An Interpretative Phenomenological Analysis of Supervisors’ Experiences of the Supervisory Relationship: Can Attachment
Theory Help Us Understand the Supervisory Relationship?
Claire Pitt
Submitted for the Degree of
Doctor of Psychology(Clinical Psychology)
School of PsychologyFaculty of Health and Medical Sciences
University of SurreyGuildford, SurreyUnited KingdomSeptember 2018
Abstract
Background: The supervisory relationship (SR) is central to psychotherapist
development and client outcomes. A review of the literature on attachment theory
(AT) and supervision failed to clarify whether the supervisor’s or supervisee’s
attachment was more significant for the relationship and whether a distinct
supervision-specific attachment exists. This suggested that the relevance of AT to
supervision is not fully understood.
Objectives: To explore in-depth how supervisors experience and make sense of the
SR and whether AT can assist in the understanding of it.
Method: An Interpretative Phenomenological Analysis (IPA) approach was used to
interview and analyse data from seven Clinical Psychologists working in the
National Health Service (NHS) with experience of supervising Trainee Clinical
Psychologists.
Results: Three superordinate themes were identified: The SR is important to me; we
both contribute to the SR and attachment underpins my understanding of the
relationship.
Conclusion: The findings suggest that AT has some relevance to the way in which
Clinical Psychologists understand the SR. However, it is possible that this is a
product of the dominance of AT within Clinical Psychology rather than the nature of
the supervisory relationship. Nevertheless, the findings do clarify Clinical
Psychologist’s understanding of good quality supervision, suggesting that the SR is
improved when both supervisor and supervisee are open and when the supervisor
takes on a caregiving role providing a secure base.
3
Acknowledgements
There are so many people I am thankful to for their support during my training. To
begin, I would like to thank my research supervisor, Dr Kate Gleeson for all the
support she has provided over the last three years. For helping me stay calm when
this project felt overwhelming, for constantly highlighting my strengths in times of
self-doubt and for supporting me with the other challenges I have faced outside of
the research project. I would also like to thank Dr Nan Holmes for co-supervising
this project and taking the time to give valuable feedback on drafts and re-drafts, for
supporting me to meet deadlines during the project and for encouraging my thinking
at various stages. In addition, my appreciations go to my clinical tutors, Dr Vikky
Petch and Dr Heidi Adshead for their support in my development over the last three
years.
Thank you to the seven Clinical Psychologists who so generously gave their time to
be interviewed for this project; this research would not have been possible without
them. It was inspiring to hear their perspectives on supervision and has made me
want to embrace these opportunities when they arise in the future.
I am also grateful for the support of my placement supervisors and the wonderful
teams I have been based in throughout my training. Your support and guidance has
been invaluable. I have learned so much from each of you.
I would like to express my gratitude to the rest of my cohort, especially my personal
and professional development group and the qualitative peer supervision group.
Training would not have been the amazing rollercoaster of a ride that it has been
without all of you!
4
Special thanks must go to my friends and family for their ongoing love and support.
My final thanks are to my husband Colin, and our two cats, CJ and Bella. The love
and support from you throughout this process I will be eternally grateful for. Special
thanks to CJ and Bella for the both wanted and unwanted distractions they provided
throughout training.
I could not have done this without any of you.
5
Table of Contents
Empirical Paper Abstract..............................................................................................2
Acknowledgements.......................................................................................................3
Part 1: MRP Empirical Paper.......................................................................................7
Abstract.....................................................................................................................8
Introduction...............................................................................................................9
Method....................................................................................................................20
Results.....................................................................................................................25
Discussion...............................................................................................................38
References...............................................................................................................48
Appendices..............................................................................................................56
Appendix A.............................................................................................................56
Appendix B.............................................................................................................57
Appendix C.............................................................................................................59
Appendix D.............................................................................................................60
Appendix E.............................................................................................................61
Appendix F..............................................................................................................64
Appendix G.............................................................................................................65
Appendix H.............................................................................................................66
Appendix I...............................................................................................................67
Appendix J..............................................................................................................68
Appendix K.............................................................................................................69
Appendix L.............................................................................................................71
Appendix M............................................................................................................72
Appendix N.............................................................................................................74
Appendix O.............................................................................................................76
Appendix P..............................................................................................................77
Appendix Q.............................................................................................................78
Appendix R.............................................................................................................80
6
Part 2: MRP Literature Review..................................................................................82
Abstract...................................................................................................................83
Introduction.............................................................................................................85
Method....................................................................................................................92
Results...................................................................................................................100
Discussion.............................................................................................................127
References.............................................................................................................136
Appendices............................................................................................................144
Appendix A...........................................................................................................144
Part 3 - Summary of Clinical Experience.................................................................145
Part 4 - Table of Assessments Completed During Training.....................................148
7
Part 1: MRP Empirical Paper
An Interpretative Phenomenological Analysis of Supervisors’ Experiences of the Supervisory Relationship:
Can Attachment Theory Help Us Understand the Supervisory Relationship?
8
Abstract
Background: The supervisory relationship (SR) is central to psychotherapist
development and client outcomes. A review of the literature on attachment theory
(AT) and supervision failed to clarify whether the supervisor’s or supervisee’s
attachment was more significant for the relationship and whether a distinct
supervision-specific attachment exists. This suggested that the relevance of AT to
supervision is not fully understood.
Objectives: To explore in-depth how supervisors experience and make sense of the
SR and whether AT can assist in the understanding of it.
Method: An Interpretative Phenomenological Analysis (IPA) approach was used to
interview and analyse data from seven Clinical Psychologists working in the
National Health Service (NHS) with experience of supervising Trainee Clinical
Psychologists.
Results: Three superordinate themes were identified: The SR is important to me; we
both contribute to the SR and attachment underpins my understanding of the
relationship.
Conclusion: The findings suggest that AT has some relevance to the way in which
Clinical Psychologists understand the SR. However, it is possible that this is a
product of the dominance of AT within Clinical Psychology rather than the nature of
the supervisory relationship. Nevertheless, the findings do clarify Clinical
Psychologist’s understanding of good quality supervision, suggesting that the SR is
improved when both supervisor and supervisee are open and when the supervisor
takes on a caregiving role providing a secure base.
9
Introduction
Clinical supervision is central to practice within psychotherapy disciplines
and the supervisory relationship (SR) has been identified as an essential component
(Ellis, 2010). There is a limited evidence base relating to the SR (Beinart &
Clohessy, 2017). One focus within the literature involves the use of an attachment
theory (AT) (Bowlby, 1958; 1969) framework to understand the SR (Hill, 1992;
Pistole & Watkins, 1995; Watkins, 1995). Pitt (2018) found inconsistencies in the
attachment in supervision research suggesting the construct is not fully understood
and raised questions about the utility of this approach. This study attempts to address
this concern using an IPA of Clinical Psychologists’ experiences of supervision in
their role as a supervisor.
Supervision
Supervision is integral to “ensuring that standards are maintained, workers
continue to learn from their practice and good practice is shared” within the United
Kingdom (UK) National Health Service (NHS) (Department of Health, 2007, p.85).
The provision of supervision is key for clinical governance, developing the
workforce and continuing professional development (CPD) (Department of Health,
2007; Wheeler & Cushway, 2012). Furthermore, supervision is key for reflective
practice and personal and professional development (Fleming & Steen, 2012).
Supervision has been defined as “a relationship-based education and training that is
case-focused and which manages, supports, develops and evaluates the work of
colleagues” (Milne, 2007, p. 439).
10
It is suggested that supervision has three functions: addressing supervisee
learning needs (formative), providing ethical advice and managing the quality of the
work (normative); and supporting the supervisee’s emotional needs (restorative)
(Inskipp & Proctor, 1993). There are various types of supervision including line
management, professional and clinical supervision. Line management supervision
considers organisational objectives and performance monitoring whereas
professional supervision is more focussed on the supervisee’s professional
development (Beinart & Clohessy, 2017). Clinical supervision includes teaching,
modelling, facilitating supervisee self-evaluation, developing evidence-based
practice and evaluating supervisee practice (Milne, 2009). The various types of
supervision can be offered by the same or different individuals. Within Clinical
Psychology, all types are frequently offered by a single individual from the same
profession. It is argued that they should be offered by different individuals although
in practice this is likely to be too time-consuming (Beinart & Clohessy, 2017).
The ultimate purpose of supervision is to ensure safe and effective therapy
(Milne & Watkins, 2014) and to support supervisee competence and capability
(Milne, 2009). It has also been argued that effective supervision impacts client
outcomes (Ellis & Ladany, 1997; Holloway & Neufeldt, 1995; Lichtenberg, 2007).
However, research within supervision has been limited by methodological
weaknesses (Watkins, 2011). Most research has focussed on clinical supervision for
applied psychologists and psychotherapists and particularly those in training. The
clinical supervision of trainee practitioners differs to that of experienced practitioners
as it combines the above types and functions with added clinical responsibility,
evaluation and gatekeeping (Clohessy, 2008). While there are difficulties in doing
supervision research, there is tentative support that effective supervision impacts
11
client outcomes (Watkins, 2011; Wheeler & Richards, 2007). In a study where
clients were allocated either supervised or unsupervised therapists; those with
supervised therapists rated the therapeutic alliance higher and reported more
symptom reduction in comparison to clients with unsupervised therapists (Bambling,
King, Raue, Schweitzer & Lambert, 2006).
The Supervisory Relationship
Beinart and Clohessy (2017) argue the SR “is the most significant aspect of
supervision and that it contributes to improved practice, as well as supervisee
efficacy, resilience, and well-being” (p.3). As highlighted, learning and development
are key for supervision and the SR facilitates this (Beinart & Clohessy, 2017). The
ability to develop an SR is now seen as a vital element in supervision training and
competency frameworks (for example, Roth & Pilling, 2008) and the quality of the
SR has been established as significant in reviews of the clinical supervision literature
(Ellis & Ladany, 1997; Holloway & Neufeldt, 1995). Several definitions of the SR
exist and the most recent of these addresses the multi-faceted nature of supervision
and the SR:
“…a collaborative, mutual working relationship, which supports and
challenges the supervisee to learn and develop their professional practice. The
relationship is developmental, needs-focussed, open, and respectful. It is
normally hierarchical and involves the negotiation of power. It has many
functions including education, monitoring and/or evaluation, and support.
The SR is influenced by multiple contextual factors including those
contributed by the supervisory dyad (or group), the working context, and the
wider sociocultural context…” (Beinart & Clohessy, 2017, p.6)
12
Learning models, such as Vygotsky’s (1978) zone of proximal development
(ZPD), have been used to understand the supervisor’s educative function. Vygotsky
defined the ZPD as "The distance between the actual developmental level as
determined by independent problem solving and the level of potential development
as determined through problem solving under adult guidance or in collaboration with
more capable peers" (Vygotsky, 1978, p.86). James, Milne, Marie-Blackburn &
Armstrong (2007) applied the ZPD to cognitive behavioural therapy (CBT)
supervision postulating that supervisors need to actively support supervisees to both
work within their ZPD and to move through it. Supervisees can be supported to
progress by ‘scaffolding’ new learning using existing skills and knowledge
(Zimmerman & Schunk, 2003). Kolb’s (1984; 2015) theory of experiential learning
has also been applied and this outlines four stages of learning; people will prefer to
enter the cycle at different points but all four stages need to be used to achieve
competence. Supervisors need to be aware of any differences between their own and
their supervisee’s learning styles (Roth & Pilling, 2008) as this could impact the SR
(Beinart & Clohessy, 2017).
How can we Understand the Supervisory Relationship?
Research has attempted to identify factors that impact the SR. Interpersonal
sensitivity and self-disclosure (Bernard & Goodyear, 2013) and allowing the
supervisee to observe the supervisor’s practice (Scaife, 2001) can both support the
SR. But, studies that have matched supervisory dyads on race or gender have
reported mixed findings (Inman, Hutman, Pendse, Devdas, Luu & Ellis, 2014).
Models of supervision can assist with understanding the SR. Broadly
speaking there are two types of supervision models; therapy-specific models based
13
on psychotherapy theory and supervision-specific models that consider processes
within supervision (Beinart & Clohessy, 2017).
Therapy-specific models. Therapy-specific models are criticised for not
providing a framework for training supervisors (Beinart, 2012) and not explaining
the intricacies of supervision (Bernard & Goodyear, 1998). Furthermore, the SR is
not the primary focus of these models. However, Cognitive-Analytic Therapy (CAT)
does stress the importance of the SR using relational theory (Pickvance, 2016).
Within supervision there is an emphasis on: the need for a strong supervisory alliance
for learning to occur; attending to the relational patterns of both the supervisor and
the supervisee; and an acknowledgement that relational patterns may be replicated in
the SR (Pickvance, 2016).
Supervision-specific models. Developmental models and social role models
too consider the SR but again it is not the primary focus. Developmental models,
such as the Integrated Developmental Model (IDM) (Stoltenberg, Bailey, Cruzan,
Hart & Ukuku, 2014) postulate that supervisees develop through stages and the SR
can be impacted if the supervisor does not respond appropriately to the supervisee’s
needs at these different stages.
Social role models of supervision, such as those of Hawkins and Shohet
(2006) and Inskipp and Proctor (1993) recognise the importance of a trusting SR
whilst incorporating the functions and process of supervision and the roles
undertaken by supervisors such as, teacher, consultant, mentor, role model etc
(Beinart & Clohessy, 2017). Holloway’s (2014) Systems Approach to Supervision
(SAS) is the only supervision-specific model that views the SR as central to
processes within supervision (Beinart & Clohessy, 2017). It emphasises the
14
development of the SR over time which enables the dyad to be more open,
vulnerable and to self-disclose (Holloway, 2014).
Models of the Supervisory Relationship.
There are further models that focus explicitly on the SR.
Bordin’s model of the supervisory working alliance. Bordin (1983) applied
his model of the therapeutic working alliance to the supervisory relationship. He
conceptualised the working alliance as “collaboration for change” (p.35). In the
supervisory alliance, change is dependent on the agreement and understanding of the
supervisory goals, who is responsible for what tasks within supervision and the bond
between supervisor and supervisee. However, Bordin’s model has been criticised for
missing other contextual factors that are equally important for the SR such as the
educative function of supervision (Beinart & Clohessy, 2017).
The Oxford Supervision Group. This group has developed two models of the
SR in the context of clinical psychology training, one from the perspective of the
supervisee (Beinart, 2002 cited in Beinart 2014) the other from the supervisor
(Clohessy, 2008). Beinart’s theory emphasised the need for a framework of
supervision based on a boundaried relationship which enables the process of
supervision to occur (Beinart, 2002 cited in Beinart, 2014). Key features of the SR
were a collaborative, respectful, open and committed relationship, with supervisors
flexible to supervisee needs (Beinart, 2002 cited in Beinart 2014). Clohessy’s (2008)
model considered the impact of contextual factors on the SR including the team or
service, the clinical psychology training course, and professional values. Within this
15
model, both supervisors and supervisees contribute to the SR through the
supervisor’s investment in the relationship and the supervisee being open to learning
(Clohessy, 2008). A measure of the SR, the Supervisory Relationship Questionnaire
(SRQ) (Palomo, 2004 cited in Palomo, Beinart & Cooper, 2010) was developed from
Beinart’s research. This measure identified six components of the SR; the most
significant component to predict variance was the ‘safe base’ which allows
supervisees to feel valued, supported, respected and safe to explore difficulties
(Palomo, 2004 cited in Palomo et al., 2010).
Attachment Theory. The Attachment Caregiving Model of Supervision
(ACMS) emphasised caregiving and attachment processes in the SR and how these
relate to supervisee learning (Fitch, Pistole and Gunn, 2010). The ACMS is based on
AT, which explains the bond that develops between a primary caregiver and child,
although Bowlby emphasised these relational patterns persist throughout the lifespan
(Bowlby, 1958; 1969). Bowlby postulated that when a child’s attachment system is
activated they go to the safe-haven of the caregiver for safety and comfort (Bowlby,
1969). Once comforted, the child feels safe to explore from the caregiver (the secure
base) knowing they can return (Bowlby, 1988). When the supervisee’s attachment
system is activated, this elicits caregiving from the supervisor who provides a safe-
haven (safety and comfort) and deactivates the supervisee’s attachment system (Fitch
et al., 2010). The exploratory system is then re-activated and the supervisor provides
a secure base for the supervisee to return to for further guidance (Fitch et al., 2010).
However, this model lacks empirical support.
Building on Bowlby’s work, three main categories of attachment orientations
in children were identified: secure; anxious-ambivalent; and anxious-avoidant
16
(Ainsworth & Bell, 1970; Ainsworth, Blehar, Waters & Wall, 1978). A fourth
attachment style (disorganized/disoriented) was added by Main and Solomon (1990)
to explain attachment behaviours that did not fit with the other three categories.
Bartholomew and Horowitz (1991) later developed a four-category model of adult
attachment and described the presentation of secure, preoccupied, dismissing and
fearful attachment styles. Crittenden’s (1995) Dynamic Maturational Model
wentfurther and expanded upon the four child attachment categories. The model
depicts the dynamic nature of attachment and how attachment behaviours (self-
protective strategies) will change as the person ages (maturates) but they will
continue to need a secure base (Crittenden, 1995).
It is proposed that the supervisor provides a secure base for the supervisee
(Hill, 1992) who in turn provides this to clients (Hill, 2001). It is further suggested
that supervisee behaviours within supervision that represent insecure attachments
(for example, dependency) can negatively impact the SR. (Bennett & Saks, 2006;
Pistole and Watkins, 1995; Watkins, 1995). Studies investigating this have reported
that supervisees with self-reported secure attachments in interpersonal relationships
have rated the working alliance/SR more positively (Bennett, Mohr,
BrintzenhofeSzoc, & Saks, 2008; Gnilka, Rice, Ashby, & Moate, 2016; Gunn &
Pistole, 2012; Marmarosh et al., 2013; McKibben & Webber, 2017; Renfro-Michel
& Sheperis, 2009; Wrape, Callahan, Rieck, & Watkins, 2017). In addition, an
insecure attachment to the supervisor (supervision-specific attachment) has been
found to be related to negative working alliance ratings more than attachment in
other interpersonal relationships (general attachment) (Bennett et al., 2008;
Marmarosh et al., 2013; Wrape et al., 2017). However, Foster et al. (2007) did not
find a difference between general and supervision-specific attachment.
17
Although supervisors take the relational position of a caregiver in supervision
(Pistole & Fitch, 2008) they need to reflect on their attachment styles and
experiences of receiving care to attend to their supervisee’s needs (Fitch et al., 2010).
Indeed, supervisees of supervisors with an insecure attachment have been found to
give poorer working alliance ratings (White & Queener, 2003). Moreover, if
supervisees perceive their supervisor has an insecure attachment they rate the
alliance more poorly (Dickson, Moberly, Marshall & Reilly, 2011; Riggs & Bretz,
2006).
Clearly, there are mixed messages about the link between attachment and the
SR. One explanation may be the lack of supervisor perspective in several of the
studies (Bennett et al., 2008; Gnilka et al., 2016; Gunn & Pistole, 2012; Marmarosh
et al., 2013; McKibben & Webber, 2017; Renfro-Michel & Sheperis, 2009; Wrape et
al., 2017). In addition, debates about the reliability and validity of adult attachment
measures and large correlations between these and measures of the supervisory
alliance call into question the robustness of the findings reported. Further discussion
of this can be found in Pitt (2018).
Some have queried the appropriateness of applying an attachment framework
to the SR (Bartholomew & Thompson, 1995). It may be the SR reflects “dynamics of
attachment”, such as the secure base, rather than a full attachment relationship
(Mayseless & Popper, 2007, p.73). This could explain why attachment-informed
supervision training for supervisors has not improved supervisee ratings of the
alliance in research by Bennett et al. (2013) and Deal et al. (2011). Attachment
processes within the SR may be better understood using a leader-follower framework
(Watkins & Riggs, 2012). Popper and Mayseless (2003) suggested that leaders e.g.
18
teachers, politicians, managers etc. could function as attachment figures by providing
safe- haven and secure base functions. Leaders that are securely attached are better
able to provide these functions to their followers (Mayseless, 2010). In the context of
the SR, supervisees may need more leading (structure and direction) in the early
stages of development until competency and confidence have developed (Watkins &
Riggs, 2012). There is some empirical support for this framework with it being
found to explain variance in supervisee working alliance ratings over and above
supervisee attachment orientation (Wrape et al., 2017).
