Clinical Supervision Primer for Counselors and Psychotherapists 2004

Clinical Supervision Primer for Counselors and Psychotherapists 2004 -05© Dr. Jeffrey K. Edwards Professor Family Counseling Program Department of Counselor Education Northeastern Illinois University 773 -442 -5541

Supervision Workshop l This workshop will present an historical, developmental, and research oriented perspective of clinical supervision. Issues of isomorphic and parallel processes, developmental stages of both clinicians and supervisors, and supervisory processes will be covered. New research and practice related to developing counselor competency and selfefficacy will be presented. This workshop is for the already practicing supervisor as well as those who are interested in developing supervision as a specialty.

COURSE OBJECTIVES The objectives of this course are to help the participant: l l Acquire knowledge of supervision process and skills from multiple domains and perspectives; Acquire knowledge of: the characteristics of good and poor supervision;

Objectives Understand the three domains of clinical supervision; l Understand the developmental stages of supervisees and appropriate supervision of each; l Understand the developmental stages of becoming a clinical supervisor and what to expect of oneself during each stage; l

Objectives Understand the importance of practicing ethical clinical supervision; l Be familiar with several supervision formats and methods; l Learn how to help in developing selfsufficiency, self-efficacy and personal agency of supervisees; l

Reasons to study Supervision l A study of 20, 000 exit interviews found the number one reason people leave jobs is "poor supervisory behavior. " In other words: a bad boss!! Do you feel comfortable with your prospective boss' interpersonal and management style? Do you feel comfortable with your own? More important, how well do either of you serve as a mentor? Are you or your boss capable and interested in their/your growth? Will you or he or she make sure those under them/you have the training and resources to get the job done? Both you and your supervisees want a supervisor who is committed to success!

Psychotherapy Supervisor Development Scale* Please circle the number that best describes how frequently you feel that each item describes you: 1 2 3 4 5 6 7 __________________________ never half the time always

1. I consider the supervision that I provide to be helpful to my supervisees. 1 2 3 4 5 6 7 2. Becoming and being a supervisor demands a commitment 1 2 3 4 5 6 7 (i. e. , to keep working at developing oneself as a supervisor) that I believe I have made. 3. Becoming a supervisor is an ongoing process that requires much time and energy, but I see myself as well on the way to getting 1 2 3 4 5 6 7 4. I have a realistic awareness about my limitations and weaknesses as a supervisor. 1 2 3 4 5 6 7 5. Sometimes I believe I’m just playing at being a supervisor. 1 2 3 4 5 6 7 6. If asked, “Do you really feel like a psychotherapy/counseling supervisor’? I could honestly answer “yes. ” 1 2 3 4 5 6 7

7. I believe that I am able to increasingly foster a sense of self-sufficiency in my supervisees. 1 2 3 4 5 6 7 8. I consider supervision to be a very important role that I perform. 1 2 3 4 5 6 7 9. If asked. “Can you give a good assessment of yourself as a supervisor”? I could easily answer “yes. ” 1 2 3 4 5 6 7 10. I have a realistic awareness about my strengths and abilities as a supervisor. 1 2 3 4 5 6 7 11. Right now, I feel ill-at-ease and somewhat confused with the supervisor role. 1 2 3 4 5 6 7 12. I must say that, when I perform my supervisory responsibilities, I often think of myself as an imposter. 1 2 3 4 5 6 7

13. I believe I am generally effective in dealing with transference/counter transference issues in supervision. 1 2 3 4 5 6 7 14. I believe I have a good awareness about myself as a supervisor, the impact that I have on my supervisees, and how I affect the supervisory situation as a whole. 1 2 3 4 5 6 7 15. I believe I have a good knowledge of and understanding 1 2 3 4 5 6 7 about the supervision process itself. 16. As a supervisor, I structure the supervision experience effectively. 1 2 3 4 5 6 7 17. When needed, I am able to be appropriately assertive and confrontive with my supervisees. 1 2 3 4 5 6 7 18. I just don’t consider myself that identified with the supervisor role. 1 2 3 4 5 6 7 *Reprinted from C. E. Watkins, Jr. 2001

