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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The effectiveness of CBT depends on the quality of the supervision and training that is provided to its practitioners. A Manual for Evidence-Based CBT Supervision is intended to significantly strengthen the available resources for training and supporting CBT supervisors. The authors drew on the insights of many accredited CBT supervisors to develop the guidance, and the work is built firmly on an evidence-based approach.
This manual will also be useful for individual supervisors and to those who support and guide trainers and supervisors (e.g., peer groups, consultants, managers, administrators, training directors), as the authors include training supervision guidelines and training materials (e.g., video clips, guidelines and PowerPoint slides).
In summary, this manual provides critical guidance in a number of areas:
- Training resources and evidence based guidance to individual supervisors in a continuing education/professional development workshop format
- Criteria and guidance (including measurement tools and competence standards) to support the certification of supervisors
- Assisting in a “train the trainers” approach suitable for agency or organization-based training of supervisors
- Coaching and training supervisors and supervisees remotely, through supplementary materials and an interactive website
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Table of Contents
Cover
Title Page
About the Authors
Foreword
Preface
Acknowledgments
1 Introduction and Overview of Evidence‐Based CBT Supervision
What a State We’re in
Now You’re Talking!
Getting Our Act Together
How Can We Act Together?
Is This Manual For You?
Will it Work?
Watch Your Language!
What’s New or Different?
Where Next?
How Do We Get There?
Six CBT Supervision Guidelines
Guideline Design and Rating of Evidence
“Evidence” Includes Research Plus Relevant Theory Plus Expert Consensus
Six PowerPoint Slideshows
Suggestions about Using the 18 Appended Video Clips with the Manual
A Note of Thanks to the 11 Video Participants
References
2 Guiding Principles behind Our CBT Supervision Manual
Principle 1: Conceptualize Carefully
Principle 2: Operationalize Systematically
Principle 3: Utilize the Best Available Evidence
Principle 4: Interpret in a Wider Context
Principle 5: Disseminate Freely
Principle 6: Utilize Correctly
Summary and Conclusion
References
3 The Context for CBT Supervision
Context Defined
A Helpful History of the Role of Context in Effective Training
Our Approach to the Training Context
The Supervisor Training Taxonomy
Conclusion
References
4 Training CBT Supervisors
Introduction
Recommendation 1: Clarify the Training Goals
Recommendation 2: Provide Structure and Support, So that Training is Properly Managed
Recommendation 3: Facilitate Experiential Learning
Recommendation 4: Offer Feedback
Recommendation 5: Evaluate the Workshop’s Effectiveness
Conclusion
Appendix: A Guideline for Training CBT Supervisors
References
5 The Alliance in CBT Supervision
Introduction
Recommendation 1: Clarify a Learning Agreement
Recommendation 2: Agree on Tasks and Create Structure
Recommendation 3: Build a Collaborative Bond
Recommendation 4: Provide a Role‐Model
Recommendation 5: Place the Supervision Relationship in Context
Conclusion
Appendix: A Guideline on the CBT Supervision Alliance
References
6 Goal‐Setting in CBT Supervision
Introduction
Recommendation 1: Provide a Consistent Framework, Scaffolding the Entire Supervision Process
Recommendation 2: Engage Supervisee in a Collaborative Effort
Recommendation 3: Conduct a Learning Needs Assessment of the Supervisee’s Competences to Establish a Baseline
Recommendation 4: Collaboratively Agree to SMARTER Supervision Goals
Recommendation 5: To Best Judge Your Actions, Take Due Account of the Context – Factors Such as the Host Organization, Culture, Individual Differences, and Learning Styles
Conclusion
Appendix: A Guideline for Goal‐Setting in CBT Supervision
References
7 Facilitating Learning in CBT Supervision
Introduction
Recommendation 1: Use Training Methods to Develop Competence
Recommendation 2: Add Educational Approaches to Develop Capability
Recommendation 3: Ask More of Your Supervisees
Recommendation 4: Acknowledge and Accept Setbacks
Recommendation 5: Take Account of the Context
Conclusion
Appendix: Facilitating Learning in CBT Supervision
References
8 Feedback and Evaluation in CBT Supervision
Introduction
Recommendation 1: Explain the Need for Feedback
Recommendation 2: Define the Gap between Current and Desired Proficiency
Recommendation 3: Monitor Progress and Provide Frequent Feedback
Recommendation 4: Use Various Sources of Feedback
Recommendation 5: Identify Corrections or Areas for Improvement
Recommendation 6: Use Suggestions and Demonstrations to Strengthen Skills
Recommendation 7: Learn the Lessons
Conclusion
Appendix: Feedback and Evaluation in CBT Supervision
References
9 Support and Guidance in CBT Supervision
Introduction: Evidence Supporting the Guideline
Recommendation 1: Clarify the Situation
Recommendation 2: Encourage Emotional Processing and Personal Growth
Recommendation 3: Strengthen the Supervisee’s Coping Strategies
Recommendation 4: Boost Morale, Motivation, and Job Satisfaction
Recommendation 5: Encourage the Supervisee to Make Use of Social Support from the Supervisor and Peers
Conclusion
Appendix: Guideline for Support and Guidance in CBT Supervision
References
10 Concluding Remarks
The Emperor is Surprisingly Scantily Clad!
We Now Have a Clearer and Better Validated Procedural Account of CBT Supervision
CBT Supervision Is Catching Up
Leaning on Neighboring Literatures is a Major Help
Empower Your Supervisees: They Are the Most Underutilized Resource
The “Modest” Evidence Base Indicates that CBT Supervision is “Probably Efficacious”
The Work Goes on with Your Help
References
Appendix Video Catalogue
Index
End User License Agreement
List of Tables
Chapter 01
Table 1.1 The rating scale used to evaluate the six guidelines during supervision workshops.
Chapter 02
Table 2.1 Teachers’ PETS, an instrument for measuring CBT teaching and training.
Table 2.2 An exemplary illustration of the details that should be included in a supervisor training manual.
Chapter 03
Table 3.1 A summary of the action implications arising from this chapter.
Chapter 04
Table 4.1 Recommendations for best practice in conducting supervisor training workshops and follow‐up consultation.
Chapter 05
Table 5.1 Roth and Pilling’s (2008) competence map related to the supervisory alliance.
Table 5.2 Practical recommendations for enhancing the emotional bond in CBT supervision.