Rationale for the Current Study
Research on supervision is limited and there are concerns about its quality
(Beinart & Clohessy, 2017; Milne, 2014; Milne et al., 2012). Additionally, studies
have mainly been conducted in the United States of America (USA). Whilst the
practice and supervision of psychotherapy may be similar, the professional context is
different meaning it may not be applicable to Clinical Psychologists working in the
NHS (Green & Youngson, 2005 cited in Clohessy, 2008). Changes to the
organisation and pay structure of Clinical Psychologists in the NHS have placed
increasing demands on them to both provide and receive clinical supervision
(Fleming & Steen, 2012). This has led to closer scrutiny of the part that supervision
plays in therapy and in training, raising a demand for an evidence base on which to
develop supervision practice. Consequently, further research is needed to add to the
small, but growing evidence base on supervision and the SR in the UK (Beinart &
Clohessy, 2017). Research investigating AT in supervision has inconsistent findings
suggesting further exploration is required. Leiper & Casares (2000) explored the
relationship between Clinical Psychologist’s attachment experiences and their
19
clinical practice and found those with insecure attachment styles reported
experiencing more difficulties in their therapeutic work. It may be reasonable to
consider that if Clinical Psychologists with insecure attachments experience
difficulties in their therapeutic relationships, they may also experience difficulties in
their SRs. The limited attachment in supervision literature has focussed on the
relationship between attachment orientation and supervisory working alliance ratings
with an over-reliance on self-report measures with questionable psychometric
properties (Pitt, 2018). Furthermore, it has been conducted with supervisees in
training and/or their supervisors but this is to be expected given the importance of
supervision to training (Beinart & Clohessy, 2017; Fleming & Steen, 2012).
Therefore, a new contribution to this literature should attempt to build on and
complement the existing evidence base. A supervisor perspective of the SR could
complement the existing evidence and help to clarify the nature of the relationship.
Furthermore, the perspective of supervisor’s is important to our understanding of the
relationship as they understand the relationship from a different vantage point in
terms of power and responsibility (Clohessy, 2008). This study will also recruit
supervisors of trainee practitioners because within the SR, attachment in understood
as the bond between the supervisor and supervisee that may be activated by the
anxiety that novel situations create, such as meeting with a client for the first time.
Therefore, this study will recruit supervisors for an in-depth qualitative exploration
of how they have made sense of their supervisory experiences, what is important for
the SR and whether attachment constructs are relevant.
Study Aim
20
This study’s aim was to explore how Clinical Psychologists understand the
experience of supervision as a supervisor and how this may relate to AT.
Research Questions
The research questions were:
What is the experience of the SR for Clinical Psychologists supervising Trainee
Clinical Psychologists.
Are ideas from AT helpful for understanding the SR? What other ways can the
relationship be understood?
Method
Design
An IPA (Smith & Osborn, 2003) approach was chosen as it allowed for a
detailed investigation of how Clinical Psychologists make sense of the SR in their
role as a supervisor. IPA facilitates exploration of nuances between individual
accounts whilst permitting cross-case analysis to capture similarities across the
participant group (Smith & Osborn, 2008). A close examination of the experiences of
a small number of people with key similarities was thought to be helpful in
developing an understanding of how supervisors made sense of relational processes
within supervision. Further rationale for IPA can be found in appendix B.
Participants
Recruitment strategy. Purposive sampling was used to achieve a small but
homogenous sample that gave access to a perspective instead of a specific population
(Smith & Osborn, 2003; Smith et al., 2009). The literature does not suggest any
specific factors are conclusively related to the SR or the attachment in supervision
21
construct (see Appendix C for full inclusion and exclusion criteria). Therefore, being
a supervisor of trainee psychotherapists, and being within a single professional group
was central. Participants were Health and Care Professions Council (HCPC)
registered Clinical Psychologists with two years’ minimum clinical experience who
had supervised Trainee Clinical Psychologists (TCPs) within the last year.
Considering the double hermeneutic within IPA research, the researcher as a TCP
was familiar with clinical training, clinical supervision and the SR in this context. It
was anticipated that this familiarity would support the interpretation of participants’
experiences.
Advertisements for the study were posted on the “UK Clinical Psychology
Facebook Group” (Appendix D). Participants were invited to email the researcher
who provided them with a participant information sheet (Appendix E), details about
what would be covered in the interview (Appendix F). Questions about the study
were answered before interviews were arranged.
Response to this advert was slow and yielded one participant. Given this
initial poor response and Smith et al’s. (2009) recommendation of eight to ten
participants for doctorate level IPA studies, the recruitment strategy was extended
(see appendix G) which resulted in a final sample of seven participants. This was
deemed sufficient for this project as the emphasis within IPA research is on detailed
accounts of individual experience and it is “important not to see the higher numbers
as being indicative of ‘better’ work” (Smith et al., 2009, p.52).
Sample. Participants were six female and one male HCPC registered Clinical
Psychologists working in various settings in the South of England and supervising
TCPs from different training programmes. Gender, age and ethnicity neutral
22
pseudonyms have been used to ensure confidentiality and can be found in Table 1. A
summary of participant characteristics can be found in Table 2.
Table 1
Participant pseudonyms
Participant Number Participant Name
1 Charlie
2 Drew
3 Jesse
4 Alex
5 Taylor
6 Reese
7 Sam
Table 2
Participant Characteristics
Ethnicity 6 White British1 White Other
Age Range 34-45
Service settings older adult, forensic, learning disability, children with disabilities and child mental health
Years Qualified Range 5-16
Attended Supervisor Training All participants had attended supervisor training
Developmental Level of TCPs supervised All participants supervised Year 2 and Year 3 TCPs
Theories and Models used by participants attachment, systemic, CBT, psychodynamic,
23
positive behaviour support, neuropsychology, behavioural, mindfulness, schema therapy, dialectical behavioural therapy, cognitive analytic therapy, and eye movement desensitisation and reprocessing.
Ethical Considerations
Ethical approval was granted by the University of Surrey Faculty of Health
and Medical Sciences Ethics Committee (Appendix H). Further ethical approval was
granted to widen the recruitment strategy (Appendix I). Additional ethical
considerations are discussed in Appendix J.
Data Collection
A semi-structured interview schedule was developed (Appendix K); this was
informed by the research question, research literature, discussions with research
supervisors, peers, a placement supervisor interested in AT, and IPA guidance
(Smith et al., 2009). The interview schedule included demographic questions,
questions about experiences of supervision, supervisory style, the supervisory
alliance and attachment within the SR. The schedule was used flexibly to explore
areas of interest and other ideas that emerged in the interviews rather than leading the
interview in line with the researcher’s beliefs and interests (Smith et al., 2009).
Participants were offered a choice of interview locations, either the
University of Surrey, their workplace, or their home. The face to face interviews
lasted between 63 and 87 minutes. All interviews were recorded and then transcribed
verbatim, one by the researcher, the rest by a professional transcription service
(Appendix L), with all identifiable information removed. On meeting participants,
24
they were given the participant information sheet to read again before signing the
consent form (Appendix M).
Data Analysis
Although not a prescriptive method for conducting IPA; the advice given by
Smith et al. (2009) was followed during the analysis. Further detail of this process
can be found in appendix N.
Individual case analysis. The first interview was read several times whilst
simultaneously listening to the interview audio recording. This led to the
development of exploratory comments. Once this had been completed for the first
interview, the process was repeated for the remaining six interviews.
Emergent themes. Each transcript was read again using the exploratory
comments to formulate emergent themes. These themes were listed chronologically
in a word document and patterns looked for which were then clustered and ordered
according to whether the themes appeared to be linked to one another (See Appendix
O for an example of this). These were then organised into superordinate and
subordinate themes.
Cross case analysis. The superordinate and subordinate themes of each
transcript were cross-referenced to identify patterns across the cases with attention
paid to how much evidence was available in each transcript to support the theme.
The cross-case analysis was continued within supervision to reduce the overall
25
number of themes for review by identifying themes that appeared to be central to the
participant’s experiences and the research question.
Validity and Quality
Smith et al. (2009) recommend assessing validity and quality when
conducting IPA research and suggest following the general guidelines specified by
Yardley (2000): sensitivity to context; commitment and rigour; transparency and
coherence; and impact and importance (supporting evidence can be found in
Appendix P). A thorough transparent and rigorous approach to analysis can be found
in Appendix Q and a self-reflective account supporting transparency can be found in
Appendix R.
Results
Three superordinate themes were identified using IPA of the interview
transcripts. Each superordinate theme had subordinate themes (see Table 3).
Table 3
Superordinate themes and related subordinate themes
Superordinate theme Subordinate themes
The supervisory relationship is important to me
I want a positive relationship with my supervisees
I want to relate to my supervisee as a person
Setting up the supervisory relationship is important
The relationship is rewarding
My experiences as a supervisee influence my relationship with my own supervisees
We both contribute to the supervisory relationship
Open-ness supports the relationship
We each bring our own traits to the
26
relationship
Attachment underpins my understanding of the relationship
A secure base is important for the supervisory relationship
Our early relationships impact how we relate in the supervisory relationship
I want to protect and care for my supervisees
What follows is an exploration of each theme which will be supported using
verbatim interview extracts noting the similarities and nuances between participant
experiences. Small amendments have been made to improve the readability of the
extracts. A description of these changes and an explanation of the selection of quotes
can be found in Appendix N.
The Supervisory Relationship is Important to Me
Participants described the process of establishing the SR. They placed value
on this relationship and wanted to get to know their supervisees outside of scheduled
supervision. They identified how they benefited from the relationship and considered
how their own experiences of being supervised informed their supervisory practice.
Taken together, these reflections suggest that the SR was important to participants.
I want a positive relationship with my supervisees. Participants valued the
relationships they developed with supervisees and wanted them to be positive,
potentially avoiding conflict to maintain this:
I think I’m keen to have quite a positive relationship with trainees. I don’t
want to be threatening or too questioning or critical. I probably am quite soft
with my approach and I’m sure that is to do with wanting to maintain a
positive relationship (Jesse).
27
Sam described her first experiences of being a supervisor, setting up the
relationship and being evaluated as anxiety provoking:
I was really anxious to make a good impression, and to make people feel
safe….I was also quite anxious about being seen as doing clinical psychology
in a thorough and proper way…(Sam)
For Charlie, if an event in supervision threatened the relationship it lead to
questions about her practice as a supervisor:
…you know we have nice relationships so they [supervisees] don’t
particularly want to upset me…if they do lose the plot a bit with an issue,
obviously I know they haven’t just done that because they fancied it, there’s
been a build-up and perhaps I’ve dismissed it a bit…(Charlie)
Drew thought a positive relationship with supervisees made it easier to give
feedback for her and her supervisees: “…When there are more tricky things to say
potentially you’ve got enough of a relationship that it doesn’t feel so…hard to say or
hard to hear as well”.
I want to relate to my supervisee as a person. Participants reflected on
establishing relationships with their supervisees outside of supervision. This involved
getting to know their supervisees as a person, such as their likes and dislikes. Charlie
reflected that getting to know them helped her “… understand and support them
better”. Jesse thought getting to know supervisees added a “different level” to the
SR:
28
I think it does break down those barriers if you were able to talk about what
you’re going to do at the weekend and where you’re going on holiday…
(Jesse)
Drew and Alex considered how sharing an office space with supervisees
supported their relationships: “…I could sit next to trainees a lot more and then you
could do a lot more…getting to know people”. (Drew), although Alex said this could
present challenges to the boundaries of the relationship: “We share offices, I don’t
have to sit in a separate room. Sometimes that tests my boundaries as soon as I say
things I think oh blimey should I be saying that in front of a trainee…” (Alex).
Setting up the supervisory relationship is important. Participants
described the importance of establishing the SR and how they would do this: “I start
where they need me to be…I always sit them down and ask them what works well for
you in supervision, what do you need from supervision, how do you want me to be?”
(Charlie). Similarly, Sam spoke of “finding out from the supervisee what approach
they like in supervision…”. It seemed particularly significant to Drew who
mentioned spending considerable time (“I always do a two-week induction with
trainees…”) on this. Alex considered first impressions when building relationships
with her supervisees: “…I’m also aware of that to make it welcoming for them.
That’s important that they have a supervisor that is welcoming. First impressions
are important”. Taylor described joint-working with supervisees during the initial
stages of the placement to support the development of the relationship: “I am quite
open to having people come and sit in on my sessions. I’ll go in and sit in on their
sessions and so, hopefully that helps with feeling, building that trust as well”.
29
For Drew and Reese, it was imperative to establish this relationship at the
beginning of the placement. Drew commented “…if you think about all that work at
the beginning that is all about creating a good enough relationship…”. Likewise,
Reese said “It feels like that’s really key to developing that [relationship]…a lot of…
what sets up the rest of the placement happens really early on”.
Charlie made links between the SR and the therapeutic relationship: “What
goes on between you is much like a therapeutic relationship, that’s kind of how I
approach it”. Charlie frequently nearly used the phrase ‘therapeutic relationship’
instead of ‘SR’ suggesting she may view these relationships as being the same in
some ways. Charlie often self-corrected when she used the phrase ‘therapeutic
relationship’ and commented on her use of language: “…I’m acutely aware that I am
using them interchangeably”. Drew also noted the similarity between the SR and the
therapeutic relationship and extended this to all relationships: “…It’s like therapy. I
mean all relationships really….In that the more time you put in at the beginning…”.
The relationship is rewarding. Participants described the SR as rewarding.
The supervisory bond supported both their own and supervisees development and
learning. Alex reflected that the turnover of supervisees can mean it is an “effort” to
keep establishing rapport with new supervisees. However, the benefits of building
new connections appeared to be vital to her:
…the other part of me thinks ‘I’ve got this whole new being in front of me
with all their history and experience and hopes and dreams. Isn’t it exciting’.
I get this opportunity to work with them and to learn from them and to
develop a new relationship (Alex)
30
For Reese, learning within the SR was comparable to CPD’; “I think I do get
a lot of learning out of those relationships and it is almost CPD time which is really
nice I think, to have that space”. Taylor too considered how she learned from her
supervisees: “They’re bringing all these skills and all this knowledge and most up-
to-date research and I learn so much…I benefit as a supervisor so much from the
SR”.
Charlie reflected that some supervisors may find it challenging to supervise a
knowledgeable supervisee but this was something she relished as a supervisor: “…
it’s alright to have brilliance in your midst and to just be facilitating that brilliance
it’s actually quite exciting because you grow from it as well…”
My experiences as a supervisee influence my relationship with my own
supervisees. Participants reflected on their own experiences of being supervisees and
how this influenced their current practice as supervisors: “I’ve had various different
experiences in supervision myself and I think that in itself changes you because you
learn…I suppose different styles and you have different experiences and you take
that through into your own relationship” (Reese). Taylor listed various behaviours
she does as a supervisor and was asked what informed these behaviours: “…I’m
drawing on my own experiences of having been supervised and what helped me at
different points”. Jesse thought that her own supervisory style may “mirror” her
own supervision. Alex too described learning from her own supervisors’ styles and
that “…being supervised by other people has been interesting and important. Not
just for support for me with the trainees, but also seeing how other people
supervise…”. Whereas for Sam, her negative experiences of being a supervisee
informed her practice:
31
…I was very anxious to be doing the right thing by people. I think I could
remember a lot of my own experiences, and as an assistant I had some really
difficult experiences and then as a trainee, I had one very difficult placement
because of my relationship to the supervisor…(Sam).
We Both Contribute to the Supervisory Relationship
Participants thought the quality of the SR was dependent on both them and
their supervisees. Participants described the tensions that differences could bring to
the relationship, how they and their supervisees react to one another and how this
affected how well the relationship worked. Participants considered what they and
their supervisees bring to the relationship and the difference that open-ness could
make to the quality of their SR.
Open-ness supports the relationship. Participants described valuing open-
ness within the SR, both from themselves their supervisees. If supervisees were open,
participants felt better able to support them whereas being closed was a barrier to the
SR. This was summarized by Drew who said “…for me the important things are the
trainees being able to demonstrate openness, curiosity, interests, being hard
working, and actually when these things aren’t happening, that is really challenging
to me in lots of ways”. Jesse too spoke of the need to be open and said “I think being
open is important. It’s not that I am wanting to be really nosy or know everything
about a trainee, but I do think it helps develop a relationship”.
Reese found supervision more challenging if she felt supervisees were
holding things back:
32
It makes supervision harder as well if you feel that someone’s not really
being honest with you and talking to you because you know there’s other stuff
going on that isn’t being allowed to talk about but clearly is having an
impact on the trainee and on their work (Reese).
Taylor recognized the importance of being open in supervision about things
that have happened in both her life and her supervisees’ lives as these will impact
clinical work:
I suppose I am quite reflective and quite open. I encourage people
[supervisees] to be thinking about their own personal stuff and how that
might impact on the work that they do…I am quite open about…what I have
had going on for me, because obviously that has an impact on my own work
(Taylor).
We each bring our own traits to the relationship. Participants talked about
the traits they and their supervisees bring to the relationship and how these impact
the relationship. Participants also explained how they respond to difficult behavioural
traits from their supervisees, for example, not adhering to instructions given.
Alex drew on her systemic psychotherapy training to think about “…what
they can bring and what I bring to supervision”. Alex needed her supervisees to be
genuine and when working with one supervisee she described feeling that she wanted
the supervisee to “drop the act”.
Sam found it easier to relate to supervisees who were like her and approached
situations more cautiously “…probably relates to what I’m like, I’m not confident in
those ways. It’s people who are [like]me, approach situations carefully….”. Sam
33
thought that if her supervisees were behaving in a way that she disagreed with and
were continuing to do so then this was a reflection on the supervision being offered:
“If the person is carrying on doing something that I’m not happy about, it’s
obviously that I’m not doing something that would help the situation because there’s
a repeated pattern being set up here”.
Drew and Reese considered how having shared interests with their
supervisees helped their relationship: “…some trainees you just do get on well with.
You have things in common with. You might like the same music…and some of these
things can make it easier in terms of the relationship” (Drew). Reese said: “I think
personality does come into it and I think there are times when you just don’t have a
lot in common with your trainee...I find it harder to supervise people I don’t feel that
connection to…”. For Reese, supervisees that were disinterested in her specialty
were hard to work with: I can feel that in those supervisions that I’m trying harder to
support that interest…. makes it feel quite a sluggish placement in a way because….
I’m having to put a lot more energy into thinking about supervision… (Reese)
Drew reflected on her values of respecting people older than she is and how
this has sometimes been a barrier for her as a supervisor: “I think I give quite a lot of
respect to people who are older than me…I’ve sometimes felt constrained when
trainees have been the same age as me or older than me…”.
Like Drew, Taylor was aware of her own traits and considered the need to be
aware of the traits she brought to the relationship:
I’m an ambivert. I have my extrovert tendencies and I have my introvert side
as well….Being aware of the style that you have. Whether it’s being an
34
introvert, being an extrovert, having a particular learning style…whatever it
is about you that you bring to the table…(Taylor)
Jesse noted that she has had different reactions to supervisees and had to
adapt her supervisory style in these circumstances:
I do feel that my reactions have been quite different to the trainees that I’ve
had here…. I think some trainees perhaps are more passive, less passionate,
less anxious or more confident and just having to respond to that accordingly
really (Jesse)
Charlie recognized difficulties in supervision impacting on her and was
ashamed to acknowledge how this made her feel towards the supervisee: “There was
a stage in supervising her when she was crying every time…. I’m a bit ashamed to
say that I used to start dreading supervision with her…”.
Attachment Underpins my Understanding of the Relationship
Participants discussed how they considered AT within the SR. Participants
talked about the role of the secure supervisory base and the impact of their own and
their supervisees’ early relationship experiences on their experience of the SR.
Finally, participants described adopting a caregiver position as supervisors and
wanting to protect and care for their supervisees.
A secure base is important for the supervisory relationship. Charlie
outlined behaviour from a supervisee that echoed the secure base concept as defined
by Bowlby (1988). The supervisee was described as checking in with the secure base
and then going off and exploring:
35
…I ‘know’ he will make a beeline straight for me to touch base with me as
sort of the mother hen, I don’t like that phrase. I must think of a better one,
as the sort of a central point within the service, touching base with the
anchor maybe, and then he can go on his way. (Charlie)
Charlie was later asked what she thought might be happening for this
supervisee in terms of attachment. She replied with nervous laughter and said: “I’m a
bit scared to think too much about it. Erm, the secure base. The unconditionality of
it…”. Taylor described behaviours within supervision from herself and her
supervisees that fit with the secure base concept: “It’s building their confidence a
little bit as well to feel like they can go off and do that on their own…”. Taylor too
conceptualized this behaviour using an attachment framework: “All those things I
was describing about supporting them to be able to go off. You’re acting as a bit of a
secure base there aren’t you?”
Sam considered the importance of a secure base for supervisees for them to
feel safe in making disclosures within supervision: “I would want them to feel safe
and secure in divulging not just the things that are going well for them obviously but
also things that they are finding much more difficult. That needs a secure base for
them”.
Participants described a variety of things that they do as supervisors and these
behaviours were interpreted as relating to the secure base through the function of
creating a safe supervisory space; this interpretation was endorsed by some of the
participants. Drew said “…if you think about all that work at the beginning that is all
about creating a good enough relationship, it's about creating like a safe base really
to work with”.
36
Charlie and Drew explained the importance of being “approachable”. In
addition, Charlie noted that creating a safe supervisory space for supervisees was
imperative for the relationship:
…if they feel that they’re in some sort of vacuous space where they’re not
held or cared for, there isn’t concern shown and space given, how can you
expect them to feel safe enough to share that...I need for them to feel safe
enough to show me the colour…(Charlie)
Reese’s approach to supervision sounded similar and she emphasized there is
no “one size fits all” method. Likewise, Drew and Sam considered the importance of
being “flexible” to the needs of their supervisees. Reese described how she would
create a safe supervisory space for anxious supervisees by “reassuring and
supporting” them. Taylor spoke of being more “available” for supervisees that
needed support and adapting her supervisory style to her supervisees’ needs: “…
being more directive…who needs that nurturing, needs that containment, needs you
to be there, you to be present more…”.
