Clinical supervision in mental health

264 Pages·2014·1.45 MB·English

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Clinical supervision in mental health:

A Foucauldian discourse analysis

Helen Carmichael

A thesis submitted for the degree of PhD Health Studies

School of Health and Human Sciences

University of Essex

November 2010
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Acknowledgements

This thesis is submitted with grateful thanks to my supervisor, Dr Peter Martin, who
has provided support and guidance throughout the duration of the project. It would
not have been possible to complete it without his consistent intellectual challenge
and his diplomatic care.

The project would never even have got started without the unstinting support and
encouragement from my sister, Sally, who has spend many hours in French gardens
discussing its progress with me and providing a wonderfully conducive environment
for working.

Thanks also to my children, Sam, Hollie and Tom who have all successfully
undertaken their own academic studies during the course of this project. I am
grateful for their ongoing support and proud of them all.

Thanks to Andy, who has given me the confidence and much-needed
encouragement to get to the end of this long journey.

This thesis is dedicated to my dad, Paul French (1930 – 2001), whose humility and
passion for learning was an example and inspiration to us all.
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Contents

Summary ......................................................................................................... 5

Chapter one: A reflexive introduction ............................................................... 7

Chapter two: Background and context ........................................................... 12

Chapter three: Theoretical positioning ........................................................... 16

Chapter four: Methodology ............................................................................ 26

Chapter five: Literature review ....................................................................... 42

Chapter six: Clinical supervision as a discursive frame ............................... 126

Chapter seven: Analysis .............................................................................. 138

Chapter eight: Discussion ............................................................................ 198

Chapter nine: Conclusion, limitations and recommendations ...................... 227

References................................................................................................... 239

Appendix one: interview protocol ................................................................. 258

Appendix two: participant invitation letter ..................................................... 259

Appendix three: participant’s information sheet ........................................... 260

Appendix four: participant consent form ....................................................... 262

Appendix five: data transcript line numbers ................................................. 263
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Summary

The practice of clinical supervision amongst mental health practitioners is hampered
by a lack of shared understanding of its nature and purpose and by a complex
mixture of assumptions and external expectations. As a result, potential benefits of
supervision are diminished and its practice risks losing credibility amongst those in a
position to resource it. This study addresses these conflicts through an analysis of
the discourse of supervision within mental health nursing, counselling and clinical
psychology.

Analysis of both policy and academic literature enabled the identification of three
dominant discourses of supervision: supervision as containment, as development
and as safeguard.

The roots and history of each discourse were explored and a discursive frame for
supervision constructed. This discursive frame was then applied to data collected
through interviews with supervisors and supervisees as well as real supervision
sessions, in order to identify ways in which participants drew from these dominant
discourses.

Application of Foucault’s approach to discourse analysis problematises the data
through the method of identifying implicit rules governing what can and cannot be
said about the nature and practice of supervision.

Analysis suggests that these dominant discourses continue to inform the nature and
practice of supervision, but that each of them is problematic in its own way.
Nonetheless, practitioners draw from them in resourceful ways through a process of
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active meaning-making, creating the possibility of positive outcomes for themselves
and for those with whom they work.

A new discourse related to the nourishing potential of supervision on practice is
identified and a new framework for supervision proposed. This framework has the
potential to facilitate meaningful and productive supervision for practitioners in a wide
range of contexts while remaining responsive to changing and competing external
expectations.
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Chapter one: A reflexive introduction

It was a chance remark in a casual conversation that became the motivation to
undertake this study. Sitting with a group of fellow counsellors, I happened to ask the
question, ‘if we weren’t obliged to engage in supervision [as part of the counselling
code of ethics and practice], would we bother?’