Table 5.3 A procedure for resolving alliance ruptures.
Chapter 06
Table 6.1 Topics to discuss when drafting a supervision contract.
Table 6.2 Useful questions that might be asked to assess learning needs.
Table 6.3 Evidence‐based principles of goal‐setting for CBT supervision.
Table 6.4 Procedure for developing effective learning goals for CBT supervision.
Chapter 07
Table 7.1 How to conduct gold standard training in supervision.
Table 7.2 Summary of the main methods in clinical supervision.
Chapter 08
Table 8.1 Feedback topics identified by Hattie and Timperley (2007).
Table 8.2 Elements of competent verbal feedback.
Table 8.3 Stepwise procedures for delivering effective feedback.
Chapter 09
Table 9.1 How experienced (“wise”) supervisors reported coping with difficulties in supervision.
List of Illustrations
Chapter 01
Figure 1.1 The supporting our supervisors (SOS) model, depicting how supervision needs to be enabled within organizations.
Chapter 02
Figure 2.1 The essential steps in applied research, providing a structure for the manual’s guiding principles.
Figure 2.2 The tandem model of CBT supervision.
Chapter 03
Figure 3.1 A supervisor training taxonomy.
Chapter 04
Figure 4.1 A process map for training CBT supervisors.
Figure 4.2 The feedback rating form used in the authors’ supervision workshops on the SAGE instrument.
Chapter 05
Figure 5.1 Supervisory alliance process map: The key steps in managing the supervisory relationship.
Chapter 06
Figure 6.1 Goal‐setting: The key steps in structuring the supervisory experience.
Figure 6.2 Vygotsky’s zone of proximal development, adapted for goal‐setting.
Chapter 07
Figure 7.2 The zone of proximal development (ZPD).
Figure 7.3 Fostering experiential learning.
Figure 7.1 Kolb’s (1984) learning cycle applied to clinical supervision.
Chapter 08
Figure 8.1 A process map for feedback and evaluation in CBT supervision.
Chapter 09
Figure 9.1 A process map illustrating support and guidance in CBT supervision.
Guide
Cover
Table of Contents
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A Manual for Evidence‐Based CBT Supervision
Derek L. Milne and Robert P. Reiser
This edition first published 2017© 2017 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Derek L. Milne and Robert P. Reiser to be identified as the authors of this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Milne, Derek L., 1949– author. | Reiser, Robert P., author.Title: A Manual for Evidence‐Based CBT Supervision / Derek L. Milne and Robert P. Reiser.Description: Chichester, UK ; Hoboken, NJ : John Wiley & Sons, 2017. | Includes bibliographical references and index.Identifiers: LCCN 2016055385 | ISBN 9781118977323 (pbk.) | ISBN 9781119030454 (epub) | ISBN 9781118977347 (ePDF)Subjects: LCSH: Cognitive therapy–Handbooks, manuals, etc. | Behavior therapy–Handbooks, manuals, etc.Classification: LCC RC489.C63 M54 2017 | DDC 616.89/1425–dc23LC record available at https://lccn.loc.gov/2016055385
Cover image: (Watercolor) © itskatjas/Gettyimages; (Galaxy) © Attila445/GettyimagesCover design: Wiley
This book is dedicated to our families, and especially to our grandchildren,Martha Rose Maddison and Finlay Milne Maddison (DM), and Lily (RR).
About the Authors
Derek L. Milne (PhD, FBPS) is a retired clinical psychologist who worked in England’s National Health Service for 33 years. During that time he specialized in staff development, including a decade as director of the doctorate in clinical psychology at Newcastle University, preceded by 12 years as a clinical tutor (Consultant to clinical supervisors) at Leeds and Newcastle Universities. Clinical supervision was a significant focus for this work, including the organization and management of placements for trainee clinical psychologists, together with workshops for clinical supervisors. This activity was preceded by providing clinical supervision to multidisciplinary NHS staff, as well as a clinical service to adults with mental health concerns. Since 1979, Derek has published 12 books, two on clinical supervision,1 over 120 papers in peer‐reviewed scientific journals, and numerous articles in professional journals. Many of these address practical issues in enhancing clinical supervision, such as clarifying conceptual models, improving measurement (especially through direct observation), conducting single‐subject (n = 1) and other evaluations, and developing supervisor training. These activities has been guided by a commitment to evidence‐based practice, drawing on a scientist‐practitioner orientation.
Robert P. Reiser is a licensed clinical psychologist in California and a Fellow of the Academy of Cognitive Therapy. His primary orientation is cognitive‐behavioral therapy, with a focus on supervising cases and treating individuals and families with complex and serious mental illnesses, including schizophrenia, bipolar spectrum disorders, and recurrent severe depression. Two of his grant‐funded clinical research projects involved close collaboration with community mental health professionals in providing supervision, clinical training, and piloting clinical interventions for individuals with serious mental illnesses. Robert has provided numerous workshops and institutes at the Association for Behavioral and Cognitive Therapies (ABCT), focused on improving supervision and training through the use of empirically supported practices.
Since 2006, he has been delighted to collaborate with Derek Milne on a series of research projects involving the development of SAGE, an instrument that assesses competence in supervision. He has written and co‐authored several journal articles and has contributed book chapters on evidence‐based approaches to clinical supervision in association with Derek for The International Handbook of Clinical Supervision. He participated as a consulting supervisor providing CBT training to VA clinicians within the CBT‐D national training program with the Veterans Administration over several years. Currently, he works as a consultant with the Felton Institute in San Francisco, providing supervision and training for clinicians and case managers using cognitive‐behavioral therapy for psychosis (CBT‐P), and supervises medical residents in the Department of Psychiatry at the University of California, San Francisco. He maintains an active interest in training and clinical supervision with eight years’ experience of running a training clinic for doctoral‐level clinical psychologists, which focused on supervising trainees providing empirically supported treatments.
Note
1
Milne, D. L. (2009).
Evidence‐Based Clinical Supervision: Principles & Practice
. Chichester: BPS/Blackwell; C. E. Watkins & D. L. Milne (Eds.) (2014).
The Wiley International Handbook of Clinical Supervision
. Chichester: Wiley.
