Abstract
Although clinical supervision is widely seen as critical for professional training and for safeguarding and promoting client wellbeing in mental healthcare, it is understudied, particularly in publicly-funded services. In surveys of two large samples of youth mental health service providers (a state sample of providers billing Medicaid [N = 1,057] and a national sample of professional guild members [N = 1,720]), we examined the amount of time providers reported spending in supervision and consultation in a typical workweek, and its covariation with characteristics of providers’ caseloads and work settings. Across both samples, providers reported spending an average of 2–3 hours per week in supervision. Serving higher percentages of low-income clients was associated with significantly more supervision time. Working in private practice was associated with less supervision while community mental health and residential facilities were each associated with more supervision time. The national survey also measured providers’ perceptions of their current supervision. On average, providers endorsed feeling comfortable with the amount of supervision received and supported by their supervisors. However, working with more low-income clients was associated with greater need for supervisor approval and oversight, and with less comfort in the amount of supervision received. Those working with more low-income clientele may benefit from additional supervision time or more focused supervision coverage of the specific needs of clients with low income. More in-depth research on critical processes and content in supervision is a much-needed future direction for supervision research.
Keywords: supervision, community-based settings, low-income, professional development
Clinical supervision (hereafter referred to as “supervision”) is widely viewed as a fundamental component of professional development and quality assurance for mental health (MH) providers. However, beyond the minimum requirements set by state licensure boards, surprisingly little is known about the quantity and perceptions of supervision for MH providers in most practice settings.
In recent years, several professional organizations have pulled together experts to produce detailed supervision guidelines and recommendations for supervision best practices (e.g., Simpson-Southward, Waller, & Hardy, 2017). These guidelines are recommended for clinical training programs and service settings to ensure appropriate training for providers and quality care for clients. Thus far, few of these proposed best practices have an extensive empirical evidence base (Watkins Jr., 2020), though the research that does exist suggests these supervision practices are indeed associated with meaningful clinical outcomes. In a review of the common elements of supervision best practices, Tugendrajch and colleagues (2021) found several common elements of supervision best practices were positively associated with therapist-level (e.g., fidelity, competence, self-efficacy) and client-level (e.g., progress) outcomes. However, supervision elements were typically not examined individually across studies, and not all associations between supervision elements and outcomes were uniformly positive (Tugendrajch et al., 2021). A recent quantitative review of supervision studies found various indicators of supervision quality (e.g., supervisory working alliance, supervisee satisfaction with supervision) were positively associated with several outcomes (e.g., therapeutic relationship, treatment outcomes, client satisfaction) with average effect sizes in the small range (Keum & Wang, 2021).
Several studies in the past decade have also begun to specifically examine the quantity and content of supervision in routine MH services, outside of research studies or graduate training programs. A national survey of 200 directors of youth-serving mental health service organizations found that 90% provided weekly supervision (Schoenwald et al., 2008). A small study of supervision in community mental health centers including 7 supervisors and 12 youth MH service providers found supervision meetings usually occurred weekly or biweekly for just under an hour (ranging from 40 to 100 minutes), and encompassed little training in or discussion of relevant evidence-based practices (EBPs; Accurso, Taylor, & Garland, 2011). In a study of 143 MH service providers employed in community mental health centers participating in an effectiveness trial, Choy-Brown & Stanhope (2018) found that providers received an average of 3.68 hours of supervision per week at baseline, though there was variability across settings and a skewed distribution (the modal length of supervision was just 30 minutes). In addition, just 59.8% of supervision time (2.17 mean hours per week) was spent addressing clinical practice content, and fewer than a third of providers reported supervision consistent with supervision best practices or EBPs. Bailin and colleagues coded 100 community-based supervision meetings of 13 supervisors and 20 providers, and similarly observed little use of supervision best practices and little coverage of EBPs in supervision meetings (Bailin & Bearman, 2020; Bailin, Bearman, & Sale, 2018). Dorsey and colleagues (2017) examined supervision among 56 supervisors and 207 youth MH service providers who participated in a statewide EBP initiative. They found that, while most received individual supervision for at least one hour per week (and many reported additional group and ad-hoc supervision), only about 20 minutes of supervision time was spent on case conceptualization and EBPs for the typical caseload of 30.
Supervision can serve many functions to benefit both the supervisee (e.g., building their self-efficacy as a provider, time to discuss challenging cases) and their clients (e.g., improved case conceptualization, time to practice key clinical skills to maximize treatment impact). However, despite advances in researching supervision in “real-world” settings, there is still much more to understand about how the amount or content of supervision impacts supervisees and clients. Further, while these recent studies provide compelling insight into supervision-as-usual, most relied on relatively small samples, often in the context of an EBP initiative or effectiveness study, making the generalizability to supervision-as-usual outside of these efforts somewhat unclear.