For Alex, regularity and availability were necessary for creating a safe
supervisory space: “…they have regular supervisions. I’ll book it in right from the
get-go…. They know how they can contact me…”.
Jesse described trying to be “supportive” and “making it feel safe”. She also
wanted to think about any practical solutions to a problem a supervisee was
experiencing on the placement: “…I think I was just trying to be quite containing
and reassuring but also to try and offer some practical solutions to think about”.
37
Our early relationships impact how we relate in the supervisory
relationship. Charlie suggested the relationships her supervisees had with their
mothers or other attachment figures may echo their relationships with her. She
referenced her age and suggested her supervisees may see her as a mother figure:
“Mirroring. Attachment behaviour between them potentially and their other half,
them and their mother, dare I say it [referencing her age - redacted]”.
For Alex, attachment was “fundamental” to all relationships including the
SR. Whilst Taylor thought “…we each bring our own experiences, our ways of
coping, with viewing the world…”. Drew too considered AT within the SR and how
early attachment relationships influenced how people formed relationships in
adulthood:
…our early experiences of learning and relationships and how we build
them. Then it also impacts on how we think about how we then go on to
create relationships…your previous experience of relationships...is going to
impact on how safe we feel in relationships as an adult and how we feel
about sharing things (Drew)
Jesse noted the link between early relationships and relationships in
adulthood and how her own early experiences played out in her relationships with
her supervisees:
I’m sure we model in supervision what we benefit from in our relationships,
what we haven’t liked in our relationships. I’m sure we try and correct some
of those things. I know I’ve always really responded to positivity and
praise…. I’m sure that’s to do with my early upbringing…I’m sure I play that
out with my trainees… (Jesse)
38
Reese considered an experience within supervision where she and her
supervisee had looked at one another’s genograms. Reese valued this exercise and
considered how it supported the SR and their understanding of one another: “I think
it did hugely improve our relationship, it was just kind of being aware of our own
things that we’re bringing in our relationships and attachments and how certain
things trigger things for us as individuals”.
I want to protect and care for my supervisees. Participants described a
sense of responsibility and wanting to look after their supervisees and protect them
from negative feelings. Participants reflected on the triadic nature of supervision
(supervisor – supervisee – client) and that caring for supervisees would help them
care for the clients they were working with.
Drew thought about the challenges of giving difficult feedback as she did not
want to upset her supervisee: “Thinking about that with her [giving feedback] was
really difficult because I didn’t want to hurt her feelings I suppose or make her feel
bad…”. Drew later reflected on being “protectionistic” (sic) of her supervisees and
how this looked after the supervisee and the clients the supervisee was working with.
Charlie had similar views. It was important to Charlie that her supervisees were
“alright” but again reflected on the triadic relationship within supervision: “…if I
take care of my supervisees they will be in a better place to take care of our families
[clients]”.
Participants also reflected on how they responded in a caring manner when
supervisees came to supervision distressed. For Jesse, she felt an instant urge to take
care of her supervisee: “I think I immediately wanted to look after her and protect
her”.
39
Taylor had a similar response and reflected she felt “defensive” on behalf of
her supervisee. For Taylor, supervisee distress in response to a situation on
placement triggered a “guilty” feeling and left her wondering “maybe I should have
planned better”.
Discussion
Summary of the Findings
This study aimed to further develop the understanding of the SR in the
professional context of Clinical Psychology in the UK and explore if AT is helpful in
understanding the SR. The results indicated the importance of the SR for supervisors.
Supervisors actively sought a positive SR with supervisees, taking time to establish it
and wanting to get to know their supervisees outside of formal supervision sessions.
Participants considered the SR rewarding and their own experiences of being
supervised informed their practice. Some of the findings were consistent with
aspects of AT, such as providing a secure base to supervisees. Participants also
reflected how both their own and their supervisee’s early attachment experiences
may impact how they related within the SR. The quality of the SR was described as a
collaborative effort between participants and their supervisees that was shaped by the
traits they each brought to the relationship. These themes will now be further
explored and discussed within the context of the evidence base.
Discussion of Findings in the Context of Existing Literature
A relationship with supervisees outside of formal supervision helped
supervisors develop positive SRs which facilitated them to better understand and
support their supervisees. Indeed, participants invested a lot of time at the beginning
40
of the relationship. This supports the importance of the SR, supervisor commitment
and investment in the SR and how the SR is developed (Beinart, 2002 cited in
Beinart, 2014; Clohessy, 2008). Participants found it easier to give feedback to
supervisees when there was a good SR which adds weight to the SR enabling the
educative and evaluative functions of supervision to take place (Beinart & Clohessy,
2017). Prior supervisory experiences are recognised as a contextual factor for the SR
in Clohessy’s (2008) model. These experiences informed the practice of supervisors
in this study in a process similar to ‘family scripts’ (Byng-Hall, 1986) whereby they
replicated behaviours of supervisors they had found supportive and made concerted
efforts not to repeat unhelpful behaviours.
Participants found the SR rewarding through the opportunities they had to
learn from their supervisee. Learning from the supervisee can influence the
supervisor’s investment in the SR (Clohessy, 2008). Collaborative and reciprocal
learning within supervision is emphasised in Roth and Pilling’s (2008) supervision
competence framework. Whilst the supervisor’s role can be viewed as an expert role,
supervision is an interaction where both the supervisor and supervisee are constantly
learning, and supervision needs to provide a space where this learning can occur
(Hawkins & Shohet, 2006).
Problems in the SR can develop when there are differences in values and
conflicts between the supervisor’s and supervisee’s personalities (Clohessy, 2008;
Ramos-Sánchez et al., 2002). SRs were experienced as easier when supervisors
shared interests or values with their supervisee. Social psychology research on the
similarity-liking effect (Byrne 1961; Collisson & Howell, 2014; Montoya, Horton &
Kirchner, 2008) can help us make sense of why this may impact the SR in that we
41
like people we perceive to be similar to us. The similarity-liking effect may have
implications for evaluation in supervision. When supervisors like trainees they may
give more positive evaluations and trainees who perceive they are liked may work
harder to please the supervisor (Goodyear & Bernard, 1998).
Participants noted how openness from both themselves and their supervisees
supported the SR. Openness included information about the therapeutic work,
personal disclosures, reflective thinking and an open-ness to learning. When
supervisees were perceived to be holding back, participants experienced supervision
as more challenging and it was therefore a barrier to the SR. This supports previous
research that supervisee openness impacts supervisor investment in the SR
(Clohessy, 2008) and that a lack of openness negatively impacts the SR (Lemoir,
2013 cited in Beinart & Clohessy, 2017). Furthermore, a lack of disclosure can
impact the quality of supervision and consequently supervisee development and
client care (Alonso & Rutan, 1988; Ladany, Hill, Corbett, & Nutt, 1996). In one
study, 84% of supervisees reported they had withheld information in a recent
supervision session (Mehr, Ladany & Caskie, 2010). Supervisor commitment is
important for the SR (Beinart, 2002; 2014) and therefore a lack of openness from the
supervisee could create a ‘vicious cycle’ in which supervisors become less invested
and the SR is impacted. Supervisees that view the supervisory alliance more
positively have a greater willingness to disclose in supervision (Hess et al., 2008;
Inman et al., 2011; Mehr et al., 2010; Ladany et al., 1996; Webb & Wheeler, 1998).
So alternatively, an initial lack of supervisor commitment to the SR could create a
‘vicious cycle’ where supervisees do not feel safe to make disclosures within
supervision. AT too has been implicated in disclosures within supervision;
supervisees with secure supervision-specific attachments disclosed more to their
42
supervisor (Gunn & Pistole, 2012). What is not clear from the research is the
direction of the relationship between disclosure and the SR. It may be a lack of
disclosure impacts the SR, but equally a poor SR could impact disclosure. It is also
not clear if attachment has a mediating role in this.
Participants described being attuned to their supervisees’ needs and
responding accordingly consistent with models of supervision and the SR (Beinart,
2002 cited in Beinart, 2014; Clohessy, 2008; Stoltenberg et al., 2014). For example,
participants offered more support and directive supervision to an anxious supervisee.
Participants also described responding to behaviours they found problematic from
their supervisees, particularly “overconfidence”. This was defined as a confidence
that was inappropriate to the supervisee’s level of training, almost arrogant and
reducing curiosity. Interestingly, this fits with Bennett and Saks (2006) description of
the behaviours of a supervisee with a dismissing attachment; “Functions too
independently and avoids asking for help” (p. 675).
AT was echoed in the accounts of participants who wanted to protect their
supervisees from emotional distress and care for them when this occurred.
Participants explained that caring for the supervisee enabled the supervisee to take
care of their clients which resonates with the idea that supervision is important for
client outcomes (Ellis & Ladany, 1997; Holloway & Neufeldt, 1995; Lichtenberg,
2007). Feeney and Woodhouse (2018) argued that AT supports the understanding of
caregiving “because it stipulates that the need for security is one of the most
fundamental of all basic needs” (p. 827). Caregiving involves emotional support,
problem solving, and being sensitively attuned and flexibly responding to needs
(Feeney & Woodhouse, 2018). Arguably this is consistent with the supervisor’s role
43
and suggests their relational position in supervision is as a caregiver (Fitch et al.,
2010; Pistole & Fitch, 2008).
An attachment concept that was relevant for participants when considering
the SR was the secure base. They described scenarios that matches Bowlby’s (1988)
description of the secure base and was also consistent with models of adult
attachment that emphasise the importance of the secure base (Crittenden, 1995). It
fits too with literature that argues the supervisor provides this function (Bennett &
Saks, 2006; Fitch et al., 2010; Hill, 1992; Pistole & Watkins, 1995) and models of
the SR that emphasise safety and trust (Beinart, 2002 cited in Beinart, 2014;
Clohessy, 2008). Furthermore, Scaife (2001) emphasised the importance of a safe
supervisory space for reflection and learning to take place which was mentioned by
participants in this study. Just as previous studies have noted (Bennett & Deal, 2009;
Fitch et al., 2010), participants described supervisees’ needs varying as the
placement progressed. The beginning of the placement was associated with anxiety
and although they became more autonomous they would still return to the supervisor
as the secure base (Fitch et al., 2010). When supervisees were anxious, participants
would provide a safe-haven by being “reassuring”, “available”, “nurturing”, and
“containing”.
Another attachment concept of relevance was “internal working models”
(IWMs) (Bowlby, 1969; 1978; 1982). IWMs are internalized early relational
experiences which impact patterns of relating in relationships including romantic,
parental, vocational relationships. Supervisors in this study reflected that their early
relational experiences impacted how they related within supervision and they
believed this was also true for their supervisees.
44
Strengths and Limitations
The perspectives of supervisors have largely been neglected in the literature
to date and this novel, exploratory study addressed this with a deliberately small
sample of supervisors for an in-depth exploration of their experiences in supervision.
This study has built on existing research, adding an attachment focus which was
needed as investigations of attachment in the SR still seem to be at an early stage
(Pitt, 2018).
The study’s small sample size of seven ensured sufficient time was dedicated
to the analysis and interpretation of each participant’s experience consistent with IPA
(Smith et al., 2009). The systematic way in which the study was conducted adds
credibility to the interpretation offered. Yardley’s (2000) guidelines were considered
from the study’s conception (appendix P). Whilst designing the interview schedule,
advice was sought from others to ensure the schedule remained exploratory and was
not overly focussed on attachment concepts. A reflexivity journal was kept from the
study’s outset and some of the reflections within this are considered in the self-
reflexivity account in Appendix R. Credibility was further ensured through research
and peer supervision during the analysis and interpretation phases of the study.
The study is not without limitations. Firstly, five of the participants were
associated with the training programme of the researcher. This may have influenced
the experiences participants chose to talk about and may have inhibited them from
expressing other ideas. Those participants not associated with the training
programme may still have felt inhibited in their disclosures to a TCP. Like previous
literature on the SR, and AT in the SR, this study recruited supervisors of trainee
practitioners. Supervising a trainee is different to supervising a qualified practitioner
45
because of additional clinical responsibility, evaluation and gatekeeping (Clohessy,
2008). Furthermore, SRs with trainees are often brief and the SR has to be
established in a short space of time. Holloway (2014) emphasises that the SR
develops over time and the supervision of experienced practitioners is often of a
longer duration. Within the AT in supervision research, the rationale for samples of
trainee practitioners is that this stage of development is characterised by anxiety,
vulnerability and threat (Rønnestad & Skovholt, 2003). Therefore, they are more
likely to experience attachment system activation. However, it may be that
experience of the SR and the relevance of AT for supervisees that are qualified,
experienced practitioners differs to that of trainees. In addition, the practice of
psychotherapy includes a broad range of professional disciplines and therapeutic
modalities. Whilst generalisability is not an aim of IPA research, the homogeneity of
this sample reflects the experience of supervision for this small group; other
psychotherapeutic practitioners may have different experiences of the SR.
The interpretations reported here are subjective and others may interpret the
transcripts differently without an attachment understanding. Care was taken to ensure
an attachment ‘lens’ did not skew the interpretation and the findings presented
include both attachment and non-attachment related ideas. However, AT is a
dominant theory within Clinical Psychology and this may explain why the
supervisors in this study thought about the SR in this way. Additionally, more
Clinical Psychologists report themselves as securely attached than the general
population (Leiper & Casares, 2000). Whilst attachment orientation was not
measured in this study, the attachment orientations of participants may have
influenced the reflections they made.
46
Implications for Theory
The SR has received increased focus in supervision research, but there is still
a need to further develop our understanding beyond the characteristics of a good and
poor SR (Beinart & Clohessy, 2017). The present study contributes to the growing
literature on the SR within the UK from the perspective of supervisors who have
largely been neglected. The study supports the importance of the SR and the need for
both supervisor and supervisee to be invested in it thereby lending support to models
of the SR by Beinart (2002 cited in Beinart 2014) and Clohessy (2008). The study
tentatively suggests AT is relevant to our understanding of the SR. Specifically, in
the supervisor providing a secure base, having the relational position of the caregiver
and the enduring nature of ways of relating that are based on early experiences.
However, the findings are more indicative of the SR reflecting dynamics of an
attachment relationship rather than a full-blown attachment. Whilst attachment
concepts were identified by participants as relevant to the SR, the descriptions given
differ to infant-caregiver attachment relationships since both the supervisor and
supervisee share responsibility for the quality of the relationship. Whilst not an
emerging finding in this study, it is important to note that the SR also differs to adult
attachment relationships because it is a hierarchical relationship with educative and
evaluative functions (Bernard & Goodyear, 1998). Therefore, attachment within
supervision may be best conceptualised within a leader-follower framework where
the supervisor (leader) provides the safe-haven and secure base functions to the
supervisee (follower). This framework highlights the hierarchy within supervision
and how the SR differs to other attachment relationships (Watkins & Riggs, 2012;
Wrape et al., 2017).
47
Implications for Research
Future studies on AT and the SR need to focus on supervisory dyads to
ensure both perspectives of the same SR are explored. It would be beneficial to
conduct longitudinal research with these dyads to establish the relationship
mechanisms; this could help untangle the relationship between disclosure and the
SR. Attachment has been implicated in disclosures within supervision in one study
(Gunn & Pistole, 2012) and further exploration of this would be useful.
It would be advantageous to conduct research with supervisees who are more
experienced practitioners rather than trainees. The SRs of experienced practitioners
may last significantly longer, and research could help establish what is different or
similar in the SRs of these practitioners and if AT has relevance.
Finally, further exploratory research within other psychotherapeutic
disciplines, such as other applied psychologists, should be conducted to establish if
the SR is different in these groups and if the attachment in supervision construct is
relevant.
Implications for Practice
The findings lend tentative support to a leader-follower attachment
framework (Watkins & Riggs, 2012). For supervisors this means that in the early
stages of development, supervisees may need more leading. This can include more
structure and direction within supervision until competency and confidence have
developed (Watkins & Riggs, 2012). This also involves establishing a secure base.
The secure base can be established through availability, regularity and consistency of
supervision sessions and being attuned to the supervisee’s needs. For the supervisee,
48
a willingness to be open in supervision is important. Supervisors and supervisees
may also want to be aware of attachment dynamics that can present within the SR;
this could inform supervisor training. This training could further emphasise the issue
of disclosure and how supervisors can facilitate this by providing a safe SR.
The findings of this study support the importance of the SR and that both
supervisor and supervisee need to invest in this relationship, particularly in the
beginning. For supervisors, this involves getting to know their supervisee as a
person. Whilst this study did not focus on supervisees’ experiences, the findings
could be incorporated into workshops on Clinical Psychology training programmes
helping trainees understand what supervisors think is important for the SR, the need
to be open and an awareness of attachment dynamics.
Conclusion
The findings supported existing models that emphasise the importance of the
SR and developed the understanding of attachment processes within this. Whilst the
SR could reflect attachment dynamics it did not appear to be a “full-blown
attachment bond” (Mayseless & Popper, 2007, p.73). The participants in this study
described being able to establish supportive relationships with their supervisees,
being attuned to their needs and adapting their style as required. The findings also
highlighted other important processes for the SR such as open-ness and having a
relationship outside of formal supervision sessions. It is anticipated that these
findings could support the introduction of attachment-based ideas into supervisor
training. Finally, it is hoped the findings will be of use to supervisors and supervisees
in the development and maintenance of their SRs.
49
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Appendices
Appendix A
Journal of Choice: Guidelines for Authors
[Removed]
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Appendix B
Rationale for IPA
When designing this study, alternative qualitative designs and analyses were considered that are in keeping with an exploratory design. These were Discourse Analysis, Thematic Analysis, Grounded Theory and Narrative Analysis.
Discourse Analysis is primarily concerned with the use of language (discourse) rather than individual experience. In other words, Discourse Analysis looks at how participants talk about their experiences rather than the experiences themselves (Willig, 2013). IPA was chosen over Discourse Analysis for its interest in individual experience.
Thematic Analysis was considered because of its relation to phenomenology and focus on human experience. However, it may not allow for the consideration of nuanced accounts (Guest, MacQueen, & Namey, 2012) and lacks the interpretative power if the analysis does not include a theoretical framework (Braun & Clarke, 2006). Both disadvantages can be overcome using an IPA approach.
Grounded Theory’s positivist epistemological roots were not a good fit with the design of this study. It has been argued that these roots “sidestep questions of reflexivity” (Willig, 2013, p.236). Furthermore, inductive approaches give limited attention to the role of the researcher as the assumption is the data “speaks for itself” (Willig, 2013 p.236). Whereas an IPA methodology recognises that observations made during the research process will be influenced by the researcher’s knowledge and experiences. Whilst more recent social constructionist versions of Grounded Theory exist (e.g. Charmaz, 2006), it has been argued that grounded theory is not suitable for psychological questions about the nature of experience and is better suited for social psychological processes.
Finally, Narrative Analysis was another qualitative method that was considered. Like IPA, some Narrative Analysis is also interested in experiences and how individuals have made sense of these. Narrative Analysis is further interested in the narrative means used to make sense of experience, for example, culturally shared stories and scripts. Narrative Analysis tends to focus on the report of a single individual given the need for the researcher to collect extensive information about the participant to understand their life context (Cresswell & Poth, 2017). Whilst it is possible to analyse multiple cases using narrative analysis it is more difficult to establish a rich cross-case analysis as can be possible with IPA.
In summary, IPA was chosen for its interest in the idiographic meanings individuals make of a lived experience (Smith et al., 2009). This fits with the research question of the current study which is interested in how Clinical Psychologists understand and experience the SR from the relational position of a supervisor. IPA asserts it is not possible to fully understand the experience and
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meanings of participants. It adopts a double hermeneutic position whereby the participant makes meaning of their world, then the researcher attempts to make sense of that meaning (Pietkiewicz & Smith, 2014). Therefore, it considers the role of the researcher in the interpretation.
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Appendix C
Participant inclusion and exclusion criteria
Participants were required to be HCPC registered Clinical Psychologists. The focus on Clinical Psychologists rather than more broadly, Applied Psychologists was to ensure homogeneity within the sample as different practising psychology professions may have differences in practice in supervision.
Participants also needed a minimum of two years’ experience as supervisors of either Clinical Psychologists or Trainee Clinical Psychologists. This would ensure that participants would have had sufficient experience of supervision as a supervisor and a range of experiences to draw on in the interview.
In addition, they were required to have supervised these clinicians within the last year so their experiences would be in the recent past and easy to recall. Factors such as gender, type of service, years of supervising were considered when determining the inclusion and exclusion criteria to ensure homogeneity. The literature does not suggest these factors are conclusively related to the SR or the attachment in supervision construct and therefore were not used in the inclusion and exclusion criteria
Participants needed to be based in the South of England region as this was the area I was based in.
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Appendix D
Recruitment advert
The following recruitment advert was posted to a group titled “UK based Clinical Psychologist Facebook Group” on the social media platform, Facebook. This social media networking group is made up of over 4000 Clinical, Counselling and Trainee Psychologists.
