LPC Models and Techniques in Clinical Supervision

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This is part 3 of 5 in a 30 hour lecture series on Clinical Supervision for Mental Health Professionals. This was made for the Approved Clinical Supervisor Certificate through the NBCC. This 6 hour course on Models and Techniques of Clinical Supervision uses a didactic lecture format followed up with experiential learning exercises, that cover many different models of conducting clinical supervision and different techniques utilized in clinical supervision. Areas covered include a working definition of clinical supervision, breaking down this definition into the components that make up clinical supervision. The Integrated Developmental Approach to supervision (Stoltenberg & Delworth) is discussed in detail, covering descriptions of level 1, 2 and 3 counselors and supervisors. Next other models of supervision are also covered, including the Discrimination Model of supervision (Bernard), the systems model of supervision (Holloway), and the Blended Model of supervision (a model crafted specifically for working with drug/alcohol counselors by Powell). Next discussed are supervision interventions and techniques (including case conferencing, utilizing self reports, process notes, audio taping, video taping and utilizing live supervision). Teaching methods include lecture, interactive exercises and group participation/discussion.

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LPC Models and Techniques in Clinical Supervision

  1. 1. Models and Techniques of Clinical Supervision Glenn Duncan LPC, LCADC, CCS, ACSCopyright © 2012, Advanced Counselor Training Do not reproduce any workshop materials without express written consent.
  2. 2. Definition of Clinical Supervision “An intervention provided by a more senior member of a profession to a more junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s), monitoring the quality of professional services offered to the client(s) she, he or they see(s), and serving as a gatekeeper of those who are to enter the particular profession” (Bernard & Goodyear, 1998; p. 6).
  3. 3. Components of Clinical Supervision Def. Relationship: Supervision is primarily, and most importantly, a relational situation between a senior and more junior member of a given profession (Watkins, 1997).• All of the supervisory approaches listed in this article recognize the importance of the supervisory relationship.• Without the relationship, all the tasks, skills, and other tools of supervision will either be less effective or not effective at all.• It is the belief of this writer that the relationship is so important, that key aspects of the supervisory relationship need to be looked and studied.
  4. 4. Components of Clinical SupervisionDef. Evaluation: A core function of supervision is evaluation of supervisees.• This evaluation takes the form of telling supervisees what their strengths and weaknesses are, what areas need to be developed, enhanced or improved, and monitoring supervisee client care (Watkins, 1997).
  5. 5. Components of Clinical SupervisionDef. Evaluation: Tasks involved in comprehensive supervisee evaluation:1. Assess supervisee’s performance of tasks and/or clinical functioning by interviews, observations, review of case records, use of periodic evaluation tools, and client feedback.2. Assess supervisee’s preferred learning style, motivation and suitability for the work setting.3. Institute an ongoing formalized, proactive process that identifies supervisees’ training needs.4. Actively involve supervisees in reviewing goals and objectives, and reinforce performance improvement in specific areas.5. Assess supervisees’ professional development level, cultural competence, and proficiency in the addiction counseling field.6. Communicate agency expectations about the job duties and competencies, performance indicators, and criteria used to evaluate job performance.7. Communicate that supervision is a two-way feedback mechanism with each party providing feedback to one another, including constructive sharing and the resolution of disagreements/disputes.8. Communicate feedback clearly, timely, monitoring and updating supervisee on performance improvement of deficiencies.
  6. 6. Components of Clinical SupervisionDef. Extends Over Time: This is one of the key distinctions between supervision and consultation.• Consultation is usually a time limited event, and often times is not evaluative in nature.• Supervision is more of a process where the supervisee has the time to professionally learn and grow.• This time can last from months to years, depending on the level of the supervisee, organizational influences and the like (Watkins, 1997).
  7. 7. Components of Clinical SupervisionDef. Enhancing Professional Functioning: A primary function of supervision is to help the supervisee become more proficient regarding becoming an LPC, and utilizing evidence based treatment models. • Conceptualizations as to what is important for the clinician to master in order to strive towards becoming an expert therapist vary depending on the theorist.
  8. 8. Components of Clinical SupervisionDef. Serving as Gatekeeper: This is a function that is consistent with the monitoring function of supervision.• If supervisee performance continues to jeopardize client care, the supervisor acts as the agent of change for that supervisee (whether that be additional training and education, recommendation of personal counseling, progressive disciplinary actions, or even in extreme cases termination from employment or field placement).• Whatever the decision, it is the supervisor who is responsible for making that judgment and serving as the gatekeeper (Watkins, 1997).
  9. 9. Components of Clinical SupervisionDef. Monitoring Quality of Professional Service: Supervisors are ultimately responsible for the treatment client’s receive. A supervisor’s first responsibility is for the welfare of the client, then the supervisee, finally the organizational structure of the facility in which they work.1. At what point does a supervisor wait for “acceptable” performance from a supervisee?2. At what price to the client?• A supervisor should intervene immediately and take action as necessary when a supervisee’s job performance appears to present problems and/or put the client at risk.• Without proper and vigilant monitoring of supervisee performance, client care can be compromised or even jeopardized (Knapp & VandeCreek; as cited in Watkins, 1997).
  10. 10. Components of Clinical SupervisionDef. Monitoring Quality of Professional Service (job performance issues):• Supervisors will actively participate in the following administrative functions to maintain high standards of clinical care: 1. Hiring (which includes background, criminal, licensure/certification verification, references, etc.) 2. Termination (ensuring due process has occurred and the correct policy and procedures have been followed in this the termination process. 3. Performance recognition (catching people doing something right). 4. Progressive disciplinary action (according to the policies and procedures of your organizations and the standards of care). 5. Other personnel decisions
  11. 11. Components of Clinical SupervisionDef. Monitoring Quality of Professional Service (pharmacological treatment):• Supervisors need to ensure supervisees are trained and knowledgeable in the latest pharmacological interventions for mental health disorders.• Supervisors need to ensure supervisees are trained and knowledgeable in the latest pharmacological interventions for substance use disorders (such as methodone, naltrexone, suboxone, and vivitrol among others).• Supervisors should be aware of their own biases (if any) surrounding these interventions and ensure that if a bias exists, it is not passed on to supervisees.