The two studies detailed in this paper describe the quantity of supervision in two large samples of youth-serving MH providers: a state-wide sample of MH service providers billing Medicaid in one midwestern state and a national sample of MH professional guild members. Data available from these provider self-report surveys include the amount of time spent in supervision and consultation in a typical workweek, along with associations between supervision time and several caseload and practice characteristics. Although neither survey focused exclusively on publicly-funded settings, a substantial proportion of respondents served predominantly low-income clients whose services are often funded via public monies (e.g., about half of U.S. youth qualify for their state’s Medicaid or Children’s Health Insurance Program or CHIP; Ronis, Slaunwhite & Malcolm, 2017) and/or work in settings that traditionally receive public funds (e.g., schools, juvenile justice, community mental health; Lourie & Hernandez, 2003). The national survey also assessed providers’ perceptions of the supervision received. As such, the representative national sample offers an opportunity to examine how perceptions of supervision differ for providers who serve predominantly low-income clients compared to those who do not. As a large representative sample of providers working across multiple service sectors, the national survey can also provide a point of comparison with the single state sample of providers billing Medicaid.
Study 1: Survey of Providers Billing State Medicaid
Method
Full details of the study procedures, survey measures, and methodology are available in Cho, Tugendrajch, McMillen, Proctor and Hawley (2022). The information most relevant to the current report is detailed below.
Participants
Participants were 1,057 providers who billed the state Medicaid and CHIP for MH services to youths (3–17) in the past year and responded to a survey regarding their therapy practices. Respondents included counselors (51.84%), social workers (35.48%), psychologists (25.26%), marriage and family therapists (15.23%), psychiatrists (0.76%) and other professionals (5.96%). They had a mean age of 47.76 (SD = 11.56) and the sample was predominantly female (68.31%) and Caucasian (88.93%), with most holding a master’s degree (53.93%). They endorsed working in private individual or group practices (48.91%) more than any other setting. See sample description in Table 1.
Table 1.
Sample Characteristics
| Study 1 (N = 1057) | Study 2 (N = 1720) | |
|---|---|---|
|
| ||
| Therapist Characteristics | ||
| Age (M, SD, Range) | 47.76 (11.56, 25–76) | 52.91 (10.14, 24–84) |
| Sex (N, % Female) | 722, 68.31% | 1096, 63.72% |
| Race/Ethnicity (N, %) | ||
| African American | 76, 7.19% | 47, 2.73% |
| Asian/Pacific Islander | 6, 0.57% | 41, 2.38% |
| Caucasian | 940, 88.93% | 1563, 90.87% |
| Hispanic/Latinx | 10, 0.95% | 47, 2.73% |
| Native American | 10, 0.95% | 12, 0.70% |
| Other | 10, 0.95% | 20, 1.16% |
| Licensure (N, %) | 196, 18.54% | 1059, 61.57% |
| Discipline (N, %) | ||
| Counseling | 548, 51.84% | 449, 26.10% |
| Marriage and Family Therapy | 161, 15.23% | 388, 22.56% |
| Psychology | 267, 25.26% | 536, 31.16% |
| Social Work | 375, 35.48% | 360, 20.93% |
| Psychiatry | 8, 0.76% | 299, 17.38% |
| Other | 63, 5.96% | 65, 3.78% |
| Highest degree (N, %) | ||
| Bachelors | 232, 21.95% | 6, 0.35% |
| Masters | 570, 53.93% | 813, 47.27% |
| Doctoral | 237, 22.4% | 899, 52.27% |
| Casemix Characteristics | ||
| Age (Mean %, SD) | ||
| Preschool/kindergarten (3–6 yrs) | 10.65 (16.28) | 7.12 (12.79) |
| Elementary (7–10 yrs) | 18.77 (16.75) | 15.78 (17.57) |
| Middle/junior high (11–13 yrs) | 20.44 (15.82) | 15.60 (15.19) |
| High school (14–17 yrs) | 26.65 (22.75) | 23.14 (22.25) |
| Adults (18–64 yrs) | 38.04 (27.96) | 35.45 (29.99) |
| Older Adults (65+) | 4.99 (12.18) | 3.04 (7.70) |
| Income (Mean %, SD) | ||
| Below poverty | 39.53 (31.15) | n/a |
| Low-income | 33.03 (23.53) | 34.98 (32.40) |
| Middle income | 23.39 (24.42) | 45.33 (27.20) |
| High income | 4.02 (7.84) | 19.46 (22.36) |
| Race/Ethnicity (Mean %, SD) | ||
| African American | 28.47 (29.79) | 15.99 (20.80) |
| Asian/Pacific Islander | 1.96 (6.25) | 2.82 (6.79) |
| Caucasian | 73.92 (38.18) | 67.18 (28.24) |
| Hispanic/Latinx | 5.58 (8.44) | 11.42 (16.10) |
| Native American | 1.84 (4.00) | 1.77 (7.79) |
| Other | 6.85 (19.71) | 0.86 (5.62) |
| Reimbursement (Mean %, SD) | ||
| Self-pay | 13.69 (41.30) | n/a |
| HMO/insurance | 37.33 (30.99) | n/a |
| Medicaid | 58.82 (33.67) | n/a |
| Other public monies | 23.56 (30.82) | n/a |
Measures
Providers, Clients and Practice Characteristics.
