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BEST PRACTICE IN INDIVIDUAL SUPERVISION OF PSYCHOLOGISTS WORKING IN THE FRENCH CAPEDP PREVENTIVE PERINATAL HOME-VISITING PROGRAM: RESULTS OF A DELPHI CONSENSUS PROCESS TIM GREACEN

EPS Maison Blanche, Paris BERTRAND WELNIARZ

EPS de Ville Evrard, Neuilly sur Marne, France DIANE PURPER-OUAKIL

Hôpital Saint Eloi, Montpellier, France JAQUELINE WENDLAND

Institut de psychologie, Université Paris Descartes, Paris ROMAIN DUGRAVIER

INSERM, Maison de Solenn, Paris ¨ THOMAS SAIAS

Université du Québec, Montreal SUSANA TERENO

Institut de psychologie, Université Paris Descartes, Paris

We thank the 440 families who participated in the study and the members of the home-visiting and assessment teams, without whom this project would not have been possible: Joan Augier, Amel Bouchouchi, Marie Danet, Sandrine Désir, Anna Dufour, Cécile Glaude, Audrey Hauchecorne, Gaelle Hoisnard, Virginie Hok, Alexandra Jouve, Anne Legge, Céline Menard, Marion Milliex, Eléonore Pintaux, Elodie Simon-Vernier, and Alice Tabareau. We also thank the members of the Infant and Children Community Mental Health Center of the 18th arrondissement of Paris, particularly Francine Messeguem, and Sebastien Favriel and the research team of EPS Maison Blanche for technical support; Estelle Marcault, Vé́ronique Laniesse, Alexandra Avonde, Cécile Jourdain, Pierre Arwidson, Béatrice Lamboy, and Gérard Guillemot for their help with research administration; Nathalie Fontaine, George Tarabulsy, and Michel Boivin for assistance with developing the research and intervention instruments; EPS Ville Evrard for contributing personnel research and supervision time; Laure Angladette, Drina Candilis, Judith Fine, Joana Matos, Anne-Sophie Mintz, Marie-Odile Pérouse de Montclos, and Françoise Soupre for their participation in the supervision process itself; and Christopher Daniell for translation assistance. The CAPEDP Study Group: Elie Azria, Emmanuel Barranger, Jean-Louis Bénifla, Bruno Carbonne, Marc Dommergues, Romain Dugravier, Bruno Falissard, Tim Greacen, Antoine Guédeney, Nicole Guédeney, Alain Haddad, Dominique Luton, Dominique Mahieu-Caputo†, Laurent Mandelbrot, Jean-François Oury, Dominique Pathier, Diane Purper-Ouakil, Thomas Sa¨ıas, Susana Tereno, Richard E. Tremblay, Florence Tubach, and Bertrand Welniarz. The CAPEDP Project (Compétences parentales et Attachement dans la Petite Enfance: Diminution des risques liés aux troubles de santé mentale et Promotion de la résilience; Parental Skills and Attachment in Early Childhood: Reducing Mental Health Risks and Promoting Resilience) is a program led by the Research Department of Assistance Publique Hôpitaux de Paris, financed by Grant PHRC AOM 05056 from the French Ministry of Health, Grant IRESP REV0702 from the Public Health Research Institute, and Grants INPES: DAS 08/2006, DAS 018/09, and DAS 084/10 from the National Institute for Prevention and Health Education. The study protocol was approved for all centers by the Institutional Review Board “Comité de Protection des Personnes d’Ile de France IV” (2006/37). Written informed consent was obtained from all participants before inclusion in the study. The trial is registered as ClinicalTrials.gov No. NCT00392847. We have no conflicts of interest. Direct correspondance to: Tim Greacen, EPS Maison Blanche, 18-20 rue Rémy de Gourmont, 75019 Paris, France; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 38(2), 267–275 (2017) C 2017 Michigan Association for Infant Mental Health View this article online at wileyonlinelibrary.com. DOI: 10.1002/imhj.21630

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FLORENCE TUBACH

AP-HP, Hôpital Bichat, Unité de Recherche Clinique Paris Nord, Département d’Epidémiologie et Recherche Clinique, INSERM CIC-EC 1425, Paris, Université Paris Diderot, Sorbonne Paris Cité, UMR 1123, Paris, and INSERM, U1123, CIC-EC 1425, Paris ALAIN HADDAD

Former head of 19th arrondissement Child & Adolescent Paris Mental Health Services, Paris ANTOINE GUEDENEY

Hôpital Bichat Claude Bernard APHP, Université Paris Diderot, Sorbonne Paris Cité, Paris CAPEDP STUDY GROUP

