Facilitated group supervision: Harnessing the power of peers
- Conflict of interest: None.
Thanks for reviewing 8 year old Billy. He has severe problems with concentration and impulse control, borderline intellectual abilities, anxiety and extremely poor emotional regulation. Recent behaviours have included threatening other children with a knife, and an attempt to strangle his cousin. His father suffers from bipolar disorder and his mother is depressed.
In the field of developmental–behavioural paediatrics (DBP), and paediatrics as a whole, practitioners are frequently faced with the management of complex, chronic problems that defy simple solutions. High levels of child and family distress, anxiety and dysfunction are our constant clinical companions. Such challenges add to the fascination of this specialist area. The emotional intensity of this work, however, places considerable demands on clinicians.[1 , 2 ] The level of emotional risk to the clinician is exacerbated by the professional isolation that can accompany the role.[3 ] Unacknowledged feelings and beliefs have the potential to dull one of our most important therapeutic tools – the capacity for empathy.[1 ] Costs of emotional burnout to the health of individual practitioners, as well as organisations (reduced quality of patient care, decreased productivity, low staff morale), are well documented.[3 ] Preventative strategies are needed.[3 , 4 , 5 ]
Psychological mindedness describes an individual's capacity ‘to reflect upon, and see relationships between, the thoughts, feelings and behaviour of oneself and others’ (p. 170).[6 ],[7 ] A heightened awareness of the psychological dimensions in daily practice is a key requirement for clinical practice in the field of DBP.
In every DBP consultation, we are called upon to interpret the behaviours of our patients, and their interactions with others, through a biopsychosocial lens. The psychologically minded paediatrician will be better equipped to arrive at a deeper understanding of behavioural elements, to provide better informed management plans[7 , 8 , 9 , 10 ] and to employ the ‘use of self to assist those in emotional distress’.[9 ] Misreading or ignoring the psychological drivers of observed behaviour risks veering off on inappropriate therapeutic tangents.
Complex developmental–behavioural cases make up a significant proportion of the workload of both community and general paediatricians. Such conditions, with their ‘intertwined psychological and environmental, social and behavioural components’ (p. 183)[11 ] have been rated by paediatricians as their most difficult clinical cases.[8 ] These facts of clinical life frequently become starkly apparent early in consultant life.[10 ] Mechanisms for ongoing professional development in the craft of DBP, however, are unfortunately less obvious.
Professional Group Supervision
Professional supervision involves a ‘working alliance’ between two or more professionals for the provision of career-related personal support.[12 ] The overall aim of professional supervision is to develop the ‘competence, creativity, confidence and compassion’ of the participants[13 ] with ultimate benefits for patient care as a result.[14 ] Other objectives (e.g. improved functioning within organisations, leadership development) are frequently included within the scope of professional supervision. Group supervision aims to meet these objectives by facilitating peer support, the sharing of experiences, and by drawing on the multiple perspectives of participants.[1 , 15 ] To be effective, group supervision requires the establishment and maintenance of a ‘good enough’ bond between the parties, agreed goals, and explicit processes, roles and responsibilities.[12 ]
Models of group supervision
A well-established model of group supervision is the Balint method. A typical Balint group would comprise 4–10 members, one or two leaders, and meet regularly for several years at least.[3 , 16 ] Participants are asked to present cases in which they have experienced a strong emotional reaction (frustration, anger, surprise, anxiety, sadness, joy).[17 ] A detailed case history is not required. Balint groups do not aim to provide an expert clinical solution. Instead, the clinician's personal experience of the case (thoughts, emotional responses, beliefs, interpersonal behaviours) is emphasised. Group members may ask brief clarifying questions of the presenter. The group then reflects upon the content, working to understand the interpersonal transactions.[17 ] There is freedom to speculate, without pressure to provide the ‘correct’ analysis.[17 ] Balint groups have been described in a variety of areas of medical practice, though published accounts in paediatrics are lacking.