  12. 12. Style, Theory and TechniquePretest1. How would you describe your style of supervision?2. How do you approach supervision with a new supervisee?3. What methods do you use to oversee your supervisee? Do these methods differ depending on the supervisee, if so how?
  13. 13. Style in Supervision • Style is the patterns we use in attempting to communicate with others. • Style consists of the recurring and consistent focus supervisors emphasize in supervision, the manner in which they state their theoretical orientation, the philosophy and practice of supervision they hold, and how they convey this to their supervisees. • Common elements of style include voice volume, voice tone, facial expressions, posture, use of arms and hands, examples given, organization and structure of sessions, physical setting of sessions, theories used, points chosen to intervene in discussion, how suggestions are made, and what suggestions are offered.
  14. 14. Observing One’s Style • The best way to observe a supervisor’s style of supervision is through viewing audiovisual recordings of supervisory sessions. • Supervisors should be exposed to the work of other supervisors in order to develop their styles. • The supervisor needs to develop an orientation or frame of reference to supervision that incorporates his/her style. This relates to the focus of the supervisory relationship (i.e., the focus should be that the primary responsibility is to the client). Practitioners who are having difficulty with their job may attempt to deal with this by attributing the difficulties to problems they are having with the supervisor. It is the supervisor’s responsibility to keep the focus on the client under discussion.
  15. 15. Main Styles• Active Style of Supervision – the active style consists of being direct with the supervisee and asking specific questions, answering questions directly, and offering interpretations. Active supervision is problem focused, based on exploring alternative interventions, focused on client dynamics, and speculative about outcomes.• Reactive Style of Supervision – This is a more subdued and indirect style. It involves asking limited general questions and not giving answers. Reactive supervision focus on the process of treatment, explores issues about interaction, and tends to focus on the practitioner dynamics, providing a forum for practitioners to struggle with their own solutions.
  16. 16. SubStyles• Philosopher – This is when a supervisor takes the everyday material from a supervisee and become philosophically abstract with their feedback. For example, a frustrated supervisee on a case will get the response “It takes 10 years before a therapist begins to know what he’s doing”. While making a philosophical point, supervisee’s can become easily frustrated with the lack of clear direction from the supervisee.• Theoretician – These supervisors believe the mastery of theory leads to good practice. Case material will be used as a means to understanding theory.
  17. 17. SubStyles • Technician – Technician style is dealing with the details of case problems and relates them to technical skills. The emphasis here is on what should be done, and this style is more problem focused and interactionally oriented. Technical Strategy takes 3 forms - Planning – planning strategies and techniques that can be used in cases. - Explanation – telling the practitioner what to say to the client. - Description – after the fact exploration of the material. Here the supervisor’s task is to explore interventions and get the supervisee to differentiate the intent of a given intervention and the actual effect that occurred.
  18. 18. The Integrated Developmental Model(Stoltenberg & Delworth, 1998) Stoltenberg & Delworth identified eight growth area domains for supervisees:1. Intervention skills competence2. Assessment techniques3. Interpersonal assessment4. Client conceptualization5. Individual differences6. Theoretical orientation7. Treatment plans and goals8. Professional ethics
  19. 19. The Integrated Developmental Model(Stoltenberg & Delworth, 1998) This model depicts the developmental levels of both clinicians and supervisors according to 3 basic structures:• Autonomy – the ability to make independent decisions, the degree of supervision required, and self-confidence.• Self and Other Awareness – fears, anxieties, and uncertainties, and how certain behaviors affect the client and others.• Motivation – process of counseling, desire to help others, and learning of strengths and weaknesses.
  20. 20. Level 1 Clinician Characteristics• It is believed that Level 1 clinicians take in paradigms of therapy and match them against their own personal experiences. Thus the paradigm that best fits their own personal experiences is the one normally used. They tend to overuse one model.• Thus level one clinicians develop simplistic understanding of complex structures, and may generalize behaviors and develop “types” of clients, not allowing for individual differences.• Level 1 clinicians are primarily focused on themselves. This focus on self includes their own anxiety about being a clinician, their lack of skills and knowledge, and the likelihood that they are being regularly evaluated.
  21. 21. Level 1 Clinician Characteristics• These preoccupations can have a negative impact on therapy in that less energy is available to focus on the task at hand with the client.• Cognitively, Level 1 supervisees are concerned with learning new information, performing the newly acquired skills, and understanding the process of therapy in a suitable manner.• This leaves little room for the clinician to be focused on the client and understanding the client’s perspective.• Has cookbook answers, limited treatment plans, lacks integrated ethics, lacks self awareness, emulates role model, anxiety is motivator.
  22. 22. Level 1 Clinician SupervisionIssues • Be sensitive to supervisee anxiety. • Promote autonomy. • Encourage risk-taking. • Expose supervisees to different models. • Help supervisees to conceptualize. • Use role play, application, and presentations. • Address strengths as well as areas of needed growth (but strengths first). • Be aware of trainees learning styles: 1. Internal (they can make things happen) vs. External (other forces in control of events). 2. Active (learn by doing, give them independent assignments) vs. Vicarious (benefit from directive skill building and modeling). 3. Oral (learning best through discussion) vs. Written (learning best through written information).
  23. 23. Level 1 Clinician SupervisionIssues • View clinicians with mirror work, videotapes, co-facilitating. • Relying on self-reports or even process recordings (techniques which will be discussed in more detail later), would not be sufficient because Level 1 clinicians cannot always perceive accurately what they are doing in a session with a client. • Expose supervisee to numerous orientations and models (skills training). • Training different skills can help the therapist gain confidence and move the therapeutic environment forward.
  24. 24. The Transition from Level 1 to 2• Resolution of Level 1 issues allows the supervisee to move into Level 2. This transition can be facilitated, or hindered, by the supervision environment.• This developmental sequence occurs within domains, so we may expect to find differential growth across domains. (For example, substance use clinical work, these domains would consist of the 12 core functions (domains) and there are core competencies within each domain that must be mastered).• This differentiation may be a function of more of a focus on some domains rather than others during prior supervision, resulting in greater growth in these domains than others (e.g., hiring a staff member who worked in a TC setting who may have much more experience with group techniques, and encounter and confrontation techniques, and less experience with assessments, individual treatment and less confrontational techniques such as motivational interviewing).• The supervisees personal characteristics may be better suited to particular domains of practice, and there may be more rapid growth in those domains.