Providers reported demographic information, professional background, clientele characteristics, and their current work setting and activities. Related to supervision, providers reported the number of hours they typically work each week and the percentage of their current workweek spent attending or providing supervision or peer consultation. We multiplied hours worked per week by the percent of time in supervision or consultation to estimate amount of supervision. Providers in Study 1 also completed a question about the proportion of their caseload whose services were reimbursed by different funding sources. See Table 1.
Procedures
All 3,084 MH therapists who had submitted claims in the previous year to the state Medicaid and CHIP were surveyed by retrieving contact information from the publicly available listing (https://apps.dss.mo.gov/fmsMedicaidProviderSearch/). The state’s Medicaid program funds coverage for youth in families below 150% of the federal poverty line and CHIP provides low-cost subsidized coverage for youth in families up to 305% of the federal poverty line (Brooks, Wagnerman, Artiga, Cornachione, & Ubri, 2017). Excluding 364 surveys returned as undeliverable, the adjusted response rate was 49.56% (n = 1,348 respondents). Of these, 1,057 reported providing youth MH services in the past year.
Data Analysis
Descriptive statistics were calculated for all variables. A correlation matrix was generated to explore associations between the following variables: % of workweek in supervision or consultation, % of cases that are below poverty or low-income (combined), % of cases reimbursed with Medicaid or other public monies, and work setting.
Results
In Study 1 (state Medicaid survey), providers reported spending an average of 3.08 hours (SD = 4.06, range: 0.00 to 25.00) or 8.72% (SD = 11.67) of their workweek in supervision or consultation. On average, providers working in jails or correctional facilities reported the most time spent in supervision (M = 6.05 hours), while those in private practice (M = 3.20 hours) and day treatment facilities or partial day hospitals (M = 2.68 hours) reported the least time spent in supervision (See Table 2).
Table 2.
Quantity of Supervision across Work Settings
| Study 1 (N = 866) | Study 2 (N = 1678) | |||||
|---|---|---|---|---|---|---|
| Work Setting | N (%) | M (SD) Hours of Supervision | M% (SD) of Workweek Spent in Supervision | N (%) | M (SD) Hours of Supervision | M% (SD) of Workweek Spent in Supervision |
|
| ||||||
| Primary or secondary school | 77 (7.28%) | 2.83 (3.60) | 6.67 (6.88) | 206 (11.98%) | 3.95 (4.86) | 9.14 (10.57) |
| College, university, medical, professional school | 50 (4.73%) | 3.60 (4.56) | 8.61 (9.37) | 169 (9.83%) | 5.69 (5.98) | 13.16 (13.71)) |
| Outpatient clinic or community mental health center | 264 (24.98%) | 3.64 (4.83) | 9.57 (12.52) | 300 (17.44%) | 3.70 (4.84) | 9.52 (11.65) |
| Day treatment facility or partial day hospital | 23 (2.18%) | 2.68 (2.92) | 6.35 (5.65) | 27 (1.57%) | 3.69 (5.59) | 10.56 (14.67) |
| Residential treatment facility or group home | 119 (11.26%) | 5.13 (5.09) | 12.93 (14.03) | 64 (3.72%) | 7.10 (7.49) | 15.98 (15.76) |
| Inpatient hospital or medical clinic | 73 (6.91%) | 3.27 (4.67) | 7.32 (8.35) | 93 (5.41%) | 4.77 (4.81) | 10.73 (11.51) |
| Jail or correctional facility | 13 (1.23%) | 6.05 (5.74) | 10.75 (9.25) | n/a | n/a | n/a |
| Private individual or group practice | 517 (48.91%) | 3.20 (4.14) | 5.62 (5.55) | 1032 (60.00%) | 1.84 (3.00) | 4.82 (7.05) |
| HMO, PPO, or other managed care organization | 13 (1.23%) | 4.77 (8.33) | 10.13 (16.37) | 26 (1.51%) | 2.55 (3.33) | 7.64 (8.50) |
| Other work setting | 74 (7.00%) | 2.75 (2.57) | 8.77 (11.51) | 244 (14.19%) | 3.88 (5.31) | 10.17 (12.96) |
| Across all work settings | 3.08 (4.06) | 8.72 (11.67) | 2.82 (4.29) | 7.22 (10.23) | ||
Note. Providers could endorse multiple employment settings, so the sum is greater than 100%.
Supervision quantity was positively associated with proportion of cases below poverty or low-income (r = .15, p < .001), and with proportion of cases reimbursed by Medicaid or other public monies (r = .16, p < .001). Not surprisingly, proportion of cases below poverty or low income and proportion of cases reimbursed by public funds were highly correlated (r = .59, p < .001). Supervision quantity was also associated with work setting, with percentage of workweek in supervision positively associated with working in outpatient community mental health (r = .10, p = .016) and in residential or group homes (r = .22, p < .001), and negatively associated with working in private practice (r = −.27, p < .001). Percentage of workweek in supervision was also associated with discipline, with supervision quantity positively associated with social work discipline (r = .12, p = .003) and negatively associated with psychology discipline (r = −.08, p = .040). Percentage of workweek spent in supervision was unassociated with licensure status. See Table 4 for all correlations between supervision quantity and practice characteristics.