I wasn’t entirely surprised by the answer: a categorical affirmation of the inherent
value of supervision and the strongly worded assertion that it would be sought out
even if not mandated. But the very speed and forcefulness with which it was
asserted took me aback. It caused me to wonder why the benefits of supervision, at
least within counselling, seemed to have attained the status of a ‘given’. I wondered
what that revealed about the way in which the relatively recent emergence of
counselling as a ‘profession’ (at least an aspiring one – with the recognisable
characteristics of an established profession: a professional body, a code of ethics, an
accreditation and regulatory process - see the section on the changing nature of the
professional on page 92) had so quickly established supervision as a core, and
mandatory, aspect of its practice. I was also somewhat concerned as to the extent of
the resistance expressed even to my asking the question. The fact that most
counsellors work either in private practice or in the voluntary sector means that they
often personally bear the, not insubstantial, cost of supervision. And the more
counselling hours practised, the more supervision is required. So it did not seem
unreasonable to suggest that it would be worth reviewing the value of the
considerable investment the practice of supervision required. This is why the answer
surprised me.

It is the fact that my interest in supervision as a topic for research was triggered by a
conversation that caused me to reflect on the potential of conversation and discourse
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as a means of meaning-making. Not until I had asked that question and been
impacted by the answer, did it acquire the nature of an issue to be researched. It
was in the discourse that the topic itself was created. So it seemed only appropriate
to explore discursive research methodologies.

But the starting point itself proved an immediate challenge. It is clear to anyone
involved in the practice of supervision that the term itself is problematic. The most
familiar context within which it is used is in respect of the oversight of someone’s
work. Workplaces have supervisors, whose responsibility is to ensure that the
workforce undertakes its tasks effectively, and to whom the workforce is accountable.
From factory floors to local authority social work teams, this kind of supervision is
visible and recognisable.

A secondary, but widespread, context in which the term is used is in the supervision
of academic work. Every student who has ever undertaken a dissertation of any sort
will have been assigned a supervisor, someone who has some expertise in the area
of interest and can guide, oversee and sometimes also assess the student’s work.

Unfortunately, both these contexts are unhelpful when trying to communicate what is
meant by supervision in counselling. Almost every text book written on the subject
attempts to reiterate a distinct meaning and several will be referenced in this thesis.
Broadly speaking, the accepted meaning of supervision for a counsellor concerns a
one-to-one conversation with another counsellor, almost always one with more
experience in counselling, with whom individual clients are discussed. The
supervisee would expect to meet up with their supervisor approximately once a
month for an hour or two and would expect to come away from this conversation with
some new ideas for ways of working with their clients. Of course, with every detail of
this most basic definition, there are variations and preferences and therein lies the
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first of many problems with any attempt to reach a consensus on what constitutes
supervision. Even more reason, then, to ensure there is always the space to ask the
basic questions. If supervision is so critical to the practice of counselling, why is it so
difficult even to identify exactly what it is? What exactly is it that is so critical that we
would pay for it even if we weren’t required to? What is supervision and is it useful?

Other professions which practise something similar in nature to this supervision that
counsellors so value, including mental health nursing and clinical psychology, the two
other professions involved in this study, have tended to adopt the term ‘clinical
supervision’, apparently to distinguish it from ‘managerial supervision’, a term more
closely associated with the more familiar uses of the term as described above.

However, in the UK, counselling has always resisted using the word ‘clinical’, largely
due to the medical connotations associated with the term. (In this study I have tended
to use the terms ‘clinical supervision’ and ‘supervision’ almost interchangeably.
Normally, when writing about counselling I have not used the word ‘clinical’ and have
included it when talking about mental health nursing or clinical psychology. But this
is not consistently the case. And this inconsistency is intentional. I want to keep in
mind the fact that both terms are used to mean more-or-less the same thing.)

Once the research question had been identified (what is supervision and is it useful?)
it became clear that literature on supervision derived from a number of different
contexts, cultures and professions and in order to understand it, it would be important
to include a range of these contexts. So I decided to identify three professions
working within the field of mental health in the UK that share a commitment to the
practice of clinical supervision and that would enable a broad exploration of the ways
in which supervision was practised and, more importantly, the way it was talked