In this chapter we review interventions for resolving critical issues related to incompetent supervision including a lack of proficiency, non-adherence to effective supervision procedures and ineffectiveness. As part of our core formulation, we use the framework of deliberate practice which establishes the necessary conditions for developing competence. The interventions we propose range from supervision of supervision through consultancy, use of peer group support, feedback from supervisees, and self-monitoring as well as clinical outcome monitoring.

In this chapter we discuss the hierarchical relationship within supervision which often creates a tension between the supervisee's wish for freedom and the supervisor's need for authority and control. Supervisors must have the appropriate power and authority to carry out their duties while maintaining a collaborative and affirmative relationship with their supervisees. We go on to discuss suitable professional coping strategies to address problematic supervisory relationships in the form of practical action implications and provide an illustration that highlights the complexities that can be involved.

Background When clinicians adopt the standard 16-26 session maximum suggested by CBTp efficacy research, clients with long-term medication resistant psychosis may receive an inadequate dose of therapy. Building engagement and trust can take significantly longer for clients who have been given a stigmatizing medical explanation for their difficulties. Methods We present a case study of successful long-term CBTp consisting of 200 sessions over a 6-year period. Supervision aided the recovery process over the last 2 years of therapy. Results A client with a 30-year history of medication resistant persecutory delusions, voices, stigma and prominent negative symptoms gradually formed a working alliance with the therapist. A CBT formulation emphasizing activating the adaptive mode led to later targeted work to reduce distress and social avoidance and address underlying trauma. Social recovery was achieved with increased independence and enhanced creativity. A commentary is provided by a senior clinician from a psychodynamic perspective. Conclusions Clients with long-term medication resistant psychosis often need an increased number of CBT sessions but can still recover. Ongoing supportive supervision prevents early discharge and a failure to achieve a recovery trajectory. We should not accept that medication resistant clients are CBT resistant following a brief course of therapy.

First posted October 12, 2021 For additional information, contact: Director, New Jersey Water Science CenterU.S. Geological Survey3450 Princeton Pike, Suite 110Lawrenceville, NJ 08648Contact Pubs Warehouse Per- and polyfluoroalkyl substances (PFAS) have been identified in two lakes near Joint Base McGuire-Dix-Lakehurst (JBMDL) in New Jersey—Little Pine Lake in Pemberton Township and Pine Lake in Manchester Township. The streams that enter these lakes begin in or near JBMDL where sources of PFAS contamination are located. The U.S. Geological Survey, in cooperation with the U.S. Air Force Civil Engineer Center, performed a study of the hydrogeology and the gaining or losing conditions associated with these lakes.Hydrogeologic characteristics in the vicinity of both lakes were assessed using qualitative vertical hydraulic profiling of the subsurface. Groundwater was pumped from test intervals at various depths below land surface, then groundwater levels were measured until they recovered to static conditions. Low permeability aquifer intervals were identified within the aquifer underlying both lakes, consistent with silty and (or) clayey subunits of the Kirkwood-Cohansey aquifer system indicated on geophysical and lithologic logs.Gaining or losing conditions between groundwater and lake surface water were assessed with continuous monitoring of water levels and temperature in the lakes and in three piezometers per lake screened at different depths in the underlying aquifer from August 2020 through May 2021. At Little Pine Lake, surface water levels were consistently lower than groundwater levels, which is indicative of a gaining condition with groundwater flowing into the lake. Gaining conditions also support the lack of diurnal temperature fluctuations observed in groundwater, but poor response of surface-water temperature prevents complete analysis. The potential for losing conditions at other locations around Little Pine Lake necessitates further assessment in regard to possible PFAS contamination of groundwater in the underlying aquifer. Temperature results were inconclusive at Pine Lake, but surface water levels were consistently higher than groundwater levels throughout the monitoring period, which indicates a losing condition with lake water flowing into the underlying aquifer. Because of the downward vertical hydraulic gradient identified at Pine Lake, there is a strong possibility that PFAS in the lake water has also contaminated groundwater in its vicinity.

Derek Milne has developed and disseminated an evidence-based model for clinical supervision (EBCS) that is unique and differs from other approaches. Based on an integrative model of evidence-based clinical practice, Derek’s research program has included a series of literature reviews, an empirical definition, a basic model of clinical supervision, and an instrument for observing and evaluating clinical supervision (Supervision: Adherence and Guidance Evaluation: SAGE). Dissemination of this work led to a manualized account of EBCS, including practical guidelines and video-demonstrations. EBCS has been particularly influential in the UK, where it has been incorporated within the IAPT initiative.