  25. 25. Level 2 Clinician Characteristics• Level 2’s are envisioned as making a transition across various domains, from a primarily self-focus to a client centered, from dependence on the supervisor to a sense of independent functioning, and from high levels of motivation to fluctuating levels of motivation.• This can be a tough time for both supervisor and supervisee, marked by periods of disruption, resistance, ambivalence, and instability.• These factors can lead to deeper chasms between supervisee and supervisor, or could result in a deeper understanding of clinicians’ skills and personal characteristics.• Motivation fluctuations are another hallmark of this stage of development. The confidence that accompanies perceptions of self-efficacy in clinical practice can be shaken by the increased knowledge of the complexity of the recovery process.• This could become evident with differences in clinician performance depending on which client, not completing tasks requested by the supervisor, or questioning their career choice.
  26. 26. Level 2 Clinician Characteristics• This could become evident with differences in clinician performance depending on which client, not completing tasks requested by the supervisor, or questioning their career choice.• The transition issues for this level of trainee revolve around the goal of personalizing an orientation to professional practice. A self-understanding that can develop from learning how ones personal characteristics interact with clinical practice issues forms the basis for the work of Level 3.• As the Level 2 therapist transitions to Level 3, a more consistent conditional autonomy will appear. This supervisee is better able to understand the parameters of his or her competence, and the dependency-autonomy conflict will fade.• They are better at conceptualizations, better at theory, focus more on the client, better formed ethics, better cultural awareness, greater awareness and confusion.
  27. 27. Level 2 Clinician SupervisionIssues • The task of the supervisor with Level 2 clinicians is to provide a balance between supporting and mentoring the supervisee, and fostering independence and self-assurance within the clinician. • Structured interventions, such as those listed for Level 1 clinicians, can be less frequent for Level 2 clinicians. However, given that the level 2 clinician may be taking on new types of clients that they have not encountered before, structured interventions should be skill dependent. • In order to enhance the growth of Level 2 clinicians, they should be challenged to provide the reason for providing certain interventions with clients. • Challenging a clinician and forcing them to articulate their conceptualizations of the client, the interventions they chose, and possible alternatives, are important during this time. • Sandwiching feedback is important.
  28. 28. Level 3 Clinician Characteristics • Level 3 clinicians are able to fully empathize with, and understand the client’s perspective on the world. • Client conceptualizations, environmental cues, and personal reactions (transference and countertransference issues) will be more easily recognized. • This stage is also marked by a better understanding of human behavior and the therapeutic process. • Motivation that vacillated during Level 2 development now approaches a more stable level. • Autonomy increases during this stage of development. • They have the following: a deeper client understanding, understanding of their own limits, accepting of supervisor with different orientation, broad ethical knowledge, able to switch tracks with clients, appropriately uses self in therapy.
  29. 29. Level 3 Clinician SupervisionIssues • Role of supervisor is to guide the supervisee toward mastery and integration of all domains, from assessment to treatment to aftercare. • Although the utility of supervision still remains for this level of therapist, the implementation of it becomes considerably more collegial, and there becomes a much less differentiation of expertise and power in the supervisory relationship. • For the Level 3 clinician, structure in supervision usually comes from the supervisee, rather than the supervisor. That is, this level of clinician knows what they need from supervision at any given time. • Supervision takes on the facilitative tone (support, caring, confrontation when needed) as opposed to the structured one (specific interventions such as live observations). • A common form of supervision with Level 3 therapists is collegial, informal group supervision. • While they can work with a level 2 or even 1 supervisor, they really need a level 3 supervisor.
  30. 30. Supervisor Developmental Tasks• Level 1: anxious about supervising, relies on how he/she was supervised in the past as a model for their supervision, anxious about having to provide feedback, plays the “expert” role, invested in supervisees following their model of therapy. Trouble with level 2 and 3 supervisees.• Level 2: resembles level 2 therapist regarding confusion and conflict, sees supervision as multidimensional, has fluctuating motivation, focuses more on the supervisee, may engage in doing therapy with supervisees, works best with level 1 supervisee but o.k. with level 2’s.• Level 3(i): motivation becomes stable and consistent as the supervisor is interested in improving his/her performance, supervisor is functionally autonomous but may seek supervision. Supervisor is able to make honest appraisals of his/her strengths and weaknesses. Level 3 supervisors can work equally well with diverse supervisees but may have preferences for level 3’s. Is a level 3 counselor.
  31. 31. Clinician and SupervisorCharacteristics Exercise Jeff is a therapist who has been working in your organization for 3 ½ years. He views himself theoretically oriented in cognitive behavioral therapies and feels that this is a model that best fits his client population (outpatient drug/alcohol clients). He is a clinician who views outpatient drug/alcohol treatment from a strict abstinence point of view. You recently sent you and your staff to an intensive training on new ways of treatment planning, which incorporated the use of ASAM PPC criteria, Prochaska and DiClemente’s Stages of Change Model, and Motivational Interviewing. This presentation viewed treatment planning as a fluid construct that really depended on the motivation level of the client. This model of treatment planning posited that if you as the clinician have a treatment goal of abstinence, and the client is in “precontemplation” regarding his drinking problem, then the treatment goal is an inappropriate one, and should be geared more towards the client gaining an understanding as to whether substance use is a problem or not, as opposed to the “action” goal of abstinence.
  32. 32. Clinician and SupervisorCharacteristics Exercise At that moment in the presentation, Jeff got into a confrontation with the lecturer regarding the lecturer’s stance on “harm reduction” work with clients when the appropriate and accepted modality of working with drug/alcohol clients is through abstinence based work and 12- step programming. A brief, yet heated discussion of the pros and cons of working with a client as opposed to against the client’s level of motivation ensued. Jeff was unable to conceive the possibility that there are other routes towards getting a person on the path of sobriety than the one he subscribes to. Four days have passed since then, and it is your first supervision session with Jeff. Before entering supervision with him, you sit down to note what had occurred just recently in the seminar, and what you wanted to address with him regarding the seminar.
  33. 33. Clinician and SupervisorCharacteristics Exercise1. Given what has occurred during at the seminar with Jeff, how are you going to enter this supervision session with him?2. What level of clinician is he according to the Stoltenberg and Delworth Developmental Model? How will your determination of clinician level impact the way you decide to handle this situation?3. How does your own theoretical orientation regarding the treatment of drug/alcohol clients, and your perception of that model of treatment planning, impact on your intervention(s) with Jeff.?