“Hi all, my name is Claire and I am a 2nd year trainee at the University of Surrey. My major research project is exploring the supervisory relationship and the relevance of attachment theory to this. I am interested in recruiting HCPC registered Clinical Psychologists that have a minimum of two years’ experience as supervisors of either Clinical Psychologists or Trainee Clinical Psychologists. Interested participants will need to have supervised these clinicians within the last year and be based in the South of England region. Participation in this study would involve meeting face to face with myself for an interview which would take up to 90 minutes. Travel expenses are available. If anyone would like some further information / to participate please email me at [email protected]. The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the Faculty of Health and Medical Sciences Ethics Committee, FHMS, at the University of Surrey.”
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Appendix E
Participant information sheet
Participant Information Sheet 01.11.2016 v1
Attachment Theory within the Supervisory Relationship
Introduction
My name is Claire Pitt and I am a Trainee Clinical Psychologist interested in the supervisory relationship, particularly whether attachment theory can be considered in this relationship. I would like to invite you to take part in a research project exploring this. Before you decide to take part, you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. Talk to others about the study if you wish.
What is the purpose of the study?
This study seeks to explore your own experiences as a supervisor and what theories you draw on to make sense of the supervisory relationship and alliance.
Why have I been invited to take part in the study?
You have been invited to take part as you are a HCPC registered Clinical Psychologist who has supervised a trainee / Clinical psychologist within the last year and have a minimum of two years’ experience of supervising trainees / Clinical psychologists.
Do I have to take part?
No, you do not have to participate. There will be no adverse consequences if you decide to not participate in this study. At the end of the interview I will check with you if you are happy for me to use your data in my research. Furthermore, you can withdraw from the study up to two weeks after the interview has taken place. If you do decide to withdraw from the study, I will destroy any data collected from you.
What will my involvement require?
You will be asked to an interview which will take up to 90 minutes. At this interview, you will be asked various questions about your experiences as clinical supervisors. Interviews can take place in various locations including the University of Surrey, your home, or your workplace depending on your preference.
What will I have to do?
If you would like to take part, please email the researcher at [email protected]
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What are the possible disadvantages or risks of taking part?
Discussing attachment may bring up difficult feelings about your own experiences of attachment relationships or experiences in supervision. In this case, you can request a short break from the interview or to withdraw completely.
What are the possible benefits of taking part?
It is unlikely that you will benefit directly but it is hoped that this research will further contribute to the current evidence base on attachment theory within the supervisory relationship. To date the research evidence has been mixed and there has been no published literature that explores the experiences of supervisors and their thoughts on attachment in the supervisory relationship.
What happens when the research study stops?
After I have interviewed all participants the interviews will then be transcribed either by myself or a professional transcriber who will be covered by a confidentiality agreement. I will then interpret the data and write up the study. If you are interested in the findings I can offer to send you a summary on completion of the research. If this is something you would be interested in, please let me know and give me a contact email.
What if there is a problem?
Any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact Claire Pitt, Principal Investigator at [email protected]. You may also contact the Head of School, Mary John, on 01483689267, [email protected].
Will my taking part in the study be kept confidential?
Yes. All of the information you give will be anonymised so that those reading reports from the research will not know who has contributed to it. However, as this is qualitative research some extracts of interviews will be reported verbatim in the write up of the research and it may be that you could recognise your own contributions in this write-up.
Data will be stored securely in accordance with the Data Protection Act 1998.
Contact details of researcher and, where appropriate supervisor?
Researcher SupervisorClaire PittSchool of PsychologyUniversity of Surrey
Kate GleesonSchool of PsychologyUniversity of SurreyGuildfordGU2 7XH01483 683 995
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GuildfordGU2 7XH
Who is organising and funding the research?
The research has been organised by Claire Pitt, Trainee Clinical Psychologist at the University of Surrey under the supervision of Dr Kate Gleeson, Research Director at the University of Surrey. This study has received no funding
Who has reviewed the project?
The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the Faculty of Health and Medical Sciences Ethics Committee, FHMS, at the University of Surrey.
Thank you for taking the time to read this Information Sheet.
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Appendix F
Interview Information Provided to Participants
To begin the interview, I will ask some demographic questions and some general questions about your experience of supervision.
In the interview, we will broadly cover the following:
Your experiences of supervision as a supervisor What informs your supervisory style What things you think are important for the supervisory alliance Supervisees you have felt more, or less, comfortable with A discussion about a time a supervisee came to supervision distressed
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Appendix G
Extended Recruitment Strategy
An email (see below) was sent to all current Trainee Clinical Psychologists at the University of Surrey inviting them to assist in recruitment. Those that expressed a willingness to help were sent the participant information sheet to forward to Clinical Psychologists they knew who met the inclusion and exclusion criteria. In addition, research participants were asked to forward the study to any colleagues they thought may be interested. This resulted in a further six participants over a four-month data collection period.
Email sent to Trainee Clinical Psychologists
Hi all,
I'm wondering if any of you would be interested in helping me recruit participants for my research. My research is exploring the SR and the relevance of attachment to this. I need to recruit Clinical Psychologists that have a minimum of two years' experience as supervisors of either Clinical Psychologists or Trainee Clinical Psychologists and are based in the South of England. Participation involves a face to face interview of up to 90 minutes. If you are willing to help me recruit, could you send me an email at [email protected] and I will send you an information pack that you can give to any psychologists you know that meet the inclusion criteria. I need to recruit another 4-6 participants and would be really grateful for any assistance.
Many Thanks, Claire
Claire PittTrainee Clinical PsychologistUniversity of Surrey
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Appendix H
Favourable ethical approval
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Appendix I
Favourable ethical approval for amendment to recruitment strategy
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Appendix J
Further ethical considerations
Informed consent
All participants were provided with a participant information sheet which outlined the key information about the study and what taking part would involve, who would access the data and how this would be stored. Participants were sent this to read and invited to email to confirm they were still happy to participate and to arrange a meeting. In this meeting, participants were provided with the participant information sheet to ensure they had read and understood this before completing a consent form. Once signed consent had been given, the interviews proceeded.
Participants were reminded that they did not need to take part and if they later wanted to withdraw their data they would need to do so within two weeks of the interview being concluded.
Confidentiality
Working in NHS/Social Service Settings participants were fully aware of confidentiality and its limits. Nevertheless, this was highlighted on both the participant information sheet and consent form. Participants were made aware that it may be possible to identify themselves from quotes used in the research but that all identifiable information such as names, locations etc. would be removed from the transcripts and subsequent write up. Participants were aware that the supervisors and examiners may look at their anonymised transcripts. Participants were aware that the audio recording of their interview may be transcribed using a professional transcriber which they had the option to consent to or not.
Potential distress
There was a low risk of causing distress in this study. Nevertheless, it was highlighted to participants that reflecting on their experiences of supervision and AT may be potentially distressing. This was addressed by providing participants with a list of topics that would be discussed in the interviews prior to meeting alongside the participant information sheet so participants could decide if they wished to continue. Participants were reminded they could withdraw their data within the time frame previously mentioned. Given the potential for distress, I sought to conduct the interviews sensitively and remained attuned to participants during the interview being prepared to stop if needed. Following the interview, participants were verbally debriefed about their experience of the study, the nature of the research, the existing literature and the reasoning for the current study.
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Appendix K
Interview Schedule
To begin the interview, I would like to gather some background information so I can describe my participants.
Demographic Questionnaire
To begin, are you comfortable telling me your age? What is your gender? What is your ethnicity? How long have you been a Clinical Psychologist? Have you completed supervisor training? What is your area of expertise / service you work in? What year trainees do you regularly supervise? What therapeutic modalities do you practice?
Interview Schedule:
As you know this interview is about exploring your understanding of supervision and how things work between you and the people you supervise. Can we start by you telling me something about your experiences of supervision as a supervisor?Prompts: How long have you been supervising Clinical Psychologists / Trainee Clinical Psychologists (please omit any periods where you have not supervised in your calculation), Do you supervise any other professionals?
I want to know about what kind of supervisor you are, are you aware you have an approach / style?Prompts: How do you think your supervisees would describe your supervisory style? What has influenced your style of supervision? (Only after thorough exploration), are there any particular models you draw on?
Are you aware of adapting your style to different supervisees? Prompts: What influences your adapting? What does the adaptation look like e.g. if you have an anxious trainee, or a confident trainee?
What do you think makes a difference to the supervisory alliance?Prompts: Any individual factors of your own? individual factors of your supervisee?
Could you tell me about supervisees you have felt more, or less, comfortable with?Prompts: What was different between these? Relationships / people, Good / Bad about these experiences
Could you tell me about a time when a supervisee came to supervision and was distressed?Prompts: What went through your mind? How were you feeling? What did
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you think was behind your supervisee’s distress? What informed that? What did you do in response?
Is there one more thing that you feel is important about the SR that we haven’t talked about?
Is there something we haven’t discussed about the SR that you think it is important for us to discuss?
Do you think that attachment has a role in understanding the SR?
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Appendix L
Confidentiality agreement with professional transcriber service (name redacted)
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Appendix M
Consent form
Consent Form
AT in the SR 01.11.16 v1
Please initial each box
I have read and understood the Information Sheet provided (version 1, date 01/11/16). I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do.
I have been advised about any disadvantages/risks/discomfort on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.
I agree to comply with the requirements of the study as outlined to me to the best of my abilities. I shall inform the investigators immediately if I have any concerns / suffer any deterioration of any kind in my health or well-being.
I understand that in accordance with the English law, insurance is in place which covers harm that is likely to result from my participation in this study as detailed in the participant information sheet
I agree for my {anonymised} data to be used for this study that will have received all relevant legal, professional and ethical approvals.
I give consent to the interview to be audio recorded
I give consent to {anonymous} verbatim quotations being used in reports
I understand that all project data will be held for at least 6 years and all research data for at least 10 years in accordance with University policy and that my personal data is held and processed in the strictest confidence, and in accordance with the {UK} Data Protection Act (1998).
I agree for the researchers to contact me to provide me with a study results summary.
I agree for my anonymised data to be shared with a professional transcriber who may transcribe my interview on the behalf of the researcher
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I understand that I am free to withdraw from the study at any time without needing to justify my decision, without prejudice and without my legal rights being affected.
I understand that I can request for my data to be withdrawn up to two weeks after the interview date. Following my request all data already collected from me will be destroyed. I understand that after this date it will not be possible to withdraw my data from the study.
I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation.
Name of participant (BLOCK CAPITALS) .....................................................
Signed......................................................
Date......................................................
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Appendix N
Data Analysis Process and Presentation
Individual Case Analysis
Annotations of the initial thoughts and ideas (exploratory comments) to the transcript were made in the right-hand margin of the text. These annotations included comments on the use of language, initial interpretations, and descriptive comments. Comments were also made on ideas that appeared to be repeated throughout the transcript. On completion of exploratory comments, the transcript was read again. These initial exploratory comments were converted into emergent themes and recorded in the left-hand margin. These emergent themes summarised the exploratory comments whilst not losing sight of the participant’s description.
Identification of Emergent Themes and Theme Clustering
Once themes had been decided these were checked against the original words of the participants to authenticate them and ensure the theme captured what had been said in the interview. Initial themes were listed in a word document, compared and contrasted and similar themes were clustered together. When clustering themes these were checked against the original transcript to ensure the clustered themes reflected the experiences conveyed by the participants. Themes relating to similar topics were clustered together and became sub-themes of master themes (See Appendix O for an example of this process). Several themes were dropped from the analysis for limited rich supporting quotes and lacking relevance to the research question. When determining which themes should be included in write up of the analysis several considerations were made. These included the relevance to the research question, the apparent importance to participants, and the availability of quotes to support the theme. Whilst frequency of themes was considered this was not a determining factor for inclusion. The selection and interpretation of themes was considered in discussions in peer and research supervision. Consideration was given to issues of reflexivity and how my perspective may have shaped the themes being identified, such as the attachment based themes. These discussions ensured that the themes reflected the data rather than my own assumptions and biases and that there was sufficient evidence within the transcripts to support these.
Cross Case-Analysis
The themes from each participant were compared for similarities and difference of all master themes and sub themes. Any themes that lacked evidence were dropped and themes that had similarities were merged. As before, the sub-themes and master themes that were included in the write up of the project were discussed with research supervisors to ensure the titles reflected the data collected. An example of how these themes evolved through discussions can be found in Appendix Q.
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Amendments Made to Improve Extract Readability
All participants are referred to using female pronouns, as are their descriptions of their supervisees. Participants used the terms ‘supervisee’ and ‘trainee [trainee clinical psychologist]’ interchangeably. Information within square brackets has been added to clarify what a participant is referring to. Dotted lines before, during or at the end of an extract indicate that the participant continued talking. Extracts are largely reported using clean verbatim; minor hesitations and utterances have been removed to improve readability and only when these do not take away from the meaning of the participant’s experience.
Selection of Quotes
Quotes were selected that illustrated each theme. Some disparities exist between the number of quotes used for each participant as some participants had more rich data than others. In general, a concerted effort has been made to ensure all participants’ voices were heard in the analysis.
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Appendix O
An Example of the Clustering Process for a Single Participant
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Appendix P
Assessing the Study’s Quality and Validity Using Yardley’s (2000) Framework
Sensitivity to Context
IPA was chosen for this study because of the close attention it pays to the individual and idiographic experiences of the participants. In this respect choosing IPA demonstrates sensitivity to context. Attention to individual experience was paramount during the data collection phase. One participant gave the following feedback at the end of the interview: “Also, you’re very nice to talk to you because you have a very nice presence and you’re not, like I don’t get the sense that you are looking through your questions it just felt like it flowed”. Whilst the interview schedule provided a framework for the interview, sensitivity to the experiences of participants was maintained throughout. Sensitivity to context was observed throughout the analysis by immersing myself in the data and my attempts to make sense of the participant’s meaning making. It has been further supported in the write up of this study using numerous verbatim extracts to give each participant a voice. The use of these extracts also allows the reader to check my interpretations. Finally, the awareness and understanding of the current evidence base was explored in relation to the current study in the discussion.
Commitment and Rigour
Commitment was met through the attentiveness that was given during the data collection and analysis stages of the study. Commitment and rigour can be seen in the examples given in the sensitivity to context section. Further examples of commitment include attending regular peer supervision sessions and additional IPA teaching sessions. Rigour can be seen in the selection of a homogenous group of participants (UK based Clinical Psychologists with experience of supervision). This group were selected based on the research question. Rigour is demonstrated in the in-depth interviews that were conducted with participants, and the thorough and systematic analysis of participant interviews. Commitment and rigour is further demonstrated in the write up of the study; whilst it was not possible to include quotes from each participant for each theme, quotes were carefully selected to ensure that each participant had an equal voice across all the themes.
Transparency and Coherence
Transparency and coherency has been achieved through a clear and systematic write up of the stages of the study. The write up has gone through multiple redrafts to ensure a coherent narrative of the study has been provided. In addition, a self-reflexivity statement (Appendix R) has been provided to highlight the potential biases of the researcher.
Impact and Importance
The impact and importance of this study in the context of the existing literature, the current study and future directions of research are explored in the discussion.
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Appendix Q
Audit Trail
Smith et al. (2009) recommend audit of stages of the project by someone independent to the project. The following is an extract from the study with my initial exploratory comments and emergent themes which were discussed with my research supervisor and in peer supervision. The evolution of this theme is then described; the revisions to the theme were made in discussions with my research supervisor and in peer supervision.
Table 3.Extract from Charlie’s interview
Emergent Theme Transcript extract Exploratory Comments
I am a secure base for my supervisees; they can check in with me and then feel safe to go and explore.
P. I know he will make a beeline straight to me to touch base with me as sort of the mother hen, I don’t like that phrase. I must think of a better one, as the sort of central point within the service. Touching base with the anchor maybe, and then he can go on his way. He’s told me what he needs to and it will be a little thing that I think has no consequence; “oh you know I said I would do that sleep assessment on Thursday, well they cancelled again…” and real stuff I don’t necessarily need to know but that he needs to tell me so I will try to hear it and if he comes back 2 or 3 times then “manage to get hold of that social worker about this” then you think none of its too worrying, but he feels the need to touch back with me and I think that’s something about his attachment to me as well.
“Touch base” – check in with the secure base?
“Mother hen” - Being a supervisor is similar to being a mother; parent-child relationship
Anchor – fixed, secure
Checks in with the secure base and then can go and explore.
Needs / urge to check in with her.
Something about attachment
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Evolution of the theme:
1. Emergent theme: I am a secure base for my supervisees; they can check in with me and then feel safe to go and explore.
2. Superordinate theme: I can see the supervisory relationship in terms of attachment
3. Initial superordinate theme: I can see the relationship in terms of attachmentInitial subordinate theme: I am a secure base
4. Revised superordinate theme: Attachment underpins my thinking of the relationshipRevised subordinate theme: A secure base is at the heart of supervision
5. Final superordinate theme: Attachment underpins my understanding of the relationshipRevised subordinate theme: A secure base is important for the relationship
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Appendix R
Self-Reflexivity
It is recognised that the interpretations that researchers make within qualitative research are done from their own personal perspectives (Mauthner & Doucet, 2003) Reflexivity is therefore an important process within qualitative research as it enables the researcher to identify their position, values and beliefs that may shape their interpretation (Shaw, 2010). What follows is a reflective statement identifying my beliefs, assumptions and experiences and how these have influenced each stage of the study and how this was explored within research and peer supervision.
Self-Reflective Account
I am a thirty-year-old white British female and I have worked in mental health for seven years, six of these years have been in clinical psychology. I am currently a Trainee Clinical Psychologist in my third and final year of training at the University of Surrey and am undertaking my core child placement. During my first post as an Assistant Psychologist I had a difficult experience of the supervisory relationship. I was unsure of the role and its expectations and what to expect within supervision. I did not feel able to turn to my supervisor for support when experiencing these feelings and instead turned to other colleagues for support. This was more apparent to me in my next post as an Assistant Psychologist. I experienced the same anxieties but felt more able to discuss these with my supervisors. I found them approachable, validating and understanding of my feelings. My confidence in myself and in my role, grew and I believe this confidence helped me secure my place on training.
I have always been strongly drawn to attachment theory since first learning of it during my A-Level psychology studies. When I first learned of attachment theory it helped me make sense of and understand my own relationship with my parents and my current patterns of relating. As my knowledge and work experience within clinical psychology grew, as did my application of attachment theory, for example, in understanding the presenting difficulties of individuals I worked with and their ways of relating to me. The differences in my experiences of the supervisory relationship are what led to an interest in researching this. When I first began reading the literature it helped me conceptualise my own behaviour and my supervisor’s behaviour in supervision. When I compared the difficult experience and the positive experience I considered how the positive experience was of supervisors that provided a secure base for me to safely explore from. This may be why the subordinate theme of a secure base stood out to me within the participant accounts. Ideas participants presented such as nurturing, validating and reassuring stood out to me and reminded me of my own positive experiences of supervision. When reading the literature, I began to strongly believe that the SR represented a true attachment relationship on par with the parent-child attachment relationship and attachment within romantic relationships.
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I am aware that attachment still is a dominant part of my thinking in my clinical work. My most recent placement offered me the opportunity to be part of a family therapy clinic and develop an understanding of systemic theory. One thing that stood out to me from this was the idea of multiple perspectives and I considered this within the context of the current study and that perhaps others did not see the relationship as an attachment relationship. I noticed a shift in my own beliefs as I read more about IPA, more about attachment in supervision and from discussions in both clinical and research supervision. My own perspective shifted more towards the supervisory relationship reflecting aspects of attachment relationships (such as the secure base) rather than a full-blown attachment. I now consider that an attachment theory perspective may be more helpful in understanding stages of the supervisory relationship, such as beginning and endings. However, I recognise that others may have different perspectives and there is no one truth when considering the relevance of attachment theory for understanding the supervisory relationship.
The impact of my beliefs, values and assumptions on the study
What follows is an exploration of how my own beliefs, values and assumptions shaped the study at each stage and how I made sense of the participant’s meaning making.
Designing the study and the interview schedule. Clinical Psychologists were chosen for the study because of the double hermeneutic inherent in IPA research. As a Trainee Clinical Psychologist, the researcher was familiar with clinical training, clinical supervision and the supervisory relationship in this context. It was anticipated that this familiarity would support the interpretation of the experiences of participants. Had the sample been supervisors of trainee psychotherapists from other professions, the interpretation of their experiences may have been influenced by the knowledge of supervision in the context of clinical training which could be very different to their actual experience. When designing the study and interview schedule I held my own beliefs about the relevance of attachment in mind and made good use of supervision to ensure this did not skew my perception. Nevertheless, my initial interview schedule was narrow with questions largely focussed on attachment. I reformulated the questions to be broader and allow me to still be able to lead the interview but not allow me to control the interview to an extent where participants would not have a voice.
Data collection. I recognised feelings of anxiety throughout the data collection process. Whilst I recognised as a researcher I have power, at the same time I felt powerless within the interviews in my relational position as a Trainee Clinical Psychologist interviewing qualified Clinical Psychologists. On reflection, there may have been follow-up questions I avoided asking to not offend or upset my research participants that may have added more depth and richness to the data collected.
