“Being part of a community – that has been the good practice ”: A qualitative study of family therapy students’ experiences with live supervision

Introduction

Live supervision has been a hallmark of couple and family therapy (CFT) training and practice, distinguishing it from other forms of psychotherapy (Castronova et al., 2020; Maaß et al., 2022). In this context, live supervision means that the supervisor is present in the room or behind a mirror, allowing direct communication with therapists during client sessions. This live supervision is a unique alternative to retrospective supervision based on therapists’ narratives or video analyses, and the immediate feedback opportunity is considered live supervision’s greatest strength (Bartle-Haring et al., 2009; Bernard and Goodyear, 2019). The research literature also highlights how live supervision is both significant and sometimes a prerequisite for acquiring therapeutic skills (Wilson et al., 2016). For example, McGoldrick (1982) argues that supervision in the early stages of training is most effectively oriented toward live supervision, as this format allows for immediate pedagogical intervention and situated skill development. At the same time, she cautions that live supervision carries the risk of inviting overly active supervisory involvement, potentially limiting trainees’ opportunities to develop sufficient autonomy if interventions occur too early or too frequently.

In family therapy training, students learn various theories and methods, practice different techniques, and acquire therapeutic competencies. They also reflect on their own experiences, values, and attitudes with supervision playing a crucial role (Cuccurullo and Visone, 2021; Vetere and Sheehan, 2017). Live supervision can be seen as a process in which a qualified therapist guides the trainee’s professional development and socialization into becoming a professional family therapist (Todd and Storm, 2014). This also is reflected in the aspect of the supervisor having the ultimate responsibility for ensuring an ethical and professional practice that meets the clients’ needs (Maaß et al., 2022) and suggests an asymmetrical relationship between trainee and supervisor. However, in systemic family therapy training inspired by postmodern perspectives, this notion might be challenged by a collaborative, non-hierarchical approach to both therapy and training (Nanouri et al., 2022). By sharing the same therapy sessions, the supervisor and therapists become personally involved, reflecting on similarities and differences in thoughts, sensations, and intuitions, forming a “therapeutic we” (Cuccurullo and Visone, 2021). There is evidence that live supervision impacts students’ perceptions of therapy progress but less is known about trainee growth and the effectiveness of the therapy (Castronova et al., 2020). Maaß et al. (2022) found in a systematic review of 138 qualitative and quantitative studies of live supervision in psychotherapy training that 87% reported positive effects. Highlighted factors include the development of therapeutic skills, increased competence, satisfaction with the therapy process, and integration of learning through the supervision process. Furthermore, in a meta-synthesis of 15 qualitative studies (3 within couple and family therapy) by Wilson et al. (2016) on students’ experiences with live supervision during training, the authors conclude that live supervision provides many valuable learning opportunities and appears to be a resource for students’ development. A distinct finding is how students experience increased competence and how the supervisor adds a quality that benefits both students and clients. At the same time, the learning outcome is clearly linked to the relationship between the student and the supervisor. However, the authors also highlight how aspects related to power dynamics and fear of negative feedback can cause students to lose confidence and trust in their own development. Furthermore, in the systematic review of Maaß et al. (2022), negative effects were found in 43% of the studies. The findings describe how those being supervised sometimes felt a lack of competence in the conversations, experienced performance anxiety, or felt overwhelmed in the situation. The asymmetrical nature of the trainee – supervisor relationship mentioned above might negatively affect the relationship between the supervisor and the supervisees. This aligns with research indicating that supervision can also have harmful effects (Ellis, 2017; Todd and Storm, 2014; Wilson et al., 2016). Harmful supervision can be understood as an experience where psychological or emotional difficulties arise for the supervisee during the supervision. While characteristics and behaviours of both parties can contribute to relationship problems, it is ultimately the supervisor’s responsibility to address and repair ruptures in the supervision relationship (Todd and Storm, 2014). Ammirati and Kaslow (2017) emphasize that the first crucial step in preventing negative effects is increasing awareness of potential harm in all forms of supervision and addressing this issue in both research and practice.

An important step in this regard, when it comes to live supervision during family therapy training, is to gain deeper insights into students’ experiences. Much has been described about supervision from the perspectives of theory, practice, and research. However, as Wong (1997) point out, it is primarily supervisor perspectives that are highlighted. Although there is more current research on the perspectives of supervised students, more knowledge is needed about student experiences of live supervision in family therapy training. In the meta-synthesis by Wilson et al. (2016) only three of the studies came from the field of family therapy. Furthermore, Maaß et al. (2022) point out that in recent years, studies of live supervision in family therapy (including family therapy training) are fewer and increasingly encompass other therapeutic approaches, such as cognitive therapy. Thus, the overarching aim of this study is to explore how students in family therapy experience live supervision in their training and the significance it might have for their development as family therapists.