  34. 34. The Discrimination Model ofSupervision (Bernard, 1979, 2009) Supervisors will tailor their responses to the particular supervisee’s needs (thus the name Discrimination) Supervisors Focus on supervisees’: 1. Conceptualization skills include the supervisee’s ability to make some sense of the information that the client is presenting, to identify themes that occur in counseling, and to discriminate what is essential information from what is nonessential. These are mainly conceptualization skills that fall under assessment. 2. Process skills refer to the observable activity of the supervisee. Process is probably a poor phrase to use, since processes can also refer to the internal realities of the clinician, or the examination and analysis of internal realities. 3. Personalization skills include the contributions of the supervisee as an individual. This incorporates aspects of the person such as their personality, cultural background, sensitivity towards others, and sense of humor.
  35. 35. Roles and Aspects of this Model• The Discrimination Model identifies three roles that the supervisor needs to adopt in order to facilitate the development of the clinician: teacher, counselor, and consultant.• The teacher role is taken by the supervisor to determine what is the necessary skill and knowledge base required for the supervisee in order to become more proficient. 5 activities encompassing the teacher role are:1. Evaluate observed counseling session interactions.2. Identify appropriate interventions.3. Teach, demonstrate, or model intervention techniques.4. Explain the rationale behind specific strategies and/or interventions.5. Interpret significant events in the counseling sessions.
  36. 36. Roles and Aspects of this Model• The counselor role is taken by the supervisor when interpersonal or intrapersonal realities of the supervisee are addressed. 5 activities encompassing the counselor role are:1. Explore supervisee feelings during counseling session or supervision session.2. Explore supervisee feelings concerning specific technique and/or interventions.3. Facilitate trainee self-exploration of confidence and/or worries in the counseling session.4. Help the supervisee define personal competencies and areas for growth.5. Provide opportunities for trainees to process their own feelings or defense.
  37. 37. Roles and Aspects of this Model• The role of consultant occurs when the supervisor allows for a more collegial, less hierarchical atmosphere, allowing the supervisee to share responsibility for his/her learning. In short, it is the development of autonomy for the supervisee. 5 activities encompassing the teacher role are:1. Provide alternative interventions and/or conceptualizations for the supervisee.2. Encourage supervisee brainstorming of strategies and/or interventions.3. Encourage supervisee discussion of client problems and motivations.4. Solicit and attempt to satisfy supervisee needs during the supervision session.5. Allow the supervisee to structure the supervision sessions.
  38. 38. The Holloway Systems Model(1995) • The purpose of the Systems Approach is to provide a framework and a language based on the empirical, conceptual, and practical knowledge to guide the supervisory process. • The Structured Approach of Supervision (SAS) views the primary goal of supervision as the establishment of an ongoing professional relationship between the supervisor and supervisee. • The supervisor designs specific tasks and teaching tactics related the supervisee’s professional development. • The SAS model has five specific goals:
  39. 39. The Holloway Systems Model(1995) 1. The goal of supervision is to provide an opportunity for the supervisee to learn a broad spectrum of professional attitudes, knowledge, and skills in an effective and supportive manner. 2. Successful supervision occurs within the context of a complex professional relationship that is ongoing and mutually involving. 3. The supervisory relationship is the primary context for facilitating the involvement of the learning in reaching the goals of supervision. The essential nature of this interpersonal process bestows power to both members as the form the relationship. 4. For the supervisor, both the content and process of supervision become an integral part of the design of instructional approaches within the relationship. 5. As the supervisor teaches, the trainee is further empowered by acquiring the skills and knowledge of the professional work, and gaining knowledge through experiencing and articulating interpersonal situations.
  40. 40. The Holloway Systems Model(1995) 1. The Supervisory Relationship. The Supervisory relationship is divided into 3 sections: 1) interpersonal structure of the relationship (the dimensions of power and involvement); 2) phases of the relationship (relationship development specific to the supervisees); and 3) supervisory contract (the establishment of a set of expectations for specific tasks and functions). 2. The phases of the relationship are subdivided into three parts: 1) beginning phase; 2) mature phase; and 3) terminating phase. 3. The supervisory contract involves the clarity of expectations from the supervisor and the supervisee. The clarity of these expectations directly impacts the supervisory relationship and the learning objectives. Thus the dyad is not only identifying specific tasks, they are also defining the parameters and boundaries of the supervisory relationship
  41. 41. The Holloway Systems Model(1995) • Tasks of Supervision. The tasks of supervision are the professional knowledge necessary for the clinician to perform. Categories of teaching skills for supervisees include: 1) counseling skills; 2) case conceptualization; 3) professional role; 4) emotional awareness; and 5) self-evaluation. • Functions of Supervision. Holloway (1995) describes the functions of supervision as the roles of the supervisor. The five functions that the supervisor takes on while working with the supervisee are: 1) monitoring/evaluating; 2) instructing/advising; 3) modeling; 4) consulting; and 5) supporting/sharing.
  42. 42. The Holloway Systems Model(1995) • Each of the 5 tasks and 5 functions can interact with one another, allowing for a total of 25 total combinations (e.g., the function of modeling, combined with the task of self- evaluation). • Still, 4 contextual factors also have to be factored into this model: 1. Supervisor Factors 2. Trainee Factors 3. Client Factors 4. Institutional Factors 5. Political Factors
  43. 43. Competency-Based Supervision(Falender & Shafranske, 2004) • All models to supervision are intended to develop competence. A competency-based approach provides an explicit framework and method to initiate, develop, implement, and evaluate the processes and outcomes of supervision. – Falender & Shafranske (2004) believe personal traits, values, and pre- existing interpersonal competencies are some of the bases upon which the foundation of clinical expertise (and depending on these features clinical biases) are developed. – Next, education and life experiences contributes to the acquisition of knowledge, skills, abilities and values that help to initially forge the conceptualizations and socialization to the profession. – Clinical training then provides the integrative learning experiences in which skills, abilities, knowledge and values interact, form learning trends, and with practice (under supervision or sometimes even without supervision), become clinical competencies.