Clinical supervision is the least investigated, discussed and developed aspect of clinical education (Kilminster & Jolly, 2000) despite being essential within initial professional training and mandated by governments. Even the basic concepts lack precision (Martin, Kumar, & Lizarondo, 2017; Milne, 2007; White, 2017). A popular form of supervision is peer supervision, especially peer group supervision (PGS). On the basis of our summary of the available literature, we offer a logical definition of PGS, then adopt an international perspective to consider some worrying weaknesses and working solutions. Peer group supervision is intended to provide informal, reciprocal, collegial assistance with group members' clinical and professional concerns. Conceptually, this assistance is closest to peer consultation, combined with social support (emotional, informational, and practical help, plus professional companionship). Like supervision (ie, clinical supervision, as defined by Milne, 2007), PGS aims to foster safe and effective practice, though PGS relies heavily on case discussion, with little routine oversight (eg, training programme; employing organization). There is also little overlap in terms of structure, as some PGS is deliberately unstructured, whereas in supervision the supervisor is the clear leader, by virtue of greater experience, expertise and through formal authorization. Unlike supervision, no one in PGS has formal authority over the other group members, and hence no member should logically attempt to monitor, evaluate, direct or assume clinical responsibility for the other group members. This is reflected in the convention in PGS that the leadership role is based on turn-taking. In this sense, PGS is an oxymoron, excluding the main defining feature of supervision, both logically and legally, namely the exercise of formal power (eg monitoring and directing the work of the supervisee) (Saccuzzo, 1997). Peer group supervision places more emphasis on restorative topics, such as professional isolation and burnout. Finally, PGS and supervision differ with respect to their empirical status, as only in supervision do we find a sound evidence-base for supervisor development (Milne & Reiser, 2017). Despite the lack of an evidence-base (Borders, 2012) PGS is generally popular, perhaps because it is relatively inexpensive and straightforward to arrange, and as it is collegial, authentic, and non-threatening. For example, a survey of private practice psychologists in the USA indicated that approximately half of the sample were using PGS, or had done so in the past (Lewis, Greenberg, & Hatch, 1988). A similar proportion (41%) was reported in the UK (Townend, Freeston, & Iannetta, 2002) but a smaller proportion (25%) was reported from an Australian sample (Martin, Kumar, Lizarondo, & Tyack, 2016). This is broadly consistent with the review by Borders (2012), who judged that PGS was widely practised. Peer group supervision appears to be most popular amongst those in private practice, those who are more experienced or prefer an adult learning approach, and those working remotely. These findings are consistent with guidance from professional and government bodies, which generally endorse PGS as an acceptable alternative to clinical supervision. In addition to being an illogical concept and an empirically unsupported method, the lack of monitoring in PGS, together with the reliance on discussion, severely limit the opportunities to judge whether clinical practice is safe and effective. This was demonstrated recently by incompetence and fatal misjudgements (Department of Health, 2016). In this sense, PGS neglects to provide staff with proper support and guidance. Similarly, PGS is somewhat fraudulent, implying that supervision is in place when it is not. Consequently, PGS members may jeopardize their professional registration. There is a related ‘imposter’ aspect, in that the supervisors in PGS are not trained to supervise. Yet, PGS participants risk vicarious clinical liability, as in law this flawed arrangement may be regarded as supervision (Saccuzzo, 1997). Peer group supervision should be properly labelled (eg, “peer consultation”), and supplemented by supervision wherever possible. Peer group supervision should be well-structured, have a trained facilitator, and include a contractual agreement between members. This contract should be explicit about the true nature of PGS (to avoid conveying a medical-legal duty of care). Peer group supervision is not suited to trainees or novice practitioners, those that have moved into a new practice area or context, and those that require extensive oversight of their clinical practice (eg, novel or challenging work). There is a need to re-package and re-design PGS in the short term. Peer group supervision needs proper empirical attention in the long-term.

Recent developments have led the UK government to deem clinical supervision essential' to a safe and effective national health service. Cognitive behavioural therapy (CBT) supervision has been increasingly operationalized and manualized, but there are few psychometrically sound observational instruments with which to measure CBT supervision. This paper reports the factor analysis of a promising 23-item instrument for observing competence in CBT supervision (Supervision: Adherence and Guidance Evaluation: SAGE). N =115 qualified mental health practitioners (supervisors and their supervisees) rated the same supervision session by completing SAGE. A principal components analysis indicated that a two-factor solution, identified as the Supervision Cycle' and the Supervisee Cycle' components, accounted for 52.8% of the scale variance and also demonstrated high internal reliability ( = .91 and = .81, respectively). These findings provide the basis for a shorter, 14-item version of SAGE, clarify the factor structure of SAGE, ease implementation, and afford more succinct feedback. Short-SAGE also improves implementation yield, taking half the time to complete as the original 23-item scale. These conceptual and practical improvements strengthen the role of SAGE as a promising observational instrument for evaluating CBT supervision, complementing self-report assessments of competent CBT supervision with an instrument that can fulfil the distinctive functions that are provided through direct observation.