ABSTRACT: Individual supervision of home-visiting professionals has proved to be a key element for perinatal home-visiting programs. Although studies have been published concerning quality criteria for supervision in North American contexts, little is known about this subject in other national settings. In the context of the CAPEDP program (Compétences parentales et Attachement dans la Petite Enfance: Diminution des risques liés aux troubles de santé mentale et Promotion de la résilience; Parental Skills and Attachment in Early Childhood: Reducing Mental Health Risks and Promoting Resilience), the first randomized controlled perinatal mental health promotion research program to take place in France, this article describes the results of a study using the Delphi consensus method to identify the program supervisors’ points of view concerning best practice for the individual supervision of home visitors involved in such programs. The final 18 recommendations could be grouped into four general themes: the organization and setting of supervision sessions; supervisor competencies; relationship between supervisor and supervisee; and supervisor intervention strategies within the supervision process. The quality criteria identified in this perinatal home-visiting program in the French cultural context underline the importance of clinical supervision and not just reflective supervision when working with families with multiple, highly complex needs.

Keywords: clinical supervision, reflective supervision, home visiting, Delphi process, perinatal prevention RESUMEN: La supervisión individual de profesionales que visitan hogares ha demostrado ser un elemento clave en los programas de visita a casa en el per´ıodo perinatal. Aunque se han publicado estudios sobre la calidad de los criterios para la supervisión en contextos norteamericanos, poco se conoce acerca de este tema en otros contextos nacionales. Dentro del contexto del programa CAPEDP, el primer programa de investigación de promoción de la salud mental perinatal con control al azar que se ha llevado a cabo en Francia, este art´ıculo describe los resultados de un estudio que usa el método de consenso Delphi para identificar los puntos de vista de los supervisores del programa acerca de las mejores prácticas para la supervisión individual de quienes visitan los hogares participantes en tales programas. Las dieciocho recomendaciones finales pudieran agruparse en cuatro temas generales: la organización y el contexto de las sesiones de supervisión; las destrezas del supervisor; la relación entre el supervisor y el supervisado; las estrategias de intervención de la supervisión dentro del proceso de supervisión. Los criterios de calidad identificados en este programa de visita a casa durante el per´ıodo perinatal en el contexto cultural francés subrayan la importancia de la supervisión cl´ınica y no sólo la supervisión con reflexión cuando se trabaja con familias con múltiples, altamente complejas necesidades.

Palabras claves: supervisión cl´ınica, supervisión con reflexión, visitas a casa, proceso Delphi, prevención perinatal ´ ´ RESUM E:

La supervision individuelle de visiteurs a` domicile professionnels s’est avérée eˆ tre un e´ lément clé pour les programmes de visites a` domicile relatives a` la périnatalité. Bien que des e´ tudes aient e´ té publiées sur les critères de qualité pour la supervision dans des contextes nord-américains, on sait peu de choses sur ce sujet dans d’autres contextes nationaux. Prenant le contexte du programme CAPEDP, le premier programme de recherche sur la promotion de la santé mentale périnatale a` exister en France, cet article décrit les résultats d’une e´ tude utilisant la méthode de consensus Delphi pour identifier les points de vue des superviseurs du programme concernant les meilleures pratiques pour la supervision individuelle des visiteurs a` domicile dans de tels programmes. Les dix-huit recommendations finales pourraient eˆ tre regroupées en quatre thèmes généraux : l’organisation et le contexte des séances de supervision; les compétences du superviseur; la relation entre le superviseur et la personne supervisée; les stratégies d’intervention du superviseur au sein du processus de supervision. Les critères de qualité identifiés dans ce programme de visites a` domiciles relatives a` la périnatalité dans le contexte culturel français souligne l’importance de la supervision clinique et pas seulement la supervision de réflexion dans le travail avec des familles ayant des besoins multiples et très complexes.

Mots clés: supervision clinique, supervision de réflexion, visite a` domicile, processus delphi, prévention périnatale ZUSAMMENFASSUNG: Individuelle Supervision für professionelle Hausbesucher hat sich als ein Schlüsselelement für perinatale Hausbesuchsprogramme erwiesen. Obwohl Studien u¨ ber Qualitätskriterien für die Supervision in nordamerikanischen Kontexten veröffentlicht wurden, ist wenig u¨ ber dieses Thema in anderen nationalen Settings bekannt. Im Rahmen des CAPEDP-Programms, dem ersten randomisierten kontrollierten perinatalen Programm

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Individual Supervision in Perinatal Home Visiting