Foreword
I am delighted to write a foreword for this manual for CBT supervision, an evidence‐based account of CBT supervision. It is unique in providing guidelines and procedures along with an exhaustive review of the empirical literature and expert consensus. It is a very important book. The growth of high fidelity and competently practiced CBT and the expanding ability to serve new populations and complicated cases depends upon the quality of supervision and training that is provided to practitioners.
This is a quintessential scientist‐practitioner approach. It combines the best science and a bridge to effective practice. The manual provides a comprehensive training package including 6 guidelines for practitioners accompanied by a PowerPoint slideshow and 2‐3 video clips for each guideline. Each of the 18 included video clips maps onto the Roth & Pilling (2008) competencies framework for CBT supervision and onto the authors’ instrument for measuring competence in CBT supervision, SAGE.
In summary, the authors have provided an original procedural account of CBT supervision and the training of CBT supervisors. It is unlike other manuals and textbooks on the subject, as it is rigorously linked to the evidence‐base. It is worth also noting that the authors worked closely with practitioners, over 100 British Association for Behavioural and Cognitive Psychotherapies (BABCP) supervisors. Also a working committee of the BACBP provided feedback at every stage of the guidelines development.
Unique, too, is the emphasis on the role of organizational context and how this relates to the use of evidence‐based training methods. This focus has resulted in advice on supervisor training that approximates a ‘gold standard’ for CBT supervision and is attuned to the age‐old problems of generalizing such training to real world conditions. CBT supervision has lacked the robust evidence base afforded to CBT treatment and this manual stands as a corrective to that longstanding oversight.
I predict that you will find that this clinical manual of CBT supervision provides a new and particularly promising viewpoint, based squarely on the evidence‐based practice approach.
Judith S. Beck, Ph.D.President, Beck Institute for Cognitive Behavior TherapyClinical Associate Professor of Psychology in Psychiatry, University of Pennsylvania
Preface
Motivation
Undertaking a task as challenging and unpromising as an evidence‐based supervision manual requires a good explanation. We certainly hesitated before deciding to give it a go, but in the end we were influenced by a sense that at long last the world of clinical supervision was evolving and moving toward a new paradigm. For decades we had labored alongside enthusiastic colleagues to get supervision acknowledged as the cornerstone of professional development within the mental health professions. We now believe we have reached that threshold (Watkins & Milne, 2014), making the next phase appropriate. Recent developments in CBT supervision further increased our sense that the time was right to contribute this much‐needed manual. There was also important and timely research progress in neighboring literatures, such as those concerned with expertise, education, and staff training. This progress suggested real improvements in the way we might address CBT supervision, in such issues as facilitating learning and providing effective feedback within supervision. Similar progress was evident concerning the optimal ways to train mental health professionals, with direct relevance to training and supporting CBT supervisors (e.g., Beidas & Kendall, 2010; Rakovshik & McManus, 2010).
Collaboration
Another boost to our ambitions was that we felt part of a small but effective group of like‐minded professionals, all striving in the “swampy lowlands,” but with the goal of finding a firmer footing in the supervision uplands (e.g., The International Handbook of Clinical Supervision, 2014; and the special issue of The Cognitive Behaviour Therapist, 2016). We received further encouragement in our workshops for supervisors, which were met with positive responses to our ideas and materials. This led naturally to some close collaboration with the intended users of this manual in the form of over 100 CBT supervisors who helped us develop the six supervision guidelines. Linked to this operational activity we were supported by a specially convened working party of the British Association for Behavioural and Cognitive Psychotherapy (BABCP), guiding us on strategic issues.
Learning
Something else helped, and made us aware we were pushing against an open and inviting door: this was the close connection between CBT and these developments in clinical supervision. Few models in the mental health sphere can match CBT for the clarity, relevance, transferability, and empirical depth of its learning principles, ones that also apply so readily to supervision. Based on many years of working as CBT therapists, supervisors, and researchers, we felt well placed, as individuals with relevant expertise, to combine this emerging material on supervision with the principles of CBT, blending in the exciting developments in neighboring literatures. Finally, our personal history of collaboration over eight years began with our initial n = 1 study of training effects in developing supervisory competence. It continued with the development of an assessment instrument – SAGE – designed to quantify competences in CBT supervision. Our working alliance continued with more joint scientific papers, alongside a series of international workshops and conferences, whch focused on improving supervisor training through evidence‐based practices. We feel that this joint work exemplifies the kind of enriching development through experiential learning that we aim to convey in this manual.
Originality
Of course, there are other manuals on CBT supervision (e.g., Newman & Kaplan, 2016; Sudak, et al., 2016), so we needed to contribute something original. This we feel we have done by taking an evidence‐based and systematic approach. Specifically, and unlike other manuals, we have critically reviewed the existing literatures in clinical supervision and the most relevant neighboring literatures to a standard comparable to scientific journal reviews. This is indicated by our linked publications in scientific journals (e.g., a survey of CBT supervisors and trainers; Reiser & Milne, 2016), in order to conduct a needs assessment for our manual; and reviews intended to clarify how we might best make a manual effective (including supervision guidelines; Milne, 2016a; Milne 2016b; Milne & Reiser, 2016). This text is also unique in terms of providing a systematic training manual, including everything needed for trainers to deliver a CBT supervision workshop. We include things that other manuals do not offer (e.g., slideshows and road‐tested guidelines), and more varied and extensive material (e.g., video‐based demonstrations of the supervision competences, linked to the competence framework of Roth & Pilling, 2008). We also offer well‐established, proven methods of training and supervision in that this manual builds on extensive earlier work (the manual linked to the text by Milne, 2009), work which has been evaluated and developed in our own workshops and more formally (e.g. Milne, 2010; Milne & Dunkerley, 2010). In summary, we believe this manual is the best available resource for CBT supervisors, providing a carefully tailored collection of video demonstrations from a variety of supervisors and supervisees. To these we have added slideshows with suitable learning exercises and supervision guidelines, representing a far more complete and evidence‐based training resource than other CBT supervision manuals or texts. In summary, we offer a comprehensive, evidence‐based procedural account of CBT supervision that is lacking in all other textbooks and manuals.
Aims
As outlined above, we hope that this manual will contribute significantly to CBT supervision by indicating how supervisors can be trained and supported according to the best available, most firmly evidence‐based practice. We aim to reduce the gap between the hope for and reality of CBT supervision, to help to “make things compute” better in this vital professional activity (Watkins, 1997). As a result, we believe that practitioners will feel more confident and skilled, and hope that their patients will receive safer and more effective therapy.
