Introduction to special issue: clinical supervision in implementation science

ABSTRACT

Implementation science is at the nexus of research and practice, and studies ways to promote the use of research findings in service settings. Clinical supervision has a rich theoretical literature for workplace support, and has also been used to ensure internal validity for “evidence based” interventions during efficacy trials. Calls to leverage supervision as an implementation strategy have prompted a focus on clinical supervision in implementation science. Articles included in this special issue address how supervision “typically” operates and how it might “optimally” promote implementation. A range of methodologies, client populations, settings, and mental health problem foci are included.

KEYWORDS:

• Clinical supervision
• implementation science
• evidence-based interventions

Clinical supervision (hereafter, supervision) is a central part of training for behavioral health service providers across disciplines, degrees, and accreditation standards (Borders et al., 2014). Supervision “manages, supports, develops and evaluates the work of colleagues” (Milne, 2007, p. 439), and is required during graduate training and, for psychologists, counselors, and social workers in the United States, post-degree to be license-eligible. In studies characterizing the use of supervision in mental health service settings, researchers have reported that clinical supervision is a typical part of the professional supports available to mental health providers (Choy-Brown & Stanhope, 2018; Laschober et al., 2012; Schoenwald et al., 2008), although the quantity, quality, and content of supervision has been found to vary widely (Bailin et al., 2018; Choy-Brown & Stanhope, 2018; Dorsey et al., 2017; Fukui et al., 2014). There is a robust theoretical literature on the purpose of supervision in the mental health workplace, variously described as administrative, educational, and supportive (Kadushin & Harkness, 2014) or – similarly – as “normative” (administrative and ethical oversight), “formative” (education and skill development), and “restorative” (Proctor, 1986). Numerous models for the practice of supervision have been developed, and many accrediting bodies list guidelines for best practices (Borders et al., 2014).

Quite separate from the theory and practice of professional, workplace-based supervision, supervision has been an essential ingredient in research, specifically as a part of mental health efficacy and effectiveness trials (Beidas & Kendall, 2010). Interventions tested in randomized clinical trials – often called “evidence-based treatments” or EBTs – typically made use of expert supervision during the trials in order to ensure high-fidelity, and therefore internal validity, to the intervention being tested (see Roth et al., 2010). In this context, supervision has been used as a means of quality assurance within the trial and, as others have noted (Falender, 2018), is often not well-described in the studies touting the benefits of these interventions. As Roth et al. (2010) noted, “What has actually been demonstrated is the impact of the therapeutic intervention in the context of dedicated training and supervision for trial therapists” (p. 296). Despite this, the interventions alone are evaluated in terms of the evidence of their benefit; these same interventions are labeled “effective,” and then often published, made available for purchase, and implemented in mental health service settings that differ in substantial ways from research trials (Weisz et al., 2014). Mental health service settings and the academic settings of clinical efficacy trials differ in terms of client characteristics, provider characteristics, the resources available, and the nature of the supervision that is provided (Accurso et al., 2011; Bailin et al., 2018; Dorsey et al., 2018; Schriger et al., 2020).

It is hardly a surprise, then, that results of efficacy trials so often fail to replicate in mental health services settings (Weisz et al., 2014). Implementation science, “or the systematic study of methods to promote the use of research findings in real-world practice settings” (Williams & Beidas, 2019, p. 430), has wisely honed in on the use of supervision as a means of increasing EBT adoption, implementation, and sustainment as interventions move from research to practice (Schoenwald et al., 2013). Since 2000, there has been increased attention to the potential relationship between supervision and implementation outcomes (see Carlson et al., 2012, for an overview). Although still an emerging area of empirical inquiry, there is growing consensus that supervision in mental health service settings is an asset that can be leveraged to support EBT implementation.

Positioned at the intersection of research and practice, implementation scientists who study supervision need to understand, and ultimately balance, both what is typical and what is optimal when it comes to supervision that supports providers and benefits clients. “Evidence based interventions” are of little use if they cannot feasibly be implemented in mental health service settings; this is also true for supervision models or practices that don’t fit into the contexts of practice. This special issue sought reflect this balance, and to add to the still small but growing research on the use of supervision in the implementation of EBTs. The special issue includes a range of practice contexts, client populations, and target problems, as well as diverse research methodologies.

The issue begins, arguably, where the very notion of supervision to support evidence-based practice began: with Derek Milne, whose seminal work to characterize and measure the micro-skills of supervision has been used to support large-scale EBT implementation in his home country of the UK . As his frequent coauthor Reiser (2021) reflects in his profile, Milne was dissatisfied with vague conceptualizations of supervision and was determined to clearly and precisely describe what supervisors do, and then to test the effect of those components. Reiser describes the rigorous process by which Evidence-Based Clinical Supervision was developed, tested, and refined – a process that continues! It is fitting that the issue begins with a profile of Milne, as his influential work is cited by nearly all of the other contributors.