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zur Förderung der psychischen Gesundheit in Frankreich, beschreibt dieser Artikel die Ergebnisse einer Studie, die die Delphi-Konsens-Methode verwendet, um die Perspektiven der Programmsupervisoren hinsichtlich der besten Vorgehensweise bei der individuellen Supervision von Hausbesuchern, die an solchen Programmen beteiligt sind, zu ermitteln. Die finalen achtzehn Empfehlungen konnten zu vier allgemeinen Themen zusammengefasst werden: Organisation und Setting der Supervisionssitzungen; Kompetenzen des Supervisors; Beziehung zwischen Supervisor und Supervisand; Interventionsstrategien des Supervisors innerhalb des Supervisionsprozesses. Die Qualitätskriterien, die in diesem perinatalen Hausbesuchsprogramm im französischen Kulturkontext identifiziert wurden, unterstreichen die Bedeutung der klinischen Supervision (über die reflexive Supervision hinaus) bei der Arbeit mit Familien mit vielfältigen, hochkomplexen Bedürfnissen.

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* * * The pioneer work of Olds with preventive interventions in infant mental health has led to a series of studies assessing the efficiency, the efficacy, and the feasibility of these programs and their cost efficiency in various settings (Olds, Kitzman, Cole, & Robinson, 1997). Among identified quality criteria, individual supervision of home visitors has proved to be a key element: The quantity and the quality of individual supervision are associated with increased retention of families in the program, decreased burnout of health workers, and better program outcomes (McGuigan, Katzev, & Pratt, 2003). Home-based preventive work in the perinatal field is recognized as being particularly emotionally demanding and stressful.

Health workers involved in home visiting are often confronted with complex and critical family situations, where psychosocial vulnerability and mental health issues are closely entwined (Fraiberg, 1980; Tomlin, Sturm, & Koch, 2009). Both home visitors and their supervisors have specific needs in terms of (a) the organizational or contextual factors required for successful supervision and (b) how to support staff so that they can be successful in implementing the goals and objectives of the programs in question (Sale & Martin, 2006). In addition, the role of the home visitor has evolved considerably over recent years, from the problem-solving expert and decision-maker to that of a collaborator, a facilitator, and a negotiator (Tomlin, Weatherston, & Pavkov, 2014). Today, home


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visitors need to have command of a larger array of competencies and greater flexibility in accompanying families. Supervisors therefore play an increasingly pivotal role in prevention and intervention programs, providing not only professional support and program fidelity control but also identifying individual training needs and giving emotional support. ASSESSMENT OF SUPERVISION IN PREVENTION PROGRAMS

The lack of an agreed model for individual supervision in homebased perinatal interventions has meant that criteria for best practice in supervision have often been limited to their quantitative administrative aspects, typically the length and regularity of supervision sessions. Regarding the actual content of these supervision sessions, the literature has tended to make a broad distinction between managerial, practical supervision, ranging from protocol surveillance through clinical supervision, and a more emotionally supportive approach aimed at optimizing supervisees’ reflective capacities; that is, their ability to understand how their own personal feelings and attitudes influence their behavior with their clients (Schafer, 2007). Reflective supervision in preventive intervention programs invites the home visitor to intentionally explore what they see, hear, and do while also taking into account their own emotional reactions to each situation in these potentially demanding interventions (Eggbeer, Mann, & Seibel, 2007; Emde, 2009; Fenichel, 1992; O’Rourke, 2011; Parlakian, 2001; Weatherston & Barron, 2009). Specific guidelines integrating reflective supervision into the field of infant mental health promotion have been published by the Michigan Association for Infant Mental Health, taking into account not only children’s mental functioning, parental functioning, and parent–infant interaction but also the professional’s own personal emotional responses. Supervisees and supervisors are invited to engage in a reflective dialogue (Weatherston, Weigand, & Weigand, 2010). However, although an increasing number of publications have underlined the importance of both program supervision and reflective supervision in home-visiting programs, to our knowledge, only one empirical study to date has specifically set out to identify best practice factors regarding the content of the supervision process itself. Using the Delphi consensus method with experts working in a North American context, Tomlin, Weatherston, and Pavkov (2014) identified 25 criteria unanimously considered to be always essential for quality reflective supervision in infant mental health care practice. The quality criteria could be grouped into five broad themes: Qualities a supervisor demonstrates: The supervisor is compassionate; is tolerant/nonjudgmental; is self-reflective; appreciates parallel process; is reliable and predictable; understands the importance of relationship to health and growth; is a safe and confidential resource; can say “I don’t know;” is able to hold ambivalence during session; is interested in helping supervisee to develop new skills; listens carefully at all times; and communicates warmth to supervisee.