Scope
As described more fully in chapter 1, this manual has been written primarily for workshop leaders who train CBT supervisors. However, it will also be useful to individual supervisors, and to those who support and guide trainers and supervisors (e.g., peer groups, consultants, managers, administrators, training directors), as we include suggestions and materials (e.g,. video clips and guidelines. which can be used independently by supervisors). In summary, this manual is designed to support and enhance multiple training functions, including:
Providing training to individual supervisors in a continuing education/professional development workshop format
Credentialing and the certification of supervisors
Assisting in a “train the trainers” approach suitable for agency or organization‐based training of supervisors
Coaching and training supervisors and supervisees remotely, through supplementary materials and an interactive website
We also aim to be multidisciplinary and systemic, as we recognize that supervision requires a supportive context and a suitable infrastructure (Milne & Reiser, 2016).
Method
The introductory chapter sets out our plan for achieving these aims, but here we note how, even in our manual design, we have been guided by the available evidence. We were particularly persuaded by the literature on instructional design (e.g., de Jong & Ferguson‐Hessler, 1996), which suggested that the manual needed to address strategic, declarative, and procedural knowledge. In practice, this means that the first three chapters are strategic and academic in style, setting out our guiding principles and core theory (e.g., on the role of organizational context on training). The heart of the manual are the six guideline chapters that follow, each chapter tackling one of the elements in effective CBT supervision. They follow the standard organization of workshops by starting with the necessary didactic teaching in order to provide a foundation in declarative knowledge. This leads on to our evidence‐based recommendations, incorporating principles of experiential learning, designed to develop procedural knowledge. Together, these three complementary forms of knowledge address the best available evidence on how to train CBT supervisors and how to conduct CBT supervision effectively. Those looking for a quick procedural guide can turn straight to the relevant guideline chapter. Each guideline chapter is written in a concise and direct style (as are the six guidelines), and summarizes the evidence for each recommendation that we offer. In the final chapter we reflect on the material and draw some conclusions on the strengths and weaknesses of the manual, and on the challenges that lie ahead.
We hope that you find this approach appealing and that you can draw on this manual to improve your work.
Derek L. MilneMorpeth, NorthumberlandandRobert P. ReiserKentfield, CaliforniaJuly 2016
References
Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence‐based practice: A critical review of studies from a systems‐contextual perspective.
Clinical Psychology: Science & Practice
,
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, 1–30.
Milne, D. L. (2009).
Evidence‐Based Clinical Supervision: Principles & Practice
. Leicester: BPS Blackwell.
Milne, D. L. (2010). Can we enhance the training of clinical supervisors? A national pilot study of an evidence‐based approach.
Clinical Psychology & Psychotherapy
,
17
, 321–328.
Milne, D. L. (2016a). Guiding CBT supervision: How well do manuals and guidelines fulfil their promise?
The Cognitive Behaviour Therapist
. doi: 10.1017/s1754470x15000720
Milne, D. L. (2016b). How can video recordings best contribute to clinical supervisor training?
The Cognitive‐Behaviour Therapist. doi: 10.1017/S1754470X15000562
Milne, D. L., & Dunkerley, C. (2010). Towards evidence‐based clinical supervision: The development and evaluation of four CBT guidelines.
The Cognitive Behaviour Therapist
,
3
, 43–57.
Milne, D. L., & Reiser, R. P. (2016). Saving our supervisors: Sending out an SOS.
The Cognitive Behaviour Therapist. doi: 10.1017/S1754470X15000616
Rakovshik, S. G., & McManus, F. (2010). Establishing evidence‐based training in CBT: A review of current empirical findings and theoretical guidance.
Clinical Psychology Review
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30
, 496–516.
Reiser, R. P., & Milne, D. L. (2016). A survey of CBT supervision in the UK: Methods, satisfaction and training, as viewed by a selected sample of CBT supervision leaders.
The Cognitive‐ Behaviour Therapist. doi: 10.1017/S1754470X15000689
Roth, T., & Pilling, S. (2008). The competence framework for supervision.
www.ucl.ac.uk/clinical ‐psychology/CORE/supervision_framework.htm
.
Sudak, D. M., Codd, R. T., Ludgate, J. W., Sokol, L., Fox, M. G., Reiser, R. P., & Milne, D. L. (2016).
Teaching and Supervising CBT
. Chichester: Wiley.
Newman, C. F., & Kaplan, D. A. (2016).
Supervision Essentials for Cognitive‐Behavioral Therapy
. Washington, DC: American Psychological Association.
Watkins, C. E. (Ed.). (1997).
Handbook of Psychotherapy Supervision
. New York: Wiley.
Watkins, C. E., & Milne, D. L. (Eds.). (2016). Clinical supervision at the international crossroads: Current status and future directions. (pp. 673–696). In
The Wiley International Handbook of Clinical Supervision
. Chichester: Wiley.
Acknowledgments
We are hugely indebted to many colleagues and helpers for their contributions to this manual. Being part‐book and part‐manual, this is no straightforward text, and we could not have compiled it without substantial input from many helpful people. Perhaps the most sustained collaborative effort took place in developing the six supervision guidelines that form the backbone of the manual. We developed them with the help of over 100 active clinical supervisors working in the NHS in England and Scotland. In a series of supervision workshops led by Derek Milne held during 2015–2016, these supervisors – mostly CBT supervisors and BABCP members – scrutinized the draft guidelines and suggested improvements. This procedure is described in chapter 1, but here we wish to thank the supervisors for their significant and willing assistance. We cannot list them all by name, but we should at least thank those who organized the workshops and facilitated the guideline development work. They are: Edith Moon (University of Derby), Nicky Kelly (in relation to the BABCP Special Interest Group in supervision and to Canterbury & Christ Church University); Craig Thompson (University of Northumbria), Sandra Ferguson (National Education Scotland), and Pam Myles (Reading University).
The time and effort taken to record the 18 video clips that demonstrate the six guidelines were similar, but the associated stress of performing supervision in front of a camera deserves a special note of thanks. We identify all the contributors by name with their affiliated employers in the video catalogue, but wish to extend a special thank you here, as we found surprisingly few colleagues were willing to record their approach to CBT supervision.
