Background
Clinical supervision has been defined as “the formal provision by senior/qualified health practitioners of an intensive relationship-based education and training that is case-focussed and which supports, directs and guides the work of colleagues” [
1]. Supervision for psychologists was offered in 43.5% of the countries surveyed by the World Health Organisation in 2010 [
2]. This survey consisted of 147 countries and included those without clinical psychologists such as Bhutan [
2,
3]. The least supervision was offered in Africa where only 28.8% of countries offer supervision for psychologists, and low-income countries were less likely to offer supervision for psychologists than high-income countries [
2] perhaps due to the insufficient “human resources to provide such regular supervision” [
4]. A country in Africa where human resources in clinical psychology are lacking is Uganda, where a total of four clinical psychologists practice in state-run mental health institutions (J. Nsereko, personal communication, 14th April 2014), catering for the mental health needs of the 34.1 million population [
5]. Burn out has been defined as a multidimensional concept, with a core component of emotional exhaustion (the practitioner’s emotional resources have been depleted due to the demands and expectations of the work), and two other components of depersonalization (when responses become excessively negative or detached) and reduced personal accomplishment/professional efficacy (when the practitioner feels inadequate professionally) [
6‐
8]. Clinical supervision has been suggested to significantly decrease levels of burn out among staff working in community mental health services in the UK [
9,
10]. Given this, it is not surprising that Ugandan clinical psychologists who are working under exceptional pressures to meet the mental health needs of this country without any clinical supervisory structures in place [
11,
12], have reported feeling “burnt out” and “demoralised” [
13].
Positive steps to set up clinical psychology supervision in Uganda have been taken by Makerere University, the country’s state-run university, which offers a 2 year Masters of Science Clinical Psychology programme. This training course began in 1998 and traditionally had a large theoretical rather than practical component, with students relying on lecture notes and books to see clients [
14]. More recently, practical teachings in cognitive behavioural therapy (CBT) and narrative exposure therapy (NET) have been taught and, in 2012, supervision of clinical placements was introduced. However, minimal research has been conducted into how best to support training and qualified clinical psychologists working in low-income countries through supervision, a gap that this research aims to begin to address.
The existing research into supervision in low-income countries describes training models using supervisors in mental health [
15‐
17] and the role of clinical supervision in decreasing burn out [
18]. These papers are of a descriptive nature, with there being a lack of empirical research into how supervision can best support mental health staff, and in particular clinical psychologists working in low income countries such as Uganda. The majority of research into supervision for psychologists has been conducted in high-income countries.
High-income countries where supervision for training clinical psychologists is a pre-requisite for accreditation of clinical psychology training courses include the UK [
19‐
21], America [
22] and Australia [
23]. A vast amount of research has been conducted into supervision for training clinical psychologists in these countries [
24], looking at models of supervision as well as what makes supervision effective. Models of supervision have suggested that effective supervision fulfil three roles: restorative (emotional support), normative (maintaining professional standards) and formative (develop supervisee’s skills) (e.g. [
25,
26]) and have looked at the stages of development in supervision (Stoltenberg et al. as cited in [
27]
). Supervision has been conceptualised in terms of the ‘stages of change’ model [
28], has incorporated narrative and positive psychology elements [
29] and theories of supervisory relationships has been researched [
30].
A wealth of research has looked into supervision from the clinical psychology students’ perspective, suggesting that supervisors should give positive feedback before constructive criticism, acknowledge process and transference, joint problem solving, let supervisees come up with their own ideas, validate the supervisee’s feelings, be reliable (e.g. turn up on time for supervision, answer supervisee’s emails) and offer a “safe space” for supervision [
31‐
36].
The aim of this research was to explore the initial experiences of supervision for clinical psychology students in Uganda. Since no previous research has been conducted into this area, no pre-determined data frameworks were used. This was with the hope of giving a rich description of the students’ experiences.