Table 4.
Correlations among Supervision Quantity and Practice Characteristics
| Caseload and Setting | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||||||
| SUP | LINC | MOH | SCH | UNI | CMH | PRI | DAY | RES | INP | MAN | JAL | OTH | ||
|
| ||||||||||||||
| Study 1 SUP | r | 1 | .154** | .163** | −0.034 | 0.018 | .095* | −.265** | −0.028 | .224** | −0.014 | 0.026 | 0.035 | 0.029 |
| p | 0.001 | 0.001 | 0.410 | 0.649 | 0.016 | 0.001 | 0.495 | 0.001 | 0.734 | 0.526 | 0.399 | 0.480 | ||
| Study 2 SUP | r | 1 | .215** | − | .070** | .190** | .104** | −.287** | 0.038 | .171** | .082** | 0.005 | − | .117** |
| p | 0.001 | − | 0.004 | 0.001 | 0.001 | 0.001 | 0.118 | 0.001 | 0.001 | 0.833 | − | 0.001 | ||
|
| ||||||||||||||
| Licensure and Discipline | ||||||||||||||
|
|
||||||||||||||
| SUP | LIS | COU | MFT | SCW | PSY | PYC | OTD | |||||||
|
|
||||||||||||||
| Study 1 SUP | r | 1 | 0.059 | −0.026 | −0.055 | .118** | −.081* | −0.058 | −0.007 | |||||
| p | 0.111 | 0.496 | 0.169 | 0.003 | 0.040 | 0.154 | 0.861 | |||||||
| Study 2 SUP | r | 1 | −0.025 | −.061* | 0.026 | −0.026 | .076** | 0.006 | 0.026 | |||||
| p | 0.407 | 0.013 | 0.281 | 0.294 | 0.002 | 0.813 | 0.289 | |||||||
|
|
||||||||||||||
Notes: SUP is % of workweek in supervision or consultation, LINC is % of low-income and below poverty cases, MOH is % reimbursement by Medicaid or other public monies, SCH is primary or secondary work setting, UNI is higher education setting, COM is outpatient or community mental health clinic, PRI is private group or individual, DAY is day treatment, RES is residential, INP is inpatient, MAN is managed care, JAL is jail or correctional setting, OTH is other work setting. LIS is licensure status, COU is counseling, MFT is marriage/family therapy, SCW is social work, PSY is psychology, PYC is psychiatry, OTD is other discipline.
Study 2: National Survey of Professional Guild Members
Method
Full details of the study procedures, survey measure and methodology are available in Cho, Wood, Taylor, Hausman, Andrews and Hawley (2019).
Participants
Participants were 1,720 youth-serving MH provider members of professional guilds, including psychologists (31.16%), counselors (26.10%), marriage and family therapists (22.56%), social workers (20.93%), psychiatrists (17.38%), and other professionals (3.78%), and who responded to a survey regarding their professional practices. Respondents had a mean age of 52.91 (SD= = 10.14), were predominantly female (63.72%) and Caucasian (90.72%), with most holding a doctoral degree (52.27%). Providers endorsed working in private individual or group practices (60.00%) more than any other setting. See sample description in Table 1.
Measures
Providers, Clients and Practice Characteristics.
Participants in Study 2 completed the same questions about themselves, their clients, their work setting and work activities as participants in Study 1, except that there was no option to distinguish below poverty versus low-income, no option to indicate working in a jail or correctional setting (beyond endorsing “other setting”), and no question assessing the percent of cases reimbursed via Medicaid or other public monies.
Perceptions of Supervision.
All Study 2 participants answered two items regarding their perception of the availability of supervision and consultation. Providers who worked in an organization (i.e., did not work exclusively in individual private practice) also reported on their experiences working in their agency or organization (n = 807). These items, including 8 items on providers’ perceptions about supervisors’ support for provider practices and decision-making, were adapted from the Children’s Services Organizational Culture Survey which assessed for youth mental health service organizations’ culture and climate (Glisson & James, 2002). Items were rated on a 5-point scale from “strongly disagree” to “strongly agree” (see Table 3).
Table 3.
Study 2 Provider Perceptions of Supervisory Practices
| Item | M (SD, range) |
|---|---|
|
| |
| I have to ask a supervisor before I do almost anything (ASK) | 1.77 (0.90, 1–5) |
| My supervisors are unsupportive of my attempts to learn or try new practices (UNSP) | 1.90 (0.91, 1–5) |
| At my work, there can be little action unless a supervisor approves the decision (ACT) | 2.35 (1.14, 1–5) |
| My supervisors require that I use particular measures or treatments (REQ) | 2.38 (1.03, 1–5) |
| I have little opportunity for ongoing clinical supervision or consultation (LOPP) | 2.62 (1.08, 1–5) |
| I regularly talk with my supervisor about new treatment strategies relevant to my work (TALK) | 3.00 (1.16, 1–5) |
| I feel comfortable with the amount of professional consultation and supervision I receive (COMF) | 3.57 (0.98, 1–5) |
| My supervisors support me in providing the best possible care (SUPP) | 3.98 (0.95, 1–5) |
Note. Items were rated on 5-point scale from 1=strongly disagree to 5=strongly agree and were only rated by Study 2 providers who worked in an organization or group practice (i.e., no individual private practice; n = 807).