We were also aided by colleagues in relation to the many issues we encountered along the way. Most frequently there was the challenge of locating key research studies, or of checking our grasp of the literature we had collated. Here we thank Carol Falender, Amanda Farr, Craig Gonsalvez, Russell Hawkins, and Ed Watkins. Of course, they have no responsibility for the material in this manual, which is entirely our own work. We wanted to acknowledge the Felton Institute and the California Institute for Behavioral Health Solutions as well as Sara Tai for assistance in producing several of our high quality supervision videos. We are also indebted to our video editor, Adam Gilroy (time and motion films), for his highly professional approach, and to graphic artist Angela Butler for contributing high‐quality figures and valuable advice on the design of the slideshows and the DVD cover. Finally, we owe a debt of gratitude to Andy Peart at Wiley for commissioning this manual, followed by assistance from editors Darren Reed, Roshna Mohan, and Nivetha Udayakumar. Jan Little provided tireless and valuable guidance on improving the draft text.
Another major consideration was that of trying to ensure that this manual is as useful as possible. We would like to thank a specially convened working party of the BABCP for guidance throughout the two years that it took to prepare this manual. This group was initiated and led by Mark Latham; the working party members were: Amanda Cole, Anne Garland, Sarah Goff, Mark McCartney, Linda Mathews, and Lucy Nicholas.
1Introduction and Overview of Evidence‐Based CBT Supervision
What a State We’re in
We are not the first to be concerned by the gap that exists between the vital role of supervision in professional practice and the means by which clinical supervisors are prepared and developed. The phrase “something does not compute” sums it up succinctly (Watkins, 1997, p. 604). Although Watkins was referring to the neglect of supervisor training, his phrase applies just as well to the way that many advocates of CBT supervision have neglected evidence, failing to create an evidence‐based approach to their supervision practice, despite the impressive commitment to evidence in therapy (Milne, 2009; Reiser, 2014). We recognize this is a timely moment to bridge that gap, in recognition of the increasing international status of clinical supervision (Watkins & Milne, 2014). This manual makes things compute by providing both a wealth of research‐based evidence, which will improve CBT supervisors’ training, and robust support for supervisors in their everyday supervision practice.
Now You’re Talking!
The gap becomes even more apparent when one considers the value of supervision, which is rightly regarded as the signature method of training in the mental health professions (Bernard & Goodyear, 2014). Our interventions are called talking therapies, but CBT places special emphasis on taking the correct action (Waller, 2009). This principle applies equally well to CBT supervision in that the role of experiential learning, which involves repeated cycles of reflection, experiencing, conceptualizing, planning, and experimenting, is viewed as the primary mechanism of development (Reiser, 2014). Our preferred summary of experiential learning is provided by Kolb (1984), who noted that humans are primarily adapted for learning: we are effectively “the learning species.” It follows that “learning is an increasing preoccupation for everyone … and an increasing occupation” (pp. 1–2). This underscores the importance of action and helps us understand why clinical supervision is such a marvelous and quintessentially human activity. Not only is it deeply satisfying, it is also highly effective. Although research on clinical supervision – CBT supervision in particular – has been sparse and of variable quality, there is reason to believe it is the single most effective method for helping supervisees (therapists) to develop the competence, capability, and professional identity they need (Falender & Shafranske, 2004; Callahan et al., 2009; Milne & Watkins, 2014). Supervision is also perceived by supervisees as the main influence on their practice (Lucock, Hall & Noble, 2006), and is currently recognized by governments as an essential component of mental health services. In the United Kingdom the Care Quality Commission (2013, p. 6) states that “clinical supervision is considered to be an essential part of good professional practice,” and a clear example of the UK government’s investment in supervision can be found in the Improving Access to Psychological Therapies program (IAPT: Department of Health, 2008). In addition, supervision has strengthened its status internationally in recent years (Watkins & Milne, 2014), and CBT supervision has developed significantly (Reiser, 2014). Therefore, this is a timely moment to attempt to tackle the long‐standing gaps and build a bridge for CBT supervision as a professional specialization (Milne, 2008).
Getting Our Act Together
How, then, can we bridge the gap between how training and supervision are conducted and the evidence base, so that we better realize the great potential of CBT supervision? Consistent with the IAPT approach, Dorsey and colleagues (2013) claim that the gold standard for supervision in clinical trials is:
Assessing the fidelity of therapy
Developing competence through behavioral rehearsal
Reviewing therapy through direct observation (usually audiovisual recordings)
Monitoring clinical outcomes
Training CBT supervisors in these methods, and supporting them so that they maintain the standards and continue to develop expertise, are as challenging as supervising therapy, but have been afforded far less interest and attention (Although we refer throughout this manual to therapy, we recognize that supervision should embrace all professional activities). Even less is known about supervisor training than supervision itself and the gaps in our knowledge base are even wider when it comes to organizational support for supervisors (see chapter 9). Although Watkin’s (1997) concern that something does not compute has been eased by what he regards as a sea change in supervisor training, his review concludes that we are still in the formative stage and know little about structuring, timing, covering, delivering, or evaluating supervision training (Watkins & Wang, 2014). Milne and colleagues (2011) reached a more optimistic conclusion, based on their systematic review of 11 controlled evaluations of supervisor training, which they believed provided enough empirical support to recommend the following training methods:
Role‐playing and use of simulations
Observational learning (competence modeled live, or by a video recording)
Corrective feedback, ideally based on direct observation
Teaching (verbal instruction, discussion, and guided reading)
Written assignments (e.g., learning exercises, quizzes, and homework)
Note how similar these methods are to the gold standards for supervision itself, not to mention CBT. This suggests a fundamental role for experiential learning (Kolb, 1984) in mental health interventions (see chapter 4). This manual reflects this status and draws attention to relevant commonalities.
How Can We Act Together?
Inspired by the potential of CBT supervision to improve competence in supervisees through experiential learning, this manual addresses the gaps in supervisor training and evidence‐based supervisory practice. Our approach has been to develop an accessible, state‐of‐the‐art product, designed to enhance supervisory training in CBT in a way that is consistent with evidence‐based practice, including relevant competence frameworks. This manual, together with associated internet content (e.g., video demonstrations of competent practice), has been developed in six user‐friendly modules, reflecting the popular and logical training cycle, starting with goals and ending with evaluation. Each module includes a guideline, condensing the essential information found in the chapters. We also tested the guidelines and other materials at supervisors’ workshops, paying close attention to feedback and retaining only the material rated as clear and accurate. To ensure that the manual was state‐of‐the‐art we reviewed the latest ideas from the best available supervision manuals and guidelines (Milne, 2016). We also studied the wider literature for evidence, such as controlled studies and systematic reviews of staff training (see chapter 3). Finally, we learned important lessons about effective dissemination and uptake through experiences with a prior manual that showed promise (Milne, 2010; Milne & Dunkerley, 2010). It is for these reasons that we are confident that our current effort will further enhance supervisors’ training.