Other models of formal group supervision include peer-led groups, cognitive behavioural therapy-based models and reflecting team models.[8 ]
Role of supervisor
The role of the group supervisor is of key importance. Although expert content knowledge is not mandatory, the supervisor needs a solid understanding of group process.[15 , 18 ] They must simultaneously encourage participation of all group members, steer towards the interpersonal elements of the case, choose their moment to stimulate discussion (e.g. by reframing a situation), help summarise proceedings and manage time.[15 , 19 ] Skill in managing resistance within groups (e.g. lateness, lack of contribution), difficulties in group dynamics (e.g. monopolising the discussion, competition) and group changes (e.g. addition of a member) assists in maintaining group cohesiveness.[1 , 15 ] The supervisor should model the behaviours expected of the group, including acceptance of different perspectives, sitting with uncertainty and displaying empathy for the clinician and the patient alike.[18 ] It is paramount that sessions remain a safe environment – a source of support rather than personal criticism.[18 ] The supervisor must explicitly set goals, clarify guiding principles and operation of the group and reinforce behavioural expectations by establishing a formal supervision agreement.[1 , 15 , 19 ]
Group Supervision – Our Experience
Establishment of the group
A small group (n = 6) of paediatricians working at various locations within a specialist child development service noted an absence of occasions in which peers were able to share the experience of practice in DBP. This was felt to constitute a risk to work performance and satisfaction, given the specific demands of the clinical work. With support of senior management, a proposal was developed to pilot a facilitated supervision group. The timeframe for the pilot was 12 months, with an opportunity for five meetings. Participating paediatricians are at different career stages. Their weekly time commitment to specialist DBP varies from full to part time. All were known to each other prior to the commencement of the group.
The group supervisor (second author) is a private consultant specialising in psychotherapy and supervision services. He has worked in the human and health services for over 20 years and has 10 years of supervision experience in areas of individual and group psychotherapy. He has an interest in the emotional components of helping relationships, and particularly the ‘self-conscious emotions’ associated with supervision. He is schooled in small group dynamics, with a sound understanding of the Balint model and other models of group supervision.
The principal aims at the outset of this professional supervision group were to assist in maintenance of job satisfaction, and prevent burnout, compassion fatigue and vicarious trauma.
Model of supervision
The scope of discussions was specified to include clinical cases (a difficult case, a ‘feel-good’ case), interventions (what is being done to bring about a difference?), relationships involved in our work and organisational or contextual issues that may be having an impact on practice. During the contracting phase with the group, it was agreed the time would be split between a case-based focus and an organisational/contextual focus (45 min each). For clinical cases, the group employed a variation of the Balint method of supervision, as outlined above. Although case material presented remained focused on the doctor–patient relationship à la the Balint model, this was also considered within the construct of the working alliance[20 ] and the contextual factors influencing this relationship. Debriefing and reflection upon organisational issues, which is outside the scope of the Balint model, was included as a separate component of the supervision process, with group members feeling this would complement the case-based discussions.
Group supervision agreement
Ground rules for group process were established at the beginning. Participants agreed that attaining group objectives would be best supported by a commitment to attend and actively participate in all sessions. Punctuality was expected. An atmosphere of mutual respect (personal and professional), non-judgmental attitudes and empathy were explicitly labelled as necessary ingredients. Confidentiality regarding group discussions was total unless the group reached agreement regarding different boundaries of confidentiality. Ethical and duty of care issues were assumed to be the responsibility of individual participants in their professional practice. Participants also agreed that the group was not to function as group therapy, line management or performance appraisal. A formal supervision agreement was drawn up and signed by all members.
The experience of group supervision: participant observations
Prior to commencement, participants were invited to respond to questions about their hopes and expectations of the group. After five sessions over a 12-month period, the group was evaluated using a brief questionnaire. The tool contained a series of questions inviting a response on a Likert scale, as well as open field questions, exploring hypothesised benefits of the group. Participants highlighted enhanced opportunities to debrief regarding stressful and/or difficult areas of work, and the exchange of useful knowledge and resources, as benefits of the group. The sharing of experiences, and group members' reflections on cases presented, were clearly valuable to participants (‘It was reassuring that some feelings were commonly held within the group’, ‘I have recognised the value of sharing and peer support’). All participants rated highly the level of support received from other members of the group. The supervisor's approach was felt to be a good fit for the group. To varying degrees, all participants reported an improved sense of job satisfaction and perception of reduced burnout risk. Notably, all participants rated as ‘extremely important’ the feeling of reduced isolation engendered by the group. Enhanced cohesion of the clinical group, and an increased sense of trust between colleagues, were other themes nominated in free field comments. Supervision was also felt to have contributed to increased confidence and enthusiasm towards clinical practice. Little change was reported in technical medical knowledge. Given the focus of the group, this was not unexpected. Participants did, however, feel that supervision had improved clinical skills (e.g. ‘development of a framework for understanding transactions within families’). The opportunity to debrief about organisational issues as well as clinical cases was reinforced as helpful. The group's longevity and attendance rates give an indication of the value placed on the group. At the time of writing, the group continues to meet bi-monthly, with near 100% attendance, 2 ½ years after its inception.