Procedures
The survey was sent to 5,000 providers randomly sampled from membership rosters of the largest national practice guilds for youth-serving MH professionals (1000 from each organization): the American Counseling Association (ACA), the American Association for Marriage and Family Therapy (AAMFT), the American Psychological Association (APA), the American Academy of Adolescent and Child Psychiatry, and the National Association of Social Workers (NASW). Some 347 (6.94%) surveys were returned undeliverable. Of the remaining 4,653 likely delivered, 2,863 (61.53%) surveys were returned complete, 151 (3.25%) participants declined to participate, and 1,639 (35.22%) did not respond. Thus, the total adjusted response rate was 64.88%. Response rates differed significantly by guild, χ2 (4, N = 5,000) = 253.40, p < .001. A series of post-hoc comparisons using a Bonferroni corrected p value of .005 indicated that psychiatrists responded at a lower rate and social workers at a higher rate than other providers.
Data Analysis
As in Study 1, descriptive statistics were calculated for all variables, including each item assessing providers’ perceptions of supervision. A correlation matrix was generated to explore associations between the following variables: % of workweek in supervision or consultation, % of cases that are low-income, and work setting. An estimate of the amount of time that providers spent in supervision per week was also calculated in the same manner as for Study 1.
Results
In the national guild sample, providers reported spending an average of 2.82 hours (SD = 4.29) or 7.22% (SD = 10.23) of each workweek in supervision or consultation. On average, providers working in reported the most time spent in supervision (M = 7.10 hours), while those in private practice (M = 1.84 hours) and managed care settings (M = 2.55 hours) reported the least time in supervision (See Table 2).
Regarding perceptions of supervision, providers were neutral or agreed, on average, that they regularly talk with supervisors, are comfortable with the amount of supervision and consultation they received, and feel supported by supervisors (see Table 3). Providers were neutral or disagreed with the negatively worded items, including supervisors being unsupportive of attempts to learn or try new strategies, being unable to act without supervisor approval, being required to use specific practices, and having little opportunity for ongoing supervision and consultation (see Table 3).
Significant correlations between percent of workweek in supervision and practice characteristics were as follows and displayed in Table 4. Like Study 1, more supervision was associated with greater proportion of low-income cases (r = .22, p < .001). Like Study 1, working in private practice was associated with less supervision (r = −.29, p < .001), while working in community mental health centers (r = .10, p < .001) and residential treatment facilities or group homes (r = .17, p < .001) were associated with more supervision. Working in primary or secondary school (r = .07, p = .004); college, university, medical, or professional school (r = .19, p < .001); and inpatient hospital or medical clinic (r = .082, p = .001) were also associated with more supervision for Study 2 only. In contrast to Study 1, psychology discipline was positively associated with supervision (r = .08, p = .002) in Study 2. Counseling discipline was negatively associated with supervision (r = −.06, p = .012). No other association were significant (see Table 4).
Correlations between percent of workweek spent in supervision and provider perceptions of supervision are displayed in Table 5. Supervision quantity was negatively associated with having little opportunity for supervision or consultation (r = −.15, p < .001) and positively associated with regularly talking with supervisor about new relevant treatment strategies (r = .07, p = .040) and with comfort with amount of supervision (r = .06, p = .016). Strikingly, proportion of low income cases was positively associated with required supervisor approval for decisions (r = .16, p < .001), with supervisors requiring specific treatments or measures (r = .14, p < .001), and with needing to ask for supervisor permission (r = .12, p = .001), and was negatively associated with comfort with the amount of supervision or consultation received (r = −.10, p < .001). There were also significant associations between discipline and perceptions of supervision. Psychology discipline was negatively associated with having little opportunity for ongoing supervision or consultation (r = −.06, p = .014) and positively associated with comfort with amount of supervision (r = .07, p = .002), while the opposite associations were found with counseling discipline (r = .06, p = .023) and (r = −.06, p = .013). Counseling discipline was also positively associated with regularly talking with supervisor about new relevant treatment strategies (r = .07, p = .045), while psychology discipline was negatively associated with this perception (r = −.12, p = .003). Finally, social work discipline was associated with higher ratings of being unsupported by supervisors (r = .09, p = .011). All correlations between supervision quantity and practice characteristics are presented in Table 5.
Table 5.