Behaviors a supervisor demonstrates during each session: The supervisor remains attentive to supervisee; is self-aware; observes skillfully; remains engaged; is curious; remains thoughtful; stays open to supervisee; and minimizes distractions during session. Mutual behaviors and qualities necessary for reflective supervision: Both parties exhibit mutual respect; a safe/confidential relationship is maintained between supervisor and supervisee; and mutual respect for professionalism is maintained during the session. Structure of reflective supervision session: a quiet, private space; and sessions that are regularly and consistently scheduled. Process of reflective supervision session: The session maintains an environment that encourages continuous learning and improvement. Although a sixth broad theme was identified concerning the behaviors/characteristics a supervisee demonstrates, none of the qualities included in this theme were unanimously ranked by experts as being “always essential.” Watkins (2014) underlines the importance of the above study as a first step towards an empirical approach in a body of literature that has until now remained primarily conceptual and practical. The findings give major scientific support to the idea that a supervisory relationship is fundamentally a learning alliance: The identified quality criteria are basically a series of relational features that “make learning possible within the supervision dyad or group” (Watkins, 2015). The aim of the present article is to contribute to this debate by describing the results from a study concerning good practice in supervision in a completely different cultural context and with a specific focus on home-based perinatal interventions with highly qualified home visitors and supervisors. Within the context of the CAPEDP perinatal mental health promotion program in France, the present study also used the Delphi method, 2 years into the program, to investigate the supervisors’ points of view concerning best practice for the individual supervision of qualified psychologists working as home visitors in such perinatal home-visiting programs.

METHOD Study Design and Setting of the CAPEDP Project

The CAPEDP Project is a prospective, randomized controlled, multicenter trial with two parallel arms comparing the CAPEDP intervention to usual care. Using Prospective Randomized Open Blinded Endpoint (PROBE) methodology, the program involved a 27-month follow-up for young, primiparous women with risk factors associated with a greater likelihood of mental health disorders in their child. Usual care comprised access to the French public well-child centers and the community mental health network, with no out-of-pocket payment, free antenatal maternity screenings, and a wide range of social services. The intervention group



received, in addition to free access to usual care, the CAPEDP home-visiting program. The CAPEDP program and its outcomeassessment methods have been fully described elsewhere (Sa¨ıas et al., 2012; Tubach et al., 2012). A major specificity of the CAPEDP program is that both the intervention and the assessment sessions were conducted at participants’ homes by two teams of qualified psychologists. All psychologists had at least a master’s degree, including some experience of being supervised through internships in various institutional settings. In total, 440 families were included in the study. The 9 psychologists of the home-visiting team all received specific training in the CAPEDP service implementation protocol, backed up with a comprehensive intervention manual. The program was designed for psychologists to visit families six times during the antenatal period, eight times in the first 3 months of the child’s life, 15 times when the child was between 4 and 12 months of age, and another 15 times during the child’s second year, resulting in a total of 44 home visits during the whole intervention. Between visits, telephone calls could be made as often as necessary. The intervention and its manual were largely based on the work of Weatherston and Osofsky (2009) and the Partners for a Healthy Baby Curriculum (Florida State University Center for Prevention and Early Intervention Policy, 2007). Assessment took place during specific home visits by a team of 7 trained psychologists working independently from the psychologists who performed the intervention program. Assessments were conducted at baseline for demographic and health characteristics and then during home visits at 3, 6, 12, 18, and 24 months after the child’s birth. The assessment team received specific training on each of the assessment tools. A team of supervisors provided weekly individual clinical supervision to all home-visiting psychologists, who also received fortnightly group supervision with the main investigator (A.G.). The supervisors were child psychiatrists and child psychologists working in a variety of different public mental health services across the Greater Paris Area (Ile-de-France). They contributed their supervision time independently from the organization that ran the CAPEDP intervention, and therefore had no hierarchical professional position regarding the home visitors being supervised. The supervisors had experience in psychoanalysis and psychodynamic training, systemic and family therapy, and cognitive-behavioral therapy. All supervisors had a minimum of 5 years of experience in roles of responsibility in infant and child mental health services and at least 10 years of experience working with infants and parents in “hard-to-reach” families. All were experienced supervisors using a variety of supervision approaches that were based mostly on their common psychodynamic background. All had received training on reflective supervision techniques as well as individual supervision during their initial training. Supervisors worked with a maximum of 2 supervisees throughout the study. The team of supervisors met before the research program began to choose a model of individual, nonhierarchical, and reflective supervision, based on the Lister and Crisp (2005), Weatherston

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and Barron (2009) and Weatherston and Osofsky (2009) models of reflective supervision. Supervision was weekly, individual, and lasted at least 1 hour. Supervisees were asked to present at least one home visit at each session. All members of both the intervention and the assessment teams had individual supervision. The team of supervisors met every 3 months, led by the head psychiatrist of a child and adolescent community mental health center. The aim of these meetings was to not to supervise supervision practices themselves but to share ideas, among experienced professionals from different theoretical and experiential backgrounds, regarding the problems encountered during the supervision process. Every 2 months, intervention and assessment teams met separately with the principal investigator and one of the co-investigators to monitor emergency care or child protection issues. A hotline with the principal investigator was available throughout the study for both the intervention and the assessment teams. All home visitors were instructed to contact the principal investigator if there was any concern for the safety of a child, for the mother, or for themselves. Further supervision was provided using video feedback of home visits. In addition, the research team was available at any stage to provide organizational as well as emotional support. Finally, the groups themselves functioned as self-help groups, with the intervention and assessment teams sharing their observations by telephone as well as meeting on a regular basis.