Psychotherapy Supervisor Process Scale* Please circle the number that best describes how frequently you feel that each item describes you: 1 2 3 4 5 6 7 __________________________ never half the time always

1. I am comfortable with providing supervision of multiple styles of counseling theory. 1 2 3 4 5 6 7 2. When interface issues arise, I work with them with ease and comfort? 1 2 3 4 5 6 7 3. Informed consent regarding my work with supervisees issues is always discussed and agreed upon prior to initiating supervision. 1 2 3 4 5 6 7 4. I am collaborative in my supervision style when it comes to setting goals for clients. 1 2 3 4 5 6 7 5. I would prefer to help my supervisee find their own style, 1 2 3 4 5 6 7 rather than insist on a specific format for therapy. 6. Deciding on future training for my supervisee’s is an ongoing part of our professional relationship. 1 2 3 4 5 6 7 7. I prefer to have my supervisees work in one mode of counseling/therapy and get it right. 1 2 3 4 5 6 7

8. I acknowledge that supervision is a distinct discipline and 1 2 3 4 5 6 7 has specific methods that I need to practice. 9. I have kept current on supervision literature and theory. 1 2 3 4 5 6 7 10. I have had supervision of my supervision skills, and continue to consult with someone else on supervision issues that occur with my supervisees. 11. I am comfortable working in several models of counseling. 1 2 3 4 5 6 7 12. I tend to use an integrated framework of supervision and 1 2 3 4 5 6 7 counseling. 13. I am more relationship oriented in my supervision style than technique oriented. 1 2 3 4 5 6 7 14. I am more technique oriented in my supervision style than process oriented. 1 2 3 4 5 6 7 15. I have had formal training in clinical supervision. 1 2 3 4 5 6 7 *Jeffrey K. Edwards, Ed. D. , LMFT

My personal experiences Who I am. l Where I’ve been. l How I’ve been trained. l What I presently believe and practice regarding clinical supervision. l

Overview of Supervision: Clinical Supervision started with l Psychoanalysis and the medical model l Watch one, do one, teach one l Management and training. Which one fits? l Allen Hess, (1980) Psychotherapy Supervision: Theory, Research and Practice. NY: Wiley

l Supervision is. . . From your point of view.

What are your ideas?

A Supervisor is. . . In charge. . ? l Responsible ? l Knowledgeable ? l Caring ? l Evaluative? l Sets goals? l

Participants’ experience with supervision l Good Supervision is: l Bad Supervision is:

A Supervisor is. . . Supervisor Domains Trainer or Instructor l Consultant Discrimination Model. (Bernard, 1979). Counselor

1. Trainer or Instructor Teaching new information or techniques l Depends on type of pedagogy - Socratic l – Didactic – Lecture – Experiential – Model l What are the pros and cons of this one?

1. Consultant Helping hands – buying service to help out l Provision of services l Facilitator of change l New views of consultation: l

Principles of Consultation l l l A Triadic relationship (focuses on a third party) that may be an individual, organization, or a group within an organization. It is not therapy! Consultants may be internal or external.

Consultation changes over the years. l l l Early on consultants were hired for direct service interventions. There may not be someone with specific skills to accomplish a task, and the consultant is responsible for doing what needs to be accomplished. (consultee is not involved in process, usually). (Serenity House – consultation/supervision/ therapy of staff) (Catholic Charities – AAMFT Clinical Supervision)

Consultation changes over the years. l l Consultation for a specific purpose and to train staff – Consultee is included in process. Children’s Memorial Hospital – need for training of clinical staff in supervision skills.

Consultation changes over the years. l l l Consultant is hired to provide specific skills and training for the purpose of exploration of problems, (process consultation) and either make suggestions for, and/or implementation of interventions to deal with the problem. (Lutherbrook and racial problems) Case consultation – suggestions, and new data or information.