Method

This study is a qualitative focus group study. The use of focus groups for gathering data appeared to be a natural choice and in accordance with informants’ experiences with reflection-oriented practice in teams (Acocella and Cataldi, 2021). The epistemological location of the study is within a social constructionist framework that assumes that social reality is negotiated through language, relations and culture (Gergen, 2015a). This accords with a qualitative research tradition supported by social constructionist theories about knowledge development as co-creation between informants and researchers (Malterud, 2017). These ideas also accord with our sociocultural view of learning by providing scientific accounts of how people think and learn (McNamee and Moscheta, 2015). In this lies also a wish to understand how meaning constructions around significant learning are presented and promoted through language.

Results

In the following section, we present the results of our analysis, which generated three main themes: (1) Frames for practice provide space in which to train and experiment, (2) Live supervision both elevates and shuts down, and (3) The relational promotes connection and cooperation. These themes and their sub-themes are further described and illustrated with quotations from the informants (referenced by focus group number and line number). The themes and sub-themes are presented in Table 1.

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Table 1.

Themes and sub-themes.

Frames for practice provide space in which to train and experiment	Live supervision both elevates and shuts down	The relational promotes connection and collaboration
The significance of a systemic context	The presence of the supervisor provides freedom	We discover relationship between theory and practice
The significance of a defined student practice	The supervisor’s position limits and bounds	Together we create a multiverse of ideas and possibilities

Discussion

In this study, we have explored how master students in Family Therapy experience live supervision in a practice and supervisory arena connected to the training program. Generally, the study suggests that this is an organization that provides students with a good space for learning about family therapy therapeutic work and development of the therapist role. Different factors contribute as parts of a whole, but we feel the study clarifies the significance of live supervision constructed as a cooperative model in which all team members are active in encounters with clients.

One theme that was generated in the analysis is how frames for practice provide space in which to train and experiment. For the students, clear frameworks are important, in which the limited experience of therapists is highlighted, and the systemic approach is implicit. A defined systemic context provides students with both proximity to the discipline and an arena in which to try it out. At the same time, the students show a distinct ethical awareness about prioritizing what clients require ahead of their own needs. Clients can be in great crisis, or disputes between parties can escalate to a level which inexperienced students cannot manage, and a dilemma arises when they do not feel they can deliver what is needed. The supervisor can then reduce this dilemma through offering both action and their knowledge and support the students by structuring an intervention in the moment. This reflects other studies (see Charlés et al., 2005; Falke et al., 2015), that show how the supervisor can play a dynamic role in the conversations. One of the strengths of live supervision is that it contributes to ensuring clients are served by and derive benefit from the therapeutic process (Bartle-Haring et al., 2009). Ethical questions around therapeutic factors are also an important element in themselves, among which those related to how the supervisor appears as a professional role model for the students. How the supervisor approaches ethical dilemmas, acknowledges contributions and perspectives, collaborates with students and behaves toward clients can influence students more than what the supervisor says (Falender, 2018; Wilson et al., 2016).

As described in our introduction, one of the most distinct aspects of educational supervision is that the supervisor is responsible for the student’s professional development. The theme the presence of the supervisor provides freedom, depicts how multivoiced teamwork contributes to this professional development, both in terms of therapeutic skills and the role of family therapist. A prerequisite is that the supervisory alliance is experienced as a secure relation in which the supervisor supports students in finding their own answers and inspires them in exploring their own roles as therapists (Moon, 2021). Systemic supervision must begin with students’ understandings and action repertoires, must create meaning, and must move them on from what they already know to that which they can come to know.