The Delphi Consensus Method

In 2008, 2 years after the program began, a study was conducted using the Delphi method with the 8 supervisors working on the program at that point to identify—in their opinion as experienced supervisors, but also based on their experience as supervisors in the CAPEDP program—the characteristics of quality supervision in perinatal home-visiting programs. All 8 supervisors (7 psychiatrists and 1 psychologist) participated in all phases of the Delphi process. The Delphi process was conducted in three rounds following a standard protocol. In the first round, each supervisor was asked to propose “up to ten or so best practice factors concerning the individual supervision of home visitors in a perinatal home visiting prevention program.” For each factor, supervisors were asked to provide a brief explanation on why they considered this factor to be important. The total list of initial factors was then reviewed by two researchers (a clinical psychologist and a social psychologist), working independently from the supervision team, using the following method: (a) Factors using different wordings to describe the same phenomenon were grouped into one single factor. (b) Factors involving more than one major element were split into more specific entities. In the second round, the resulting 37 factors were then sent back to the supervisors, who were asked to rate, in their opinion, the importance of each of these 37 good-practice factors for the individual supervision of home visitors in perinatal home-visiting


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TABLE 1. Organization and Setting of the Supervision Sessions

The supervisor maintains complete confidentiality regarding what happens during the supervision sessions. Supervision sessions are organized to be regular in terms of place and time. The supervisor is cleared of the responsibility of judicial/Child Protection Services report obligation within the framework of the supervision. The supervisor is fully present during the supervision sessions (no telephone, no other appointments). The supervisor is not in a hierarchical professional position regarding the person being supervised. The supervisor participates in a peer discussion group. The supervisor is not in a hierarchical professional position regarding the persons in charge of the whole project. The supervisor guarantees the anonymity of the cases being discussed. The supervisor remains accessible outside standard supervision sessions.

Mdn (IQR) 8 (6.75–8.25) 8 (4.0–8.25) 7.5 (7.0–8.0) 7.5 (6.75–8.25) 7.5 (6.75–8.25) 7.5 (6.5–8.0) 5.5 (1.75–8.0) 5 (5.0–7.5) 5 (3.75–8.25)

IQR = interquartile range.

TABLE 2. Supervisor Competencies

The supervisor has experience working with mother–child relationships. The supervisor should be a psychologist or a psychiatrist with a theoretical and practical background in care provision for children and families. The supervisor has experience and training in supervision. The supervisor has experience in working with low-income families. The supervisor needs to have some knowledge of ethnography and cultural diversity issues. The supervisor needs to be acquainted with local support networks and available resources.

Mdn (IQR) 8 (8.0–8.25) 8 (8.0–9.0) 7 (6.75–7.25) 7 (6.5–8.0) 6 (3.75–6.25) 5.5 (2.0–7.25)


TABLE 3. Relationship Between Supervisor and Supervisee

The supervisor creates a secure relationship with the supervisee. The supervisor strengthens the home visitors’ interventions by helping them to adapt to their role, to play it well, and to stick to it. The supervisor asks the home visitor to evaluate the supervision. The supervisor regularly takes stock with the home visitor on the supervision work. The supervisor makes it quite clear what the aims of the supervision process are and how the supervision session is to be organized, thus allowing the home visitor to make the most of what is happening during each session.

Mdn (IQR) 9 (8.0–9.0) 7 (7.0–8.25) 7 (5.75–7.25) 6 (5.75–7.25) 6 (4.75–7.0)


programs on a scale from 1 (not important) to 9 (very important). A median (interquartile range; IQR) score based on the scores of the individual supervisors was calculated for each factor. Finally, in the third round, each supervisor was sent the list of 37 factors comparing, for each factor, the score that they had given it to the median (IQR) score for that item for all the supervisors. Supervisors with ratings varying by more than 1 point from the rounded median group rating were asked to reconsider their rating on that factor in the light of the median score for all supervisors.

RESULTS

Using thematic analysis, the 37 final recommendations were grouped by the research team into four general thematic categories: •

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Organization and setting of supervision sessions (n = 9) (Table 1) Supervisor competencies (n = 6) (Table 2)

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Relationship between supervisor and supervisee (n = 5) (Table 3) Supervisor’s intervention strategies within the supervision process (n = 17) (Table 4).