  44. 44. Competency-Based Supervision(Falender & Shafranske, 2004) – Competencies are specific external standards of professional functioning (an acquisition of skills and understanding). – Central to a competency-based approach is the identification of learning goals and objectives that lead to the development of measurable competencies. – Competencies are developed through reflection, conceptualization, planning, practical experience and experimentation within a structured learning environment.
  45. 45. Competency-Based Supervision(Falender & Shafranske, 2004) The critical role of supervision in a competency based is the following: 1. The supervisor must have working knowledge of the specific evidence based treatment methodologies that they will be using with their supervisees. 2. In working with the supervisee, supervisors must help the supervisee in identifying the knowledge, skills, and values that form the basis of competency in a particular evidence based training (EBT). 3. Supervisors will then utilize specific learning strategies and evaluation procedures to sequentially build the supervisee’s skills appropriate to the supervisee’s clinical setting. 4. High quality competency based supervision requires direct observation of supervisee’s counseling, the use of performance feedback and individualized coaching, and the utilization of practice scenarios and role playing. 5. Feedback and coaching consists of discussing techniques utilized, skill when implementing strategies/techniques, and discussion of any strategies that are incompatible with the EBT.
  46. 46. The Blended Model of Supervision(Powell,1993, 2004)• Philosophical Foundation of the Blended Model1. People have the ability to bring about change in their lives with the assistance of a guide.2. People do not always know what is best for them, for they may be blinded by their resistance to and denial of the issues.3. The key to growth is to blend insight and behavioral change in the right amounts at the appropriate time.4. Change is constant and inevitable.5. In supervision, as in therapy, the guide concentrates on what is changeable6. It is not necessary to know a great about the cause or function of a manifest problem to resolve it.7. There are many ways to view the world.
  47. 47. The Blended Model of Supervision(Powell,1993, 2004)• Two Other Foundations of the Blended Model1. Stage of Development – the supervisee’s (and supervisor’s) level of training, experience, knowledge and skill.2. Contextual Factors – characteristics of the client, counselor, supervisor, and setting that affect the environment of supervision.• The Blended Model is a supervisory process that blends insight-oriented with skills-oriented approaches.• The Blended Model utilizes these foundations, along with it many descriptive dimensions in order to structure its view of clinical supervision when working with the substance abuse counselor.
  48. 48. Other Models of Supervision Other Models of Clinical Supervision• Psychodynamic Model of Supervision• Cognitive-Behavioral Model of Supervision• Family Therapy Model of Supervision• Person-Centered Model of Supervision• Feminist Model of Supervision• Solution Oriented Model of Supervision
  49. 49. Random Licensure Fact of the Day• LPC/LAC DCA Licensure requires that every licensee put their license number on any promotional or marketing materials, including business cards.
  50. 50. Supervisor vs. Supervisee Exercise You were just hired as a consultant clinical director. Your private practice allows you to be consultant to this organization as a part-time clinical director of 2 different organizations. Before coming into the job, you were not told who else is employed in a supervisory capacity at the agency. Tom is one of your supervisees now, and he is currently supervising three other clinicians, in his function as the outpatient supervisor. You supervise Tom and two others, both of whom run different departments in the agency. Tom was a recent hire, approximately six months ago, and is 28 years old and has his LPC. This is Tom’s first supervisory position. Tom just acquired his LPC 7 months ago. Tom, who was hired 6 months prior to you coming on board, comes to you in supervision to discuss an issue that had been going on since he entered the organization. The issue is one of his supervisees is resistant to Tom. One supervisee, Jason, outwardly states he will not follow some of Tom’s suggestions. Jason has been working in the field of mental health for 8 years and has his master’s in counseling psychology, but is has never pursued his licensure. Just this past week Jason told Tom he does not need supervision, and does not want supervision from “somebody younger than some of the scars on his body. Yes Jason can be quite descriptive sometimes.
  51. 51. Supervisor vs. Supervisee Exercise Tom’s other two supervisees are young clinicians, just out of college 1 year (both with master’s in counseling degrees, both unlicensed). Tom states supervision with them is not problematic. When Tom first presented this issue, you had thought it could be due to the fact that he is new to the position and Jason had been in the position for over 8 years. What Tom does not know is that Jason applied for the supervisory position, but did not get it, due to the fact that he was unlicensed. In the past you have checked in with all three clinicians as to how things are going with Tom, and the answers received from Jason is that Tom’s suggestions are at times over simplified, and if more suggestions are required, Tom becomes rigid and defensive. He also stated that Tom doesn’t appear to have a good grasp of many different therapeutic approaches, and when Jason wants to talk about utilizing more appropriate, confrontational approaches, Tom answers back with “some motivational, sissy crap suggestions.” Both you and Tom are seeing that the difficulties aren’t due to an issue of adjusting into a new staff, as there is a definite lasting problem. Tom comes to you wanting to know what to do as he is frustrated. All staff within this program have definite strengths and bring a lot of good help to the clients they serve.
  52. 52. Supervisor vs. Supervisee ExerciseQuestions1. What level of supervisee is Jason according to the IDM? What level of supervisor is Tom?2. Are any of the dynamics you see expected given the level of professional development in both your clinical supervisor and his supervisees?3. What suggestions do you have for Tom?4. Is it appropriate that Tom know that Jason applied for his job, but did not get it? Why or why not?5. Is there an issue here regarding Tom as supervisor? If so what? What is the corrective action plan you would suggest to the organization?
  53. 53. Supervision Interventions• Borders and Leddick (1987) listed six reasons for choosing different supervision methods.1. The supervisee’s learning goals.2. The supervisee’s experience level and developmental issues.3. The supervisee’s learning style.4. The supervisor’s goals for the supervisee.5. The supervisor’s theoretical orientation.6. The supervisor’s own learning goals for the supervisory experience.
  54. 54. Supervision Interventions• Supervision methods will need to take into account: 1. The supervisee’s stated goals and known supervision needs. 2. How far down the training-supervision-consultation axis the supervisee has traveled. 3. Most importantly, supervision methods will reflect the supervisor’s vision of supervision more than the supervisee’s.
  55. 55. Supervisor Vision• The convictions held by the supervisor about how supervisee’s become competent practitioners.• Regardless of its origin or validity, the supervisor’s vision will inspire the process of supervision. Structured Supervision vs. Reflective Supervision• Structured supervision are those techniques (e.g., live supervision) in which the supervisor dictates to the supervisee proper techniques and methods of clinical interactions with the client.• Reflective supervision is less structured supervision where the goal is to increase supervisee thoughtfulness and ability to reflect on their work as they increase in their skill.
