A challenge for UK therapists learning to do Acceptance and Commitment Therapy is access to supervision. Outside of working at the specialist clinical and research centres that focus on ACT or accessing supervision online from international trainers, there are currently very limited options to get supervision from an experienced ACT therapist.
One option is to start your own peer supervision group: finding like-minded colleagues and working together to develop your practice as ACT therapists. In this post I’ll describe how we set up our peer supervision group within the South London & Maudsley NHS Foundation Trust.
We have been running a peer supervision group for the past 6 years in Lambeth, with up to 20 psychologists and therapists meeting monthly. Just about all of the people who participate in our peer supervision group have a background in CBT, many of them interested in third wave approaches through mindfulness (usually through exposure to MBCT).
The peer supervision group is on the large size: our strategy has been to promote ACT by providing a space where people of varying levels of experience can interact. This means less regular supervision for any particular therapist’s work (presenting a case once or twice a year), with the trade-off of learning from the experiences of others (Group members also receive individual supervision for their cases). The group largely consists of NHS clinical and counselling psychologists, along with trainees and assistants, so discussions are informed by similar settings and working practices.
The group started following an “Introduction to ACT” workshop that we ran for psychologists working in NHS adult mental health services in Lambeth. There was a lot of enthusiasm after the workshop so we suggested some follow-up activities, including an “ACT Video Club”. The DVDs of “ACT in Action” had just been released, and this seemed like a good opportunity to increase familiarity with the model and encourage discussion.
Following six months of the “ACT Video Club”, our focus shifted to peer supervision, as a core group of therapists wanted to develop their skills and become familiar with case formulation. Due to the interests of this core group the case discussions tended to be around working with people with serious mental illness (psychosis) and making links with other cognitive behavioural therapies.
The usual format of the group is to:
1) review a chapter of an ACT book,
2) for someone to practice/ demonstrate an experiential exercise, and
3) for case material to be discussed.
The books we have reviewed have been:
• ACT Made Simple – Russ Harris
• Learning ACT – Jason Luoma, Steve Hayes and Robyn Walser
• The 2nd edition of the ACT manual – Steve Hayes, Kirk Strosahl and Kelly Wilson
Assigning a chapter a month has been workable. In our experience, clinical material (e.g., Russ Harris’ books) have been easier to get to grips with for the majority of the group, compared to sources written from a more academic perspective, such as the ACT manual. Material about methods and techniques, rather than theory, has also led to more free-wheeling discussion.
Our group has members who are pretty familiar with functional contextualism and Relational Frame Theory, so there can be theoretical discussions: however (from my perspective) these tend to involve greater reticence from most group members to engage with(!). I think also that when a group that has a core set of members and a larger number that occasionally participate, reviewing clinical rather than theoretical reading is more engaging, and requires less from the occasional members to get up to speed.
Experiential exercises usually work best if there is a way of doing them in a larger group (on any given meeting we may have 8 – 12 people attending), or at least in pairs. My observation is that therapists new to ACT like to practice mindfulness exercises first, possibly due to the scripts and structured way that they can be done (also taking exercises from MBCT/ MBSR), and then start to branch out to defusion and values-based exercises. More adventurous therapists bring in exercises they have created, to try out before sessions with clients.
Usually someone leads an exercise, we discuss what the exercise evoked, give feedback on delivery, and then finally link to the psychological flexibility model.
There are several ways that case material is worked with in the meeting. The most typical situation is when a therapist feels stuck, or unsure of how to approach a client problem.
Similar to CBT supervision, the therapist may outline the client’s presenting problems, background and goals, then describe their understanding of maintaining factors, triggers, personal strengths etc. This may lead to a group discussion of the case formulation in ACT terms, with some variant of describing in terms of the six core processes of psychological flexibility (or three – Open /Aware /Active, or two – mindfulness /values-based action).
My observations are that clarifying the goals of the client can be useful, particularly there may be unclear links to values. Examples would be identifying elimination/suppression goals toward private events, client experience suggesting an unworkable change agenda, or process goals being used as outcome goals. Another common task is using our understanding of Relational Frame Theory to create therapeutic metaphors based on the client’s description of problems, which we hope may engage the client and promote flexible responding.
Other times (or indeed following on from discussion), the therapist may want to take a more experiential approach, such as:
• roleplaying the therapeutic interaction,
• engaging in perspective taking about the client, or
• contacting an experience evoked by the client work that may be acting as a barrier.
Roleplays may be done in pairs, with either another group member playing the client, or with the therapist playing the client, and the rest of the group being observers. We have also run role-plays as a round, with group members taking turns acting as therapist, or having a pause for someone to suggest an ACT-consistent move to try in the interaction (this is similar to the “ACT Tennis” game that Gordon Mitchell and colleagues from NHS Fife use to develop ACT skills – responding back and forth like a volley in tennis). Perspective taking and practicing willingness have been done using imagery, such as imagining being behind the client’s eyes and how they experience the therapist, or the Physicalising Exercise to practice just observing and being curious toward feelings and thoughts that invite therapist struggle.
I send a summary email after each meeting to the larger group of therapists, outlining the chapter discussion, description of experiential exercises, and the themes from the case discussion (no client details). The email describes the reading for the next group along with the volunteers for leading exercises and case discussion. This keeps people linked in and serves as the record of our activities.
I hope that you have found this a useful outline. It’d be great to hear about your experiences of ACT peer supervision, any useful tips etc. Feel free to comment below!