Our project is ambitious in at least two ways: it addresses the shortage of suitable training resources and fosters successful dissemination. When we surveyed the current supervisor training manuals we found that most were restricted to academic discussions of supervision, but provided minimal interactive content, limited internet‐based connectivity, and, with very few exceptions (Milne, 2009; Sudak et al., 2016), had minimal enactive, DVD‐supported content. While these manuals are excellent for restricted, classroom‐based teaching or as a reading assignment, they are neither user‐friendly nor accessible across disciplines and countries, and none appeared to be easily adaptable to the highly enriched, complex experiential and procedural learning required for the effective training of clinical supervisors. This last shortcoming seemed especially egregious, as experiential learning lies at the heart of our method in CBT therapy and supervision. In short, most manuals offer limited practical support and do little to advance supervision in practice.
We have addressed dissemination by studying what works and then incorporating useful lessons (Milne, 2016). In particular, we sought to work closely with the British Association for Behavioural Psychotherapy (BABCP) through a working party which guided us toward the most accessible and appealing approaches for this manual. As we have noted, we also piloted and evaluated some sections of this manual with CBT supervisors and trainers (see Table 1.1), and conducted a survey of senior CBT supervisors in the UK in order to assess training needs (Reiser & Milne, 2016). The survey indicated that only one third of respondents were satisfied with the resources available to them for supervisor training.
Table 1.1 The rating scale used to evaluate the six guidelines during supervision workshops.
Guideline Evaluation Form
Please take a few minutes to give your opinion of the guideline that you have just read. When rating, remember that the guideline is intended for
new CBT supervisors
. We are interested in knowing whether it is ready for use, or ways to improve it. If you prefer, feel free to write comments on the guideline itself. Name of the guideline: ________________________ Today’s date:_________________ Rating Scale: 1 = Not yet acceptable 2 = Acceptable 3 = Good
1
Was the guideline easy to read? (Concise; user‐friendly; expressed simply; right level of detail).
1
2
3
2
Did the content seem factually accurate? (e.g., was the information comprehensive?)
1
2
3
3 4
Was the guideline acceptable? (Expressed appropriately; relevant; “face‐valid’) Is the information credible? (Current and relevant? Reflect other practice guidelines?).
11
22
3 3
5
Does the guideline enable competence in supervisors? (Are there practical suggestions or helpful ideas?)
1
2
3
CommentsPlease add any notes to clarify the ratings that you have made above, or to offer suggestions for improving the guideline: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Is This Manual For You?
This manual has been written primarily for workshop leaders who train CBT supervisors. However, supervisors and those who support and guide trainers and supervisors (e.g., consultants, managers, administrators, training directors), working in clinical mental health services will also find it useful, as we have included suggestions and materials (e.g., slideshows and learning exercises) for trainers in addition to guidelines and video clips which supervisors and others can use independently (including supervisees). Thus, we offer guidance and resources to trainers, but also provide directed self‐instruction for supervisors. For those who support supervisors, chapter 9 is devoted to what we know about restorative and normative CBT supervision. Further information on our systemic and organizational emphasis is set out below.
In addition to a focus on workshops and those who lead them as part of introductory and subsequent training in CBT supervision, the manual is designed to support and enhance multiple training functions, including:
Providing training to individual supervisors in a continuing education/professional development workshop format
The initial credentialing and certification of supervisors
Assisting in a “train the trainers” approach suitable for agency or organization‐based training of supervisors
Providing supplementary materials and an interactive website for the continuing coaching/training of supervisors and supervisees
Our emphasis is multidisciplinary and systemic, and recognizes that supervision requires a nurturing environment if it is to flourish. In reviewing the literature (Milne & Reiser, 2016) we developed a “support our supervisors” (SOS) framework to clarify the kind of organizational support required for supervision to flourish. This describes an evidence‐based and systematic organizational process to ensure that supervisors receive the leadership, support, and development to perform their role effectively and with job satisfaction. The SOS framework differs from informal, traditional, or organizationally flawed arrangements (e.g., peer supervision) in that it positions supervision within a normative, formative, and restorative infrastructure. These functions are achieved by evidence‐based methods, such as drawing on competence frameworks, undertaking gold standard training in supervision, and receiving supervision‐of‐supervision (or consultancy). Figure 1.1 presents our model.
Figure 1.1 The supporting our supervisors (SOS) model, depicting how supervision needs to be enabled within organizations.
Source: Milne & Reiser (2016).
The main components of the SOS model for present purposes are the inner supervision cycle, designed to develop supervisors’ expertise, and the outer cycle, indicating how organizations influence supervision through such means as effective leadership and supervisor training. Note that the examples describe an organization’s supportive function (e.g., peer support groups and work satisfaction surveys), which help supervisors “feel that they are supported, accepted, nurtured, acknowledged and validated” (Milne, 2009, p. 185). Therefore, the SOS model acknowledges the need for normative, formative, and restorative functions to be performed by supervisors’ organizations, as these are the essential conditions for a systematic support infrastructure. In this sense, the manual is relevant for service managers, occupational health advisors, and others with an interest in creating a healthy workplace. This broader systematic approach is consistent with our collaborative, empirical stance in the development of materials for the manual. In fact, in order to make things compute, our focus throughout has been oriented toward developing systematic organizational support for the training and development of supervisors. Our position is inclusive: as far as reasonable, we want the manual to be helpful to everyone, not just the workshop leader or supervisor; and we provide information and make suggestions that are as relevant as possible to all those involved.
Will it Work?
We have noted that this manual is evidence‐based, that is to say it is based on research findings, expert consensus, and theory, which support the effectiveness of the methods we recommend. This includes evidence from an earlier manual (Milne, 2010), the feedback of CBT supervisors and trainers who read parts of the present manual (see, e.g., Table 1.1), and corroboration from the CBT staff training literature (e.g., Beidas & Kendall, 2010; Rakovshik & McManus, 2010). So, we have good reason to believe that this manual will work. But consistent with the CBT model of collaborative empiricism, we urge continued evaluation of our manual, our methods, and our procedures. We would be delighted to collaborate with those who would like to undertake such an evaluation, and have previously piloted a suitable approach (Culloty, Milne & Sheikh, 2010).