While the students emphasize the great generosity of the supervisor and the freedom to try things out themselves, it is important to highlight how the supervisors position also limits and bounds. Students’ knowledge of the supervisor as teacher and professional can also limit their use of ideas and interventions in the conversations. Castronova et al. (2020) describes how the supervisor’s position within an educational clinic can appear unclear and characterized by ambiguous relationships. The supervisory context becomes unclear, and students can feel the stress and pressure of having to succeed on several levels simultaneously to satisfy the different roles of the supervisor. The challenges our findings describe though not dominant in the data, can nevertheless be understood as significant and indicative of how institutional power is always present as part of how educational courses and student practices are constructed and regulated (Gergen, 2015a). Hierarchical positions in educational supervision can be challenging to manage, but it is still the supervisor’s professional responsibility to create a supervisory context that takes best possible care of all participants. When the students are challenged by an asymmetric relation the supervisor in accordance with a cooperation-oriented supervision model can attempt to be more participatory in the therapeutic process. The students can thus move from a position of feeling judged to being part of cooperation toward a goal of being as providing the best possible help to clients. In accordance with social constructionist ideas there is also much power in words and language. Conscious use by the supervisor of descriptive rather than judgemental feedback can help students to do the same about their own performance, about the clients and about the situation (Guiffrida, 2015). We also believe that the asymmetry of the power relationship can be reduced through constant reminders as well as open and dialogical meta-reflections. If the students experience becoming critically engaged we have what Moody et al. (2014) describe in how hierarchical disruption can be processed into enthusiasm for learning and mastery of skills. Similar to Ammirati and Kaslow (2017), we see it as necessary to constantly elevate and problematize the power of the supervisor and strive for self-reflexivity about how the supervisory role is performed. Supervisors also form convictions about professional discourses that can exclude alternative ways of acting. Several actions can be taken to equalize this relational imbalance. The supervisor should be transparent about their preferred therapy style and encourage active reflections around this (Wilson et al., 2016). The supervisor should also provide opportunities for evaluation where different aspects such as roles, coping strategies and preferred ways of giving and receiving supervision can be reflected.

We want to emphasize that power in this context in itself must not be misunderstood as negative or positive, but as a force that contributes to and influences supervision in a direction (Grøver, 2017). Reflection over this finding is also important to understanding the studies we have described in the introduction which present how a relational asymmetric in supervision can appear damaging and influence students’ ideas about themselves as professionals and therapists (Ellis, 2017; Maaß et al., 2022). The finding in this way suggests the significance of raising and holding closely to a systemic ideal of both being and educating multivoiced, reflecting practitioners who relate to a complex reality (Bertrando and Lini, 2019; Maturana and Varela, 1988). By striving toward a pluralistic attitude to professional discourses we can attempt to elevate ourselves over the level of debates about theories, models and methods and toward inclusion and dialogue (McNamee, 2021).

An unsurprising, but nevertheless meaningful theme that was constructed is how students find relationship between theory and practice, when they try out ideas and new skills in conversations with clients. When they experience how theory can be applied in practical situations theory “parts” begin to form a coherent whole and the larger significance of how to practice becomes clearer. I accordance with Falke et al. (2015) we wish to highlight immediate and continuous feedback that can occur when a supervisor is active in the therapy and can demonstrate interventions and tailor reflections. In the shared space, students can draw on the supervisor’s knowledge and integrate this with their own experiences (Bernard and Goodyear, 2019). This cooperation helps students to ground the base of values, theoretical knowledge and experience on which systemic work rests. A frequently active and continuous reflection in which new and generative questions can be posed can thus be understood as an active learning versus a more traditional educational model (Butler et al., 2021; McNamee and Moscheta, 2015). Group dynamics is itself a pedagogical learning element in which interaction between individual constructions and co-creation offer a new dimension. For new therapists in a learning process, factors such as social support, someone to lean on and someone to share responsibility with are important for mastery (Castronova et al., 2020). Teamwork promotes a multiverse of ideas and perspectives on how to intervene, develop, and bring conversations with clients forward.

In this perspective, words and actions derive their meaning in relation to others who already practice the same activity (McNamee, 2021), and as professionals we stand on each other’s shoulders. Gergen (2015b, p. 49) argues that “knowledge lies somewhere within the complex context between descriptions, explanations, logic, principles, laws, formulas and related forms of representation.” It involves students understanding traditions, history and the concrete contexts that make up the discipline of family therapy. At the same time, they need to experience the narrative process by being able to reflect experience, critically assess it and not least, find the words and language to express it (Guiffrida, 2015). Only then is new knowledge created. The possibilities that lie in cooperation-oriented live supervision appear to be those of a constructive learning space in which new clinicians can develop skills and work towards gaining theoretical understanding as well as values and norms related to disciplinary culture (Butler et al., 2021).

Conclusion

This study illuminates that live supervision can have significance for students’ development and understanding of the family therapist role. Cooperation in a team with a supervisor and co-student offers a multiverse of ideas and makes possible reflective interventions during conversations that are experiences as significant for student learning. A cooperative supervisory model is described both as an opportunity to build bridges between theory and practice, but also to protect ethical and disciplinary standards towards clients during therapy conversations. At the same time, it is important that the supervisor is sensitive toward how the relation in the supervisory context is influenced by an asymmetrical power relation that can be difficult for students to manage. When the study and practice place is connected, it is therefore important for the supervisor to reflect over and distinguish the different roles and acknowledge which hat should be worn for each. Further, the supervisor can put this into words and make it possible to reflect and discuss the different roles with students.