Development of an effective ‘working alliance’ is key to the success of group supervision. This can be a challenging task, especially where the group is already part of an organisational work system. Research on group supervision in workplace settings indicates members need an experience of a protected space, where they can make pressure-free connections, and enjoy active participation.[21 ] In this group, collaborative development of the supervision agreement was crucial in developing a successful working alliance. Clarifying the role of the supervisor in supporting exploration of the emotional or unconscious dynamics of the doctor–patient relationship was also critical to clearly differentiate professional supervision from clinical supervision. The fact that the supervisor is not a medical professional but possesses psychological and interpersonal expertise assisted in this regard. Typically, the level of intervention of the supervisor decreases over time as a group develops. Cohesion of this group has increased on the basis of a good working alliance and existing professional peer relationships. In parallel with this development, members have also chosen to draw more deeply on the supervisor's expertise for a time, reflecting a growing interest in developing their understanding of interpersonal psychodynamics and their utility in effective treatment.
The group continues its evolution. At the 18 month mark, a review of the model and content of supervision was undertaken by group members. Changes were suggested to the focus of cases (to include greater emphasis on positive clinical experiences and ‘moments of change’[22 ]) and to the role of the supervisor (deeper exploration of countertransference reactions, increased direct teaching of counselling techniques). The group is currently constituted by five of the six original members, plus another who joined after the initial pilot was completed.
Discussion – How does Group Supervision Work and Why Is it Good for DBP?
Regular ‘Balint-type group discussions’ have previously been suggested as a mechanism to aid the development of a psychologically minded paediatrician.[10 ] Reflective analysis, in a contained setting, of the interpersonal dynamics of a consultation can lead to an increase in ‘emotional literacy’ of the clinician,[4 ] thereby enhancing one's ability to ‘consider, utilize and influence the psychological aspects of the doctor-patient relationship’.[23 ]
Shedding light upon the often unconscious emotional influences that pervade clinical encounters[2 , 24 , 25 , 26 ] can, for example, lead to a better understanding of counter-transference reactions.[27 , 28 ] Clinicians can be assisted to recognise and tolerate such emotions, to help avoid unhelpful habitual reactions and to incorporate these feelings into an overall understanding of a child and family's predicament.[25 , 26 ] Through improved self-awareness, defensive reactions can be lessened, blind spots opened up and empathy for patients in troublesome situations increased.[9 , 16 , 24 , 26 ]
Doctors can help each other understand why particular patients or families may be perceived as ‘difficult’.[9 , 29 ] Personal biases (e.g. ‘I can't work with parents with mental health difficulties’) and irrational personal beliefs (e.g. ‘it is my responsibility to make my patient feel better’) that can derail clinical care can be brought into the open and examined.[9 , 30 ] Practical communication skills and self-management tools (e.g. active listening techniques, mindfulness strategies, conflict resolution methods) can be shared between peers.[8 ] Thus, management of complex, emotion-laden consultations can be improved,[8 , 10 ] and clinical work targeting behavioural and psychosocial problems made more effective.[9 ] Without explicitly focusing on beliefs, emotions and biases, doctors are less likely to come to grips with how these factors may be driving the clinical care they provide.[9 ]
The quality of the therapeutic alliance with our patients and their families is all important. The utility of clinical supervision in enhancing this alliance in has been demonstrated empirically.[31 ] Clinicians involved in Balint groups have been shown to develop more patient-centred consultations.[32 ] Graham et al. studied Balint-style supervision groups in a small cohort of psychiatry trainees and demonstrated changes including ‘better understanding of case dynamics, developing helpful insight into the emotions generated by clinical work and the introduction of new psychological perspectives or conceptual frameworks’.[23 ] General practitioners involved in a well-established group supervision process in Denmark also report improvements in communication skills.[8 ] The self-awareness stimulated by group supervision provides a mechanism for strengthening the therapeutic alliance across our caseload.