Study 2 Correlations among Supervision Perceptions and Practice Characteristics
| ASK | UNSP | ACT | REQ | LOPP | TALK | COMF | SUPP | ||
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| SUP | r | 0.026 | 0.006 | 0.055 | −0.004 | −.146** | .073* | .059* | −0.008 |
| p | 0.458 | 0.872 | 0.123 | 0.903 | 0.001 | 0.040 | 0.016 | 0.822 | |
| LINC | r | .115** | 0.025 | .160** | .137** | 0.048 | 0.031 | −.098** | 0.003 |
| p | 0.001 | 0.491 | 0.001 | 0.001 | 0.050 | 0.382 | 0.001 | 0.934 | |
| LIS | r | 0.034 | −0.002 | 0.001 | 0.029 | −0.025 | −0.003 | 0.018 | −0.055 |
| p | 0.418 | 0.959 | 0.972 | 0.486 | 0.403 | 0.950 | 0.547 | 0.187 | |
| COU | r | 0.052 | 0.030 | −0.011 | −0.043 | .056* | .071* | −.061* | 0.056 |
| p | 0.140 | 0.392 | 0.762 | 0.230 | 0.023 | 0.045 | 0.013 | 0.111 | |
| MFT | r | 0.001 | 0.062 | −0.008 | 0.052 | 0.012 | 0.001 | −0.026 | −0.032 |
| p | 0.986 | 0.081 | 0.811 | 0.142 | 0.630 | 0.978 | 0.281 | 0.371 | |
| SCW | r | 0.054 | .090* | 0.033 | 0.055 | −0.019 | −0.016 | −0.026 | −0.004 |
| p | 0.126 | 0.011 | 0.350 | 0.119 | 0.447 | 0.647 | 0.294 | 0.906 | |
| PSY | r | −0.048 | −0.036 | −0.032 | −0.018 | −.060* | −.105** | .076** | −0.048 |
| p | 0.176 | 0.306 | 0.365 | 0.615 | 0.014 | 0.003 | 0.002 | 0.174 | |
| PYC | r | −0.066 | −0.055 | 0.038 | −0.008 | 0.029 | 0.051 | 0.006 | −0.015 |
| p | 0.063 | 0.117 | 0.283 | 0.816 | 0.235 | 0.152 | 0.813 | 0.677 | |
| OTD | r | 0.041 | 0.056 | 0.005 | 0.036 | 0.043 | −0.037 | 0.026 | −0.027 |
| p | 0.249 | 0.111 | 0.878 | 0.309 | 0.076 | 0.296 | 0.289 | 0.450 | |
Notes: SUP is % of work spent in supervision or consultation, LINC is % of low-income cases, COU is counseling, MFT is marriage/family therapy, SCW is social work, PSY is psychology, PYC is psychiatry, OTD is other discipline. ASK is I have to ask a supervisor before I do almost anything, UNSP is My supervisors are unsupportive of my attempts to learn or try new practices, ACT is At my work, there can be little action unless a supervisor approves the decision, REQ is My supervisors require that I use particular measures or treatments, LOPP is I have little opportunity for ongoing clinical supervision or consultation, TALK is I regularly talk with my supervisor about new treatment strategies relevant to my work, COMF is I feel comfortable with the amount of professional consultation and supervision I receive, SUPP is My supervisors support me in providing the best care possible.
Discussion
Based on two large surveys of youth-serving MH providers, we found that providers reported an average of 2–3 hours per week of supervision or consultation each week, with some variability across work settings. This suggests that mental health services providers in routine service settings usually have access to regular, ongoing supervision, but may spend more or less time in supervision and consultation depending on work setting (Choy-Brown & Stanhope, 2018). For example, in both surveys, private practice was negatively associated with supervision quantity while community mental health and residential facilities were each positively associated with supervision quantity. We also found in both surveys that higher proportion of low-income clients was associated with spending more time in supervision each week (and, for Study 1, those with more clients reimbursed by public monies showed a similar positive association with supervision quantity). Given the increased struggles and high needs of clients living near or below poverty (e.g., Ehrenreich-May et al., 2011), this may reflect that supervision may require more time to address multiple risk factors and challenging life events during the course of treatment (Chorpita et al., 2014).
In the national survey sample, we were also able to evaluate provider perceptions of supervision. When providers were asked if they talked regularly with supervisors about practices, felt comfortable with the amount of supervision and consultation received, and felt supported by supervisors to provide the best care possible, the mean response from providers fell between neutral to agree. While most respondents fell short of disagreeing with those statements, there is clearly room for improvement in helping providers feel adequately supported by the supervision received. Not surprisingly, supervision quantity was positively associated with regularly talking with supervisions about new practices and feeling comfortable with the amount of supervision and consultation received and negatively associated with reporting little opportunity for supervision or consultation.
