan skje. Det vil kanskje lede oss til den konklusjonen at det likevel er viktig for terapeuten å ha god kompetanse om sin metode for at alliansen skal virke – noe som er like relevant i møter mellom veilederen og vei- ledningskandidaten.
  11. 11. 0000 120102 GRMAT F#5D0083.book Page 205 Friday, July 6, 2012 11:21 AM fra enveisspeil til løsvegger 205 Litteratur Duncan, B.L. et al. (2004). The Heroic Client: A Revolutionary Way to Improve Effective- ness through Client-Directed, Outcome-Informed Therapy (revised ed.). San Francisco: Jossey-Bass. Duncan, B.L. (2010) On Becoming a Better Therapist. Washington D.C.: American Psychological Association. Ogden, T. & Hagen, K.A. (2008). Treatment effectiveness of Parent Management Trai- ning in Norway: A randomized controlled trial of children with conduct problems. Journal of Consulting and Clinical Psychology, 76, 607–621. Orlinsky, D.E. & Rønnestad, M.H. (2005). How Psychotherapists Develop: A Study of Therapeutic Work and Professional Growth. Washington, D.C.: American Psychological Association.