Watch Your Language!
It seems that, like the NHS, the CBT community remains comfortable with the term “patient,” so we will use it interchangeably with the equally acceptable term of “client.” In mental health services these patients are seen by therapists who are also supervisees, in keeping with the NHS policy of career‐long supervision. In the United States and many other countries, supervision stops when a therapist completes training and gains the initial professional qualification enabling registration as a mental health professional. However, in this manual we assume career‐long supervision as this is the ideal, not least as it provides for continued development and sustained treatment fidelity, rather than regression to earlier levels of competence (Tracey, Wampold, Lichtenberg & Goodyear, 2014) or therapist drift (Waller, 2009). In receiving supervision, therapists are supervisees, so we also use these terms interchangeably. In turn, supervisors should be trained in CBT supervision before becoming a supervisor and then receive career‐long education from workshop leaders or trainers, or benefit from supervision‐of‐supervision or consultancy. Other terms we use interchangeably are “clinical supervision,” “CBT supervision,” and “supervision,” however, we mostly use “supervision,” as we refer to both “CBT supervision” and “evidence‐based clinical supervision” (Milne, 2009).
What’s New or Different?
We have said that this manual is readily accessible and can be considered state‐of‐the‐art, designed to enrich supervisory training in CBT in a manner consistent with evidence‐based practice. It is also collaborative, multidisciplinary, systemic, and inclusive. However, it also has some distinctive features: not only is it the first true and empirically based CBT supervision manual, to our knowledge it is also one of only two or three manuals following any therapeutic approach to be based on over a decade of programmatic research and development. The methods have therefore been tried and tested; our concepts and theoretical models are clear and carefully grounded; and we are committed to measurement and refinement. Support for these claims is given throughout the manual, most especially in chapter 2.
Where Next?
In chapter 5 we note that: “The empirical evidence‐base behind supervisor training has to be the most meager in any area of supervision,” and does not appear to have improved significantly since Milne (2009) concluded that “the supervision of supervisors is the most deficient area in the whole enterprise of clinical supervision” (p. 186). However, there is now growing research attention to supervisor development (Inman et al., 2014), and an increasingly international recognition that supervisor training is necessary (Watkins & Milne, 2014). This view is shared by professional bodies (e.g., APA, 2015). In this improving context Watkins and Milne (2014) concluded that “More consistent, sustained, and systematic attention across researchers and educators will be needed if the evidence‐based challenge of supervisor training is to be most fully realized as practical reality” (p. 688). We believe that this manual consolidates the knowledge base of CBT supervision and hope that you will find it instructive. We conclude by commenting on the organization of the manual.
How Do We Get There?
Chapters 2 and 3 provide context for the experiential work described in the following guideline chapters. They are similar to the typical organization of workshops, providing both a didactic or theoretical background and strategic knowledge. The guideline chapters (chapter 4–9) are the heart of this manual, setting out in detail procedural knowledge regarding the best available evidence on how to conduct CBT supervision. Each of these chapters follows the same format. It opens with a summary, including recommendations from the guideline. Unlike the traditional academic chapters 1–3, each guideline chapter is written in the concise style of the guidelines and summarizes the key evidence for each recommendation, starting with a definition and some background to the topic. Each recommendation from the guideline is then explained, drawing on the evidence that we identified. By “evidence” we mean the best available research findings, relevant theory, and expert consensus, including guidelines published by others and competence frameworks. We close each chapter with a brief conclusion and a guideline to each for use in workshops.
Six CBT Supervision Guidelines
All six guidelines have been checked by qualified mental health practitioners to ensure that they are clear and appropriate. Most of these practitioners are employed in the NHS, and most are CBT therapists and members of the BABCP. Guideline evaluation was conducted at supervision workshops led by Milne during 2015–2016, and included the ratings of 107 supervisors, resulting in 9–26 supervisors’ ratings for each guideline. Table 1.1 sets out the guideline evaluation form (GEF) used to record these ratings. This is an abbreviated version of the form used in Milne and Dunkerley (2010).
All six guidelines received an average rating of 2 or more (i.e., they were rated as “acceptable”) in each workshop. When changes were suggested these were considered and often made. The versions in the manual are therefore at least second drafts that have been vetted by this group of supervisors. For example, the process maps in each guideline were suggested at the first workshop during the consultation process. Participants in later workshops strongly endorsed these maps, and added suggestions on the optimal length (e.g., no more than two pages), as well as other desirable features (e.g., plentiful examples of typical situations). A working party of the BABCP also gave input, as did the supervision special interest group of the BABCP. As we shall see more fully in chapter 2, the guidelines are intended as recommendations regarding the key CBT supervision skills rather than as strict protocols, and suggest how the skills might best be applied. We welcome further suggestions for their development.
Guideline Design and Rating of Evidence
We have borrowed from existing guidelines so that our guidelines are as user‐friendly and helpful as possible. For example, our approach has been to follow a standard format for all guidelines (NICE, 2014). The format:
Offers a focus on the action that needs to be taken
Includes only what readers need to know
Reflects the strength of the recommendation
Emphasizes the involvement of the patient in decisions
Is written in plain English where possible and avoids imprecise language
There are several ways to summarize the strength of the research evidence supporting the recommendations. The American Psychological Association (APA, Division 12) has adopted the rating scheme devised by its working party (Chambless et al., 1998). This scheme distinguishes between “well‐established” therapies with “strong” research support and “probably efficacious” therapies with more “modest” support. To meet the well‐established standard, there should be several well‐designed studies that have been conducted by independent investigators; the findings must be unanimous. Research support is regarded as modest and probably efficacious if there is only one well‐designed study, or two or more adequately designed studies. Of significance here, it is possible for both the strong and modest thresholds to be met in a series of carefully controlled, single‐case studies.
