My name is Kelly Cukrowicz and I am an Assistant Professor at Texas Tech University. My research focuses generally on emotional and interpersonal correlates of suicide ideation in older adults, as well as longitudinal predictors of change in suicide ideation. Instead of contributing a piece in this area, I’d like to focus on the topic of supervision. Being a supervisor is an important role for me and one that I really enjoy. I take pride in being able to assist graduate student therapists in their growth as therapists, as well as in sharing information with them about empirically supported treatments. This semester my supervision team is reading articles on this topic and gaining experience offering supervision within student dyads.
As such, I’ve given a lot of thought recently to questions such as, “What makes good supervision?” and “How do differences in supervision impact treatment implementation and outcomes?” The literature has provided us with more information pertinent to the first question, so I’ll focus here on the second one. Basically, what impact does supervision have on the client, through (presumably) increased skill in treatment delivery of the therapist? In 2005 I was the lead author on a manuscript that examined the impact of a shift to empirically supported treatments on client outcomes at the Florida State University Psychology Clinic (Cukrowicz, White, Reitzel, Burns, Driscoll, Kemper, & Joiner, 2005). This article was discussed previously on PBB, so I won’t repeat the details. The gist of the study was that requiring training and supervision on empirically supported treatments drastically improved client outcomes.
A recent study published in Journal of Clinical and Consulting Psychology has also examined the impact of clinical supervision on treatment outcomes. Schoenwald, Sheidow, and Chapman (2009) examined the relations between clinical supervision, therapist adherence to the treatment protocol, and changes in youth behavior and functioning problems one-year post treatment in a sample of youth with serious antisocial behavior problems. In a review of the literature on this topic, the authors point out that some existing studies have examined the impact of supervision on client outcomes for trainees; however, there is a dearth of research examining whether supervision impacts treatment adherence and client outcomes in usual care settings.Schoenwald et al. examined data from a National Institute of Mental Health-funded study on practice context factors that may impact the implementation and client outcomes for multisystemic therapy (MST). The authors predicted that therapist adherence would mediate the impact of supervisor adherence on outcomes over this one-year period. The participants in this study included 1,888 families, 429 therapists, and 122 supervisors. This intensive treatment (see Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) averaged 22.2 weeks for this sample and included a typical caseload of four to six families (youth and caregiver) per therapist. Treatment length averaged four to six months depending on the needs of the family. Supervision was offered to teams of three to four therapists by supervisors who devoted at least half of their time to offering supervision and obtaining consultation from experts in this treatment.
Therapist adherence to the treatment was assessed monthly via caregiver ratings on the MST Therapist Adherence Measure – Revised (TAM-R). This 28-item scale allows caregivers to rate therapist adherence to the nine principles of MST. Supervisor adherence was assessed via the Supervisor Adherence Measure (SAM), on which therapists rate their supervisor every two months.
Mixed effects regression models were used to test the primary prediction indicated above. The results of this study indicated that two of the four dimensions of MST supervision predicted one-year outcomes for youth behavior. These dimensions were adherence to structure and process and focus on clinician development. Another dimension, adherence to principles, predicted therapist adherence to the treatment protocol. Further, therapist adherence ratings completed by the caregiver were associated with reduction in youth behavior problems over the one-year time period. Due to a lack of support for the initial prediction that supervisor adherence would impact both therapist adherence and youth outcomes, the mediational model was not tested.
Taken together, the results of this study suggest that some aspects of the supervision process may be more important than others in their association with therapist adherence and client outcomes. In this study, adherence to the principles of the treatment by the supervisor was most important. This subscale assesses the extent to which the focus of supervision was on the consistent assessment and therapeutic principles of MST. Thus, the therapist’s actions in therapy that are observable to caregivers (and subsequently can be rated on the TAM-R) are most prominent. As such, it may be that this factor appeared most important in part due to the fact that it was easier to rate. It is interesting to note that this dimension was most associated with therapist adherence, but not to one-year outcomes in youth behavior. The most important dimensions of supervision for youth outcomes were adherence to structure and process and clinician development, suggesting that supervisory efforts to teach the specific skills of MST and to ensure that the therapist’s goals, skills, and competencies were addressed had the greatest impact of youth behavior outcomes.
The results of this study are very encouraging to me as a supervisor. This study finds that important elements of the supervision process impact not only therapist adherence to the treatment, but also client outcomes. This study did not find any factor that was jointly associated with both; however, it does suggest that high-quality supervision does have a strong impact on both the delivery of services, as well as the benefits experiences by clients. An incredibly important element of this study was the long-term nature of the follow-up period. It isn’t just that high quality supervision has short-term benefits for clients – it actually yields effects that are maintained a full year later. When significant psychopathology is the focus, as in this study, this is incredibly important.
As I consider how all this applies to my own work as a supervisor, I am reminded of just how important it is to stress the need to “stick to it” with regard to continued use of the techniques, principles, and associated assessment principles associated with the selected treatment.
If you would like to learn more about empirically supported treatments for mental illness in general or multisystemic therapy in particular, Psychotherapy Brown Bag recommends the following products, all of which are available through the site's online store:
- A Guide to Treatments that Work
by Peter Nathan and Jack Gorman
- Science and Pseudoscience in Clinical Psychology
by Scott Lilienfeld, Steven Lynn, and Jeffrey Lohr
- Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
by David Barlow
- Multisystemic Treatment of Antisocial Behavior in Children and Adolescents
by Scott Henggeler, Sonja Schoenwald, Charles Borduin, Melissa Rowland, and Phillippe Cunningham
Kelly Cukrowicz is an assistant professor of psychology at Texas Tech University
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