Analysis. During the data collection I had noticed that some ideas were raised by several participants. I realised I would need to take a step back before completing the analysis to ensure I did not focus solely on those ideas that my attention had been drawn to. To do this I ensured I read each transcript carefully several times before recording my initial thoughts. By taking this action, I was better able to immerse myself in the experiences of my participants rather than looking for meaning I had already established. This helped identify both attachment related and non-attachment
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related themes. During analysis I considered that I would be using interpretation to understand the experiences of the participants and they may not feel able to share their experience with me in its entirety, especially as I was a Trainee Clinical Psychologist on a training programme that participants may be associated with.
Part 2: Literature Review
Attachment Theory and the Supervisory Relationship: A Review of the Literature
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Abstract
Background: Supervision is integral to psychotherapy disciplines and supports skill
development, monitors practice and ensures clients receive quality care. The
supervisory relationship (SR) has been identified as central for these outcomes.
Attachment theory (AT) has been used to explain what may impact upon the
supervisory working alliance.
Objectives: To assess what the evidence is that attachment is related to the SR and
other processes in supervision. To identify directions for further research.
Method: Psychology Cross Search, Scopus and Web of Science were systematically
searched alongside reference and citation scanning to identify articles for inclusion.
This yielded 14 articles for review.
Results: Studies have investigated the relationship between attachment style and
ratings of the supervisory working alliance, attachment style and ratings of
supervisee professional development and the impact of attachment informed
supervision training on ratings of the alliance. Some papers have explored the
relationship between general attachment style in adult relationships, supervision-
specific attachment style and ratings of the alliance.
Conclusion: There are inconsistent findings about the relationship between
attachment and the supervisory alliance which may reflect flaws within the research
methodologies and measures employed or may indicate our understanding of AT in
the SR is incomplete. In addition, attachment may have implications for other
processes in supervision such as supervisee professional development. Further
exploration of the attachment in supervision construct is recommended to improve
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our knowledge which could help inform supervision practice and supervisory
outcomes.
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Introduction
Supervision and the Supervisory Relationship
Clinical supervision within psychotherapy disciplines has been defined as “a
relationship-based education and training that is case-focused and which manages,
supports, develops and evaluates the work of colleagues” (Milne, 2007, p. 439). The
term ‘Supervisory Relationship’ (SR) within this paper refers to the psychotherapy
SR. Supervision has various functions and is central to psychotherapy disciplines and
healthcare services (Milne, 2007). Within the UK, The British Psychological
Society’s (BPS) Division of Clinical Psychology (DCP) adopts Milne’s definition
and adds; supervision ensures “safe and accountable practice and high quality
clinical and professional services” (BPS, 2014, p. 3). Furthermore, it has been argued
that effective supervision has an impact on client outcomes (Ellis & Ladany, 1997;
Holloway & Neufeldt, 1995; Lichtenberg, 2007).
Ellis (2010, p.106) noted that “good supervision is about the relationship, not
the specific theory or techniques used”. Beinart and Clohessy (2017) define the SR
as:
“…a collaborative, mutual working relationship, which supports and
challenges the supervisee to learn and develop their professional practice. The
relationship is developmental, needs-focussed, open, and respectful. It is
normally hierarchical and involves the negotiation of power. It has many
functions including education, monitoring and/or evaluation, and support.
The SR is influenced by multiple contextual factors including those
contributed by the supervisory dyad (or group), the working context, and the
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wider sociocultural context. The relationship is bound by the ethics of safe
practice, and acknowledges difference and diversity in order to allow the
supervisee to safely disclose and explore their professional dilemmas. Key
tasks in establishing and developing the relationship are contracting and
feedback” (Beinart & Clohessy, 2017, p.6)
Reviews of the clinical supervision literature have found the quality of
supervision and the SR to be important for supervisee and client outcomes (Ellis &
Ladany, 1997; Holloway & Neufeldt, 1995). Research on the therapeutic relationship
has been used to understand the SR. Bordin (1979) hypothesised that change within
psychotherapy was dependent on the agreement and understanding of the two parties
on the goals, the tasks each are responsible for and the therapeutic bond that
facilitates goal achievement. A practical example of this is evidence that the
therapeutic relationship (the bond) is related to therapy outcomes (Flückiger, Del Re,
Wampold & Horvath, 2018; Horvath, Del Re, Flückiger & Symonds, 2011). Bordin
(1983) later applied the same ideas to the SR. In the supervision context, outcomes
include client outcomes (Ellis & Ladany, 1997; Holloway & Neufeldt, 1995;
Lichtenberg, 2007) and the supervisee’s skill acquisition (Holloway & Neufeldt,
1995).
Though attempts have been made by researchers to explore the SR it is
acknowledged that our current understanding is limited (Beinart & Clohessy, 2017;
Watkins, 2012). A pan-theoretical competency framework developed for supervisors
in the UK recognised the importance of the SR and included the competency “ability
to form and maintain a supervisory alliance” (Roth & Pilling, 2008, p.10). Building
the alliance is imperative given the triadic relationship between supervisor,
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supervisee and client and the impact of supervision on both the supervisee’s
development and client outcomes (Holloway & Neufeldt, 1995). Factors that have
been suggested to impact the alliance include interpersonal sensitivity and the use of
self-disclosure (Bernard & Goodyear, 2013). Scaife (2001) also suggested supervisor
practices that can support the development of the alliance, including allowing the
supervisee to observe their practice. Milne (2009) highlighted that whilst
professionals agree the SR is important, there is a lack of evidence to empirically
support this.
Attachment Theory
An attachment theory (AT) framework has been applied to understand this
complex relationship (Watkins & Riggs, 2012). AT originated through John
Bowlby’s observations in his clinical work with children (1958; 1969). Bowlby
commented:
“Not only young children, but human beings of all ages are found to be at
their happiest and to be able to deploy their talents to best advantage when
they are confident that, standing behind them, there are one or more trusted
persons who will come to their aid should difficulties arise.” (Bowlby, 1973,
p. 359)
He developed the concepts of the safe-haven and secure base, both of which
the primary caregiver provides to the child. When the child’s attachment system is
activated they return to the safe-haven of the primary caregiver for safety and
comfort (Bowlby, 1969). Once comforted, the child feels safe to explore from their
caregiver (the secure base) knowing they can return to have their emotional and
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physical needs met (Bowlby, 1988). Whilst primarily focussed on the infant-
caregiver attachment, Bowlby (1969) emphasised that attachment was an enduring
relational pattern that persists throughout the lifespan. Following Bowlby’s work,
researchers identified three attachment styles: secure; anxious-ambivalent; and
anxious-avoidant (Ainsworth & Bell, 1970; Ainsworth, Blehar, Waters & Wall,
1978). Children with a secure attachment seek the caregiver when distressed and are
confident the caregiver will meet their needs. Children with anxious-ambivalent
attachment will alternate between being dependent on their caregiver and rejecting
them, whereas, children with an anxious-avoidant attachment style do not seek their
caregiver when distressed. A fourth attachment style (disorganized/disoriented) was
added by Main and Solomon (1990) to explain attachment behaviours that did not fit
with the other three categories, such as overt fear and freezing.
AT has subsequently been applied to adult attachment relationships
(Bartholomew & Horowitz, 1991), romantic relationships (Hazan & Shaver, 1987),
the therapeutic relationship (Pistole, 1989), and the psychotherapy supervision
relationship (Hill, 1992; Pistole & Watkins, 1995). Bartholomew and Horowitz
(1991) developed a model of four adult attachment styles: secure; preoccupied;
fearful; and dismissing. Individuals with a secure adult attachment see themselves as
worthy of love and expect that others will be responsive. Preoccupied adults believe
themselves unworthy of love but view others positively. Those with a fearful-
avoidant adult attachment regard themselves as unworthy of love and anticipate
others will be rejecting. The final adult attachment style of the model is dismissive
avoidant. These individuals view themselves as worthy of love but see others as
rejecting. These attachments lead to self-protective strategies, such as an avoidance
of close relationships for those with dismissive avoidant attachments.
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Attachment and attachment behaviours as self-protective strategies underpin
Crittenden’s (1995) Dynamic Maturational Model (DMM) of attachment. In this
model, Crittenden expanded the four attachment styles described by Ainsworth and
colleagues (1970; 1978) and Main and Solomon (1990). The DMM postulates that
attachment styles are self-protective strategies from harm or danger that are learned
through early interaction with attachment figures (Crittenden, 1995). This harm or
danger changes as the person ages and therefore the self-protective strategies change,
as does the attachment figure’s role. However, an attachment figure’s role will
always include providing a secure base from which to explore (Crittenden, 2005).
This model emphasises a lifespan approach to attachment and introduced the concept
of different attachment challenges at different life stages. For example, in adulthood
the attachment challenge is establishing and maintaining a romantic attachment with
another adult.
Attachment Theory and the Supervisory Relationship
Several conceptual papers have applied AT to the SR within
psychotherapeutic disciplines. A more detailed examination of these can be found in
a previous review of the attachment in supervision literature by Watkins and Riggs
(2012). Hill (1992) was the first to propose that the supervisor provides a ‘secure
base’ for the supervisee in psychotherapy supervision. This enables supervisees in
turn to provide a secure base for their clients (Hill, 2001) and can support their
professional development (Neswald-McCalip, 2001).
Conceptual papers have also described problematic attachment behaviours
that may present within supervision and suggest these can negatively impact the SR
(Bennett & Saks, 2006; Pistole and Watkins, 1995; Watkins, 1995). Problematic
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attachment behaviours include the supervisee not asking for help and/or even directly
or indirectly resisting or refusing help, and being overly dependent on the supervisor
(Watkins, 1995). Resistance behaviours in supervision could be understood as
attachment behaviours; the function being to reduce supervisee anxiety by restoring
relatedness to the supervisor (Des Pres, 2015). In addition, Bennett (2008) suggested
transference and counter-transference dynamics that are re-enacted in supervision
reflect early relational patterns of attachment.
It is suggested that the attachment needs of supervisees can change, for
example the beginning and end of student placements can activate attachment
processes in supervisees (Bennett and Deal, 2009). Furthermore, attachment may
influence professional development; when a supervisee’s attachment system is
activated this can be a barrier to learning unless the supervisor takes the caregiver
role, restores attachment security and thereby reinstates an effective learning
environment (Pistole & Fitch, 2008). Building on this, Fitch, Pistole and Gunn
(2010) developed the ‘Attachment Caregiving Model of Supervision’ to explain how
the supervisee’s attachment system can be activated, moving them to seek proximity
to their supervisor to elicit a caregiving response.
Whilst the conceptual literature assumes attachment is a useful explanatory
theory for the SR, to a large extent these papers are not underpinned by empirical
evidence. Some research has investigated the ideas presented within the conceptual
literature, such as, the impact attachment orientation has on the supervisory working
alliance (Bennett, BrintzenhofeSzoc, Mohr, & Saks, 2008; Bennett, Mohr, Deal, &
Hwang, 2013; Deal, Bennett, Mohr, & Hwang, 2011; Dickson, Moberly, Marshall, &
Reilly, 2011; Gnilka, Rice, Ashby, & Moate, 2016; Gunn & Pistole, 2012;
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Marmarosh et al., 2013; McKibben & Webber, 2017; Renfro-Michel & Sheperis,
2009; Riggs & Bretz, 2006; White & Queener, 2003; Wrape, Callahan, Rieck, &
Watkins, 2017). This research has largely employed samples of trainee therapists
and / or supervisors from psychotherapeutic disciplines including clinical
psychology, counselling, and social work. Most published research has been
conducted in the United States of America (USA) except for one study that was
completed with a sample in the United Kingdom (UK). However, there are
conflicting findings from studies with regards to whether it is the attachment of the
supervisor or the supervisee that is most associated with ratings of the supervisory
working alliance.
Rationale for the current review
The literature to date has suggested that AT can be applied to further our
understanding of processes within the SR. However, this is an area that requires
further exploration. Hill (1992) initially suggested a link between AT and the SR, yet
a previous review (Watkins & Riggs, 2012) identified only seventeen published
papers (seven empirical and ten conceptual) investigating this. Whilst Watkins’ &
Riggs’ (2012) review is relatively recent, they did not provide a detailed method of
their search strategy and inclusion/exclusion criteria. Thus, this review will provide a
detailed systematic search strategy that can be replicated, identify any papers not
included in the original review and provide an update of literature published in the
years since.
This review aims to answer: What is the evidence that attachment is related to
the SR? This will be achieved by identifying and evaluating empirical research on
AT in the SR within psychotherapeutic disciplines. The review will ascertain what
93
we currently know about attachment processes in supervision and what is yet to be
established; therefore, informing directions for future research.
94
Method
Data Sources and Search Strategy.
The Psychology Cross Search (PsycINFO, PsycARTICLES, Psychology and
Behavioural Sciences Collection, PsycBOOKS, MEDLINE), Web of Science and
Scopus databases were searched from the first available year of publishing to the 10 th
and 11th April 2017 using a range of keywords related to attachment and the SR (see
Table 1). Due to the nature of the SCOPUS database, the search terms were specified
for different field codes e.g. searching titles and abstracts.
Attachment and supervision were selected as key search terms. Additional
keywords were used to exclude articles that focused on attachment within the
therapeutic relationship or on a purely administrative SR. This is because within the
SR, attachment is understood as the bond that develops between the supervisor and
supervisee that may be activated by anxiety that novel situations create, so,
supervision that is less likely to provoke anxiety such as administrative supervision is
not likely to benefit from the application of AT (Pistole & Fitch, 2008). Therefore,
terms were used to concentrate on articles that focussed on the supervision of
psychotherapy practitioners regardless of their professional role. For this reason,
research from social work professions was not excluded as within the USA, ‘Clinical
Social Work’ is considered a professional discipline within the field of
psychotherapy. The focus of clinical supervision in social work is like other
psychotherapeutic disciplines and is not purely administrative, instead including
reflective practice and process issues (Morrison, 2005). Medical, nursing and
psychiatric professions were excluded as articles featuring these professions focussed
on administrative supervision rather than psychotherapy supervision. Results were
95
further filtered by only including articles written in English and excluding books,
book chapters and dissertation/thesis research. Dissertation/thesis research was
excluded from the review for quality control purposes; only papers published in peer-
reviewed journals were selected for review. Furthermore, excluding
dissertation/thesis research ensured the size of the data to be reviewed remained
manageable.
Table 1
Search strategy and results
Database and Date
Search Terms Used Number of Citations
Psychology Cross Search; Searched on 10/04/2017
( ATTACHMENT* AND SUPERVIS* NOT ( treatment or intervention or therapy ) NOT ( medic* OR nurs* OR Psychiatr* ) ) NOT TI ( Parent* or child or adoles* )
244
Web of Science; Searched on 11/04/2017
( ATTACHMENT* AND SUPERVIS* NOT ( treatment or intervention or therapy ) NOT ( medic* OR nurs* OR Psychiatr* ) ) NOT TI ( Parent* or child or adoles* )
179
Scopus; Searched on 11/04/2017
TITLE-ABS ( attachment* ) AND TITLE-ABS ( supervis* ) AND NOT TITLE-ABS ( treatment OR intervention OR therapy ) AND NOT TITLE-ABS ( medic* OR nurs* OR psychiatr* ) AND NOT TITLE-ABS ( parent* OR child OR adolesc* )
203
Note. TI = Title. ABS = Abstract.
Records identified from these databases were exported to a folder in
Refworks, a reference management software package. Across all databases 626
citations were initially identified. A manual review and citation search of the twelve
eligible papers for inclusion in the review yielded a further six results totalling 632
records identified. Once duplicates were removed 436 citations remained. An
updated search of the databases was completed on 21/02/2018. This yielded one
further article that was included in the review after the inclusion and exclusion
96
criteria were applied. See Figure 1. for a PRISMA diagram (Moher, Liberati,
Tetzlaff, Altman, & Prisma Group, 2009) of this process.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria were applied at two-stages (see Table 2 for
inclusion and exclusion criteria).
Inclusion Criteria Exclusion Criteria
Articles published in peer-reviewed journals
Articles using quantitative and qualitative methodology
If the terms “attachment” and/or “supervision” were used in either the title or abstract and fell within the psychotherapeutic disciplines
Articles written in English Articles where the focus of the paper
was AT in the SR Articles that add to the evidence base
Non- peer-reviewed articles Dissertation / Theses Articles exploring AT within
organisational psychology contextsa
Articles on the SR but not including AT
Articles discussing attachment in the context of relationships other than the SRb
If the article clearly had no relation to the topic of interest.
If written in a language other than English
Papers that discussed either supervision, or attachment but not these two concepts together
Conceptual / practice-based papers discussing AT in the SR
Previous literature reviews
Note.
aWhilst some of these papers considered AT within the SR, the abstracts made clear that the focus was on how this impacted performance rather than the relational processes of supervision which is the focus of this review.
bRelationships such as the therapeutic relationship, romantic relationships, and the parent-child relationship.
Table 2
Inclusion and exclusion criteria
Firstly, the inclusion/exclusion criteria were applied to the titles and abstracts
of all 436 articles. This resulted in the exclusion of 406 citations and 30 articles
97
being selected for full screening. Secondly, each of these papers was re-reviewed
against the inclusion/exclusion criteria resulting in the exclusion of a further 16
articles and a total of 14 articles for full review.
98
Figure 1. PRISMA Diagram
99
Critical Appraisal of Included Studies
There were difficulties identifying an appropriate tool to evaluate the
different methodologies employed in the empirical papers (ex-post facto and
Randomised Controlled Trial (RCT)). There are arguments about the utility of such
tools as different tools can generate diverse findings (Deeks et al., 2003). Often these
tools use a single total score to determine whether a study should be included and the
meaningfulness of this has been questioned (Wells & Littell, 2009). Mindful of these
limitations, the Standard Quality Assessment Criteria for Evaluating Primary
Research Papers (Kmet, Lee & Cook, 2004) was utilised to guide and inform the
assessment of the quality and credibility of the findings of each paper. This is a
commonly used tool and it was chosen due to its flexibility in being suitable for both
RCT and ex-post facto designs and the option to eliminate non-applicable items.
Studies included in this review were evaluated using the 14 criteria for the evaluation
of quality of quantitative studies developed by Kmet et al. (2004). These 14 criteria
were applied to each paper with the three items relating to RCT designs excluded for
the ex-post facto design papers. Each article was appraised by the author, a post-
graduate Trainee Clinical Psychologist, using Kmet et al’s. (2004) guidelines. Each
study was assessed as meeting (a score of 2), partially meeting (a score of 1) or not
meeting (a score of 0) each criteria. These criteria related to the quality of the study’s
write up and aspects of methodology (design, objectives, sampling, measures),
analysis and conclusions. An overall summary score for each paper was calculated
using Kmet et al’s. (2004) instructions. Scores ranged from 0.64 to 0.9, with scores
closer to 1 being indicative of higher quality. See Table 3 for ratings of the studies
included in the review.
100
Table 3
Quality appraisal scores of studies included in the review
Ben
nett
et a
l (20
08)
Ben
nett
et a
l (20
12)
Dea
l et a
l. (2
011)
Dic
kson
et a
l. (2
011)
Fost
er e
t al.
(200
6)
Fost
er e
t al.
(200
7)
Gni
lka
et a
l. (2
016)
Gun
n &
Pis
tole
(201
2)
Mar
mar
osh
et a
l. (2
013)
McK
ibbe
n &
Web
ber (
2017
)
Ren
fro-
Mic
hel &
She
peris
(200
9)
Rig
gs &
Bre
tz (2
006)
Whi
te &
Que
ener
(200
3)
Wra
pe e
t al.
(201
7)
1. Question/objective sufficiently described 2 2 2 2 1 1 2 2 2 2 2 1 2 1
2. Study design evident and appropriate 1 2 2 1 1 1 1 1 1 1 2 1 1 2
3. Method of subject/comparison group selection or source of information/input variables described and appropriate
1 1 1 1 2 1 1 2 1 2 2 2 1 2
4. Subject (and comparison group selection if applicable) characteristics sufficiently described?
1 2 2 1 1 2 2 2 2 2 2 2 1 1
5. If interventional and random allocation was possible, was it described?
n/a 2 2 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
6. If interventional and blinding of investigators was possible, was it reported?
n/a 0 0 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
7. If interventional and blinding of subjects was possible, was it reported?
n/a 1 1 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
8. Outcome and (if applicable) exposure measure(s) well defined and robust to measurement/misclassification bias?
1 1 1 1 1 1 1 1 1 1 1 1 1 1
101
Ben
nett
et a
l (20
08)
Ben
nett
et a
l (20
12)
Dea
l et a
l. (2
011)
Dic
kson
et a
l. (2
011)
Fost
er e
t al.
(200
6)
Fost
er e
t al.
(200
7)
Gni
lka
et a
l. (2
016)
Gun
n &
Pis
tole
(201
2)
Mar
mar
osh
et a
l. (2
013)
McK
ibbe
n &
Web
ber (
2017
)
Ren
fro-
Mic
hel &
She
peris
(200
9)
Rig
gs &
Bre
tz (2
006)
Whi
te &
Que
ener
(200
3)
Wra
pe e
t al.
(201
7)
Means of assessment reported?