Tables 1 to 4 present the median (IQR) scores for each of these four categories. For the present study, items with a median score >7 on the 9-point scale are defined as being “important recommendations concerning good practice,” which was the case for 18 of the final 37 recommendations. Regarding the organization and setting of supervision sessions (Table 1), the necessity of guaranteeing complete confidentiality regarding what happens during the supervision sessions is clearly seen to be a key element for quality supervision (Mdn = 8; IQR = 6.75–8.25), as are questions of regularity in terms of place and time (Mdn = 8; 4.0–8.25) and the presence and availability of the supervisor, with minimal distractions during the session (Mdn = 7.5; 6.75–8.25). Equally important is the recommendation that



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TABLE 4. Supervisor’s Intervention Strategies Within the Supervision Process

The supervisor shows empathy, and is understanding and attentive. The supervisor acknowledges and valorizes the home-visiting role. The supervisor helps the home visitors understand the limits of their interventions. The supervisor helps the visitor to adopt the appropriate professional attitude, between listening to the family’s problems and intervening with regard to these problems, or seeking outside help. The supervisor does not have a judgmental attitude regarding the home visitor’s choices and opinions during the sessions. The supervisor is aware of transferential and countertransferential issues between the visitor and the families being visited. The supervisor is prepared to adapt his/her role to the home visitor’s needs (emotional support, theoretical contribution, resolution of practical problems, conflict management within the project teams, etc.). The supervisor helps the home visitor to focus on the more sensitive issues, being able to formulate them in an understandable way, and knowing when to seek appropriate help. The supervisor reminds home visitors of the tools that will allow them to achieve each visit’s objectives: framework, content, attitude. The supervisor is aware of transfer and countertransfer issues in the supervisor–supervisee relationship. The supervisor is a professional model for the supervisee. The supervisor understands the program and appreciates its value. The supervisor gives his or her professional opinion as to how the case is progressing. The supervisor is able to identify issues that may not be initially obvious to the home visitor regarding each particular situation. The supervisor plays a more listening role, rather than counseling. The supervisor helps the home visitor find concrete and adapted solutions. The supervisor helps the home visitor use the program’s manualized intervention strategy when handling more complex cases.

Mdn (IQR) 9 (8.75–9.0) 8.5 (8.0–9.0) 8.5 (8.0–9.0) 8.5 (7.0–9.0) 8 (7.0–8.25) 8 (7.5–9.0) 8 (6.75–8.25) 7.5 (6.75–8.0) 7.5 (6.75–8.25) 7 (4.0–7.25) 7 (5.5–7.0) 6.5 (3.75–8.0) 6 (5.0–7.25) 6 (4.5–7.0) 5 (4.75–5.5) 4 (3.0–7.5) 3 (2.5–6.0)


the supervisor should not be in a hierarchical professional position with regard to the person being supervised (Mdn = 7.5; 6.75–8.25), thus allowing supervisees to bring up issues that they may be more reticent to discuss with another employee of the same employer. This is in line with the recommendations (a) that the supervisor should be free from all judicial responsibility including with regard to Child Protection Services (Mdn = 7.5; 7.0–8.0), this being the responsibility of the program coordinator. Finally, the supervisor participating in a peer discussion group with the other supervisors was held to be important (Mdn = 7.5; 6.5–8.0). Concerning supervisor competencies (Table 2), two items scored >7, both of which underline the skills needed for effective perinatal mental health promotion, which was the principal objective of the CAPEDP intervention. First, the supervisor should have experience working with mother–child relationships (Mdn = 8.0; 8.0–8.25) and, second, they should be a psychologist or a psychiatrist with a theoretical and practical background in care provision for children and families (Mdn = 8; 8.0–9.0). Concerning the relationship between supervisor and supervisee (Table 3), only one of the five items scored >7: “The supervisor creates a secure relationship with the supervisee” (Mdn = 9; 8.0-9.0). Finally, concerning the supervisor’s intervention strategies within the supervision process (Table 4), supervisors underline the importance of empathy (Mdn = 9; 8.75–9.0), valorizing the home-visiting role (Mdn = 8.5; 8.0–9.0), helping the home visitors understand the limits of their interventions (Mdn = 8.5; 8.0–9.0), helping the home visitors keep a professional stance (Mdn = 8.5; 7.0–9.0), keeping a nonjudgmental attitude regarding home visi-

tors’ choices (Mdn = 8; 7.0–8.25), being aware of transferential and countertransferential issues between the visitor and the families being visited (Mdn = 8; 7.5–9.0), adapting to the needs of the home visitors (Mdn = 8; 6.75–8.25), helping home visitors to focus on the more sensitive issues and to know when to seek help (Mdn = 7.5; 6.75–8.0) and, last, helping them to use the right tools to achieve their objectives with the families in question (Mdn = 7.5; 6.75–8.25).