  56. 56. Structured vs. UnstructuredInterventions• Highly structured supervision can be seen as an extension of training while highly unstructured supervision can be viewed as approaching consultation.• Structured interventions are supervisor directed and involve a reasonably high amount of supervision activity.• Unstructured interventions may be supervisor or supervisee directed and require more discipline on the part of the supervisor for letting learning take place without directing it.• Most supervisee’s will benefit from both types of interventions at different points in their professional development.
  57. 57. Group Supervision - Defined• Bernard and Goodyear (2009) define group supervision: “Group supervision is the regular meeting of a group of supervisees (a) with a designated supervisor or supervisors, (b) to monitor the quality of their work, and (c) to further their understanding of themselves as clinicians and the clients with whom they work, and of service delivery in general. These supervisees are aided in achieving these goals by their supervisor(s) and by their feedback from, and interactions with, each other.”
  58. 58. Group Supervision - TypesThere are different types of group supervision1. Case consultation: This involves one member of a group presenting a case to others in the group for the purpose of clarification, feedback, help, collaboration, technique discussion, etc.2. Peer supervision: This involves a group of similarly trained or skilled individuals (e.g., all addiction counselors, or most clinicians at a certain developmental level). This group meets regularly for mutual supervision; and may or may not consist of a group leader (supervisor) depending on the setting (e.g., private practice vs. licensed facility).3. Team supervision: Usually agency/facility setting supervision with a defined leader or leaders; can be intra-disciplinary or interdisciplinary, and can involve various skill levels (e.g., students to level 3 clinicians).
  59. 59. Group Supervision - Size• Group supervision should not be so large that members are shortchanged in the attention they receive.• Group supervision should not be so small that the disruptions caused by dropouts or absences does not negatively impact the group.• Researchers studying group size have recommended the size of the average group being at the low end 4-6 and at the top end 12.• According the Marriage and Family Therapy Examiners they state that “group supervision means the ongoing process of supervising no more than six mental health counselors at one time in a group setting by a qualified supervisor.” 13:34-10.2
  60. 60. Group Supervision - Benefits1. Economics of time, costs and expertise.2. Opportunities for vicarious learning. When supervisees observe peers conceptualizing and intervening with clients, vicarious learning can occur with other supervisees not presenting/speaking. Past research has shown that novice (level 1) supervisees who observe their peers performing/talking about performing a particular skill are more likely to show skill improvement and increased self-efficacy than those who instead observed only an expert.3. Breadth of client exposure. Group supervision enables supervisees to be exposed to a broader range of clients than any one person’s caseload could afford.
  61. 61. Group Supervision - Benefits4. Supervisee feedback of greater quantity, quality and diversity. Other supervisees can offer perspectives that are broader and more diverse than what a single supervisor could provide. Quality increases due to the fact that novice supervisees are likely to employ language that is more easily understandable by other novices than is the language used by the supervisor.5. More comprehensive picture of the supervisee. The group format enriches the ways a supervisor is able to observe a supervisee (e.g., a supervisee may be blocked in some way when discussing their own work with a client, but may be very insightful when helping others’ in their work with clients. This can provide a different perspective on a supervisee’s needs (and why they may be occurring) than would occur in individual supervision.
  62. 62. Group Supervision - Benefits6. The opportunity for supervisees to learn supervision skills.7. The normalization of supervisees’ experiences. Many times novice (level 1) supervisees believe the challenges they face may only be occurring with them, or in their own reactions to clients or other aspects of their work. To see others struggling with, or encountering similar issues can decrease anxiety and provide reassurance.
  63. 63. Group Supervision - Limitations1. The group format may not permit individuals to get what they need. 1) supervisees with heavier caseloads may not get the time to review all the cases they need; 2) less skilled group members may receive more supervision attention than more skilled group members.2. Certain group phenomena can impede learning. Personality conflicts between supervisees or between supervisees and supervisors, inter-member competition.3. The group may devote too much time to issues of limited relevance to, or interest for some group members. It is the supervisor’s responsibility to ensure that all group members perceive they are getting something out of group.4. Group supervision does not have a parallel process to individual supervision. While group supervision could potentially help one out with their group processes, (depending on the modality) a large portion of discussions in group supervision is regarding individual work with clients.
  64. 64. Group Supervision – SupervisoryTasks1. Assume an active stance in the group; one that steers a careful course between over- and under-control.2. Assert yourself as necessary to redirect the group; impose limits and so on.3. Listen to and then following the group, challenging direction as necessary.4. Be able to choose the right fights when inevitable conflicts emerge between supervisees or within the group itself.5. Communicate clearly just what you want to happen. Be confident, but not authoritative (dictatorial).6. As the leader be able to process the groups interaction style and level of development. This processing helps you to understand where members are at and what direction you need to be going with the group.
  65. 65. Case Management Vs. Supervision• Case Management. The fundamental characteristics of the case management process focus on the client and include the following: o Information gathering about the client o Interdisciplinary o Talk about client placement o Discuss coordination of services o Case reviews o Case management absorbs time and detracts from clinical supervision – which can directly impact client care. o Case management is administrative oversight, but is often mislabeled as clinical (group) supervision.
  66. 66. Case Management Vs. Supervision• Clinical Supervision. In contrast, the fundamental characteristics of clinical supervision focus on the counselor and include the following: o Assessment and feedback of the counselor o Intra-disciplinary individual (and sometimes) group supervision o Client care o Clinical skill development o In-depth case presentations o Clinical supervision is an ethical/legal duty set aside from case management o A supervisor has “ethically and legally defined responsibilities (a duty of care) that demand careful consideration when interacting with clients, supervisees, colleagues, employers, and society at large” o The clinical work of supervisors and counselors directly (and sometimes powerfully) influences the lives of others o Clinical supervisors are obligated to: 1) be alert; 2) address competing demands; and 3) be cognizant of potential consequences of decisions and advice o Personal quality control reduces errors in judgment that could potentially lead to problems and clinical liability issues.