Consultation Process Effective decision making requires free and open choice – Consultee (supervisee) has choice. l Implementation requires Internal Commitment – consultee needs to be committed to process of change. l Goal is to establish a relationship and solve problems together so they work and stay solved. l Change works best when consultee feels the need, and goals and solutions are mostly their ideas. l Process means examination of all data, and choice making. l Collaboration works best, over that of “expert” role. Block, P. (2000). Flawless Consulting. l

3. Counselor/therapist Original clinical supervision – analysis l Dealing with interface issues (transference issues) l What problems arise with this one? ? l – Informed consent – Possible dual relationship l Person of the Therapist Supervision.

Psychotherapy supervision is important because it: Provides supervisee with feedback from someone who is supposed to have more experience, and is objective. l Offers them guidance as to how to proceed when they are stuck; l Provides them with alternative views of the situation; l

Psychotherapy supervision is important because: Provides them with suggestions of case dynamics, treatment options, and gives them a “secure base” (Watkins, 2001) from which to operate. l Provides a quality control regarding care. l

Theories of Supervision l l l Developmental - Stoltenberg & Delworth, Systemic - Liddle, Bruenlin & Schwartz, Person of therapist supervision - Aponte or Atkinson Wu-wei - Edwards & Chen. But by and large there is NO universal theory of supervision. Instead, the different models of counseling use there own theory base, so. . .

Theories of Supervision Client centered supervisors stress empathy, and modeling l Cognitive supervisors stress cognition l Systemic supervisors stress systems l Etc. , etc!! l

Heath & Storm Supervisors need to prove their usefulness to those they supervise, if they are to be effective - respect for those they supervisee. l Use your theory of Cx, and your theory of Supervision. l

Strategies, Models and Techniques l l Interpersonal Process Recall Review of taped interviews – Supervisor listens and provides feedback later – Supervisor and Supervisee both listen to selected sections. l l Review of Video tapes Live supervision either by one way mirror, televised observation, or by supervisor sitting in on sessions. Group Supervision Peer supervision

All forms Counseling/Psychotherapy supervision, however, seems to have some similarities: l An intervention that is provided by a senior member of a profession to a junior members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the junior member(s), monitoring the quality of professional services offered to the clients she, or they see(s), and serving as a gatekeeper for those who are entering the particular profession. (Bernard and Goodyear, 1992, p. 4)

All forms Counseling/Psychotherapy supervision, however, seems to have some similarities: l l l l According to Watkins (2002), this means that supervision has as components: A relationship Evaluation Extends over time Enhances professional functioning Monitors quality of professional service Serves as gate keeper.

Counseling/Psychotherapy supervision factors of supervision functioning: l Assumptive world – past professional and life experience, training, values, and general outlook on life; l Theory or Model; client centered, systemic, etc. l Supervisory style - consistent characteristic manner of relating, i. e. , dictatorial, passive, controlling; l Roles/strategies, i. e. , case review, teacher, lecturer, colleague, mentor, administrative, etc.

Counseling/Psychotherapy supervision factors of supervision functioning: l Foci of supervision – professional, organizational, assessment/planning, implementation/intervention/evaluation, and personal factors; l Format of supervision – individually or group, face to face, or over phone. l Techniques – facilitative, supportive, confrontive, conceptual, problem solving, etc. (Watkins, 2002)

Developmental Stages of Counselors l Development is Organic - “Importance is not placed on events or combinations of events as much as on the transformation of these events into meaningful information, which is then incorporated into prior knowledge. The developing person is viewed as emerging and moving towards a goal or end state” (Stoltenberg & Delworth, 1988, p. 4 -5).