9. Sample size appropriate? 2 1 1 2 2 1 2 2 2 2 1 2 2 2
10. Analytic methods described/justified and appropriate? 1 2 2 1 2 1 2 2 1 2 2 2 1 2
11. Some estimate of variance is reported for the main results?
1 1 0 0 0 1 2 2 1 2 2 1 1 2
12. Controlled for confounding? n/a 0 0 n/a n/a n/a 1 n/a n/a n/a n/a n/a n/a 0
13. Results reported in sufficient detail? 2 2 2 2 1 2 2 2 2 1 2 2 2 2
14. Conclusions supported by the results? 2 2 2 2 2 2 2 2 2 2 1 2 2 2
Total 0.7 0.68 0.64 0.65 0.65 0.65 0.9 0.9 0.75 0.85 0.85 0.8 0.7 0.77
Note.
2=criteria met. 1=criteria partially met. 0=criteria not met. n/a=non-applicable
102
Results
Summary of Empirical Study Characteristics
A summary of the characteristics of the studies included in this review is in Table 4.
Participants. Most of the empirical studies (n=9) included in the review used
a sample consisting of supervisees. This fits with the conceptual literature which
takes the position that it is the supervisees’ attachment insecurity that is associated
with negative supervisory outcomes. However, five studies employed dyads thereby
gaining the perspective of both supervisors and supervisees. Much of the research
(n=13) was conducted in the USA with one study taking place in the UK.
Supervisees. Eighty-four percent of participants in the supervisee samples
were female and 14.7% were male (1.2% unspecified / other). The average age of
participants was 29.6 years old and 77.5% were Caucasian. Supervisees in the studies
were enrolled on a variety of educational programmes including: clinical
psychology; counselling; social work; and family therapy. These programmes varied
from masters to doctorate level and participants varied in their levels of clinical
experience.
Supervisors. Eighty percent of participants in the supervisor samples were
female and 19.7% were male. The average age of participants was 42.6 years old and
70% were Caucasian.
103
Table 4
Characteristics of studies included in the review
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
Bennett et al. (2008).
General attachment style and supervision specific attachment style and its relationship to perceptions of the supervisory working alliance and supervisory style.
72 foundation level Masters Social Work Students on a programme in the USA. but demographics only collected from 32 individuals
26f, 5m (no explanation given for this totalling 31 when demographics were collected from 32 participants).
Mean age = 32.5 years
6.5% African American/Black; 77.5% Caucasian/White; 6.5% Asian; 9.7% Other;
All students enrolled on the programme were issued with a survey pack that was voluntary to complete.
Data was collected over two years and two consecutive cohorts.
RScQ-K; WAI-TK; RSQ; Supervisory Styles Inventory
48% Ex post facto; Cross-Sectional Study
Bennett et al. (2013)a
Interrelationships between supervisor attachment, supervisory working alliance, supervision-related affect and the moderating effect of supervision training.
100 Social Worker Field Instructors (supervisors) from two USA university social work programmes.
93f, 7mMean Age=41.2 years
21% African American/Black; 70% Caucasian/White; 6% Latino/Hispanic; 3% Other
64 students (supervisees) of the supervisors.
59f, 5mMean Age= 31.1 years
Supervisors were recruited during orientation sessions and followed up via phone and email.
Once supervisors were recruited, their students were invited to participate by mail.
Data was collected over two years and two consecutive cohorts.
Time 1 supervisor: WAI-TK; RScQ-K; PANAS
Time 2 and 3 Supervisor: WAI-TK; PANAS
Time 1: Supervisee: RScQ-K; WAI-TK; PANAS. Time 2 and 3 Supervisee: WAI-
21%. Pre-test - post-test follow-up control group design.
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Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
9.4% African American/Black, 3.1% Asian, 79.7% Caucasian/White, 3.1% Latino/Hispanic, 4.7% Other.
TK; PANAS.
Deal et al. (2011).
Relationship between student competencies, supervisory alliance, student attachment style and the moderating effect of supervisor training
Same sample as Bennett et al. (2013)
Same as Bennett et al. (2013)
Supervisor:
Time 1: WAI-TK; CBE.
Time 2 and 3: WAI-TK; CBE.
Supervisee:
Time 1: RScQ-K; PANAS; WAI-TK; SLQ-R
Time 2 and 3: WAI-TK; PANAS; SLQ-R.
21% Pre-test – post-test follow-up randomised control design.
Dickson, et al. (2011).
Factors affecting the supervisory alliance. Replication of Riggs & Bretz (2006) study.
259 British Postgraduate Trainee Clinical Psychologists.
229f, 25m, 5 unspecified.Mean Age=28.6 years
71% Caucasian/White. Other demographic data not reported.
15 course directors of the 28 DClinPsy programmes contacted to invite their trainees to participate. No explanation given as to why these 15 course directors were chosen to be contacted.
MOPS; RAQ; RQ; WAI-B
Not reported. Data not provided that would make it possible to calculate.
Ex Post-Facto; Cross-sectional study.
105
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
Foster et al. (2006).
Relationship between the supervisor’s attachment style and ratings of supervisee development
90 distinct supervisor-supervisee dyads (n=180) in the USA enrolled in clinical psychology programmes, marriage and family therapy, counselling and social work.
90 supervisors63f, 27mMean age=44 years87% Caucasian/White.
90 supervisees73f, 17mMean age=29 years.82% Caucasian/White
Other demographic data not reported.
Non-random internet search of graduate programmes. Letters sent to training directors. Those willing to help were mailed questionnaire packets to distribute to supervisees.
Questionnaire for the measure of psychological reactance; Supervisee Levels Scale P-subscale; RQ
Return rate 12% Ex Post-Facto; Cross-Sectional study
Foster, et al. (2007)b
Relationship between attachment and ratings of professional development
Same sample as Foster et al. (2006) Same as Foster et al. (2006)
SLQ-R; SLS; RQ Return rate 10% (reason for different reporting of return rate to Foster et al., 2006 not explained).
Ex Post-Facto; Cross-Sectional study
Gnilka et al. (2016).
The moderating role of perfectionism on attachment and client and supervisory alliances
170 participants in counselling programmes in the USA.
148f, 22mMean age=29.4 years.
84.1% Caucasian/White, 5.9%
Programmes identified using directories. Recruitment emails sent to 20 faculty personnel of these programmes for them to forward to
Almost Perfect Scale-Revised; ECR-R; SWAI
Not reported. Ex Post-Facto; Cross-sectional study
106
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
Latino/Hispanic, 5.3% African American/Black, 4.8% Other
students enrolled on placements. Email included details how to complete the surveys online.
No explanation given for how or why these 20 programmes were chosen or how many accredited programmes there were overall.
Gunn & Pistole (2012).
Supervisee attachment to supervisor and disclosure in supervision as mediated by the supervisory working alliance.
480 participants enrolled on clinical/counselling masters and doctoral training programmes in the USA.
393f, 80m, 7 unspecifiedMean age=29.8 years
83.1% Caucasian/White; 3.5% African American/Black; 3.1% Asian; 2.3% Latino/Hispanic; 5.9% Other
Programmes identified using directories. Programme directors contacted and invited to forward recruitment email to their trainees. Web-based participation.
It is not clear if all programme directors from the directories were contacted or how many of those contacted forwarded the email.
ESS; SWAI; Disclosure in Supervision Scale
Not able to be determined
Ex Post-Facto; Cross- sectional study
Marmarosh et al. (2013).
Relationship between adult romantic attachment and attachment to supervisor and supervisory working alliance. Relationship between adult attachment,
57 participants enrolled on a graduate psychology training programme in the USA.
46f, 11mMean age=27
All students on placement enrolled in a graduate psychology programme and had been in supervision for three months were invited to
WAI-TK; ECR-S; TAS; The Counselling Self-Estimate Inventory - Short
88% of participants that met recruitment criteria consented to
Ex Post-Facto; Cross- sectional study
107
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
supervisory attachment and supervisee perceptions of their counselling ability.
5.3% African American/Black; 3.5% Asian; 86% Caucasian/White; 3.5% Other (1.8% unspecified).
participate and complete a survey packet.
Data collected over two academic years from two cohorts.
Form participate
McKibben & Webber (2017).
The relationship between the supervisee attachment to their supervisor and ratings of the SR when recalling critical feedback
179 students in counsellor education programmes in the USA.
152f, 18m, 3c, 3n 2o, 5 did not indicate their gender. This total exceeds 179 because some participants identified with more than one descriptor Mean age = 29.7
72.6% Caucasian/White; 10.1% African American/Black; 4.5% Hispanic; 3.4% Multiracial; 2.8% Asian; 1.7% Jewish; 1.1% Latino; 1.1% Native American, 0.06% Pacific Islander; 2.2% Other; 3.9% unspecified. Some participants identified with more than one racial background which is why they total >100%.
Programmes identified using directories and faculty members contacted (where contact details were available) and asked to forward participation request to current students. Recruitment email included an email link to access the study online.
It is not clear of the faculty members contacted, how many of those contacted forwarded the email.
ESS; S-SRQ Not able to be determined
Ex Post-Facto; Cross sectional study
Renfro-Michel & Sheperis (2009).
Relationship between supervisee attachment and perceived bond with supervisor over time and across levels of experience
117 masters level counselling students on a programme in the USA.
102f, 15m
University professors agreed to distribute information about study to their students with web-based participation.
RQ; SWAI 45% Ex Post-Facto; Longitudinal
108
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
Mean age=27.8
67.5%% Caucasian/White; 12% African American/Black; 1.7% Asian; 18.8% Latino/Hispanic.
Data collected over two academic semesters.
No information given about how professors were identified
Riggs & Bretz (2006).
The perspective of supervisees on their and their supervisor’s general attachment style and their perspective of the supervisory working alliance.
86 postdoctoral psychology interns in the USA.
66f, 20mMean age=32.6
78.2% Caucasian/White, 9.2% Asian, 3.4% Latino/Hispanic, 1.1% African American/Black, 4.6% Other
200 Internship sites randomly selected from a directory. Directors contacted and asked to forward invite to participate to current interns. Web-based participation.
WAI-HG; MOPS; RAQ; RQ
30% Response from internship sites; 50% from those that received invitation to participate
Ex Post-Facto; Cross-sectional study
White & Queener (2003).
Relationship between supervisor and supervisee attachment, social provisions and perceptions of the supervisory working alliance.
67 supervisor-supervisee dyads (134 participants) on three masters and doctoral level programmes in the USA.
67 supervisors47f, 20m
67 supervisees56f, 11m
Other demographic data not reported
Survey packets given to both supervisors and supervisees around week 5 of their placement.
No information given for how the three programmes were selected or how participants were recruited.
SWAI; The Social Provisions Scale; AAS
50% Ex Post Facto; Cross-sectional study
109
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
Wrape et al. (2017).
Relationship between attachment style, leader-follower dynamics and attachment expectations and the supervisory working alliance.
44 doctoral students based at a training clinic associated with three training programmes in the USA.
31f, 13mMean age=26.6
73% Caucasian/White, 18% Latino/Hispanic, 9% Asian
A training clinic associated with doctoral training programmes.
Participants recruited over two semesters.
No further information given on how this clinic was selected or how participants were recruited.
Leader-Member Exchange (LMX); RQ; ECR-RS; WAI-TK
All measures completed at Time 1.
LMX; ECR-RS; WAI-TK at Time 2
68% Ex Post Facto; longitudinal
Note. f=female. m=male. c=cisgender. n=non-binary o=other.aSame sample as Deal et al. (2011). bSame sample as Foster et al. (2006).
AAS=Adult Attachment Scale. CBE=Competency Based Evaluation.ECR-R=Experiences in Close Relationships Questionnaire-Revised. ECR-RS=Experiences in Close Relationships-Relationship Structures Questionnaire. ECR-S=Experiences in Close Relationships Scale. ESS=Experiences in Supervision Scale. MOPS=Measure of Parental Style. PANAS=Positive and Negative Affect Scale. RAQ=The Reciprocal Attachment Questionnaire. RScQ=Relationship Scales Questionnaire. RScQ-K=Relationship Scales Questionnaire (Kurdek, 2002)RSQ=Relationship Structures Questionnaire. RQ=Relationships Questionnaire. SLS=Supervisee Levels Scale.SLQ-R=Supervisee Levels Questionnaire-Revised. S-SRQ=Short Supervisory Relationship Questionnaire. SWAI=Supervisory Working Alliance Inventory. TAS=Therapist Attachment to Supervisor Scale. WAI-B=Working Alliance Inventory (Baker, 1990).
110
Authors Topic Investigated Sample Recruitment Method Measures Response Rate Design
WAI-HG=Working Alliance Inventory (Horvath & Greenberg, 1989). WAI-TK=Working Alliance Inventory (Tracey & Kokotovic, 1989).
111
Methods. The design, recruitment strategy, and response rate are described in
Table 4 and the data analysis strategy for studies included in this review can be found
in Table 6.
Design. The most popular design was ex post facto cross-sectional designs
used by twelve studies (Bennett et al., 2008; Dickson et al., 2011; Foster, Heinen,
Lichtenberg, & Gomez, 2006; Foster, Lichtenberg, & Peyton, 2007; Gnilka et al.,
2016; Gunn & Pistole, 2012; Marmarosh et al., 2013; McKibben & Webber, 2017;
Renfro-Michel & Sheperis, 2009; Riggs & Bretz, 2006; White & Queener, 2003;
Wrape et al., 2017). Two studies employed a RCT design (Bennett et al., 2013; Deal
et al., 2011).
Measures. A key problem with the research to date is an over-reliance on
self-report data from various measures of attachment and the supervisory working
alliance (Table 5).
Attachment Measures. The attachment measures used have acceptable
reliability and validity (Ravitz, Maunder, Hunter, Sthankiya & Lancee, 2010).
However, a key problem is these measures have only been validated for parent,
partner and peer relationships, not the SR. Whilst some of the measures can be re-
worded for specific relationships, it is questionable how appropriate this is for the SR
as these measures are based on a relationship that does not fit the context of
supervision (Marmarosh et al., 2013) The SR is arguably very different to these
relationships because of the power dynamic and its educative and evaluative
functions (Bernard & Goodyear, 1998). Moreover, though the Relationships
Questionnaire (RQ) (Bartholomew & Horowitz, 1991) can be used by one adult to
rate another person’s attachment style, the validity of this is in question given the
112
wider debate surrounding the use of self-report attachment measures. It has been
argued self-report attachment measures miss the underlying dynamics of attachment
systems and only access conscious mental processes (Jacobvitz, Curran & Moller,
2002). Furthermore, the measures “do not detect those attachment phenomena that
need to be activated to be manifested” (Ravitz et al., 2010, p. 420). Additionally,
self-report attachment measures are limited since they cannot capture the
idiosyncrasies of an individual’s attachment history (Crowell & Treboux, 1995) and
like all self-report measures, they are vulnerable to socially desirable reporting
(Shaver & Mikulincer, 2004). Nevertheless, Shaver and Mikulincer (2004) argue that
self-report measures have validity in the measurement of attachment processes. A
further broad critique of the use of self-report attachment measures has relevance for
the current review. Waters, Crowell, Elliott, Corcoran, and Treboux (2002) argue
that self-report attachment measures may in fact measure constructs unrelated to
individual attachment orientation. Papers included in this review (Bennett et al.,
2008; Dickson et al., 2011; Gunn & Pistole, 2012; Marmarosh et al., 2013; Renfro-
Michel & Sheperis, 2009; Riggs & Bretz, 2006; Wrape et al., 2017) report strong
correlations between attachment and the supervisory alliance. These high inter-
correlations may call into question whether these assessment tools are measuring the
same or distinct constructs. The internal consistency of both measures of attachment
and the supervisory relationship range from adequate to excellent (see Table 5) and
therefore validity could be compromised as the measures may not be accurately
capturing the constructs they purport to be. A recent measure of the SR, the
Supervisory Relationship Questionnaire (SRQ) (Palomo, 2004 cited in Palomo,
Beinart & Cooper, 2010; Palomo et al., 2010) highlights how attachment and the SR
may overlap. The SRQ identified six components of the SR and the most significant
113
of these to predict variance was the ‘safe base’ which allows supervisees to feel safe
to explore difficulties (Palomo et al., 2010).
Supervisory Working Alliance Measures. Research on the SR in general has
been limited by difficulties in creating a measure that captures the complexity of the
relationship (Tangen & Borders, 2016). Besides the S-SRQ (Cliffe, Beinart &
Cooper, 2014) the short version of the SRQ, and the Supervisory Working Alliance
Inventory (SWAI), the measures of the supervisory alliance employed by the studies
have been adapted from measures of the psychotherapeutic relationship. Arguably
the therapeutic relationship and the SR are very different (Beinart & Clohessy,
2017). Moreover, these measures are based on Bordin’s tasks, goals and bond
conceptualisation of the therapeutic relationship but both the therapeutic relationship
and SR have other broader contextual influences (Beinart & Clohessy, 2017). Whilst
the SWAI (Efstation et al., 1990) is derived from models of supervision, its
psychometric properties have been debated (Beinart & Clohessy, 2017; Tangen &
Borders, 2016).
Data Analysis Strategies. Correlation and regression analyses are employed
as data analysis strategies in all but two of the papers meaning causal inferences are
not possible.
Effect sizes. Effect sizes were either calculated or gathered from the papers;
these ranged between small to large and are reported in Table 6.
Key findings. The key findings of papers can be found in Table 6. Watkins
and Riggs (2012) identified that several of the conceptual papers (Fitch et al., 2010;
Pistole & Fitch, 2008; Pistole & Watkins, 1995) suggested supervisee insecure
114
attachment style may accompany negative relational outcomes in supervision such as
the supervisee resisting or refusing the supervisor’s help or being highly dependent
on the supervisor. Empirical papers have subsequently explored the relationship
between AT and the supervisory working alliance. However, the literature has also
investigated whose attachment is important for the working alliance, the difference
between general attachment and supervision-specific attachment, training
interventions, and the relationship between attachment, the working alliance and the
professional development of the supervisee. Each of these themes within the
empirical literature will now be reviewed.
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Table 5
Measures of Attachment and the Working Alliance used in the empirical papers
Name of Measure
Author (s) Description of Measure Used by and for what purpose Reliabilitya Validityb
Attachment Measuresc
Relationship Scales Questionnaire (RScQ)
Griffin and Bartholomew (1994)
A 30 item measure of adult attachment. The wording of the measure can be adapted to a specific attachment figure.
Foster et al. (2006) to measure supervisor’s general attachment orientation
Foster et al. (2007) to measure supervisee’s and supervisor’s general attachment orientation
+ ++
Relationship Scales Questionnaire (RScQ-K)
Kurdek (2002)
13 item shorter version of Griffin and Bartholomew’s RSQ (1994). Participants rate the extent to which each statement best describes their characteristic style in close relationships. The wording of the measure can be adapted to a specific attachment figure.
Bennett et al. (2008); Deal et al. (2011) to assess supervisee general attachment style
Bennett et al. (2013) to assess general attachment style of supervisor and supervisee
+ ++
Relationship Structures Questionnaire (RSQ)
Fraley (2005)
10 item measure to assess attachment patterns in relation to a specific person e.g. romantic partner.
Bennett et al. (2008) to assess supervisee attachment to their supervisor.
++ Unable to access validity statistics
The Experiences in Close Relationships Scale (ECR-S)
Brennan, Clark and Shaver (1998)
36 item measure of general adult attachment style in close interpersonal relationships.
Marmarosh et al. (2013) to assess supervisee general attachment in close interpersonal relationships
++ +++
The Fraley, 36 item measure of adult attachment avoidance and adult Gnilka et al. (2016) to measure general adult ++ +++
116
Name of Measure
Author (s) Description of Measure Used by and for what purpose Reliabilitya Validityb
Experiences in Close Relationships-Revised Questionnaire (ECR-R)
Waller and Brennan (2000)
attachment anxiety attachment avoidance and general adult attachment anxiety of supervisee
Experiences in Close Relationships – Relationships Structures Questionnaire (ECR-RS)
Fraley, Heffernan, Vicary, and Brumbaugh (2011)
A 9-item measure of relationship-specific attachment Wrape et al. (2017) to measure supervisee attachment to supervisor
++ ++
Therapist Attachment to Supervisor Scale (TAS)
Marmarosh et al. (2013)
Adapted from Mallinckrodt, Gantt and Coble (1995) Client Attachment to Therapist Scale (CATS); a 36 item measure of three dimensions of attachment in psychotherapy.
Marmarosh et al. (2013) to assess supervisee attachment to their supervisor by re-wording items.
+ Validity study
needed for TAS
Relationship Questionnaire (RQ)
Bartholomew and Horowitz (1991)
A measure of continuous attachment orientations as they relate to important relationships and can be modified to specific relationships. Each attachment style is described in a brief statement and participants are asked to rate their degree of correspondence to the statement. It can also be reworded and used to rate others’ attachment patterns
Renfro-Michel and Sheperis (2009); Wrape et al. (2017) to measure supervisee general attachment orientation
Riggs and Bretz (2006); Dickson et al. (2011) to measure supervisee general attachment orientation and supervisee perception of their supervisor’s general attachment orientation
+ ++
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Name of Measure
Author (s) Description of Measure Used by and for what purpose Reliabilitya Validityb
Experiences in Supervision Scale (ESS)
Gunn and Pistole (2012)
A 36 item measure to measure attachment in the SR. Adapted from the ECR (Brennan et al., 1998) by re-wording items.