Enhancing clinician resilience
Studies of similar models of facilitated supervision have shown such groups are valued as a means of avoiding burnout and combating isolation.[1 , 3 , 4 , 8 , 23 ] Reductions in work-related stress and increased professional satisfaction have resulted from involvement in supervision groups.[8 , 17 , 24 ] The group can provide a safe location for the cathartic airing of stressful work-related situations.[23 ] This ‘sharing of affective experience’ (p. 128)[1 ] with sympathetic colleagues who know the territory can help normalise emotional reactions.[23 , 30 ] Unreasonable expectations and criticisms of self can be calibrated by group feedback.[1 , 3 ] Highlighting the positives in a difficult situation can help maintain optimism.[23 ]
It is also valuable to scrutinise consultations that run smoothly and generate positive feelings. This can highlight a clinician's personal strengths, reinforce good clinical skills, help document one's development and ensure the many positive, sustaining aspects of our work receive due attention.[5 , 33 ]
The form of group supervision described in this paper complements other formats of professional support, such as individual supervision[2 , 14 ] or ‘co-mentoring’.[34 ]
The unique benefits of facilitated group supervision
Informal networking, hospital meetings, corridor consultations and clinical ‘diagnosis and treatment’ case discussions, while all potentially helpful in their own ways, do not meet the specific needs addressed by formal supervision such as the model described in this paper.
The commitment to attendance, a relatively structured approach, the facilitative skills of the supervisor, the sharing of perspectives from supportive peers and an explicit focus on the psychological dimensions of developmental–behavioural consultations constitute a unique and valuable tool for professional development and well-being.
Parallels with mental health workforce
There is a need among paediatricians for competence in many aspects of mental health care.[10 , 35 , 36 , 37 , 38 , 39 ] In fact, for many clinical concerns about behaviour and emotional well-being, there is often no clear demarcation between paediatricians and psychiatrists as to who should, can and does provide medical care.[38 , 39 , 40 ] Given this overlap, it makes sense for paediatricians to examine methods of ongoing skill development and professional support with an established pedigree in the mental health field. Requirements for mandatory supervision within mental health disciplines are a well-established part of the professional culture, with evidence to show that mental health clinicians regard supervision as a crucial component of professional development.[2 , 4 , 9 , 14 , 41 ] Similarities in the nature and complexity of developmental–behavioural and child psychiatry clinical caseloads[38 , 39 ] adds to the logical argument for similarly structured ‘reflective educational experiences’ (p. 502)[9 ] to become mandatory for those working in the field of DBP.
There are economic benefits for measures such as group supervision that have demonstrated capacity to improve the well-being and resilience of clinicians.[42 ] Practitioners who have reached the point of burnout are more likely to commit errors, be impaired or be absent from work, all of which are a drain on the scarce health dollar.[42 , 43 ] They may even leave practice altogether, with the resultant loss of a substantial training investment that health professions can ill afford.[42 , 43 ] Multiple clinicians are assisted simultaneously in the group supervision setting, further enhancing cost effectiveness.[19 ]
To help a professional supervision group get up and running, several potential barriers may need to be explicitly labelled and discussed. Many paediatricians would still understand supervision to mean line management, direct clinical oversight or performance appraisal.[4 ] As in our model, it is suggested that these functions be explicitly excluded. Some level of anxiety about disclosing one's emotional reactions, or perceived interpersonal errors of judgement, is anticipated and should be acknowledged up front.[15 , 23 ] Paediatricians will be very familiar with a traditional model of clinically orientated case-based discussions and may take some time to adjust to, or recognise the benefits of, a different format.[17 , 23 ]
As in some other areas of medicine,[3 , 17 , 26 ] a tradition of structured peer support or professional supervision is yet to be firmly established within paediatrics in Australasia.
The isolationist ‘culture of self-sufficiency’[4 ] that has pervaded medicine is an anachronistic straitjacket on our professional development and well-being. It is heartening to note that the newly formed Neurodevelopmental and Behavioural Paediatric Society of Australasia has recognised, as one of its key agendas, the need to explore a range of resilience-promoting strategies for clinicians, including supervision.[44 ] Where such opportunities do not exist, we need to create them.
Conclusion and Recommendations
The psychologically challenging nature of paediatrics, and the risk for emotional burnout for paediatricians, should not be underestimated. The particular skill set (psychological mindedness) required to perform clinically in DBP demands mechanisms of professional development that look beyond the technical mechanics of diagnostic and treatment algorithms. Sharing experiences in a facilitated supervision group can provide valuable peer support and lead to reduction in work-related stress and insight into the emotional subtext of clinical consultations. This is good for individuals and good for health services. Exploration of different types of professional supervision is strongly encouraged for all areas of paediatrics. For those engaged in specialist DBP work, professional supervision initiatives should be mandatory.
The authors would like to thank Louise Butler, Alison Harris, Louise Marsh, Susie Thornton and Kerri Webb for their collaborative planning, enthusiastic participation in the group and helpful commentary on this manuscript, and Ven-nice Ryan and Neil Wigg for managerial support of this professional supervision initiative.