There is growing evidence that clinical supervision may be experienced as harmful (Ellis et al., 2013). The 11 narrative accounts of supervision that form the focus of this Special Issue of The Clinical Supervisor corroborate this evidence, providing vivid and alarming accounts of supervisee experiences of unethical and harmful supervision. In order to treat these worrying reports of supervision with the seriousness that they deserve, we adopt a CBT formulation approach and apply it systematically to these narratives. First, we formulate the data contained in these narratives within a framework for judging unethical supervision. Then we develop proposed solutions to address the problems reported. Last, we describe practical implications for improvements in identifying and addressing unethical supervision and for minimizing harm to supervisees.

In this Introduction to the Special Issue of the Cognitive Behaviour Therapist on clinical supervision we start by highlighting the unmet and overdue need for coherent organizational systems to support, guide and develop clinical supervisors. We identify a seven-step, cyclical model that describes how such a system might work, with particular reference to CBT supervision. These steps start with conceptualization (e.g. definition of CBT supervision) and complete the problem-solving cycle with evaluation (e.g. corrective feedback). We provide an overview of typical research and development activity for each part of this model to illustrate how a sound supervision infrastructure might best be developed. The SOS model provides a systematic approach to indicate the organizational conditions under which CBT supervision might flourish.

Supervision is probably the single most effective method for helping therapists to develop competence, capability and a professional identity (Falender & Shafranske, 2004; Callahan et al. 2009; Watkins & Milne, 2014). Supervision is also perceived by supervisees as the main influence on their practice (Lucock et al. 2006), and has been recognized by governments as an essential component of mental health services in the 21st century (e.g. Care Quality Commission, 2013). Paradoxically, supervisors themselves may receive inadequate support and guidance. This is an unacceptable strategic and moral oversight, one which presumably undermines the fidelity of CBT while increasing burnout: in one survey, 82% of participating supervisors expressed dissatisfaction over their support arrangements (Gabbay et al. 1999). Recent surveys of CBT supervisors indicate that despite an overall sense of satisfaction with supervision, considerably more can be done to support supervisors in terms of developing improved supervisory and training materials (Reiser & Milne, 2016). The phrase ‘something does not compute’ sums up this paradox succinctly (Watkins, 1997, p. 604).

Contributors to this Special Issue of the Cognitive Behaviour Therapist have considered the kind of infrastructure that should be in place to best support and guide CBT supervisors, providing practical advice and extensive procedural guidance. Here we briefly summarize and discuss in turn the 10 papers within this Special Issue, including suggestions for further enhancements. The first paper, by Milne and Reiser, conceptualized this infrastructure in terms of an SOS' (supporting our supervisors) framework, from identifying supervision competencies, to training, evaluation and feedback strategies. The next nine papers illustrate this framework with specific technical innovations, educational enhancements and procedural issues, or through comprehensive quality improvement systems, all designed to support supervisors. These papers suggest an assortment of workable infrastructure developments: two large-scale and comprehensive initiatives, some promising proposals and technologies, and a series of local, exploratory work. Collectively, they provide us with models for further developing evidence-based cognitive-behavioural supervision, and offer practical suggestions for giving supervisors the tools and support to maximize their supervisees' learning, and to improve the associated client outcomes. Much research and development work remains to be done, and successful implementation will require institutional and political support, as well as cross-cultural adaptations. We conclude with an optimistic assessment of progress toward addressing some of the infrastructure improvements required to adequately support supervisors.

Suicide risk increases for those with Bipolar Disorder or PTSD, however little research has focused on risk for co-occurring Bipolar Disorder and PTSD. The aim of this article was to evaluate increased suicide risk in co-occurring disorders, and differences in suicide risk for patients with Bipolar I versus Bipolar II. This study evaluated suicide risk in patients with co-occurring PTSD and Bipolar Disorder (n=3,158), using the MADRS and Suicide Questionnaire. Those with history of PTSD had significantly higher suicidal ideation than those without (U=1063375.00, p<.0001). Those with Bipolar I had higher risk than those with Bipolar II. Patients with Bipolar I and PTSD were at higher risk for suicidal ideation, implying the importance of diagnosis and risk assessment.