DISCUSSION

The present Delphi study within the CAPEDP intervention aimed to describe elements of good practice identified by supervisors after 2 years of supervision in this large, controlled perinatal homevisiting prevention study using qualified psychologists as home visitors. Regarding the relationship that the supervisor should aim to create with the supervisee and the supervisor’s intervention strategies during supervision sessions, results from the present study highlight the value that these highly qualified French professionals place on the reflective supervision approach concerning supervising home-visiting interventions: Supervisors show empathy, are understanding and attentive; they do not have judgmental attitudes regarding the home visitors’ choices; and they take into account transferential and countertransferential issues. Similarly, regarding the organization of the supervision sessions, the present study underlines the importance of establishing a safe and confidential relationship between supervisor and supervisee, with minimal distractions during supervision sessions.


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Concerning the training and experience supervisors should possess and the actual organization of the supervision process, experts in the present study concerning perinatal home-visiting intervention programs—in addition to recommending empathy, valorizing the home-visiting role, keeping a nonjudgmental attitude, and being aware of possible countertransferential attitudes of the home visitors in the family setting—underlined the importance of professional clinical support and advice in the supervision process: helping the home visitors keep a professional stance, adapting supervision to the needs of the home visitors, focusing on the more sensitive home-visiting issues, helping home visitors decide when to seek help, and, finally, helping them use the right tools to achieve their program objectives with the families in question. Clearly, this is reinforced in the CAPEDP program, where all home visitors, although qualified clinical psychologists, were young professionals with little experience with vulnerable families in difficult social situations. Thus, it comes as no surprise that their supervisors, all highly experienced in these matters, often perceived the need for clinical supervision and practical advice to deal with difficult situations. The finding that previous supervisory experience was less valued than was previous clinical experience - the score was below the threshold of being an “important” recommendation - underlines (a) the specificity of professional culture for psychiatrists and psychologists in a European cultural setting which has been so extensively influenced by psychodynamic approaches that reflective supervision is taken for granted as the professional norm, and (b) the fact that the present intervention is the first perinatal health promotion program, to our knowledge, to use only trained professional psychologists as home visitors, none of whom had had prior experience with home visiting with vulnerable families. Furthermore, the fact that these home visitors were exclusively psychologists may well mean that they brought to the table higher expectations concerning supervision and greater awareness of what quality supervision can provide, as compared to home visitors with other professional backgrounds, such as social workers, counselors, or educators. Second, concerning the way supervision is organized within home-visiting programs, experts in the present study emphasized the importance of the supervisor not being in a hierarchical professional position regarding the supervisee, and of being cleared of judicial responsibility, including that with Child Protection Services, arguing that this allows freer discussion around issues that might be too delicate to bring up in front of one’s work colleague or one’s employer. Clearly, in other cultural contexts, where supervisors often have judicial responsibilities within their supervisory role, this sort of recommendation concerning supervisory independence would be impossible. Strengths and Limitations

The principle strength of the present study was that all experts were not only trained psychologists and psychiatrists with years of supervision experience in a large variety of institutional contexts

but that they also had at least 2 years of experience as supervisors on a weekly basis in a perinatal home-visiting program in France. This latter strength also is the principal weakness of this study, in that they were all participating in the same program in the same geographical area. Other experts working on other interventions in other cultural contexts, including in France, may well have identified or prioritized other quality criteria. A further limitation is the relatively reduced total number of experts. Although, as Hsu and Sandford (2007) noted, there is no consensus in the literature on what constitutes the optimal number of experts in a Delphi study, clearly a greater number of participants would have increased the probability of obtaining a comprehensive pooling of judgments regarding the targeted issue.

