Models of clinical supervision

Models of clinical supervision

Andy Farrington

This article describes

several schools of
practice in relation to
clinical supervision
and discusses models
of supervision,
particularly an
integrative approach
to clinical
supervision in
mental health
practice. While it is
recognised that
clinical supervision is
more likely to occur
in mental health
nursing, the article
concludes by
suggesting a broader
application of the
underlying principles
described.

Andy Farrington is Senior

Research Fellow in
Nursing, Department of
Nursing and Midwifery,
De Montfort University,
Scraptoft Campus,
Leicester LE7 9SU

876

uch attention has been focused

on clinical supervision in nursing since the
Working in Partnership report of the
Mental Health Nursing Review Team
(Department of Health, 1994). However,
clinical supervision has, for many years,
been a common aspect of the everyday
working practices of practitioners in coun
selling and psychotherapy. For example,
for the last 20 years supervision has been
familiar to nurses working in behavioural
psychotherapy, with sophisticated models
being developed and implemented
with success.

analysis of transference and counter trans

ference in the relationships of the supervi
sor, supervisee and client. Supervision is
concerned with the exploration of process.
Behavioural school
The third behavioural school considers
supervision as being primarily concerned
with the development of the supervisees
professional skills. The supervisor has
responsibility for what is taught and the
focus of clinical supervision is on the con
tent of what the supervisee is doing for
his/her client.

Schools of clinical practice

Models of clinical supervision

The model of supervision initially selected

by the supervisor will largely depend on
the school of counselling or psychother
apy to which he/she subscribes. However,
as supervisors develop greater competence
and confidence they are likely to create a
personalised model of clinical supervision
as part of their own reflective practice.
Several schools of counselling and psy
chotherapy can then be integrated,
improving a supervisors flexibility by
replacing dogmatism with pragmatism.
It is helpful to overview the different
schools that are used in relation to models
of clinical supervision.

Several models of supervision can be iden

tified that have been developed from the
schools of practice.

Humanistic school
The humanistic school views supervision
as being concerned with the development
of a supervisees self-understanding, selfawareness and emotional growth, the
emphasis being centred on the supervisees
cognitions. The supervisee has responsibil
ity for the content of the learning, the
focus of supervision and the way in which
he/she completes the task. Supervision
concentrates on the here and now and
focuses on the feelings of the client and
supervisee.
Psychoanalytical school

The psychoanalytical school emphasises

the importance of the interpretation and

Six-category intervention analysis

model
Heron (1990) suggests a six-category
intervention analysis model in which
equal value is placed on each of the inter
vention styles that can be used inter
changeably and in combination at any
point in supervision. The six styles are
divided intp two key areas: authoritative
and facilitative.
Authoritative: The authoritative area is
concerned with assertive styles used by
the supervisor to focus on what the super
visee is doing in practice.
Prescriptive : This concerns giving advice
to the supervisee and explicitly directing
his/her behaviour.
Inform ative : In this style the supervisor
seeks to instruct, impart knowledge and
inform the supervisee.
Confrontative : As the name suggests, this
style of supervision is concerned with
being upfront with the supervisee, by giv
ing clear, direct feedback and challenging
beliefs and attitudes.
Facilitative: This area is focused on the
supervisor being less directive and eliciting
information about the general wellbeing
of the supervisee.
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Models of clinical supervision

...different styles
of clinical
supervision are
connected to the
constant choices
and decisions that
supervisors make
about what to
focus on in the
tripartite
relationship
between
supervisor and the
supervisee client. 5

C athartic : The supervisor attempts to

enable the supervisee to release tensions
and emotions, e.g. grief and anger.
Catalytic. This supervision style is one of
encouraging the supervisee to be reflective,
self-directive and problem-solving.
Supportive: With this style, the supervisor
aims to confirm and validate the value and
worth of the supervisee.
Triadic model

Milne (1986) proposes the idea of a triadic

model in which there is a three-way inter
action between the supervisor, supervisee
and client. The supervisor provides the
skills and knowledge of the techniques to
the supervisee, who has an important
influence upon and relationship with the
client.
Milnes argument, which is commonly
heard elsewhere (Farrington and Telford,
1995), is that therapists who are in clinical
practice should be adequately trained and
supervised. All three people in the triadic
model are clearly in both an educative and
learning position during the interactions.
Multicultural model

Ramirez (1991) suggests the use of a multi

cultural model which, strictly speaking, is
not a model of supervision but has much
to offer the supervisory process. He argues
the case for considering that all individuals
develop learning styles that reflect and rep-

Table I . Key aspects and features

underpinning the growth and
support model of supervision
Generosity
Rewarding
Openness
Willingness to learn
Thoughtful and thought-provoking
Humanity
Sensitivity
Uncompromising
Personal
Practical
Orientation
Relationship
Trust
Source: Faugier ( 1992)

British Journal of Nursing, 1995, Vol 4, No 15

resent the attitudes, values and belief sys

tems of the family, culture and community
from which they come. Matching the cog
nitive style and cultural background of the
supervisor and supervisee is therefore
important in the development of good
working relationships.
Interactive model

Proctor (1991) discusses a model of super

vision comprising a set of three interactive
functions that occur within the learning
environment: normative tasks that are
about helping people to develop standards;
formative tasks that are concerned with
helping people to develop skills, ability
and understanding; and restorative tasks
that help everyone to validate each other
and develop a climate of safety and refresh
ment in which creativity can flourish.
G row th and support model

Faugier (1992) makes a case for a growth

and support model of supervision. Table 1
lists the key aspects and features underpin
ning this argument.