Importantly, serving a higher proportion of low-income clients was associated with feeling less comfortable with the amount of supervision received. Having higher percentages of low-income clients was also associated with higher ratings of (a) having to ask supervisor before doing anything, (b) being unable to act without supervisor approval, and (c) being required to use specific measures or treatments. Taken together, these findings suggest that although providers serving low-income clients may be receiving more supervision on average, they still may need more or different supervisory support to feel comfortable (e.g., increased support for agency requirements; increased attention to case management or basic needs of clients). The associations with needing to follow supervisor directives and agency requirements may also reflect that those working with more low-income clients are likely also working within publicly-funded services that may hold additional requirements than private pay or private insurance. Across disciplines, there were stark differences between providers from counseling and psychology, suggesting that those in psychology may feel more comfortable with the amount of supervision received, but are less likely to discuss new treatment strategies, whereas counseling providers reported the opposite.
While we believe these studies add to the growing evidence base for clinical supervision, there are certainly limitations. First, both surveys use provider-reported data only, with no corroboration from supervisors. Nonetheless, provider report of supervision has often been used to determine perceptions of supervision (e.g., Spence et al., 2001) and the anonymous surveys asked about current supervision to reduce biases and problems with recall. Second, providers report combined supervision and consultation, which are distinct constructs worthy of separate examination. Third, although we examined correlations between supervision quantity and several practice characteristics beyond work setting (e.g., discipline, licensure status), we have not fully explored variability in supervision quantity or perceptions within work settings. Fourth, the surveys did not evaluate the presence or perception of specific supervision techniques. As such, we are not able to extrapolate our findings to specific supervision practices (e.g., creating a supervision contract, focusing on multicultural competence). We are also only able to draw correlational, not causal relationships between amount of supervision received or provided, perceptions of supervision, and practice characteristics. Finally, recruitment for the national sample was not focused on providers of publicly-funded services and national sample providers were not asked to report reimbursement sources. Still, given the large sample sizes of these two surveys of mental health service providers, we hope these findings help elucidate the quantity and perceptions of supervision in youth mental health service settings.
Clinical Recommendations
Our findings lend themselves to a number of practical recommendations for improving routine clinical supervision in publicly-funded settings. Of note, such efforts to improve routine supervision will need to overcome likely barriers to changing the structure of supervision meetings and/or the content covered in supervision, including the lack of physical and temporal resources (see Sewell, 2021). The relationship between serving more lower income clients and increased time for supervision suggests that supervisors may want to consider client income and resources when allocating supervision time, as therapist may need to assist with case management (e.g., connecting with additional health and social services) in addition to therapeutic services. Additionally, given greater requirements to use specific measures or treatments and to seek and obtain supervisor approval for decisions when working with more low-income clients, supervisors may want to prioritize collaborating with supervisee providers to promote their self-efficacy and autonomy in providing treatment. We have focused heavily on the quantity of supervision provided across settings but, regardless of time allotted for supervision each week, it is critical to consider how to maximize supervision time in order to support providers in meeting the multifaceted needs of their clients. We hope providers and supervisors will consider these recommendations to support a dialogue on how to best support providers of publicly-funded mental health services.
Impact Statement.
In two large provider samples, providers reported spending 2–3 hours per week in supervision on average, with those serving more low-income clients reporting more supervision time. Providers also reported feeling generally comfortable with the amount of supervision they received, but less so when they served more low-income clients. This adds to the sparse literature describing supervision in usual care settings, and provides context for those working to improve supervision for publicly-funded services.
Acknowledgments
Data collection for Survey 1 was supported by NIMH P30 MH068579 to Enola Proctor and Survey 2 was supported by NIMH R03 MH077752 to Kristin Hawley. No presentations or publications have reported on the supervision information reported here, and this manuscript is not under consideration elsewhere. Other data from Survey 1 have been published in Psychiatric Services and presented at the Association of Behavioral and Cognitive Therapies annual conventions (2017, 2020) and the Annual Research and Policy Conference on Child and Adolescent Behavioral Health (2018). Other data from Survey 2 have been published in Assessment, Administration and Policy in Mental Health and Mental Health Services Research, Journal of Clinical Child and Adolescent Psychology, and Psychiatric Services. The authors have no potential conflicts of interest to disclose.
