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An Update on Microsupervision

Bennett, D., 1999. An Update on Microsupervision. Reformulation, ACAT News Summer, p.1.

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The Background

Micro-supervision is the result of two strands of work; firstly my doctoral research supervised by Glenys Parry and partially funded by the Mental Health Foundation (MHF) and secondly Tony Ryle's work in contributing to this research and refining ideas relating to its focus.

Between 1995 and 1997, my research involved the intensive process analysis of cases in the CAT project for borderline personality disorder. The focus was on how therapists and clients resolved potential threats to the therapeutic alliance due to the emergence of RRPs in the therapy relationship. During this time, Tony began to invite therapists to bring audio-tapes of therapy sessions to supervision to identify 'what was missed'. By the autumn of 1997, Glenys, Tony and I had developed and refined a model of 'competent' practice for the resolution of RRPs enactments based on therapist performance in good outcome cases.

Meanwhile, Tony was developing a checklist of therapist interventions — Therapist Intervention Coding (TICa) based on both strands of work, which was piloted in supervision groups by Tony and Fierman Bennink-Bolt. The TIC was refined on the basis of the final model for enactment resolution (TICb) and applied in a second supervision group by Tony. It focused on the therapist's performance in working with RRPs reported in client's narratives (outside events) and emerging in the in-session interaction. This form of supervision using audio-taped excerpts of therapist and client process and giving specific feedback to therapists on their performance in terms of the TIC items was referred to as Micro-supervision.

Between autumn 1997-8 we secured further funding from the MHF. The aims of the project were to: firstly, refine the TIC to produce a 'competence measure' for training and audit purposes. This would identify if therapists had reached a criterion performance on the identification and resolution of RRP enactments, particularly where they threaten the therapeutic alliance. Secondly, we aimed to investigate the skill of timing the model and TIC consistent interventions and thirdly we hoped to plan how to incorporate the work into CAT training. 

The Products
1. The empirically-derived model

We have a model and series of associated therapist guidelines describing model consistent interventions along with a range of case-based material for training purposes. The aim was not to develop a rigidly prescriptive intervention manual but a guide for therapists which could be used to help them become more sensitised to identify alliance threatening RRP enactments and to the skilful technical interventions associated with resolution and better outcomes.

2. The TIC

We have a refined TIC checklist which incorporates all the elements of the empirically derived model and findings from the pilot applications in micro-supervision. It has 5 parts comprising 14 items. It is concerned with the presence or absence of therapist interventions and does not include ratings of the quality of the intervention. For two TIC versions - therapist (TIC-T) and supervisor (TIC-S) versions, the items and codes are identical in content and differ only in instructions and additional materials for identifying and tracking training needs. Their intended application is use by therapists and supervisors within micro-supervision of CAT practice. A third version, the TIC — observer rating scale (TIC-O) allows external raters to assess the degree to which a given session of psychotherapy meets performance criteria related to the empirically derived model. In this format the appropriate interventions, if present, are coded on a five-point scale for how competently they are performed. If an item is absent for a 'tactical' reason or picked up at a later point then this is identified. The therapist's score on the TIC-O represents a judgement of their performance across the whole session.

3. Timing

The investigation of well-timed enactment resolution interventions refined one item in the TIC and resulted in a checklist (Timing Checklist) which can assist supervisors and therapists to focus on timing interventions so to deliver RRP links more effectively. It can be used in micro-supervision.

The Findings

The TIC-T and TIC-S have been used in further applications of micro-supervision in Manchester (Dawn) and London (Tony). To briefly summarise - the TIC was found to distinguish between 'expert', 'intermediate' and 'novice' CAT therapists; there was an association between therapists' ability to identify enactments and their ability to resolve them as measured by the TIC; for the intermediate and expert therapists scores on the TIC showed an increasing linear trend with supervised practice focusing on the constituent skills but this was not the case for novice therapists.

The TIC-O was applied by pairs of external raters to a total of 52 sessions from the CAT therapies in the micro-supervision phase above. The TIC-O was found to have good inter-rater reliability, that is, the two raters applying the TIC-O to the same sessions reached high agreement on scores of therapist competence; there was evidence for an association between therapist competence in enactment resolution (TIC—O scores) and quality of the therapy alliance (Working Alliance Inventory-Observer scores); there was evidence for a significant association between therapists' ability to recognise enactments in their own work and their ability to resolve them as judged by independent raters.

On the basis of these findings we consider there is support firstly, for the validity of the TIC as a measure of therapist competence in acquiring new CAT specific techniques and applying these without detriment to the therapeutic alliance and secondly, that the TIC is useful as an early predictor of outcome, able to signal training needs with regard to both resolving enactments and recognising them. Therapists in all phases of the work reported their experience of micro-supervision to be challenging but instructive.

The work on timing studied therapeutic process and sought the views of the actual therapists and new therapists on the issue of timing. Adopting a consensus groups methodology, the new therapists reached consensus on what constituted 'well-timed' interventions.

Publications

Finally, we are working on a number of papers for submission for publication based on this work which will be available later in the year.

Where next - Future applications for training

There are three main areas of application: The TIC is available for use in CAT research and we have a further grant to develop it as an audit tool. However, we wish to also incorporate the findings into CAT training and continuing professional development (CPD). Possible applications include:

Micro-supervision: Setting up and running a co-ordinated training programme for CAT supervisors nationally, so that the use of the model of supervised practice and the TIC based training and competency measure can be extended.

In addition, Tony has proposed a less intensive programme of CPD. It could be available to CAT therapists who have completed their CAT practitioner training.

Diagnostic micro-analysis:

Therapists would receive empirical model / TIC based feedback on their therapeutic practice for an early and a late therapy session (audio-taped) for a series of cases.

Supervision in recapitulation of sessions:

Therapists can be instructed to recapitulate the main themes and feel of the session at the end of each session giving an opportunity for empirical model / TIC based work. This could be transcribed and coded on the TIC.

Self-supervision:

In order to make the best use of listening to audio-tapes of sessions, therapists could code their sessions using rating procedures developed through the research work described here.

NB. Ethical Issues

Clients would need to be informed of the use made of the audio-tapes of their CAT sessions, how they will be labelled and stored and what will happen to the tapes at the end of their therapy. If therapists are participating only for training purposes and the TIC scores are not being used in any research capacity nor will they be cited in any document submitted for publication, then ethical approval is not required. If however, data on the TIC is being used for research purposes then ethical approval will be required and this will be sought before training begins and client's will be informed of this.

Dawn Bennett

Full Reference

Bennett, D., 1999. An Update on Microsupervision. Reformulation, ACAT News Summer, p.1.

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