Developmental Stages of Counselors l Level One - The beginning of the Journey l Level Two -Trial and Tribulations l Level Three - Challenges and Growth

Level One - The beginning of the Journey l dependent on supervisor, l imitative l lacking self-awareness l categorical thinking, with limited experience l

Level One - The beginning of the Journey l high motivation to do well l high anxiety channeled to hard work l focused on skill acquisition l highly dependent on supervision

Level One - The beginning of the Journey l Supervision Environment 1. provide structure to keep anxiety low, 2. provide positive feedback regarding counselor’s abilities, 3. focus on data rather than on supervisee

Nancy’s Plight l. Video

Level Two -Trial and Tribulation l fluctuating motivation, striving for independence, becoming more self-assertive and less imitative. l dependency/autonomy conflict l confusion stage

Level Two -Trial and Tribulation l Supervisee’s skills, strengths and weaknesses are becoming evident. l Beginning awareness that this is not a job for the faint of heart

Level Two -Trial and Tribulation l Realization that there is more to counseling than technique. l not all cases respond as hoped for, even with good skill level usage l Professional Ethics relates

Level Two -Trial and Tribulation l Awareness of the limitations of counseling process with certain clients l The horrors of cases begin to become toxic l Taking cases home emotionally

Level Two -Trial and Tribulation l Autonomy is increased l supervisee may not seek opinions or advise of supervisor l May even resist discussion of cases -

Level Two -Trial and Tribulation Supervision Environment l Highly autonomous, little structure l Blend of client types is important l Supportive environment l Consultative,

Level Two -Trial and Tribulation Supervision Environment Focus on theory and application l Alternative views of clients l Broadening repertoire of theory and technique l Focus on relationship, both with client, and isomorphicly in supervision. l Confrontation and interface issues are more a part of supervision now. l

Level Two -Trial and Tribulation Supervision Environment l Less inclined to take the supervisors word without critically evaluating suggestions as applied to clients. l Supervisory relationship is less hierarchical, and this should be supported.

Video Marilyn sees the worst.

Level Three - Challenge and Growth l l l Personal sense of counselor identity and self-confidence. Motivation more stable Autonomy is not threatened Self- and other awareness is heightened. A second-order shift has occurred. Able to be with the client, yet not be drawn in. Able to pull back and evaluate.

Level Three - Challenge and Growth l Generally aware of their own strengths and weaknesses. l Can think of individual differences of clients. l Understand ethics and professional perspective.

Level Three - Challenge and Growth l Supervision Environment 1. dependency and strengths need to be acknowledged and supported (sometimes even encouraged), l 2. case accountability needs to be provided within this context

Level Three - Challenge and Growth l Supervision Environment Supervisee may be beyond formal, regular supervision but may seek help with specific cases. There is a need for supervision to advance past a single theoretical framework, broadening the supervisee’s repertoire. Focus should be on integration of all aspects of the counselor.

What research says about: l l l Good Supervision is: Self-reflective and selfmonitoring of the emotional/interpersonal processes with supervisee; Ability to identify with as well as observe experiences of supervisee and his/her clients’; l Poor Supervision is: l Evidence of psychopathology; Evidence of narcissistic needs and vulnerability with excessive need to be liked or be in control. Some novice supervisors who have not had training, or supervision of supervision. l l

What research says about: l Good Supervision is: l Flexibility about theory, technical principles, and trainee’s learning style; Respectful attitude, supportive and nonjudgmental; Humility toward knowledge, curiosity, relaxed and patient manor l l l Poor Supervision is: l If you decide to get supervision of your own supervision, find out what they know about the process of supervision, not just if they have advanced degrees or have supervised for a long time.

What research says about: l Good Supervision is: l Ability to convey principles and concepts with clarity; Ability to think out loud in order to model clinical inference process; Willingness to allow students to view supervisor’s own clinical work; l l l Poor Supervision is:

Isomorphic and Parallel processes in supervision – Howard Liddle Isomorphism means identity or similarity of form, " (Kerlinger, 1986, p. 395). l Parallel means : extending in the same direction, everywhere equidistant, and not meeting, or the development of similar new characters by two or more related organisms in response to similarity of environment -called also parallel evolution l

Isomorphic processes in supervision l l The word comes from Iso - meaning same, and morph - meaning structure. Any two systems that are connected are said to have isomorphic properties when there is similarity between the two. Isomorphy refers to that part of two or more structures that have a correspondence. As there is an interconnection between all systems that are interrelated, this correspondence has the potential of influence.