Contributor Information
Siena K. Tugendrajch, University of Michigan, Ann Arbor
Evelyn Cho, Harvard University
Jack H. Andrews, University of Missouri, Columbia
Kristin M. Hawley, University of Missouri, Columbia
References
- Aarons GA, Glisson C, Hoagwood K, Kelleher K, Landsverk J, & Cafri G (2010). Psychometric properties and US national norms of the Evidence-Based Practice Attitude Scale (EBPAS). Psychological Assessment, 22(2), 356. 10.1037/a0019188 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Accurso EC, Taylor RM, & Garland AF (2011). Evidence-based practices addressed in community-based children’s mental health clinical supervision. Training and Education in Professional Psychology, 5(2), 88. 10.1037/a0023537 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bailin A, & Bearman SK (2020). Coverage of EBT practices in routine clinical supervision for youth: how much overlap with the evidence base?. The Clinical Supervisor, 1–20. 10.1080/07325223.2020.1844107 [DOI] [Google Scholar]
- Bailin A, Bearman SK, & Sale R (2018). Clinical supervision of mental health professionals serving youth: Format and microskills. Administration and Policy in Mental Health and Mental Health Services Research, 45(5), 800–812. 10.1007/s10488-018-0865-y [DOI] [PubMed] [Google Scholar]
- Brooks T, Wagnerman K, Artiga S, Cornachione E, & Ubri P (2017). Medicaid and CHIP eligibility, enrollment, renewal, and cost sharing policies as of January 2017: Findings from a 50-state survey. Washington: Kaiser Family Foundation. Retrieved from: https://www.kff.org/medicaid/ [Google Scholar]
- Cho E, Tugendrajch SK, McMillen JC, Proctor EK, & Hawley KM (2022). Use of evidence-based practices under treatment-as-usual and evidence-based practice initiatives. Administration and Policy in Mental Health and Mental Health Services Research, 49, 757–784. 10.1007/s10488-022-01197-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cho E, Wood PK, Taylor EK, Hausman EM, Andrews JH, & Hawley KM (2019). Evidence-based treatment strategies in youth mental health services: Results from a national survey of providers. Administration and Policy in Mental Health and Mental Health Services Research, 46(1), 71–81. 10.1007/s10488-018-0896-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Chorpita BF, Korathu-Larson P, Knowles LM, & Guan K (2014). Emergent life events and their impact on service delivery: Should we expect the unexpected?. Professional Psychology: Research and Practice, 45(5), 387. 10.1037/a0037746 [DOI] [Google Scholar]
- Choy-Brown M, Stanhope V The availability of supervision in routine mental health care. Clinical Social Work Journal, 46, 271–280 (2018). 10.1007/s10615-018-0687-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Dillman DA (2000). Mail and internet surveys: The tailored design method. New York: Wiley. [Google Scholar]
- Dorsey S, Pullmann MD, Kerns SE, Jungbluth N, Meza R, Thompson K, & Berliner L (2017). The juggling act of supervision in community mental health: Implications for supporting evidence-based treatment. Administration and Policy in Mental Health and Mental Health Services Research, 44(6), 838–852. 10.1007/s10488-017-0796-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ehrenreich-May J, Southam-Gerow MA, Hourigan SE, Wright LR, Pincus DB, & Weisz JR (2011). Characteristics of anxious and depressed youth seen in two different clinical contexts. Administration and Policy in Mental Health and Mental Health Services Research, 38(5), 398–411. 10.1007/s10488-010-0328-6 [DOI] [PubMed] [Google Scholar]
- Keum BT, & Wang L (2020). Supervision and psychotherapy process and outcome: A meta-analytic review. Translational Issues in Psychological Science. 10.1037/tps0000272 [DOI] [Google Scholar]
- Lourie IS, & Hernandez M (2003). A historical perspective on national child mental health policy. Journal of Emotional and Behavioral Disorders, 11(1), 5–9. [Google Scholar]
- Paris M, & Hoge MA (2010). Burnout in the mental health workforce: A review. The Journal of Behavioral Health Services & Research, 37(4), 519–528. 10.1007/s11414-009-9202-2 [DOI] [PubMed] [Google Scholar]
- Ronis ST, Slaunwhite AK, & Malcolm KE (2017). Comparing strategies for providing child and youth mental health care services in Canada, the United States and The Netherlands. Administration and Policy in Mental Health and Mental Health Services Research, 44, 955–966. 10.1007/s10488-017-0808-z [DOI] [PubMed] [Google Scholar]
- Rupert PA, & Morgan DJ (2005). Work setting and burnout among professional psychologists. Professional Psychology: Research and Practice, 36(5), 544–550. 10.1037/0735-7028.36.5.544 [DOI] [Google Scholar]
- Sewell KM (2021). Supporting children’s mental health evidence-based interventions: feasibility study of a workplace-based supervision model. The Clinical Supervisor, 40(1), 134–157. 10.1080/07325223.2021.1905126 [DOI] [Google Scholar]
- Simpson-Southward C, Waller G, & Hardy GE (2017). How do we know what makes for “best practice” in clinical supervision for psychological therapists? A content analysis of supervisory models and approaches. Clinical Psychology & Psychotherapy, 24(6), 1228–1245. 10.1002/cpp.2084 [DOI] [PubMed] [Google Scholar]
- Spence SH, Wilson J, Kavanagh D, Strong J, & Worrall L (2001). Clinical supervision in four mental health professions: A review of the evidence. Behaviour Change, 18(3), 135–155. 10.1375/bech.18.3.135 [DOI] [Google Scholar]
- Tugendrajch SK, Sheerin KM, Andrews JH, Reimers R, Marriott BR, Cho E, & Hawley KM (2021). What is the evidence for supervision best practices?. The Clinical Supervisor, 40(1), 68–87. 10.1080/07325223.2021.1887785 [DOI] [Google Scholar]
- Watkins CE Jr. (2020). What do clinical supervision research reviews tell us? Surveying the last 25 years. Counselling and Psychotherapy Research, 20(2), 190–208. 10.1002/capr.12287 [DOI] [Google Scholar]