Conclusion

The CAPEDP perinatal mental health promotion program provided the opportunity to build and then experience a multilayered supervision program with weekly individual reflective supervision and bimonthly group supervision. In France, with its long tradition of psychodynamic approaches, reflective supervision is part of everyday life in professional settings. Within this scientific cultural setting, the professional independence of the supervisor with regard to the supervisee is considered to be an essential element, guaranteeing, within the supervisee–supervisor relationship, a freedom of speech with regard to program implementation and professional constraints that would otherwise be impossible. Regarding the importance placed on clinical supervision in the present study, it is essential to underline that mental health professionals in France rarely receive intensive and specific initial training regarding supporting families with complex psychosocial needs, and this is so despite the fact that they are likely to be faced with increasingly demanding situations in their everyday professional life. In real-life home-visiting programs in different cultural settings, the possible need for clinical and not just reflective supervision cannot be ignored. Watkins’ (2014) learning alliance within the supervisory process necessarily includes a clinical and not just a reflective dimension. By underlining the importance of clinical supervision when working with families in difficult situations, the results of the present study should contribute to optimizing supervision training and procedures in perinatal prevention programs working with vulnerable populations in different cultural contexts. REFERENCES Eggbeer, L., Mann, T., & Seibel, N. (2007). Reflective supervision: Past, present, and future. Zero to Three Journal, 28(2), 5–9. Emde, R. (2009). Facilitating reflective supervision in an early child development center. Infant Mental Health Journal, 30, 664–672. doi:10.1002/imhj.20235 Fenichel, E. (1992). Learning through supervision and mentorship to support the development of infants, toddlers, and families: A source book. Arlington, VA: ZERO TO THREE Press.



Florida State University Center for Prevention and Early Intervention Policy. (2007). Partners for a healthy baby home visiting curriculum. Tallahassee. Fraiberg, S. (1980). Clinical studies in infant mental health: The first year of life. New York: Basic Books. Hsu, C.-C., & Sandford, B. (2007). The Delphi Technique: Making sense of consensus. Practical Assessment Research & Evaluation, 12(10). Available at: http://pareonline.net/getvn.asp?v=12&n=10 Lister, P.G., & Crisp, B.R. (2005). Clinical supervision in child protection for community nurses. Child Abuse Review, 14, 57–72. McGuigan, W.M., Katzev, A.R., & Pratt, C.C. (2003). Multi-level determinants of retention in a home visiting child abuse prevention program. Child Abuse & Neglect, 27, 363–380. Olds, D., Kitzman, H., Cole, R., & Robinson, J. (1997). Theoretical foundations of a program of home visitation for pregnant women and parents of young children. Journal of Community Psychology, 25, 9–25. O’Rourke, P. (2011). The significance of reflective supervision for infant mental health work. Infant Mental Health Journal, 32, 165– 173. Parlakian, R. (2001). Look, listen, and learn: Reflective supervision and relationship-based work. Washington, DC: ZERO TO THREE. Sa¨ıas, T., Lerner, E., Greacen, T., Simon-Vernier, E., Emer, A., Pintaux, E. et al. (2012). Evaluating fidelity in home visiting programs a qualitative analysis of 1058 home visit case notes from 105 families. PLOS ONE, 7, e36915. doi: 10.1371/journal.pone .0036915 Sale, L., & Martin, S. (2006). What makes supervision work: Recommendations from the home visiting field. Retrieved March 2, 2016, from http://eclkc.ohs.acf.hhs.gov/hslc/resources/ECLKC_Bookstore/ PDFs/6AD738B897CA1BCF3825388E700CAF47.pdf

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Schafer, W. (2007). Models and domains of supervision and their relationship to professional development. ZERO TO THREE Journal, 28, 10–16. Tomlin, A., Sturm, L., & Koch, S. (2009). Observe, listen, wonder, and respond: A preliminary exploration of reflective function skills in early care providers. Infant Mental Health Journal, 30, 634–647. doi:10.1002/imhj.20233 Tomlin, A., Weatherston, D., & Pavkov, T. (2014). Critical components of reflective supervision: Responses from expert supervisors in the field. Infant Mental Health Journal, 35, 70–80. Tubach, F., Greacen, T., Sa¨ıas, T., Dugravier, R., Ravaud, P., Tereno, S. et al. (2012). A home visiting intervention targeting determinants of infant mental health: The study protocol for the CAPEDP randomized controlled trial in France. BMC Public Health, 12:648. doi: 10.1186/1471-2458-12-648 Watkins, C.E. (2014). The supervisory alliance: A half century of theory, practice, and research in critical perspective. American Journal of Psychotherapy, 68(1), 19–55. Watkins, C.E. (2015). The alliance in reflective supervision: A commentary on Tomlin, Weatherston and Pavkov’s critical components of reflective supervision. Infant Mental Health Journal, 36(2), 141– 145. Weatherston, D., & Barron, C. (2009). What does a reflective supervisory relationship look like? In S. Heller & L. Gilkerson (Eds.), A practical guide to reflective supervision (pp. 61–80). Washington, DC: ZERO TO THREE Press. Weatherston, D., Weigand, R.F., & Weigand, B. (2010). Reflective supervision: Supporting reflection as a cornerstone for competency. ZERO TO THREE Journal, 31, 22–30. Weatherston, D.J., & Osofsky, J.D. (2009). Working within the context of relationships: Multidisciplinary, relational, and reflective practice, training, and supervision. Infant Mental Health Journal, 25, 424–439.
