Clinical Supervision in Supportive Housing: Scrutiny or Support?

BACKGROUND AND PURPOSE: Clinical supervision is an established strategy to ensure quality service provision and an opportunity for support and learning in practice. Clinical supervision is conceptualized as a combination of educational, administrative, and supportive elements to facilitate case manager competency in service provision. When case managers provide services off-site and direct supervisors are their primary anchor to the program, the supervisor-supervisee micro-system is integral to the implementation of supportive housing models. Yet, little is known about clinical supervision practices in supportive housing programs and its impact on consumer outcomes. Supportive housing programs for formerly homeless people diagnosed with severe mental illness can use the Housing First or a Treatment First model. Housing First programs provide housing with no preconditions of sobriety or treatment compliance while Treatment First programs graduate consumers from transitional to independent housing. This qualitative inquiry investigates case managers’ reports of clinical supervision in both of these models.  

METHODS: Data were derived from a NIMH-funded qualitative study investigating perspectives of case managers and consumers from two supportive housing programs in New York City. Semi-structured interviews were conducted with case managers as the consumer participants entered housing, at 6 months, and at 12 months as long as the consumer remained in the program. A total of 84 interviews with 35 case managers were analyzed using Boyatzis’ (1998) coding and thematic analysis and a conceptually clustered within-case matrix (Miles & Huberman, 1994) focusing on case manager views of clinical supervision, their supervisors, and the impact on their work with consumers.

RESULTS: Analyses indicated three main themes: clinical practice support, perceived autonomy, and responsive style. Differences between programs were identified in clinical practice support and perceptions of autonomy while preferred leadership style characteristics were consistent across programs. 1) Clinical practice support. In Treatment First programs, documentation adherence dominated supervision time leaving little room to meet support and learning needs. In Housing First programs, supervision content varied with staff needs; 2) Perceived autonomy. Supervision more often emphasized task completion rather than the process of service delivery resulting in more case manager autonomy in their consumer interactions in Treatment First as compared to Housing First programs; and 3) Responsive style. Case managers across programs identified positively supervisors responsive to their individual professional growth and focused on consumer needs rather than agency demands.

CONCLUSIONS AND IMPLICATIONS: In Treatment First programs, supervision time was largely devoted to administrative scrutiny of documentation. This undermines the intended supportive function of clinical supervision to facilitate self-reflection and learning with potential implications for practice quality. Whereas, practices like Housing First with its consumer choice approach involved supervision that was more focused on helping case managers meet consumer needs. These findings suggest front-line supervisors play a critical role in the implementation of service models balancing tensions between ensuring responsiveness to consumers and documenting programmatic success.