In the UK the main rating scheme is NICE’s (The National Institute for Health and Clinical Excellence, 2014). NICE takes the view that, because there is currently no well‐designed and validated approach for summarizing a body of evidence, a narrative of the quality of the evidence should be provided. As some recommendations will have stronger research support than others, NICE (2014) suggests that the wording of recommendations should vary accordingly. This is consistent with APA’s approach (e.g., APA, 2015). There are three levels of research support or evidential strength: recommendations that must (or must not) be used; recommendations that should be used; and recommendations that could be used. Given the paucity of controlled research, we believe that the most relevant category for CBT supervision is “could,” with few “should” recommendations, and few or no “must not” cautions.
For recommendations on CBT supervision techniques that could be used, the present authors are confident that the intervention will do more good than harm for most supervisees. Our confidence comes in part from the available research, but, while piloting the guidelines, as already noted, we have also had the benefit of input from over 100 CBT supervisors throughout the UK. This is consistent with NICE (2014), in that a “strong” recommendation may be appropriate when the majority of supervisors and supervisees would be expected by the present authors to choose a particular supervision technique if they considered the evidence in the same way as the authors did. The “could” category recognizes that other techniques may also do good. Another reason for selecting this category of evidence is that it places greater emphasis on the supervisees’ context, values, and preferences.
When we believe that the evidence supporting a specific recommendation is strong we record this alongside the specific recommendation, otherwise the reader should assume that the recommendation is based on weaker evidence (i.e., the recommendations “could” apply). This implies that supervisors should spend more time considering and discussing the options with the supervisee than would be the case with strong evidence. This is congruent with the collaborative stance taken in CBT. In practice, NICE suggests using direct instructions for recommendations of this type where possible, such as the term “consider” (this is less directive than a “should” recommendation). Because it would be repetitive to keep using the term “consider” with most or all of our recommendations, we follow the general NICE (2014) guidance by making statements after each suitably worded recommendation in order to summarize the research evidence. Therefore, with regard to style and quality rating, we follow NICE’s approach, as the logic appeals to us; our collaborating organization, the BABCP, is also British; and this approach fits readily with APA’s use in the US.
“Evidence” Includes Research Plus Relevant Theory Plus Expert Consensus
Given the inadequate state of research in CBT supervision, we welcome NICE’s (2014) approach to other forms of evidence, which accepts that recommendations may need to be developed using a range of scientific evidence in conjunction with other evidence (e.g., expert testimony, the views of stakeholders, people using services, and practitioners). Furthermore, NICE acknowledges that theories should be considered (“conceptual framework or logical model/s,” p. 169). For this reason, in chapters 4–9 we routinely consider the best‐ available research, judging it in the context of relevant theory and expert opinion.
Six PowerPoint Slideshows
Training materials are appended to each of the guideline chapters and, like the guidelines, are primarily intended for use in CBT supervisors’ training workshops. The materials include a core slideshow in which we provide a few essential PowerPoint slides. These cover the recommendations, an example of supporting information, suggested learning exercises for each chapter, and slides recommending the use of video clips created for this manual. These clips illustrate the guidelines and are usually prepared as learning exercises within the slideshow.
We have kept the slides to a minimum, based on our experience of what works best in workshops (see the SAGE case study in chapter 2) and on what we know about training supervisors (see chapter 4). Guided by these principles, we use a few essential slides as an orientation to the topic, to suggest learning exercises, and to encourage workshop participants to read the guidelines for additional information. The slides are consistent with what we know about training CBT supervisors, in terms of encouraging needs‐led training, a blend of evidence‐based, experiential learning methods, the opportunity to observe demonstrations of competent practice, and the chance to self‐assess and gain feedback.
However, if the participants’ questions, comments, or discussion suggest that more slides would be helpful, our approach is to add our reserve slides (i.e., a ‘just‐in‐time’ teaching approach). The slideshows referred to in each guideline chapter are therefore those we would probably use if were we leading a workshop using this manual. As with the video clips, we recognize that other workshop leaders may have different preferences, so they should feel free to customize and contextualize their slideshow accordingly; we do though caution against use of the time available for wider considerations, if this is at the expense of the overriding goal of encouraging the participants’ experiential learning.
Suggestions about Using the 18 Appended Video Clips with the Manual
The video clips can be accessed via the Wiley‐Blackwell website. Each one lasts at least 5 minutes and all were prepared for the manual, with the exception of clip 3, which was kindly provided by colleagues from the University of Wollongong, NSW. With the exception of clips 4 and 12, all clips are role‐plays. Although there was in some cases extensive planning, including consultation with the BABCP working party, the clips were not scripted, to ensure they would be naturalistic examples of how these participants usually provide CBT supervision. The video clips are intended to demonstrate the guidelines and provide competent and detailed modeling of CBT supervision. For example, all clips are expected to be rated between “competent” and “expert” on the SAGE rating scale (see chapters 2 and 3). But note that the video clips that we suggest are our own preferences; workshop leaders may wish to choose to use different clips.
The clips are rich in supervision material and most include multiple techniques and elements of more than one guideline. Therefore, several clips may serve equally well to illustrate something that a workshop leader wishes to highlight. This is demonstrated in the video catalogue (appended), which provides a breakdown of the overlap between the 18 clips and Roth and Pilling’s (2008) competences and the SAGE competence measurement instrument (Milne, Reiser, Cliffe & Raine, 2011). The catalogue is only a general guide, based on competences that the authors judged to be sufficiently clear and proficiently demonstrated (i.e., equivalent to at least a “competent” rating of 3 on SAGE).
A Note of Thanks to the 11 Video Participants
The participating supervisors are all qualified and multidisciplinary mental health practitioners, with considerable experience in providing CBT supervision within the health services. They were either actual supervisees or were the supervisors’ role‐playing supervisees.
All patients’ names used in the video clips are fictitious, and all those who kindly helped us to compose the video catalogue have checked their clips to ensure that they contain suitable material. However, some of the material is based on actual incidents, and while no identifying material is found, workshop leaders and participants (and others) should treat the video content with the usual professional confidence.
A disclaimer
The guidelines and all other materials in this manual are support tools and require professional judgment for their proper use, appropriate to a particular context and/or participant group. Those who use our materials should be suitably qualified and must take full responsibility for judging the suitability of the guidelines, materials, suggestions, and other recommendations, taking into account their circumstances and clients (e.g. supervisors receiving training in supervision). This applies to workshop leaders, supervisors, or other professionally qualified users. We also assume that anyone using these materials does so in the context of their professional practice guidelines, supervision, management, and other appropriate arrangements.
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