An integrative approach to
clinical supervision
The final model of clinical supervision
originates from the work of Hawkins and
Shohet (1993) who suggest the use of a
double matrix model which differs signifi
cantly from other ways of looking at clini
cal supervision.
The model turns the focus away from the
context and wider organisational issues and
looks more closely at the process of the
supervisory relationship. Hawkins and
Shohet (1993) argue that different styles of
supervision cannot be explained by develop
mental stages, primary tasks or intervention
styles. Instead they suggest that different
styles of clinical supervision are connected
to the constant choices and decisions that
supervisors make about what to focus on in
the tripartite relationship between supervi
sor and the supervisee client.
Situations involving supervision can be
divided into four main components:
1. Supervisor
2. Supervisee
3. Client
4. Work context.
Hawkins and Shohet (1993) argue that
the process can also be separated into
two interlocking systems or matrices.
These are:
1. The therapy system which interconnects
the client and the supervisee through an

877

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Models of clinical supervision

agreed contract that may include regular
time spent together and shared tasks.
2. The supervision system that involves the
supervisee and the supervisor through a
similar type of agreed contract of time
spent together through negotiated
shared tasks and goals.
These two systems for managing super
vision can also be further subdivided into
three distinct categories depending on
the specific emphasis and focus of atten
tion giving six modes of supervision
within an integrated model.
The therapy system deals with:
Reflection on the content of the therapy
system
Exploration of the strategies and inter
ventions used by the supervisee
Exploration of the therapy process and
relationship.
The supervision system deals with:
Focus on the supervisees counter-trans
ference
Attention to the supervisory relation
ship
Focus on the supervisors own counter
transference.
Clearly, it would be very unusual to find
a supervisor who stuck rigidly within one
of the six modes of supervision. Good
supervision must inevitably involve the
movement between modes and the adop
tion of several modes at the same time.
The integrated model suggested by
Hawkins and Shohet (1993) demonstrates
that similar parallel processes occur in
therapy to the ones that can occur in
supervision. A supervisee, for example,
may be unable to form an effective thera
peutic alliance with a client in the same
way that a supervisee may not be able to
work effectively with a supervisor. A client
may distrust a supervisee, for whatever

KEY POINTS
Clinical supervision is commonly seen in counselling and
psychotherapy practice and to some degree in mental health
nursing.
Several different models of clinical supervision have been
used to good effect.
The four main components of clinical supervision are:
supervisee, supervisor, client and practice situation.
Models of clinical supervision can be adapted for use in
general nursing practice.
Research needs to examine if models of supervision can be
effective in general nursing.

878

reason, compared to a supervisor who is

unable to trust a supervisee to work
independently.

Conclusion
Effective models of clinical supervision in
counselling and psychotherapy are well
grounded and are becoming more estab
lished in mental health practice, as advan
tages for supervisor and supervisee can be
seen in terms of increased professional
autonomy, improved self-esteem and effec
tiveness in dealing with uncertainties in
clinical practice.
While supervision in midwifery has been
in existence for some time, only recently
has supervision started to break through
into general nursing practice, no doubt
spurred on by the higher profile given
recently to clinical supervision, e.g. the
Kings Fund Centre (Kohner, 1994),
Nursing Times (1995), and the U K C C
(1995).
It is argued that the models currently in
existence in mental health care, particularly
an integrative approach to clinical supervi
sion, can be transferred and used in general
nursing practice. Some adjustments and fine
tuning will clearly have to be made to these
models in order to ensure that they have
meaning for those using them. However,
more research is obviously needed in order
to establish whether they can be used effec
tively in general nursing.
Department of Health (1994) Working in Partnership
A C ollaborative Approach to C are. HMSO,
London
Farrington A, Telford A (1995) Naming the problem
assessment and formulation. In: Marshall S,
Turnbull J, eds. Cognitive Behaviour Therapy: An
Introduction to Theory and Practice. Baillire
Tindall, London (in press)
Faugier J (1992) The supervisory relationship. In:
Butterworth CA, Faugier J, eds. C linical
Supervision nd Mentorship in Nursing. Chapman
and Hall, London: 18-36
Hawkins P, Shohet R (1993) Supervising in the
H elping Professions. Open University Press,
Milton Reynes
Heron J (1990) Helping the Client A Creative
Practical Guide. Saee, London
Kohner N (1994) Clinical Supervision in Practice.
Kings Fund Centre, London
Milne D (1986) Training B ehaviou r Therapists:
Methods, Evaluation and Im plem entation with
Parents, Nurses and Teachers. Brookline,
Cambridge
Nursing Times (1995) News item: A project funded
by the Department of Health to examine clinical
supervision at 23 sites in England and Scotland.
Nurs Times 91(22): 8, 31
Proctor B (1991) On being a trainer. In: Diyden W,
Thorne B, eds. Training an d Supervision fo r
Counselling in Action. Saee, London: 49-73
Ramirez III M (1991) Psychotherapy and Counselling
with M inorities: A C ognitive Approach to
Individual and Cultural D ifferences. Pergamon
Press, Oxford.
UKCC (1995) Clinical Supervision fo r Nursing and
H ealth Visiting. Registrars letter. 24 January.
UKCC, London
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