Most behavioral intervention trials use supervision, and there have been many varied approaches to the format and structure of supervision in multisite trials.5
Researchers have noted the dearth of clear supervision guidelines for clinical work, and there are even fewer supervision guidelines in the context of a behavioral intervention research study.3,6
Baer et al5
note that the procedures of supervision remain understudied. In detailing the aims and implementation of supervision in Project Eban, this article offers specific procedures for effective supervision in a behavioral intervention trial. A clear framework, derived from theoretical and methodological considerations, allows supervisors to address the challenges that may arise when implementing a behavioral intervention for a research study.1
The importance of framing supervision within a theoretical model is also emphasized in Fehrenbach and Coffman’s4
analysis of supervision issues arising from the use of experienced private practitioners in clinical trials. Based on prior clinical experience, facilitators may have different expectations about what an intervention for couples should be. Supervisors must be attentive to the difference between a behavioral intervention for a research study and therapy. When supervisors train facilitators, issues related to behavioral intervention research, such as the importance of the eligibility criteria, need for structure, methodological rationale for the protocol, goals guiding the intervention, research ethics, and participant and facilitator roles, are made clear. Supervisors must train facilitators to handle any clinical issues that may arise in the session according to research protocols, such as addressing participants’ needs and making appropriate clinical referrals for suicidal or violent research participants.
The Eban Theoretical Model for Supervision in Project Eban integrated 3 theories: (1) a cognitive behavior therapy (CBT) approach to supervision6
; (2) elements of Barretta-Herman’s7
Model of Life-Long Supervision; and (3) “Empowering supervisees to empower others: a culturally responsive supervision model.”8
Project Eban adapted these client-focused models to set the goals, process, and outcomes for supervision that were useful for addressing the tension between the demands of research and the need for clinical flexibility.2
Cognitive Behavior Therapy
Supervisors Model Skills
Rosenbaum and Ronen’s6
CBT model was developed to guide supervision of cognitive behavior therapists. Many of its goals and features, however, are applicable to supervision of Project Eban facilitators. First, the CBT supervision process uses modeling to demonstrate how the intervention sessions should be conducted, to teach the skills of setting up role-plays, and to use problem-solving techniques, which are an integral part of the interventions in Project Eban. Supervisors model these procedures in the group supervisory sessions with the facilitators.1,6
Facilitators Practice Skills
Second, the CBT model emphasizes the importance of practicing new behaviors as part of the change process.6,9,10
In Project Eban, facilitators practice their facilitation skills through strategies such as role-playing, problem solving, and behavioral rehearsal. Behavioral rehearsal, for example, might involve facilitators practicing how to convey critical session content in a clear, well-paced manner or how to guide couples to more realistic weekly goals. This permits the facilitators to learn experientially in supervision rather than solely through self-report and discussion.
Reinforce Skills as Change Agents
Third, the CBT model emphasizes the skills and strengths needed for facilitators and participants to become their own agents of change.7
Supervision helps facilitators improve and maintain their skills in implementing the interventions, which then promotes participants’ behavior change. Supervisors highlight how facilitators’ skills serve to effect change. In particular, facilitation skills help couples learn the skills necessary to make changes in their relationships and risk behaviors for the treatment intervention and in health screening and behaviors for the control intervention.
Understand Context of Beliefs
Fourth, supervision and the effective delivery of the intervention are opportunities where experiences can be understood in the context of one’s belief system.6
Eban facilitators need to be aware of the meaning that condom use and other health behaviors have for themselves, first, and then for participants, to understand how to help couples change maladaptive behaviors (eg, by framing condom use as communicating intimacy and love rather than solely reducing risky behaviors). Supervisors must attend to the impact of facilitators’, and their own, meanings and beliefs on the intervention and supervision process. For example, if a facilitator had the belief that a man’s sexual pleasure was more important than a woman’s, the supervisor would identify this belief, examine its accuracy and usefulness, explore how it might impact the facilitator’s implementation of the intervention, and collaborate with the facilitator to change it.
Set Realistic Goals
The model uses a goal-directed approach to the clinical process.6,9,10
Because Eban facilitators must help participants set realistic goals for behavior change and problem-solve barriers to achieving goals, the supervision process must support this key element of the intervention.Supervisors discuss with facilitators the degree to which the goals of the intervention are being met for each couple in the treatment condition and each individual in the control condition. Supervisors and facilitators collaborate to use planning and problem solving to develop strategies to help the participants work toward their behavior change goals. For example, if a couple is having difficulty using condoms because they do not want to interrupt the buildup of their sexual experience, the supervisor and facilitator would plan when and how to explore solutions with the couple. The supervisor would work with the facilitator to develop some possible strategies, such as specific ways of incorporating condoms into the couple’s sexual experience (eg, putting a condom on in a sexy way).
Ongoing Supervision Model
The theoretical framework for supervision in Project Eban also uses elements of Barretta-Herman’s7
Model of Life-Long Supervision, which emphasizes the importance of ongoing supervision throughout the supervisees’ careers. Ongoing supervision serves educational, supportive, and administrative purposes, and it contributes to the ongoing professional development of the supervisees.6,9,10
In this model, supervising and implementing the clinical goals are collaborative efforts between the therapist and the client, making no assumption of the supervisor’s clinical superiority. In Project Eban, facilitators work with the research participants to help them change their behavior to achieve goals that they set for themselves as part of the intervention. The expertise of both supervisors and facilitators is valued, and they decide together how best to help couples achieve their goals. This explorative, collaborative atmosphere establishes trust and openness between facilitators and supervisors.
“Empowering supervisees to empower others: A culturally responsive supervision model” describes a 4-stage, culturally responsive psychotherapy training process, moving from didactic to experiential, from cognitive and objective to personal and subjective. Each of the 4 stages of the model is incorporated into Project Eban facilitator training. The first stage (introducing a culturally responsive, cross-cultural perspective) involves teaching facilitators about the ecological framework guiding the intervention, factors influencing health behaviors, health issues specific to African Americans, and the Afro-centric perspective. In the second stage (introducing a sociocultural framework and analysis of oppression), the effects of oppression and racism on health behaviors are discussed. Recognition of the achievements of African American people despite these barriers is used to inspire participants to draw on their strengths and resources to battle HIV and other health behaviors by reducing their risk behaviors. Real-life issues and barriers to behavior change are problem-solved. In the third stage (exploring supervisees’ biases and stereotypes), facilitators identify their assumptions, experiences, and biases; and how these can affect reactions to participants and implementation of the intervention. They also explore how to respond when participants’ assumptions or biases affect the group process or their responses to facilitators. In the fourth stage (inclusion of a collective social action perspective in healing), facilitators are taught a conceptualization of behavior change, building from the individual and the couple and expanding to the broader community. Facilitators also learn how to help couples support each other’s healthy behavior change.