Next, Bailin and Bearman (2021) provide an overview of supervision “as usual.” Using self-report from supervisory dyads as well as audio recordings, the authors describe the coverage of evidence-based practice content discussed in supervision meetings in community-based mental health settings serving children and adolescents. They found coverage of evidence-based practice content was typically brief, with some practices missing altogether – suggesting areas for targeted quality improvement if workplace-based supervision is to support EBTs. At the same time, coverage of content outside of the evidence base suggested that supervision “as usual” may include other important aspects that do not receive attention in research-supported protocols, but may be of value to mental health service settings.

This theme of “typical” supervision is continued in a study by Boyd et al. (2021) in which they examined how training asymmetry between supervisors and supervisees impact the supervisory working alliance. Supervisory working alliance was compromised when supervisors had less EBT training than their supervisees. The results make a compelling case that EBT implementation efforts must train not only frontline providers, but also their supervisors.

In the article that follows, Tugendrajch et al. (2021) review the evidence that supports “best practices” in supervision. The authors identified common supervision practice elements (e.g., supervisor provides feedback to supervisee) recommended by three sets of professional guidelines: The American Psychological Association’s (APA, 2015) Guidelines for Clinical Supervision in Health Service Psychology, the Association for Counselor Education and Supervision’s (ACES, 2011, Borders et al., 2014) Best Practices in Clinical Supervision, and the National Association of Social Workers (NASW, 2013) Best Practice Standards in Social Work Supervision. Then, they reviewed the empirical support for 17 common supervision elements. Although some best practices had been studied in a majority of the reviewed studies, others appeared in few or no studies. These results point to the work that remains in order to realize the goal of a strong evidence-base for supervision.

In a complementary review by Bradley and Becker (2021) that follows, the authors used a systematic distillation approach to review the evidence for supervision practice elements that fall into the formative (e.g., skill development) and restorative (e.g., well-being) functions of supervision proposed by Proctor (1986). It is striking that the most common practices for promoting formative outcomes were corrective feedback, discussing interventions, and role play – all concrete supervisor behaviors described in Milne’s (2009) EBCS model.

In the remaining articles, authors explore consultation and supervision used in the implementation of three EBTs. Although not synonymous with supervision, consultation is an analogous process often utilized in implementation wherein the person providing education and support is not employed by the same agency as the provider. First, Caron et al. (2021) explore the strategies used by consultants to engage therapists in active learning during implementation of Attachment and Biobehavioral Catch-up (ABC), a home-based preventive intervention for infants who have experienced adversity. Results indicate that key consultant strategies were associated with greater likelihood of therapist active learning; these results could be easily applied to the supervisor-supervisee process. Next, Sewell (2021) describes a feasibility study of a clinical supervision model to support Stop Now and Plan (SNAP), an evidence-based intervention for disruptive behavior in children in Canada. Provider report suggested that the supervision model was acceptable and that there was demand for specified supervision. Lastly, Giannopoulos et al. (2021) describes a pre-post study of supervision for addictions counselors using the Pathways to Comorbidity Care Program (PCC), an intervention to address comorbidity in state-funded drug health services across urban and regional Australia. Clinical note audits indicated that, following supervision, there were significant increases in rates of prescribed screening and treatment strategies. Counselor self-efficacy also improved.

Although the articles in this special issue were selected because of the salient topics they address, their methodological diversity, and the range of provider disciplines, client populations, and practice settings they reflect, there are some important limitations. We received no submissions that directly addressed issues of racial and ethnic diversity and multiculturalism, despite cultural humility being a critical competency for both clinical work and supervision (Falender & Shafranske, 2017). EBT implementation efforts are often in publicly funded mental health settings that serve diverse client populations and seek to address inequities in mental health access and effectiveness, yet most EBTs were developed and tested with primarily White participants (Pina et al., 2019). Whereas organizational culture is a key part of conceptual models of implementation (Williams & Beidas, 2019), individual and community culture is largely absent. This point underscores the need for studies on supervision in implementation of EBTs – and in implementation science more broadly– that center cultural diversity.

Additionally, the articles included in the special issue are largely observational or systematic reviews, with no studies that explicitly test causal theories of supervision for EBT implementation using experimental designs. This point again reflects the bulk of implementation research (Williams & Beidas, 2019). Studies that directly test causal theories of supervision will help to inform practice and increase the rigor of the evidence-base for supervision. As well, whereas studies that examine provider behaviors following guidance from expert consultants and supervisors are instructive with regards to potential mechanisms of change, the use of workplace based supervisors as interventionists would increase the ecological validity of this research.

I would be remiss if I did not also acknowledge the unusual backdrop for this special issue, which largely took place during the COVID-19 pandemic. As a result of many challenges this posed, several promising submissions were withdrawn and some notable contributors were unable to participate. I am especially grateful to all the authors whose work is reflected here despite very difficult working conditions, and to the journal’s editor, DiAnne Borders, for her patience and encouragement throughout the process.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Sarah Kate Bearman

Sarah Kate Bearman, Ph.D. is an Assistant Professor in the School Psychology program of the Department of Educational Psychology in the College of Education at The University of Texas at Austin. A clinical child psychologist, her interests focus on advancing effective and scientifically supported treatments for youth and families in low-resource settings. In particular, she is interested in the supportive infrastructures, such as clinical supervision, that can promote successful adoption and implementation of evidence-based therapies.