Gunn and Pistole (2012); McKibben and Webber (2017) to measure supervisee attachment to supervisor.
+ Validity study
needed for ESS
The Adult Attachment Scale (AAS)
Collins and Read (1990)
An 18 item measure of adult attachment White and Queener (2003) to measure supervisor and supervisee perceived ability to develop healthy attachments with others
++ +++
Supervisory Working Alliance Measuresd
The Working Alliance Inventory (WAI-HG)
Horvath and Greenberg (1989)
A 36 item self-report measure of the client’s perception of the therapeutic working alliance.
Riggs and Bretz (2006) to measure supervisee perception of the supervisory working alliance. Items were re-worded to reflect this e.g. “therapist” was changed to “supervisor”.
+++ ++
Working Alliance Inventory (WAI-TK)
Tracey and Kokotovic (1989)
12 item shorter version of Horvath and Greenberg (1989) WAI. Both are designed to measure the therapeutic working alliance.
Bennett et al. (2008); Bennett et al. (2013); Deal et al. (2011); Marmarosh et al. (2013); Wrape et al. (2017) to measure supervisee perception of the supervisory working alliance. Items were re-worded to reflect this
+++ ++
The Supervisory Working Alliance Inventory (SWAI)
Efstation, Patton and Kardash (1990)
19 item self-report measure of the perceived strength of the SR
Gnilka et al. (2016); Gunn and Pistole (2012); Renfro-Michel and Sheperis (2009) to measure supervisee perception of the supervisory working alliance
White and Queener (2003) to measure supervisor and supervisee perception of the supervisory working alliance
+ ++
118
Name of Measure
Author (s) Description of Measure Used by and for what purpose Reliabilitya Validityb
The Working Alliance Inventory (WAI-B)
Baker (1990) Adapted from the 36-item client version of the WAI (Horvath & Greenberg, 1989). The original version measures client perceptions of the therapeutic working alliance. Items were re-worded for example “therapist” was substituted for “supervisor”.
Dickson et al. (2011) to measure supervisee perception of the supervisory working alliance
+ Baker (1990) did not do validity study.
Short Supervisory Relationship Questionnaire (S-SRQ)
Cliffe, Beinart and Cooper (2016)
An 18 item self-report measure of the SR from the supervisee’s perspective
McKibben and Webber (2017) to measure supervisee perception of the supervisory working alliance
++ ++
Note. Some measure abbreviations feature author initials to differentiate them from measures with the same abbreviation
a Reliability Scores: (+ to ++) adequate test-retest or internal consistency; one “+” for each criterion; (+++) excellent properties.b Validity Scores: (+) convergent with other attachment / working alliance scales; (++) other evidence of convergent, discriminant, and predictive ability; (+++) excellent propertiesc A comprehensive review of attachment measures is beyond the scope of this literature review. For a review of the reliability and validity of attachment measures see Ravitz et al. (2010)d A comprehensive review of alliance measures is beyond the scope of this literature review. For a review of measures of the therapeutic alliance that studies used and adapted e.g. (WAI-HG) see Elvins and Green (2008). For a review of measures of the supervisory working alliance see Tangen and Border (2016).
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Table 6
Results of studies included in the review
Authors Analysis Key Findings and (Effect Size) Strengths Limitations
Bennett et al. (2008).
Multiple Regression analysis
Supervisees with supervision-specific attachment avoidance rated the supervisory alliance bond as weaker irrespective of general attachment style (Large. R2 =0.72**)
Distinguished between general and supervision-specific attachment; Distinguished between avoidant and anxious attachment styles and the relationship to the supervisory alliance; large effect size
48% response rate; unable to generalise as data collection specific to one program and only foundation year students; self-report data; relationship structures questionnaire may be more suited to personal rather than professional relationships
Bennett et al. (2013).
Multilevel Regression analysis
Supervisor attachment was not related to change in ratings of the alliance for both the training and control groups as rated by both students and field instructors.
Experimental research design; randomised control trial (RCT)
Lack of control over type 1 errors; some Field Instructors changed groups and therefore the condition was no longer blind; self-report data
Deal et al. (2011).
Multiple Regression Analysis
Training with an attachment focus improved the supervisor’s perception of the alliance (Large. dGMA-raw=0.99*) but not the supervisees’s perception of the alliance.
RCT; included both supervisor and supervisee ratings; data collected over time points; large effect size
Not blind - participants were aware of which condition they were allocated to; self-report data
Dickson, et al. (2011).
Multivariate Analysis of Variance
Supervisee perception of supervisors as insecurely attached associated with lower ratings of the working alliance (Large. ηp2 = 0.19***); Attachment style of supervisee not associated with ratings of the working alliance
First published paper investigating AT in supervision with a UK sample; large sample; large effect size
Self-report; supervisee perspective only; quality of supervision not measured; cross-sectional design – perspectives of the alliance may change through training; response/return rate not reported.
Foster et al. (2006).
Hierarchical multiple Regression
Supervisors with a preoccupied attachment style rated supervisees as less professionally developed than supervisors with other attachment styles
Controlled for other variables in the analysis; Investigates relationship between attachment
Self-report; correlational; response rate 12%; results cannot be generalised; Supervisee Levels Scale has limited use as a
120
Authors Analysis Key Findings and (Effect Size) Strengths Limitations
Analysis (Small. R2= 0.08**). and developmental ratings measure of the developmental level of supervisee; small effect size
Foster, et al. (2007).
Chi-Square goodness of fit test and Hierarchical Multiple Regression Analysis
No significant difference between general attachment style and supervision-specific attachment (Not reportable as 100% of the supervisees were attached to their supervisor); There was a significant difference between insecurely attached and securely attached supervisee’s self-rated professional development scores (Small ΔR2=.12**).
Controlled for other variables in the regression; Investigates another aspect of attachment in the SR beyond the alliance;
Response rate 10% - not representative; differences in ratings of professional development by the supervisor and supervisee may be explained by use of different measures; self-report; correlational; small effect size; the Relationships Scales Questionnaire does not have psychometric properties for the SR
Gnilka et al. (2016).
Correlation; Hierarchical Regression Analysis
Supervisee general attachment anxiety associated with supervisee poorer ratings of the working alliance (Small. r=-0.21*); Supervisee general attachment avoidance associated with supervisee poorer ratings of the working alliance (Small. r=-0.23*). Supervisee general attachment anxiety and supervisee maladaptive perfectionism predicted lower ratings of the working alliance (Small β=-0.20*).
Investigated whether perfectionism may moderate impact of attachment on supervisory alliance; large sample size
Cross-sectional correlation study; no supervisor perspective; self-report; group supervision not controlled for; small effect sizes.
Gunn and Pistole (2012).
Correlation Analysis
Supervisees that were securely attached to their supervisors rated the working alliance positively (Large. β= 0.89**).
Explores supervision specific attachment; Large sample size; Large effect size
ESS measure adapted and DSS developed for this study – both need validity study; response rate unknown; self-report; correlation; no supervisor perspective.
Marmarosh et al. (2013).
Correlation analysis
Self-reported adult avoidant attachment in supervisees associated with poorer ratings of their own self-efficacy (Medium. r=-0.30*); Secure supervisory attachment strong predictor of ratings of the alliance (Large. r=0.83**); Fearful avoidance in supervision but not avoidance in
Investigates relationship between attachment and self-efficacy; Distinguishes between general and supervision specific attachment; Medium – Large
TAS measure adapted from a client measure and therefore a relationship that is different to the SR; correlation; self-report no supervisor perspective.
121
Authors Analysis Key Findings and (Effect Size) Strengths Limitations
romantic relationships associated with poorer ratings of the alliance (Large. r= -0.75**); Avoidance in close interpersonal relationships outside of supervision associated with fearful attachment in supervision (Medium. r=0.33**).
effect sizes
McKibben and Webber (2017).
Multiple Regression Analysis
Anxious supervisee attachment to supervisor associated with lower supervisee ratings of the alliance (Small. β =-0.23*); Avoidant attachment to supervisor associated with lower supervisee ratings of the alliance (Small. β=-0.26*)
Large sample size Response rate not calculable; ESS had low internal consistency and dropping items to improve this may have impacted how avoidant attachment was measured; small effect size; no supervisor perspective; self-report
Renfro-Michel and Sheperis (2009).
Two-way analysis of variance
Supervisees with self-reported secure attachments in interpersonal relationships rated the alliance higher at mid-semester (Large. ηp2= 0.229***) and end of semester (Medium-Large. ηp2= 0.116**)
Longitudinal study; large-medium effect sizes
Not generalizable; RQ adapted for supervisor relationship but it is a different relationship because of the power dynamic; low return rate; self-report; no supervisor perspective
Riggs and Bretz (2006).
Multivariate analysis of variance;
Working alliance task (Medium-Large. ηp2 = 0.14**) and working alliance bond (Medium-Large. ηp2 = 0.17** ) rated more positively by supervisees who perceived their supervisors to have a secure attachment regardless of their own attachment style.
Considers the role of the supervisor’s attachment for the alliance; medium-large effect sizes
30% response rate from internship sites; 50% response rate from those that received invitation; no supervisor perspective; use of adapted measures
White and Queener (2003).
Multiple Regression Analysis.
Supervisee attachment and social provisions did not predict their or their supervisor’s perceptions of the alliance; Supervisors attachment and social provisions was predictive of both their own (Medium. R2= 0.33***) and their supervisee’s (Small. R2= 0.16*) perceptions of the alliance.
First empirical paper published investigating attachment and the alliance; sample includes supervisors and supervisees
Return rate of 50%; primarily female sample; data collected from only 3 universities from participants of similar developmental levels; self-report.
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Authors Analysis Key Findings and (Effect Size) Strengths Limitations
Wrape et al. (2017).
Linear Regression, and Hierarchical Regression.
Supervisee attachment avoidance in supervision significantly associated with supervisee ratings of the working alliance at time 1 (Large. β=-.72***) and time 2 (Medium. β= - 0.43**); Supervision-specific attachment more strongly associated with ratings of the alliance than general attachment (Large. r=-.86***);
Longitudinal; Large effect sizes no supervisor perspective; self-report; adapted measures
Note. *p<.05. **p<.01. ***p<.001. FI=Field Instructors. Only analyses relating to the topic under review are reported in this table.
123THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
Attachment Theory and the Supervisory Working Alliance
The conceptual literature suggested that supervisee insecure attachment may
relate to negative outcomes within the SR and empirical papers have explored this.
There have been mixed findings from the research as to whose attachment, the
supervisor’s or supervisee’s, impacts ratings of the supervisory working alliance.
The supervisor’s attachment and the supervisory working alliance. Only
five studies included in the review recruited samples of both supervisors and
supervisees. This may be due to the assumption within the conceptual literature that
it is the supervisee’s attachment style that is associated with ratings of the
supervisory alliance (Watkins, 1995; Watkins & Riggs, 2012) and that the
supervisor’s relational position is that of the caregiver (Pistole & Fitch, 2008). White
and Queener (2003) were the first to publish an empirical paper investigating the
relationship between attachment and the supervisory alliance. They recruited
supervisory dyads and found that the attachment orientation of the supervisee did not
predict either their own, or their supervisor’s perception of the working alliance.
However, the supervisor’s attachment did partly predict their own and their
supervisee’s ratings of the alliance. These findings suggest the supervisor’s
attachment may be more important for the supervisory alliance than the supervisee’s
attachment (White and Queener, 2003). However, the ex-post-facto design employed
in this study limits the ability to make causal inferences i.e. we cannot say with
certainty that attachment style affected the ratings of the working alliance.
In another study, Riggs and Bretz (2006) randomly selected 200 internship
sites across the USA inviting programme directors to forward an invitation to
124THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
participate to their current interns. They found the supervisee’s perception of their
supervisor’s attachment was related to ratings of the working alliance rather than the
supervisee’s own attachment. In other words, those who perceived their supervisors
had a secure attachment were more likely to positively rate the working alliance
(Riggs & Bretz, 2006). Like the work of White and Queener (2003), this study
suggests the attachment orientation of the supervisor is important for ratings of the
working alliance, although in this case, it is the supervisee’s perception of the
supervisor’s attachment. However, this study is also limited by a low response rate
from the internship sites and from those that received an invitation to participate in
the study. Furthermore, the study did not include the perspective of supervisors.
While most of the research used American samples, Dickson et al. (2011)
replicated Riggs’ and Bretz’s (2006) study using a UK sample of British
postgraduate Trainee Clinical Psychologists. They too reported that the supervisee’s
perception of the supervisor’s attachment was associated with ratings of the
supervisory working alliance. However, as with Riggs’ and Bretz’s (2006) study,
they were reliant on the supervisee’s self-report of the working alliance and on their
perception of the supervisor’s attachment. There was no measure of the quality of
supervision being received which could potentially impact ratings of the alliance. In
addition, data was collected at only one time point so there was no account of
whether perspectives of the working alliance changed at different stages of training
which may reflect changes in the supervisee’s view of the SR (Dickson et al., 2011).
These findings are interesting as they conflict with the assumptions laid out in
the conceptual papers and the idea that the supervisor’s relational position is that of
the caregiver (Gunn & Pistole, 2012; Pistole & Fitch, 2008). However, the findings
125THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
are consistent with research on couples that has concluded that the perceptions by
one in the relationship, of the attachment style of the other is associated with
satisfaction and functioning in that relationship (Cobb, Davila, & Bradbury, 2001;
Murray, Holmes, & Griffin, 1996). Riggs and Bretz (2006) explained these findings
by highlighting that the SR is a hierarchical one and therefore supervisors are
primarily responsible for the alliance. They argued that securely attached supervisors
may be more able to provide a secure base compared to insecurely attached
supervisors (Riggs & Bretz, 2006). Furthermore, the SR is a “structured, task-
oriented, and professional relationship” (White & Queener, 2003, p. 213).
Consequently, supervisees may feel inhibited in making emotional disclosures and
have few expectations for the relationship meaning their attachment orientation may
not influence the supervisory alliance (Dickson et al., 2011).
General attachment and the supervisory working alliance. Studies have
supported a relationship between the supervisee’s general attachment style in
interpersonal relationships and the supervisee ratings of the working alliance (Gnilka
et al., 2016; Renfro-Michel & Sheperis, 2009). Gnilka et al. (2016) reported
relationships between self-reported general attachment anxiety, self-reported general
attachment avoidance and poorer ratings of the supervisory working
alliance/relationship. Gnilka et al. (2016) also investigated the relationship between
adult attachment style, adaptive and maladaptive perfectionism and the supervisory
working alliance finding a significant three-way interaction. They concluded that
supervisees with high attachment anxiety paired with high maladaptive perfectionism
(severe self-criticism and setting high standards for oneself) and low adaptive
126THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
perfectionism (having high standards for oneself with low self-criticism) may have
more difficulty in forming positive SRs (Gnilka et al. 2016).
Supervision-specific attachment style and ratings of the alliance. It has
been suggested that it is possible to have multiple attachments for various kinds of
relationships (Klohnen, Weller, Luo, & Choe, 2005). Several studies have measured
the general attachment style of participants and more specifically participants’
attachment to their supervisors. They have reported findings that supervision specific
attachment avoidance in supervisees was more related to negative ratings of the
working alliance than general attachment avoidance (Bennett et al., 2008;
Marmarosh et al., 2013; Wrape et al., 2017). However, these findings are limited
due to the use of self-report measures and the focus on the supervisee. Gunn and
Pistole (2012) and McKibben and Webber (2017) too found self-reported attachment
insecurity in supervision was associated with poorer ratings of the alliance. But,
neither measured participant’s general attachment style or comparison. These
findings would suggest it is supervision-specific attachment that has more
significance for ratings of the supervisory working alliance than general attachment
orientation. Although, Foster et al. (2007) found no significant difference between
general attachment style in interpersonal relationships and supervision-specific
attachment style in their sample of supervisor-supervisee dyads. Nonetheless, this
study is limited by a low response rate meaning the findings are not representative.
Gunn and Pistole (2012) also queried the relationship between supervisee
attachment orientation and supervisee disclosure in supervision. A lack of disclosure
within supervision is important (Bernard & Goodyear, 2013) as it could inhibit the
supervisor in their supervisory practice and potentially impact the working alliance
127THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
(Gunn & Pistole, 2012). Although not formally defined within the paper, disclosure
appeared to relate to thoughts, feelings and beliefs the supervisee may have in
relation to their therapeutic practice. They found that supervisees with secure
attachments to their supervisor were likely to disclose more in supervision (Gunn &
Pistole, 2012). This highlights how attachment orientation may influence specific
processes within the SR, in this case disclosure.
These studies would suggest that the attachment orientation (either general or
supervision-specific) of the supervisee is related to ratings of the supervisory
working alliance. However, a lack of supervisor perspective in these papers may
explain the differences in findings in comparison to Riggs and Bretz (2006), Dickson
et al. (2011) and White and Queener (2003). Whilst Foster et al., (2007) recruited
supervisory dyads, only supervisees completed the attachment measures in this
study. Furthermore, although the papers by Gunn and Pistole (2012) and Marmarosh
et al. (2013) report large effect sizes, these studies are cross-sectional correlation
designs and therefore it is not possible to make any conclusions about causality.
Training Supervisors about Attachment Theory and Impact on the Working
Alliance
Another theme that emerged within the research literature is whether training
supervisors to be aware of attachment issues in the SR improves the alliance. Deal et
al. (2011) recruited social work supervisor-supervisee dyads in the USA and
allocated supervisors to either a training group or a control group. The training group
were provided with training on the SR and AT. They found that ratings of the
working alliance by supervisees did not significantly change after their supervisors
128THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
had received this training, nor did supervisee self-ratings of their own performance
and development. However, supervisors who received training rated the alliance as
higher following the training when compared to the control group. Bennett et al.
(2013) published a study using the same data from the Deal et al. (2011) paper. They
investigated if the training given to supervisors had a moderating effect on supervisor
attachment, ratings of the supervisory working alliance by supervisors and
supervisees and ratings of supervision-related affect. However, the training they
provided did not lead to significant changes in any of these variables. These studies
have strengths in their use of a control group although participants were not blind to
the condition they were in and it is possible that the numerous null findings across
both papers reflect a lack of power within the sample. Furthermore, the mixed
findings across these studies makes it difficult to make any firm conclusions about
the impact of training on ratings of the supervisory working alliance. Deal et al.’s
(2011) study found supervisors rated the alliance as higher following the training but
it is not clear which aspect of the training led to this finding.
Attachment Theory and Professional Development
Supervision literature has highlighted the importance of supervision for
supervisee skill acquisition (Holloway & Neufeldt, 1995) and the attachment in
supervision conceptual literature has noted the importance of supervision for
supervisee development (Bennett & Deal, 2009; Fitch et al., 2010; Pistole & Fitch,
2008; Pistole & Watkins, 1995). Empirical papers have thus sought to understand the
relationship between attachment and the professional development of supervisees.
Foster and colleagues studied this in a group of supervisors and supervisees (Foster
et al., 2006; Foster et al., 2007). In their first paper they reported that supervisors
129THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
with preoccupied attachment styles rated supervisees as less professionally
developed in comparison to supervisors with other attachment styles (Foster et al.,
2006). Foster et al. (2006) suggested that when presented with a confident
supervisee, the preoccupied supervisor may feel self-doubt and then give lower
ratings of professional development to maintain their own self-confidence. In the
second paper they found a significant difference between supervisee attachment
orientations and supervisee ratings of their own professional development (Foster et
al, 2007). They explained that the supervisee may focus on their attachment feelings
towards their supervisor which leads to inaccurate self-evaluations. However, both
papers were limited by a low response rate and small effect sizes. Deal et al. (2011)
reported that high attachment anxiety in supervisees was associated with lower than
average self-evaluations but they relied on self-report data and were limited by a
small sample size. Marmarosh et al. (2013) too found that adult attachment
orientation accounted for variance in novice therapist self-reports of their counselling
abilities but this was correlational data.
Discussion
AT and its relevance in the SR is an under-researched area despite first being
conceptualised over twenty years ago with just fourteen empirical papers being
identified in this review. The research reports conflicting findings suggesting the
need for further investigation.
Watkins & Riggs (2012) identified seven empirical papers in their overview
of the attachment in supervision literature. The current review has provided an
update of the literature published in the five years since, as well as identifying
literature they did not include. In addition, this review outlined a clear and
130THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
comprehensive search strategy that can be used as the basis for future reviews and
included the effect sizes of the empirical research to date; both are missing in the
Watkins and Riggs (2012) review. However, this review excluded research from the
grey literature and as such the findings and themes presented may be subject to
publication bias.
