Book review: Kamilla Varsha Rawatlal,Clinical Supervision in South Africa: Improving Practice With Limited Resources

Clinical supervision is an essential component in the training of psychologists (Borders et al., 2014). Supervision plays a critical role in gatekeeping the profession of psychology and safeguarding the public through ensuring therapists are adequately trained to provide ethical and competent care (Bernard & Goodyear, 2019; Falender & Shafranske, 2022).

In ‘Clinical Supervision in South Africa: Improving Practice with Limited Resources’, Dr Kamilla Rawatlal tackles the issue of supervising in resource-constrained settings. In this body of work, Rawatlal proffers an ecological approach to supervision that addresses cultural diversity, socio-economic inequalities, and infrastructural challenges. Given the paucity of local texts on clinical supervision, this book is a valuable resource for developing efficient and culturally relevant supervisory practices. It makes a noteworthy contribution to the field of clinical supervision.

Aim and purpose of the book

According to the author, a primary aim of the book is to serve as both a ‘resource and a self-directed supervisory guide’ (p. iv) for psychology trainees, practitioners, clinical supervisors, and other mental health professionals working in environments with limited resources. Rawatlal encourages a shift away from traditional supervision models to an ecological framework, arguing that it provides a more meaningful and contextually relevant approach to supervision. The ecological model incorporates systemic, cultural, and self-reflective elements aimed at addressing the challenges faced by supervisors and supervisees in public practice.

Structure and content

The book is succinctly organized into 10 chapters. Chapter 1 contextualizes the mental health landscape in South Africa, distinguishing between supervision in higher education institutions (Zone A) and the public health care sector (Zone B).

Chapter 2 focuses on logistical challenges, traditional supervision models, how they have evolved over time, and their applicability to South African practice. Rawatlal notes the value of using the ecological framework to conceptualize the cultural contexts of supervisees’ lives, their clients, and the treatment process.

Chapter 3 provides an overview of the Systemic and Relational Ecological framework. Rawatlal specifically draws on Bronfenbrenner’s (1979) ecological framework, outlining how it can be adapted for clinical supervision. The author identifies three key levels: (1) the supervisee’s internal frame of reference, (2) the supervisee’s interpersonal frame of reference, and (3) navigating the external/institutional level and the critical function that the supervisor plays in helping the supervisee navigate a variety of contexts. At each of these three levels, supervisees are carefully guided by supervisors to navigate several different interpersonal, intrapersonal, and institutional challenges. Some of these include managing relational dynamics, ethical dilemmas, emotional detachment, developing professional boundaries, relational strategies, and communication skills. At the institutional level, supervision focuses on assisting supervisees in overcoming organizational challenges or exploring elements influencing professional identity (Bronfenbrenner, 1979).

In the next three chapters, Rawatlal delves into the heart of the model. Chapter 4 unpacks the first level and focuses on the development of professionalism and self-awareness and its importance in developing cultural awareness, including its role in educating and building a thorough awareness of self and others. It is based on the premise that many supervisees are insufficiently prepared at the graduate level to develop deep introspection. The model suggests that if supervisees lack self-understanding, it can limit their ability to learn about others, especially clients from different racial or cultural backgrounds. Rawatlal points out the implications of a lack of self-awareness, as well as the value of resilience and reflective practice in shaping professional identity and professionalism. Supervisees are encouraged to examine underlying motives, strengths, and beliefs, and how social and political context influences their identity, cultural awareness, and worldview.

The focus of Chapter 5 is on strengthening the supervisees’ external frame of reference (the supervisor-supervisee relationship). This chapter examines how self-reflection develops as a structured process when supervisors offer guidance and support. The author draws on Casement’s (1985) concept of the ‘internal supervisor’ before exploring a resilience-based mind-set approach to supervision (Casement, 1985).

In Chapter 6, Rawatlal highlights the shift and expansion in the psychologist’s role, from reactive and remedial service provision to one that is preventive and proactive, allowing for ‘multi-systemic and ecological interventions’. The author also advocates for the use of the biopsychosocial paradigm utilized in the health care system, to assess and manage clients. According to the author, a more balanced approach is needed where case conceptualization is centred on clients’ resources and strengths rather than their shortcomings. Rawatlal, thus incorporates a positive psychology approach to supervision, referred to as a ‘best practice formulation’.

Chapter 7 discusses case management, presenting problem management, outlining client intake, referral pathways, key role players, and various therapeutic orientations. The interplay between the several systemic influences in preventing the onset of pathology and promoting client wellness is also considered, alongside the use of a strength-based counselling model.