It was hypothesised that the clinical psychology students would find clinical supervision useful. This was because previous research suggests “Western” therapies and methods of clinical psychology are useful in the Ugandan context (e.g. [
37]) and clear gaps had been identified previously by Ugandan clinicians in the restorative and normative aspects of supervision [
13]. It was expected that the useful and not so useful aspects of supervision may be different to those described by the Western clinical psychology students. Ugandan health and education sectors are based on the British systems, following the colonial rule from 18951 to 962 [
38]. The hierarchy and ethnic division which was imposed on Uganda within this time [
39] may still be impacting on Ugandan society, for example it has been stated that a “Doctor is next to God” in Uganda [
13]. Due to this, it possible that the Ugandan clinical psychology students may show a preference for a power hierarchy and a need to be “told” what to do. Due to supervision being a new concept, it is possible that the trainees’ answers may not be as in-depth, in particular with regards to the not-so-useful aspects of supervision.
Method
Context
A collaboration between Hull University in the UK and Makerere University in Uganda set up a supervisor training for Ugandan-based clinical psychologists in October 2012. This was in response to a need identified by staff at Makerere University. A presentation outlining the importance of supervision in clinical psychology was given at the Ugandan Clinical Psychology Conference, also in October 2012 [
40]. Following this, nine Ugandan-based clinical and counselling psychologists voluntarily attended the training course, which started the following week. All supervisors had been trained up to at least a Masters level in either clinical or counselling psychology, with seven of them being Ugandan and the remaining two being European (one English and Spanish).
The training lasted 5 days and followed the curriculum specified for Supervisor training developed by the Group of Trainers in Clinical Psychology in the UK, approved by the British Psychological Society. Second year Masters students were then assigned individual supervisors for the practical element of the course, a placement at the country’s psychiatric inpatient hospital, Butabika. At the end of the first semester, after the students had received 6 weeks of supervision, it was felt that the students had gained enough experience in supervision to share their initial thoughts. A focus group was held in the Department of Psychology at Makerere University in Uganda at the end of December 2012.
Participants
Second year clinical psychology students who received clinical supervision were asked to partake in the focus group. Out of the 18 second year clinical psychology students, 12 volunteered to be in the focus group (males = 4; females = 8), with the other 6 students having other engagements. Informed consent was sought from all participants partaking in the study, and all were told that their identities would be kept confidential.
A reflective commentary of emerging themes and ideas was kept by one of the authors from the start of the research.
Focus group questions
Questions and prompts were based on the models of supervision discussed above. The aims of the questions were to explore the student’s experience of clinical supervision and to ascertain whether clinical supervision for students in Uganda is useful and appropriate. Questions asked were as follows:
How often do you receive supervision?
What have been the benefits of supervision?
What have been the not so useful aspects of supervision?
How has supervision helped you to learn?
How has supervision given you emotional support?
How has supervision helped you think about your relationship with your clients and your supervisor?
Any suggestions for future supervision?
Open ended group questions and prompts were used to facilitate the discussions. The facilitators were members of staff at Makerere University in Uganda, with whom the students were familiar. The focus group lasted approximately 1 h.
Qualitative analysis
A qualitative design using focus groups was utilized. The focus group transcript was analysed using a thematic approach, following detailed guidelines and “checklist of criteria for good thematic analysis” [
41]. In order to keep an emphasis on the experiences of the students, an inductive “bottom up” approach was taken, whereby all of the data set was included in the analysis without any pre-conceived framework. The first author transcribed the focus group discussion and coded the text into different semantic themes, looking at the dialogue presented rather than the meaning behind the data. An essentialist stance was taken, whereby a simple uni-directional link between language and meanings was assumed. The first author generated initial codes for all of the data set, ensuring equal emphasis was given to all of the data. Additional file
1: Table S1 shows an example of a data excerpt and coding. These codes were then collated and organized into initial themes. These themes and codes were checked against each other and revised until each theme was felt to be unique in its own right, and the coded text to fit within these themes. The overall analysis was then checked and revised again to ensure the themes encapsulated the data set as a whole. This process was not linear, but circular with themes and codes constantly being updated.
Discussion
Following a qualitative focus group design, thematic analysis was used to present the Ugandan clinical psychology students’ initial experiences of clinical supervision. The students reflected on the aspects of supervision that had helped them and those that had not, and they suggested changes for future clinical psychology supervision. Aspects voiced as helpful were receiving emotional support, building their own confidence and self awareness, learning how to do therapy practically and understanding expectations of supervision/the course. Learning through discussion, talking about the supervisory relationship, observation of the supervisor and joint working with the supervisor were deemed useful. The not so useful aspects of supervision included the supervisor not addressing student’s emotional issues as much as the student desired and the supervisor not being able to give the student time or observational experiences.