Parallel Process in Supervision l l One way of stating the parallel axiom is through a point not on a given line, only one line can be drawn parallel to the given line. Parallel process is a description The process is one-directional, originating in therapy dyad and directed toward the supervisory dyad. Is comparable to transference and counter transference. Is unavoidable, and is believed by some to be essential in good supervision when it is resolved.

Parallel Process Isomorphic

From child, to parent to therapist to supervisor. video

Process of Clinical Supervision Research by Keller, Protinsky, Lichtman, & Allen, (1996). The Process of Clinical Supervision: Direct Observation Research. l 1. What is the nature of supervision? , l 2. What patterns of interaction can be identified in the process of supervision? l

Process of Clinical Supervision Themes: l 1. Imparting Knowledge - direct or indirect, by either giving suggestions and directions, or by asking Socratic questions. l 2. Self-understanding, or personal growth. Raising awareness of what strengths already existed or what might be inhibiting fuller expression of strengths. (Person-of-thetherapist supervision. l

Process of Clinical Supervision l Hierarchy - This is a function of clinical tradition - isomorphic to the training one receives, and theories one uses. l Two domains of Hierarchy. Hard side and soft side.

Patterns of Interaction in Supervision 1. Rapport-building. Both participants seek to structure a feeling of comfort in a context where work is being evaluated. Length of time is related to contexts of overt hierarchy, gender, familiarity with one another, and new or ongoing cases to talk about. l 2. Getting down to work stage - “What would you like to focus on? Where Stuck? l

Patterns of Interaction in Supervision 3. Resolution of questions raised and options discussed. Case specific future directions and options, follow-up on past supervision sessions, asking questions regarding supervisee’s intentions. Often suggestions go un-heeded. l 4. Wrapping-up - abbreviated period of chitchat, and good-byes. l

Patterns of Interaction in Supervision l Research Implications l During research they discovered that the process increased the level of trust and collegiality between students and supervisors. Supervision can be enhanced by increasing vulnerability and collegiality. Supervision can be relationship-focused and multihierarchical. The process appears to have much to do with the nature of the relationship. l

Patterns of Interaction in Supervision can be multidirectional l Clinical supervision might be best defined as the joint monitoring of: l 1) each supervisee’s current therapy cases, 2) growth of supervisee as a therapist, 3) the process of supervision, 4) the interaction between supervisor and supervisee. l

Ethics in Clinical Supervision Codes of Ethics – practice within the boundaries of one’s competences. l Impaired Supervisee or supervisor. l – 4. 6 % of Psychologists report they have been impaired at sometime during their career. 6% report alcohol excess, others have depression and other series impairments. Most are never confronted or asked to seek help.

Ethics in Clinical Supervision l l l Codes of Ethics – sexual attraction to clients also applies here too, with regard to those we supervise and those of us who are supervising. Non exploitation of those under them. 17 % reported that they had sexual relationships with their supervisor, 1 out 4 women who obtained their doctorate had sexual relationships with their supervisor or teacher. Tarasoff – the psychologist's supervisor, a psychiatrist was also found to be liable. Need to maintain case records on supervisees.

Ethics in Clinical Supervision Informed Consent of supervisees. l Direct liability – due to supervisees’ erroneous actions or omissions. l Vicarious Liability – Courts assume that supervisor is responsible for the conduct of the supervisee. l l Knapp and Vandecreek (2001).