Chapter 8 addresses contextual factors such as culture-bound syndromes and cultural responsiveness and practices that have become salient in contemporary professional practice, specifically the shift towards online counselling service delivery prompted by the COVID-19 Pandemic, such as telepsychology, and its ethical considerations.

Chapter 9 delves into the importance of self-care and well-being. The author points out the risk of burnout and compassion fatigue associated with working in a resource-constrained public practice environment. The final chapter considers the usefulness of the ecological model in fostering ethical, competent, and resilient professionals.

Strengths

The book introduces a different approach to clinical supervision. In doing so, the author considers the difficulties faced by supervisors and supervisees in general and those in public service settings with limited resources, in particular. This book advances a model that fosters critical self-reflection, self-awareness, and cultural awareness.

A key strength of the book and its proposed model is its emphasis on the relational and contextual nature of supervision. Unlike general texts on clinical supervision that adopt a Eurocentric or Western approach, this book is grounded in the realities of mental health services in South Africa. The ecological model builds on the developmental models (Stoltenberg & McNeill, 2010), which tend to focus on supervisee growth and progression, by also incorporating culturally responsive practices. It highlights the importance of cultural humility in strengthening the supervisory alliance. Supervisory relationships that lack cultural humility weaken the alliance, risk perpetuating misunderstandings, power imbalances, and biases. This, in turn, may hinder collaboration, trust, and positive supervision outcomes. Supervisees frequently experience racial and cultural microaggressions, resulting in traumatic effects that negatively impact the supervisor-supervisee alliance (Helms et al., 2012; Hendricks & Cartwright, 2018). Therefore, the ecological model would be useful in internship/supervision environments where cultural sensitivity is necessary for effective supervision. Rawatlal maintains that an ecological approach promotes inclusivity, resulting in practitioners feeling valued, supported, and understood. The model encourages practitioners to reflect on their personal practices, inherent biases, assumptions, and underlying beliefs – a crucial process in the internship setting where psychology trainees may feel overwhelmed by several complex personal, professional, and organizational challenges.

This corpus of work also provides insight into the challenges that may be encountered during internship placements and offers realistic, relevant solutions. The inclusion of telepsychology as a contemporary practice area along with cultural competence underscores the text’s adaptability to modern challenges, such as the growing reliance on online platforms post-COVID-19. Integrating telepsychology ethics and guidelines into internship supervision is considered an invaluable addition.

Chapter 10 stands out for integrating self-care and promoting practitioner well-being. Rawatlal broadens the scope of clinical supervision beyond competency and skills development by including a section on self-care guidelines for supervision practice. These guidelines are useful for navigating stressful work contexts, offering practical skills that can foster better relationships with clients, enhancing positive outcomes, improving client care, reducing compassion fatigue, preventing burnout, malpractice issues, and unethical practice. The integration of domains of self-care would assist psychologists-in-training who may struggle with vulnerability to secondary traumatic stress and the emotional demands of working in the mental health field. Borders et al. (2014) outlined 12 key areas of supervision best practices, including goal setting, feedback, and ethical considerations but omitted self-care. In this regard, Rawatlal’s integration of self-care in supervision practice should be regarded as a best practice.

Many traditional supervision models focus less on self-awareness, the relational context of supervision, or self-reflection, and instead place more emphasis on technical skills, knowledge transfer, competence, ethical practice, and professional boundaries. An additional strength is the integration of the ‘personal self’ in supervision, which fosters supervisees’ attunement to their own emotional and relational dynamics, especially relevant in contexts requiring cultural sensitivity, empathy, and understanding the context of clients’ experiences. This practice encourages supervisors and supervisees to explore their own vulnerabilities, strengths, and growth areas.

Limitations

Despite its many strengths, the book has a few limitations. First, while the author acknowledges the evolving nature of supervisor competence, the book could be strengthened by advocating for formal training in supervision and an in-depth focus on the lack of formalized supervision training programmes, aligning with international best practices in competency-based supervision.