These findings resonate with previous research [
36,
42] which suggested that joint problem solving, reassurance and direct guidance on clinical work was useful. The supervisor being unreliable was thought to be unhelpful, which is consistent with previous research (e.g. [
34,
35]). The students stated that supervision is helpful when restorative (e.g. emotional support), formative (e.g. expectations of the Masters course) and normative (e.g. therapeutic skills) needs are met, consistent with the functions of supervision proposed (e.g. [
25]). Previous Western research suggests that supervisors “telling” the supervisees what to do is seen as unhelpful (e.g. [
35,
36]), something which was contradicted in this study, with students finding this helpful. Perhaps the reason for this being that the students were all in the beginning of their development as clinical psychologists and, in line with the developmental model designed by Stoltenberg et al. as cited in [
27]) showed a tendency to be more dependent on their supervisor. Hirons and Velleman’s [
36] sample stated that talking to the trainee as if they are a client was found unhelpful, whereas psychological therapy within the supervisory relationship was requested in this study. Perhaps this is because very little is known about psychological therapy within the Ugandan culture, and the students wanted to experience therapy themselves.
The clinical psychology students stated that supervision helped them to manage their negative emotions which resulted as a feeling of being overwhelmed by training as clinical psychologist, and that it helped for them to feel more confident in knowing what they were doing (through learning from supervision and the supervisors helping them to manage their anxieties). These two aspects of the results can be compared to the two domains of burn-out emotional exhaustion and reduced personal accomplishment/efficacy [
6,
7]. Hence it is possible that supervision helped the clinical psychology students to manage these domains of burn out and hence decreased the likelihood of them experiencing burn out, however more research is needed to ascertain this. Supervision has previously been shown to decrease symptoms of burn out in low income countries [
18].
Hence, the finding that the clinical psychology students stated that clinical supervision was useful was in line with the hypotheses.
It was also hypothesised that the useful and not so useful aspects of supervision would be different to those described by Western clinical psychology students due to the differences in culture. However, the results do not support this second hypothesis, with the vast majority of helpful and not so helpful aspects from this study being mirrored in previous Western research. Hence this study suggests that Western “models” can be applied to these initial findings in supervision, however more research is required to determine this.
Limitations in this study include that the clinical psychology students had only received a small number of supervision sessions, and so may not yet be fully aware of the expectations of supervision and be able to critically analyse the useful and not useful aspects. The authors of this paper were all involved in the training and implementation of the supervision at Makerere University, meaning that the students may have felt an implicit need to “please” the facilitators. Furthermore, this may have caused bias in the data analyses stages.
The scope for further research into supervision for clinical psychology students and other mental health professionals in low income countries is vast, with it being suggested that further qualitative research is conducted looking at developmental models, functions of supervision, impact of supervision on burn out and into the useful and not so useful aspects of supervision at different stages of training.
Results from this study suggest that supervision for clinical psychology students in Uganda should continue. Supervisors should focus on being reliable through offering regular time-slots for supervision and they should teach the students the practical elements of psychological therapy through role play, co-therapy and observational experiences. It is vital to ensure that all of the restorative, normative and formative elements of supervision are fulfilled.
The mental wellbeing of practitioners needs to be prioritised in the mental health systems in order to decrease the high levels of burnout and to enable clinical psychology in Uganda to grow as a profession in its own right. This initial research suggests that supervision may be a way to support the emotional needs of clinical psychology students in Uganda. Regular, structured clinical supervisory structures should be set up and evaluated, with the view of this becoming a requirement for accreditation within the Ugandan Clinical Psychology Association. Only once the emotional wellbeing of Ugandan clinical psychologists and other mental health professionals have been addressed can these professionals begin to work securely and safely in this high stress environment. Further research into regular supervision of clinical psychologists, both during training and once qualified, is necessary to ensure that clinical psychology develops in a culturally appropriate manner in Uganda.
Authors’ contributions
All authors were involved in the set up and design of this research project, JH and RK carried out the focus group, JH transcribed the focus group, all authors were involved in the analysis of the data. JH led on the write up of the paper. All authors read and approved the final manuscript.