  67. 67. Case Conferencing & Focus ofSupervisor• Challenge for the supervisor occurs with needing to think like a supervisor rather than a therapist.• Most seasoned practitioners tend to continue to be fascinated by therapy issues, thus focusing on client issues rather than the learning and developmental needs of the supervisees.• How much time do you spend in supervision focusing on client behaviors vs. supervisee behaviors.• What goals and outcomes do you have for each individual you are supervising? Are these different from therapist to therapist?
  68. 68. Some Case Presentation GuidelinesCase Presentation Guidelines:• Decide how much time is to be allotted for each person presenting, and assign somebody as the “timekeeper”.• All staff on the case presentation team should be fully aware of the procedures surrounding case presentations.• The case presentation method should be built around problem- and solution-oriented questions to be answered.• The supervisee should be granted time to prepare the case for presentation and the presentation should be organized an focused.
  69. 69. Case Conferencing DistractionsSome common distractions during case presentations:1. Not enough or too many presentations within the case conference time frame.2. Over focusing on a specific problem instead of giving a case overview.3. Anecdotal material/presentation that is not conceptualized or structured by the clinician.4. Supervisee dynamics that interfere with free and open discussion of the case.5. Expectations for interventions beyond the capabilities of the clinician.
  70. 70. Group Supervision – Final ThoughtsSome basic questions before embarking on group supervision:1. Will it be defined as supervision or peer consultation?2. What methods will be used to get counselors to risk exposure in group supervision, and how will anxiety about such risk be handled?3. Will, or how will, competitiveness be handled?4. How will you deal with different backgrounds and skill levels of group participants?5. How will overtly reticent group members be handled?6. Will the group have an impact on other elements of the agency or organization?7. How large will the group be? Day and Time?8. How will feedback be channeled, or occur within the group?
  71. 71. Group Supervision – Final ThoughtsSome basic questions before embarking on group supervision (continued):9. How will the goals of group supervision differ from the goals of individual supervision?10. How will the feedback of group supervision differ from the feedback given in individual supervision, if the group and individual supervisors differ? How will this difference be handled by each supervisor, and by the agency?11. What kind, and what amount of record keeping will occur?12. Should the supervisor present cases?13. How will poor presentations be handled?14. Will the group be time limited or open ended?15. What limits will be set on the group, and how will they be presented?
  72. 72. Group Supervision Exercise You are currently supervising 6 mental health counselors (which you pat yourself of the back for maintaining fidelity with the LPC regulations). Each clinician has their own unique style and presentation dynamic, that is sometimes different than their presentation in individual supervision. Your group of LACs is a mix of those clinicians clearly still in the beginning stages of clinical development (Level 1 clinicians according to the IDM) and some who are moving along the clinical continuum (Level 1-2 depending on the skill set). The clinician of focus currently in the group supervision session is Anita (which you have secretly renamed Anita Lotta Supervision). In individual supervision she presents as anxious, timid, unsure of herself and needing a lot of prescriptive feedback and reassurance. In short she’s a high maintenance unit.
  73. 73. Group Supervision Exercise However, in group supervision, her presentation takes on a much different flavor. She presents as confident, often giving feedback and suggestions, some of the very same suggestions she has struggled accepting and implementing in your individual supervision with her. When she presents cases, she is beginning to develop a pattern of only presenting success stories and in the past presentation did not even have a question for the group. Another group member saw this latter pattern also and asked about why she presented the case if she didn’t have a question. Anita became defensive, stating everything has been resolved from her caseload in individual supervision and then ubruptly stopped talking and finishing her case presentation.
  74. 74. Group Supervision Exercise1. What is your role in that moment with Anita in the group supervision; how do you handle the sudden tension?2. When in the next individual supervision session with Anita, what are going to be your primary tasks (topics of discussion) for that session with her?3. Going forward, what is your assignment to her for the next group supervision session (when it is her turn to present again, which could be 2 group sessions from now)? If it is not her turn to present in the very next group supervision, and issues were left unresolved in the last group supervision session, what is your expectation of her, if any, in the next group?
  75. 75. Self-Report• The most commonly used form of supervision.• Self-report has many problems attached to it.• Without direct observation, you forfeit the opportunity for independent judgment regarding the client.• Without direct observation, you forfeit the opportunity to illustrate directly from the case in question, how to draw inferences from the client and from the session.
  76. 76. Self-Report (cont.)• Studies have shown that over 50% of issues evident in taping of sessions, were not reported by trainees in supervision.• Wynne et. al., 1994, showed that experienced supervisees showed only a 42% recall rate for main ideas expressed in session, and 30% recall rate for supporting ideas expressed in session with a client.
  77. 77. Process Notes• The use of any form of systematic written documentation of the cases being presented in supervision.• Process notes suffer the same pitfalls as does self-report.• Process Note Outline For Supervisors:1. What were your goals for this session2. Did anything happen during the session that caused you to reconsider your goals? How did you resolve this?3. What was the major theme of the session? Was there any content that you consider critical?4. Describe interpersonal dynamics between you and the client during the session?
  78. 78. Process Notes (cont.)5. How did the individual differences between you and the client (e.g., gender, ethnicity or race, developmental level) affect the session?6. How successful was the session? Were your initial goals achieved?7. What did you learn (if anything) about the helping process from this session?8. What are your plans and goals for the next session?9. What specific questions do you have for your supervisor regarding your work with this client?
  79. 79. Audio Taping• It is the supervisor’s responsibility to outline the plan as to how audio taped supervision will take place.• With beginning supervisees, you may listen to a whole audio tape before supervision in order to get an overview of the supervisee’s ability, and you’ll have control over what part of the tape you’ll want to focus on in supervision.• With more advanced supervisees, pre-selected segments can be chosen for a variety of reasons:1. To highlight the most productive part of the session.2. To highlight the most important part of the session.
  80. 80. Audio Taping (cont.)3. To highlight the part of the session where the supervisee is struggling the most.4. To underscore any number of content issues, including metaphors and recurring themes.5. To ask about confusing part of the session.6. To focus attention on the point in the session where interpersonal or cross-cultural dynamics were either very therapeutic or very strained.
  81. 81. Audio Tape Format• While many formats can be used, a typical format consists of letting a supervisee choose a part of a session in which they felt confused, lost, overwhelmed, or frustrated.• Have supervisee state the reason for selecting this part of the session for discussion in supervision.• Briefly state what transpired up to that point.• Explain what he or she was trying to accomplish at that point in the supervision.• Clearly state the specific help desired from the supervisor.