Second, although the first few chapters are short, some readers may find the theoretical sections lacking in practical examples, particularly those new to the ecological framework. Third, while the book addresses culture-bound syndrome, the discussion is brief, with the section describing various religious practices among different faiths. Given the prevalence of ancestral calling among students (Zone A), and the overlap in symptomology with psychosis, practitioners would have benefitted from a more thorough explanation of culture-bound syndrome symptom presentation, manifestation, assessment, and management. Of the four worldviews discussed, the section on the Islamic faith appears fragmented – the explanation is superficial, lacks depth, and reflects minimal engagement with current research. For example, the author focuses primarily on treatments, instead of highlighting Muslims’ beliefs about the causes of mental illness and other culture-bound syndromes. Some Muslims attribute mental illness to affliction, ‘jinn’ possession, or ‘Sihr’ (black magic), while others attribute it to a mix of internal, external, or supernatural factors (Rassool, 2018). These perspectives are rooted in Islamic tradition and greatly influence the perception of mental illness and practices of some Muslim traditional healers (Rassool, 2018). The author’s reference to the religious practice of ‘Eid-ul-Fitr’ (a Muslim celebration marking the end of Ramadan) may confuse the reader as it is unrelated to mental illness. Incorporating an Islamic indigenous perspective on mental illness and treatment methods may have contributed to a more comprehensive understanding of this worldview and enhanced understanding of Muslim clients’ cultural and traditional beliefs and practices.

Certain sections could be expanded for greater practical relevance. For example, Chapter 8 focuses on several key contextual elements that supervisees need to be aware of, such as ethics in teletherapy, micro-skills, and guidelines on setting up a teletherapy session, culture-bound syndrome, the clinical use of photography, and career counsellor competencies in the 21st century. A stronger emphasis on the use of psychological assessments, including psychometric tools relevant to both Zones A and B (career and projective assessments), is important training competencies that have been omitted, and importantly, how interns and supervisors can navigate the lack of psychometric assessments in resource-constrained settings. In addition, given that psychologists often work alongside medical professionals, social workers, educators, and key university stakeholders (SRC, student advisors), the author could have strengthened the contribution by explicitly emphasizing the importance of interdisciplinary collaboration, and multidisciplinary teamwork, both of which are instrumental in enhancing practical skills.

While the author considers ethical issues in teletherapy, a deeper exploration of supervision-related ethical dilemmas such as dual or multiple relationships, confidentiality in multidisciplinary teams, informed consent, and so on, would provide additional guidance for supervisees.

Although the author introduces the concept of cultural humility, the discussion is brief and overlooks strategies for implementation within supervision. The use of current research on cultural humility to demonstrate its impact on the supervisory relationship and patient outcomes, especially among marginalized populations, would have also enhanced the conversation. Research on cultural humility identifies it as a best practice in supervision, because it enhances multicultural competence, strengthens the supervisory alliance, increases supervisees’ receptivity to feedback, and promotes active engagement in supervision (Upshaw et al., 2020; Watkins et al., 2018). Moreover, placing a high value on cultural humility may be regarded as both a professional necessity and a hallmark of best practice (cf. Vandament & Shengnan, 2021). Supervision, by definition (Bernard & Goodyear, 2019), involves an unequal power dynamic, and supervisees are generally reluctant to bring issues of race or culture into supervision, because doing so may negatively affect their evaluations and also depends on them getting along with their supervisor (Burkard et al., 2006). Practitioners and supervisors might have benefitted from a greater focus on cultural humility as well as a general explanation of how supervisors can incorporate cultural humility into their daily supervision practice.

Given the documented prevalence of negative supervision among interns in South Africa (Hendricks & Cartwright, 2018), an exploration of power dynamics, race and culture, role conflict, and key aspects of the supervision process could have enriched the discussion. The book’s practical relevance might have been further enhanced by the inclusion of case studies demonstrating issues related to cultural humility, the supervisory relationship, culture-bound syndromes, and ethical dilemmas in teletherapy. Similarly, including practical examples when explaining the model would have bridged the gap between theory and practice.

Finally, the use of dated references, textual repetitions, grammatical, and syntax errors throughout some parts of the text diminish clarity and impact. Future editions would benefit from a comprehensive editing process to enhance readability.

Conclusion and recommendations

Clinical Supervision in South Africa: Improving practice with limited resources is a valuable contribution to the psychology field. This book is not intended to offer guidelines on how to carry out supervision. However, it offers practitioners a useful guide to supervising in resource-constrained settings. The inclusion of a broader Afrocentric perspective could extend its relevance beyond South Africa. Despite the shortcomings, the book’s strengths far outweigh its limitations, and its proposed framework is relevant and impactful.

Shariefa Hendricks Head: Counselling & Career Development Unit-KwaZulu Natal Student affairs and Regional Services, University of South Africa Email: [e-mail]