Supervision thoughts You cannot work effectively without your supervisee/employee’s cooperation and goodwill! l People cooperate better when they feel their own best interests are at stake; growth and development. l Supervisee’s are stakeholders in the process. l

Supervision thoughts People are motivated, not only by the possibility of wage earnings, but by intrinsic care and the knowledge that their immediate supervisors and administrators have their goodwill in mind. l Supervisees or employees work harder and more effectively, when they believe that they have a voice. l

Supervision thoughts All of this happens better with the development and maintenance of positive relationships. l It is a supervisor/administrators responsibility to provide for positive growth and development. l Betsy – care of others l

Supervising to Develop Selfefficacy and Self-Reliance l Wu-Wei

Wu-wei Action/non action l Non Hierarchical l Suggestions rather than mandates l Strength Based rather than deficit based l Multiple views of the problem l Co-construction l Respectful of covisee l

Self-Efficacy in Counseling l Efficacy in dealing with the environment (or with a client) does not entail certain behaviors or simply knowing what to do. It involves “a generative capability in which component cognitive, social and behavioral skills must be organized into integrated courses of action to serve innumerable purposes’ Bandura, (1982).

Self-Efficacy in Counseling l Counseling Self-efficacy (CSE) is defined as one’s beliefs or judgments about her or his capabilities to effectively counsel a client in the near future. CSE beliefs are the primary causal determinant of effective counseling action, and effect choices of counselor responses, effort expenditure and persistence in the face of failures, and risktaking behavior (Bandura, 1977).

Self-Efficacy in Counseling l Self-efficacy beliefs affect the mediating influences of other self-generated process, and which act collectively as personal agency that allows humans to both respond and proactive in an ever-changing environment. This allows counselors to use forethought to anticipate potential scenarios and prepare for them. They set goals for themselves and their clients based in part on forethought and in part on feedback (Larson & Daniels, 1998, p. 181). (Feedback loops)

Self-Efficacy in Counseling CSE is highly correlated to the developmental stage of the counselor, however it is not linear, as the second stage may produce a lower correlation. Anxiety seems to lower CSE also. l The enhancement of CSE is based on Modeling, visual imagery and role playing. l

So, what really counts in counseling? l 40% of outcome is related to the client l 15% of outcome is related to technique l 35% of outcome is related to therapeutic relationship l The rest is related to extra ordinary factors

Supervision for Counselor Competency l Focus on strengths l Ask “narrative” questions, i. e. , “when you did that, what sort of things did you tell yourself? What did you do in this session that you really like? What would you do differently? Would you like to hear what I think? Knowing what you do know, what else do you think you might have done? As you reflect on how well you have come along, what thoughts and feelings do you have about your counseling? What do you think “so-in-so” would have done? ” l

Preventing burnout in counselors Self Care l Begin today to take steps toward self care l Put the big rocks in first l Limit case loads l Vary case loads l Don’t let the job be your life l Dance, walk, do physical activities l

Questions What are the salient parts of supervision that you would like to talk about?

Summary l There is no one unified theory of supervision l Hierarchy seems to be a usual part, but the decrease of it adds to the relationship, hence effective supervision.

Where to get more information l Syllabus and reference list is at: http: //www. neiu. edu/jkedward/super vision. htp

References l l l Bernard, J. M. (1979). Supervisory Training: A Discrimination Model. Counselor Education and Supervision, 19, 60 -68. Edwards, J. K. , & Chen, M. W. (1999). Strength-Based Supervision: Frameworks, Current Practice and Future Directions: A Wu-wei Method. The Family Journal. Larson, L. A. , & Daniels, J. A. (1998). Review of the Counseling Self. Efficacy Literature. The Counseling Psychologist, 26, 179 -218. Keller, J. F. , Protinsky, H. O. , Lichtman, M. , & Allen, K. (1996). The Process of Clinical Supervision: Direct Observation Research. The Clinical Supervisor, 14, 51 -63. Liddle, H. A. , Bruenlin, D. C. , & Schwartz, R. C. (1988). The Handbook of Family Therapy Supervision. New York: Guilford Press.

References l l l Steward, R. J. (1998). Connecting Counselor Self-Efficacy and Supervisor Self-Efficacy: The Continued Search for Counseling Competence. The Counseling Psychologist, 26, 258 -294. Stoltenberg, C. D. , & Delworth, U. D. (1987) Supervising Counselors and Therapists. San Francisco: Jossey Bass. Watkins, C. E. (Ed. ) (2001). Handbook of Psychotherapy Supervision. . New York: John Wiley & Sons, Inc.