  82. 82. Videotape• Focus videotape supervision by setting realistic goals for the supervised therapy session.• Relate internal process across contexts (i.e., what the therapist experiences in the session is important to discuss in supervision).• Select tape segments that focus on remedial performance (i.e., corrective feedback should be on performance that the therapist has the ability to change).
  83. 83. Videotaping (cont.)• Use supervisor comments to create a moderate evaluation of performance (i.e., tracking your feedback to see if progress towards the goal is made across supervision sessions).• Refine supervision goals moderately (feedback given in supervision may be hard to initiate in the actual therapy session).• Maintain a moderate level of arousal (make sure the supervisee is stimulated to grow without becoming overly threatened).
  84. 84. Interpersonal Process Recall• The supervisor and supervisee view a prerecorded videotape of a counseling session together.• At any point in which either person believes that something of importance is happening on tape, the tape is stopped.• The supervisor does NOT adopt a teaching role and instruct the trainee about what might have been done.• Supervisor needs to allow the supervisee the psychological space to investigate internal processes to some resolution.
  85. 85. Live Supervision• Live supervision was initiated by Jay Haley and Salvadore Minuchin in the late 1960’s.• Live supervision combines direct observation of the session with some method that enables communication with the supervisee.• Highest safeguard of client welfare, but is very time consuming for the supervisor.• More complete picture of therapist and client than can be captured in videotape (e.g., static camera angles)• Allows for excellent and at times immediate feedback loop for the supervisee.
  86. 86. Methods of Live Supervision• Bug in the Ear (BITE) is a wireless earphone worn by the supervisee that allows feedback from the supervisor at any point in time, without the “interruption” of the therapy session.• Monitoring is where the supervisor observes the session and intervenes directly into the session if there is perceived difficulty. Supervisor takes over when coming into the session.• In Vivo is similar to monitoring, except the supervisor comes in and consults with the supervisee in front of the client(s), allowing the client(s) to have access to all information.• Phone-ins and Consultation Breaks. Interruption of therapy by either a phone call or a break of therapy session. With phone-ins, the therapist does not have the chance to clarify what the supervisor is suggesting.
  87. 87. Supervision - HDAP1. Group Supervision2. Individual Supervision3. Live Supervision4. Process Recordings (for required students) Hunterdon Drug Awareness Program Live Supervision
  88. 88. Live Supervision - HDAP In 2005, Hunterdon Drug Awareness Program incorporated live supervision at a cost of just over $2,000• High resolution, yet discreet, camera: $854• Omni-directional Audio Microphone: $129• (2) All in one 13” Monitor/VCR’s: $710 (2 x $355)• Cabling to network: $102• Installation Labor: $400 Total Cost for Permanent Live Supervision: $2,185 Ability to permanently, discreetly supervise your employees live: Priceless
  89. 89. Ranking of Techniques• Munson (2002) ranks the most to least useful supervision techniques, with 1 being the most useful and 10 being the least useful:1. Live joint interviews2. In-ear listening devices3. One-way mirror observation4. Videotapes – live material5. Videotapes – commercially produced6. Audiotapes – live material7. Audiotapes – commercially produced8. Discussion of case material9. Process Recordings10. Role-play
  90. 90. Bibliography • Bernard, J. M. (1979). Supervisor Training: A Discrimination Model. Counselor Education and Supervision, 19, pp. 60 – 68. • Bernard, J. M. (1997). The discrimination model. In Watkins, C. E. Jr., Handbook of Psychotherapy Supervision. New York, John Wiley & Sons, Inc. • Bernard, J. M. & Goodyear, R. K. (2009). Fundamentals of Clinical Supervision, 4th Ed. Pearson Education Inc., Upper Saddle River, NJ. • Borders, L. D. & Leddick, G. R. (1987). Handbook of Counseling Supervision. Counselor Education and Supervision, Alexandria, VA. • Durham, T. G. (2009) Clinical Supervision: A Twenty-Module Course (Participant Workbook: Utilizing 5-2: Case Management Vs. Supervision). • Falender, C. A. & Shafranske, E. P. (2004). Clinical Supervision: A Competency-Based Approach. American Psychological Association, Washington, DC.
  91. 91. Bibliography• Holloway, E. L. (1992). Supervision: A way of teaching and learning. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology. New York: John Wiley.• Holloway, E. L. (1995). Clinical Supervision: A systems Approach. Sage, Thousand Oaks, CA.• Holloway, E. L. (1997). Structures for the analysis and teaching of supervision. In Watkins, C. E. Jr., Handbook of Psychotherapy Supervision. New York, John Wiley & Sons, Inc.• Martino, S. (2010). Strategies for training counselors in evidence-based treatments. Addiction Science & Clinical Practice, 5(2), 30-39.• Meichenbaum, D. (2001). Anger management: A cognitive-behavioral developmental perspective. Lecture presented at the Cap Cod Institute, 08/13/01 – 08/17/01.• Munson, C. E. (2002). Handbook of Clinical Social Work Supervision, 3rd Ed. New York, Haworth Press, Inc.
  92. 92. Bibliography • Powell, D. J. & Brodsky, A. (2004). Clinical Supervision in Alcohol and Drug Abuse Counseling. Jossey-Bass Publishers, San Francisco, CA. • Stenack, R. J. & Dye, H. A. (1982). Behavioral descriptions of counseling supervision roles. Counselor Education and Supervision, 22, 295-304. • Stoltenberg, C. D. & Delworth, U. (1987). Supervising Counselors and Therapists. Jossey-Bass Publishers, San Francisco, CA. • Stoltenberg, C. D., McNeil, B., & Delworth, U. (1998). IDM Supervision: An Integrated Developmental Model for Supervising Counselors and Therapists. Jossey-Bass Publishers, San Francisco, CA. • Watkins, C. E. Jr., (1997). Handbook of Psychotherapy Supervision. New York, John Wiley & Sons, Inc.
  93. 93. Bibliography• Wynne, M. E., Susman, M., Ries, S., Birringer, J., & Katz, L. (1994). A method for assessing therapists’ recall of in-session events. Journal of Consulting Psychology, 41, pp. 53 – 57.

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