The conceptual literature postulated that the supervisor’s attachment is
unimportant as their relational position is that of the caregiver (Pistole & Fitch,
2008). However, some empirical papers have concluded that the attachment
orientation of the supervisor, or the supervisee’s perception of the supervisor’s
attachment orientation is important for ratings of the working alliance (Dickson et
al., 2011; Riggs & Bretz, 2006; White & Queener, 2003), and the supervisor’s
ratings of the supervisee’s development (Foster et al., 2006). Others have concluded
that the supervisee’s attachment orientation is related to ratings of the working
alliance (Gnilka et al., 2016; Gunn & Pistole, 2012; Marmarosh et al., 2013;
McKibben & Webber, 2017; Renfro-Michel & Sheperis, 2009), and supervisee
ratings of their own skills and development (Deal et al., 2011; Foster et al., 2007;
Marmarosh et al., 2013). Furthermore, there are findings which suggest attachment
within supervision can be distinguished from general adult attachment orientation
(Bennett et al., 2008; Marmarosh et al., 2013; Wrape et al., 2017). However, Foster
et al. (2007) found no significant differences between general adult attachment
orientation and supervision specific attachment orientation.
There are several possible explanations for these conflicting research
findings. Firstly, studies that report the supervisee’s attachment being associated with
ratings of the working alliance do not have the perspectives of supervisors. It has
131THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
been argued that the supervisor’s attachment may be more important for the
relationship since its hierarchical nature may mean they are more responsible for the
alliance (Riggs & Bretz, 2006). Therefore, neglecting their perspective may explain
the inconsistent findings. Future research should seek to recruit supervisors to ensure
their perspective is captured. In addition, more research is needed with supervisory
dyads to explore any interactional effects of the supervisor and supervisee’s
attachment. Secondly, the papers use a variety of measures of both attachment and
the working alliance. These measures have been validated for parental or romantic
attachment and the client-therapist working alliance, not the SR. Adapting these
measures is further problematic because they are based on relationships that are
inherently different to the SR (Bernard & Goodyear, 1998; Marmarosh et al., 2013;
Tangen & Borders, 2016). In addition, the reliability and validity of self-report
measures of adult attachment has been debated (Crowell & Treboux, 1995; Jacobvitz
et al., 2002; Shaver & Mikulincer, 2004; Waters et al., 2002). Furthermore, the
strong correlations between attachment and the supervisory working alliance
reported by several papers (Bennett et al., 2008; Dickson et al., 2011; Gunn &
Pistole, 2012; Marmarosh et al., 2013; Renfro-Michel & Sheperis, 2009; Riggs &
Bretz, 2006; Wrape et al., 2017) calls into question whether the same or distinct
constructs are being measured and it might be that part of a good SR is feeling
attached to one another.
Menefee, Day, Lopez and McPherson (2014) attempted to remedy the lack of
attachment measures specific to the SR and described the initial validation of the
Supervisee Attachment Strategies Scale (SASS). Factor analysis resulted in two
interpretable factors, anxiety and avoidance. Avoidance correlated with the Working
132THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
Alliance Inventory (Horvath & Greenberg, 1989) suggesting that avoidance may be
an indicator of a poor working alliance. However, the sample employed for this
validation study was imbalanced in gender and data was only collected at a single
time point (Menefee et al., 2014). Therefore, it would be helpful if further validation
studies were completed using the SASS with more balanced samples and over a
period of time. In addition, the S-SRQ (Cliffe et al., 2016) used by one study in this
review includes the ‘safe base’ component of the SR. Cliffe et al. (2016) suggested
that future research could explore the relationship between specific attachment
patterns and scores on the S-SRQ.
The generalisability of the research included in this review is to be
questioned. Disciplines in the literature include clinical psychology, social work,
counselling and family therapists. However, practitioners of psychotherapies are
much more diverse than the small number of professions included here. Furthermore,
there are numerous therapeutic modalities practised within psychotherapy (BACP,
n.d.). Given the broad range of professions and therapeutic modalities, the small
literature on attachment in supervision at this stage cannot be said to be
representative of all these groups. Therefore, future research may consider recruiting
professionals from other psychotherapeutic disciplines.
The attachment in supervision research has focussed on the relationship
between supervisors and trainee therapists. It is assumed that attachment processes
are activated in novice therapists and that experience, competence and the
development of a professional identity reduces attachment system activation and as
such the supervisee no longer requires an attachment-based supervision (Pistole &
Fitch, 2008). However, to date attachment has not been investigated in the SRs of
133THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
experienced practitioners and it may be helpful to empirically investigate if
attachment has relevance for these relationships. In addition, more longitudinal
research is needed using more homogenous dyads of supervisors and supervisees to
further understand the relationship between supervision specific attachment and
processes in the SR and if this changes as the supervisee’s level of experience
increases.
Another possible explanation for the inconsistency is our understanding of
attachment processes within supervision may be incorrect and we are therefore
investigating the wrong things. This could explain the null findings in studies where
attachment-based training was provided to supervisors (Bennett et al., 2013; Deal et
al., 2011). Although it has been identified that it is possible to have multiple
attachments for different relationships (Klohnen et al., 2005), it has been queried
whether it is appropriate to apply an attachment framework to the SR. Bartholomew
and Thompson (1995) assert: “We caution against the indiscriminate extension of
attachment notions to social relationships that may be better understood in terms of
other conceptual models” (p. 485).
Other models have been developed that inform the understanding of the SR
outside of the conceptual framework of AT. Therapy-specific models of supervision
do consider the SR, although this is not the focus of the model. For example:
Cognitive-Behavioural Therapy (CBT) places emphasis on a collaborative and open
SR; psychodynamic supervision explores how the supervisory and therapeutic
relationships can parallel one another, humanistic models emphasise how the quality
of the SR facilitates supervisee learning; and systemic models consider the impact of
multiple contexts on the SR (Beinart & Clohessy, 2017).
134THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
Developmental models of supervision have also considered the SR. These
models assert that supervisees develop through stages, at each stage their needs will
be different and it is therefore the supervisor’s role to respond flexibly to their
supervisee’s needs at each stage (Beinart & Clohessy, 2017). Whilst supporting the
supervisee to progress through the stages of development supervisors can use a
process called ‘scaffolding’ (Bruner, 1978; Zimmerman & Schunk, 2003).
Scaffolding supports the supervisee by helping them to use previously acquired
knowledge to assimilate new learning. The Integrated Developmental Model (IDM)
(Stoltenberg, Bailey, Cruzan, Hart & Ukuku, 2014) emphasises that if a supervisor
does not match the needs of the supervisee this can be detrimental to the quality of
the SR.
Other supervision models that consider the SR include models based on
social role. These propose that supervisors undertake social roles including teacher,
consultant, mentor, role model etc (Beinart & Clohessy, 2017). In their model,
Hawkins and Shohet (2012) consider how the SR may parallel the therapeutic
relationship. Holloway’s (2014) Systems Approach to Supervision (SAS) is the only
supervision model that considers the SR in great detail and views this as central to
processes within supervision (Beinart & Clohessy, 2017). Holloway’s model
emphasises the development of the SR over time and as this relationship strengthens
those in the relationship can be open, vulnerable and self-disclose (Holloway, 2014).
The Oxford Supervision Research Group has developed two models of the
SR. Beinart’s 2002 model (cited in Beinart, 2014) considered the SR from the
perspective of supervisees whereas Clohessy (2008) considered it from the
perspective of supervisors. Beinart’s model emphasised the need for a framework of
135THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
supervision based on a boundaried relationship which enables the process of
supervision to occur (Beinart, 2002 cited in Beinart, 2014). Key features of the SR
were a collaborative, respectful, open and committed relationship with supervisors
flexible to supervisee needs (Beinart, 2002 cited in Beinart 2014). Supervisors
considered how both they and their supervisees brought their identity, experience and
values to the SR and how this contributed to the flow of supervision (Clohessy,
2008).
In summary, models of supervision and models of the SR emphasise the role
and importance of the SR. Given, the existing recognition of the SR one may ask
whether there is a need to consider AT. However, AT can add to these models and
potentially explain difficulties in the SR. For example, Clohessy’s (2008) model of
the SR considers the role of contextual influences on the relationship. Attachment
could be considered a contextual influence on the relationship. Attachment could
also fit within the developmental models of supervision since the early stages of
supervisee development are characterised by anxiety, threat and vulnerability
(Rønnestad & Skovholt, 2003) when a supervisee may be more in need of a secure
base. It has been proposed that attachment processes within the SR may be better
understood using a leader-follower framework (Watkins & Riggs, 2012). Popper and
Mayseless (2003) suggested that leaders e.g. teachers, politicians, managers etc.
could function as attachment figures by providing safe-haven and secure base
functions. Leaders that are securely attached are better able to provide these
functions to their followers (Mayseless, 2010). The leader-follower relationship
reflects attachment dynamics rather than a true attachment relationship (Mayseless,
2010). In the context of the SR, in the early stages of development, supervisees may
136THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
need more leading. This can include more structure and direction within supervision
until competency and confidence have developed (Watkins & Riggs, 2012). Wrape et
al. (2017) found support for a leader-follower attachment framework; this explained
variance in ratings of the working alliance over and above attachment orientation.
Whilst the attachment in supervision research is not without limitations, it
does provide a useful conceptualisation of the SR and has some practical
implications for supervisory practice. Firstly, the research tells us that the supervisor
can be an attachment figure for supervisees (Fitch et al., 2010; Pistole & Fitch, 2008)
and the SR can provide a secure base and safe-haven function (Neswald-McCalip,
2001; Pistole & Watkins, 1995). In addition, the supervisor and supervisee’s
attachment orientation can influence how they perceive the SR (Bennett et al., 2008;
Deal et al., 2011; Dickson et al. 2011; Foster et al, 2007; Renfro-Michel & Sheperis,
2009; Riggs & Bretz, 2006; White & Queener, 2003). In light of this, it would be
pertinent for supervisory dyads to initiate discussions about the relationship and
attachment in the early phases of the relationship. Safe SRs can be established
through contracting, establishing expectations and regularly reviewing the
relationship within supervision (Beinart & Clohessy, 2017). In that respect, it will be
important for any difficulties that arise in the relationship to be explored and
reflected upon, for example, are the difficulties arising because of attachment?
Whilst supervisors need to be attuned to their supervisees and attachment processes
in supervision, it is important to hold in mind that supervision is largely an
educational process and not a therapeutic one (Watkins & Riggs, 2012). It is also
vital to consider contextual factors beyond attachment that may impact the SR, such
as the service context (Clohessy, 2008).
137THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
Overall, there is a lack of published empirical research investigating
attachment in supervision. The research to date has all employed quantitative designs
reporting conflicting findings and are limited by similar methodological flaws such
as small response rates, reliance on self-report data, small sample sizes and questions
about the reliability and validity of the measures used. Furthermore, most papers
have neglected to collect data from supervisors. Whilst quantitative research can
produce reliable and generalisable results, it does not offer an insight into the
complexity of human experience and an exploratory qualitative approach could
explore whether attachment is a helpful focus for understanding the SR. Whilst this
approach cannot address the contradictions in the literature, can only offer cautious
conclusions and subjective interpretations, it does offer an opportunity for the in-
depth exploration of the experience of supervision, the relationship and whether
attachment constructs are relevant for this relationship. The inconsistent findings
within the empirical research would suggest that the application of AT to the SR
does warrant further investigation to better comprehend the mechanisms within this
relationship and a qualitative approach could add a new dimension to this still under-
researched area. To date the literature has tended to focus on the supervisee. A
perspective of how supervisors experience supervision and whether attachment
underpins their supervisory practice would add to the current evidence base.
In summary, it is hoped that an in-depth qualitative exploration of supervisor
experiences within supervision can further the understanding of how supervisors
experience the SR and whether attachment is relevant. These findings could inform
the development of new measures of attachment in supervision and could tentatively
inform supervision practice and training. Clarification of what role, if any,
138THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
attachment has in the SR could lead to further directions for research being
identified.
139THE SUPERVISORY RELATIONSHIP: IS ATTACHMENT RELEVANT?
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Appendices
Appendix A
Journal of Choice: Guidelines for Authors
[Removed]
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Part 3: Summary of Clinical Experience
Year 1 Adult Crisis Resolution and Home Treatment Team and an Adult Assessment and Treatment Service In my first placement, I was split across two services. In the Crisis Resolution and Home Treatment Team I worked with adults aged 18 years old onwards, presenting acutely with a range of moderate to severe mental health difficulties. The team supported individuals in their own homes to prevent an inpatient admission and also supported individuals following discharge from the acute inpatient wards. Clients were supported for a brief period (6-8 weeks) and either referred on to other mental health services or back to their GP. In the assessment and treatment service I worked with adults aged 18 years old onwards, presenting with a range of moderate to severe mental health difficulties. I saw clients either at the team base or in their own homes. Both placements involved working with people with complex risk issues and highly sensitive difficulties including: depression, anxiety, panic disorder, bipolar affective disorder, chronic pain and health anxiety, post-traumatic stress disorder, borderline personality disorder, and a history of traumatic experiences e.g. child abuse, self-harm and suicidal behaviours. My work in the crisis team involved a combination of assessments (service suitability, therapy and risk related) and interventions, on an individual and group basis. In the Assessment and Treatment service I completed assessments (for therapy) and individual psychology interventions. Intervention models used in individual therapy included Cognitive Behavioural Therapy (CBT), Behavioural Activation (BA), and Acceptance and Commitment Therapy (ACT). In terms of group work, I co-facilitated a group at a day centre for clients with the crisis team. This group was a CBT based psychoeducational group on understanding and managing feelings. I also conducted an audit on the use and efficacy of relapse-prevention plans within the crisis team, comparing data against a fidelity measure of best practice for crisis resolution home treatment teams. In addition, I completed a neuropsychological assessment with one individual in the assessment and treatment team who was presenting with memory difficulties alongside a history of trauma. During the placement I attended and contributed to different meetings including handovers/Multi Disciplinary Team (MDT) meetings, reflective practice and business meetings. To develop my teaching and training competencies, I delivered a piece of training, alongside another trainee clinical psychologist on ‘strategies to support clients who are hearing voices’ to a variety of mental health professionals working in inpatient and crisis team settings.
Year 2 Mental Health and Learning Disability (MHLD) Service During this placement I worked with adults aged 18-65 years of age who had been diagnosed with a learning disability and were also experiencing mental health difficulties such as depression, anxiety, adjustment issues, anger difficulties, personal identity, hallucinatory experiences, and relationship difficulties. In addition, to a learning disability, several individuals also had a diagnosis of Autism Spectrum Disorder (ASD). Work in the service was completed at the team base, in residential homes and client homes. Most of my work in this service was working therapeutically with individuals ensuring that assessments and interventions were tailored and adapted to each individual’s need. Whilst adapting interventions I had to consider the individual’s learning disability and any communication difficulties. I worked both individually and indirectly (with staff, family, carers) and used interventions from CBT, Compassion Focussed Therapy (CFT) and systemic ideas. I also completed an observation where there was concerns about the behaviour of a client. During the placement I delivered a workshop on ‘ASD
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and Gender Identity Disorder’ to psychiatrists working in Mental Health Learning Disability services across the trust. I also attended MDT meetings and liaised with other professionals in the team when we were both working with the same client. In addition, I liaised with the social care learning disability team and completed two assessments for dementia using tools specifically designed for adults with a learning disability. I completed cognitive and adaptive behaviour assessments with two individuals as an eligibility assessment for the service.
Older Adult Community Mental Health TeamMy second placement in the second year of training was working with older people aged 65 upwards. In this placement I worked across settings including the team base, residential homes and client homes. I worked with individuals with a range of difficulties including organic difficulties (dementia), adjustment difficulties, anxiety, depression, trauma and suicidal ideation and behaviours. Most of my work was individual and group therapy although I also completed an observation of challenging behaviour. I drew on a range of approaches on this placement including, CBT, CFT, ACT, and behavioural approaches. In addition, systemic and psychodynamic ideas informed my practice. I co-facilitated a 10 session ACT group to men and women with a variety of difficulties for which we received excellent feedback. I developed a mindfulness CD for members of the group with mindfulness exercises we had completed in the sessions. I also completed a neuropsychological assessment of a client presenting with memory difficulties and gave feedback to the psychiatrist working with the client. I regularly attended the weekly team meeting where cases were discussed and presented to the team on ASD in older adults. I learned about older people’s experiences outside of the therapeutic relationship by visiting a dementia charity, and a music group that older people with dementia attended.
Year 3Child and Adolescent Mental Health Service (CAMHS), Tier 3 and CAMHS Learning Disability (CAMHS LD)I was split across both these placements and worked with children and young people aged 8-17 years old and their families. I worked in a variety of settings including the team base, schools, residential homes and client homes. Difficulties experienced by the children and young people I worked with included moderate to severe mental health difficulties such as depression, self-harm, suicidal ideation and behaviours, anxiety, social anxiety, low self-esteem, emotional intensity, behavioural difficulties, anger management, attention deficit hyperactivity disorder (ADHD) and Autism Spectrum Disorder (ASD). In CAMHS LD, the young people I worked with had the difficulties above in addition to a learning disability, genetic conditions and chromosomal disorders. I used a range of models to inform my assessments and interventions including CBT, CFT, behavioural (parenting) approaches and systemic theories. My interventions consisted of both individual, family-based and parent work. I provided consultation to schools, participated in a family therapy clinic as both lead therapist and in the reflective team. I also co-facilitated a group to support young people with LD and their parents to understand and manage their feelings. I undertook one neuropsychological assessment with a child who was attending a SEN school but whose cognitive profile was unknown. In terms of leadership, I co-developed the group mentioned with a psychology undergraduate placement student. Furthermore, I supervised four psychology undergraduate placement students in a monthly supervision group. I delivered a teaching session on anxiety to parents of children with ADHD and had the chance to talk to them about their experiences outside of this session.
Specialist Placement – National Deaf CAMHS outpatient team and National Deaf CAMHS inpatient unit In my specialist placement, I worked across the inpatient and outpatient services of National Deaf CAMHS. I worked with children up to 17 years old who were experiencing mental health difficulties and were also D/deaf. I also completed some parent work as part of this placement.
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The young people I worked with communicated in a variety of ways including aural, British Sign Language (BSL) and Sign Supported English (SSE). In addition, within the teams I was based there were D/deaf staff and I would communicate with them and clients using a mixture of BSL and SSE and the support of BSL interpreters. Clients presented with a variety of difficulties including emotion regulation, identity issues, anxiety, anger, depression, self-esteem, cognitive impairment and ADHD and ASD. My interventions were informed by CBT, CFT, Mentalisation-Based Therapy (MBT) and ACT. Systemic thinking and attachment theory also informed my practice. On the inpatient unit I facilitated a two-session ACT based groups supporting young people to identify their values and goals. I co-facilitated a reflective group for young people with the ward occupational therapist. All work had to be adapted to be accessible to the people I was working with, for example using visual resources. I completed indirect work through school observations and consultation. I completed two cognitive assessments during this assessment taking into consideration that these are not validated for D/deaf young people and therefore can only provide useful qualitative information about their abilities. Leadership experience included providing consultation to a school for the Deaf on a young person’s cognitive assessment findings. I attended weekly team meetings in both teams which was an integral aspect of both services. I was also involved in Care Programme Approach (CPA) meetings for young people I worked with on the inpatient unit. I delivered a teaching session on Attachment Theory to two Speech and Language Therapists in the team and teaching on CFT to the outpatient team. I worked jointly with other professionals in initial assessments and fed these back at the weekly team meeting.
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Part 4: Table of Assessments Completed During Training
PSYCHD CLINICAL PROGAMME
TABLE OF ASSESSMENTS COMPLETED DURING TRAINING
Note: All names used in the titles of assignments are pseudonyms to ensure client confidentiality.
Year I Assessments
ASSESSMENT TITLE
WAIS WAIS Interpretation (online assessment)
Practice Report of Clinical Activity
Practice report of Clinical Activity with Mary: a female client in her 30s presenting with difficulties in emotion regulation
Audio Recording of Clinical Activity with Critical Appraisal
Audio Recording of Clinical Activity with Critical Appraisal of a therapy session with Ella, a female in her late thirties presenting with anxiety
Report of Clinical Activity N=1
Report of Clinical Activity with Jane, a female in her late forties presenting with difficulties managing anger.
Major Research Project Literature Survey
A literature Survey on Attachment in the Supervisory Relationship
Major Research Project Proposal
Exploration of the theory of attachment in the supervisory relationship using an Interpretative Phenomenological Analysis of supervisors’ experiences
Service-Related Project An audit on the use and efficacy of relapse prevention plans within a Crisis Resolution Home Treatment Team
Year II Assessments
ASSESSMENT TITLE
Report of Clinical Activity – Formal Assessment
A learning disability assessment for David, a male in his early twenties.
PPLD Process Account Reflections on the Process of Being in a Personal and Professional Development Group
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Year III Assessments
ASSESSMENT TITLE
Presentation of Clinical Activity
“I don’t feel myself”: Working with June, a woman in her early seventies presenting with low mood and anxiety
Major Research Project Literature Review
Attachment Theory and the Supervisory Relationship: A Review of the Literature
Major Research Project Empirical Paper
An Interpretative Phenomenological Analysis of Supervisors’ Experiences of the Supervisory Relationship: Can Attachment Theory Help Us Understand the Supervisory Relationship?
Report of Clinical Activity
An integrative approach to treating social anxiety in Morgan, a teenage girl.
Final Reflective Account On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training
