Advancing Counselor Care:

Transcription

1 Advancing Counselor Care: The Science of Clinical Supervision Thomas (Tom) L. Moore, LMSW, LLP, CAADC, CCS September

2 List elements of inadequate and harmful supervision Identify Three (3) supervisor roles as described in the Bernard- Goodyear Discrimination Model Name methods of fidelity and adherence to evidence based practices

3 What is Clinical Supervision? [The] relationship is evaluative and hierarchical, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the junior person(s), monitoring the quality of professional services offered to the clients and serving as a gatekeeper for the particular profession the supervisee seeks to enter. (Bernard and Goodyear, 2014)..the supervisory relationship is a relationship about other relationships (Fiscalini, 1997, p. 30.) The supervision relationship extends over time-it is not a one-time interaction. This underscores the importance of relationship building. (Bernard and Goodyear, 2014)

4 QUALITY OF SERVICES 2011 n= 6,600 patients; 696 clinicians Average=11 years in field Mostly social workers and mental health counselors Used TOP (Treatment Outcome Package) CATEGORY No change Worse Harmed Panic/anxiety 34% 25% 10% Substance Use Disorder 50% 19% 16% Psychosis 36% 23% 9% Suicidality 49% 15% 7% Depression 25% 20% 3% Overall, 11-38% of average patients are worse off following treatment than when they initiated care (Kraus, et al, 2011)

5 Essential Elements Primary goal to protect the welfare of the client monitors quality of services and ensures integrity Supervision emphasizes the relationship culture and ethics influence all supervisory interactions Supervisor is an advocate for the client, counselor, and organization serves as a gatekeeper for the profession Supervisor uses current scientific and evidence-based practices Guidance provided is operational and practical (e.g., give advice that can be implemented) Supervision is outcome oriented to improve counselor competence and enhance professional skills creates a sense of mastery and growth for supervisee (Roche, Todd, & O-Connor, 2007; Bernard and Goodyear, 2014)

6 Minimally Adequate Supervision Has the proper credentials as defined by discipline or profession Has appropriate knowledge of and skills for supervision + awareness of limitations Collaboratively constructs a supervision contract providing informed consent regarding expectations and roles and responsibilities Provides a MINIMUM of 1 hour f2f weekly (individual) Provides accurate, formative, and evaluative feedback (fair, respectful, honest, ongoing and formal) anchored in competencies Promotes and is invested in supervisee welfare, professional development, including worldviews, attitudes and biases Maintains supervisee confidentiality Is aware and attentive to the power differential (and boundaries) and its impact on supervisory relationship including personal factors, unusual emotional reactivity, and counter-transference Regularly observes, reviews or monitors supervisee s sessions (directly, or on video) (Falender & Shafranske, 2014)

7 Minimally Adequate Supervision Demonstrates respect for supervisee and client Collaboratively assesses, reflects on and enhances supervisee competence Infuse awareness of role diversity plays in clinical and supervision practice, including observation of the multicultural identities (client, supervisee and supervisor) Encourages and supports supervisee reflection on clinical practice and process of supervision Forms a supervisory alliance Maintains supervisee confidentiality Identifies any strains within relationship and works to repair Monitor and protect the client. Role of gatekeeper Engages the supervisee in skill development using interaction and experiential methods (e.g., role play, modeling, etc.)

8 Inadequate supervision occurs when the supervisor is unable or unwilling to meet the criteria for minimally adequate supervision enhance the supervisee s professional functioning monitor the quality of the professional services offered to the supervisee s clients serve as a gate keeper to the profession Inadequate supervision may include, but is not limited to, the behaviors and descriptors delineated in Ellis s (2001) definition of bad supervision

9 Harmful Supervision Essential components supervisee was genuinely harmed in some way by the supervisor s inappropriate actions or inactions supervisor s behavior is known to cause harm even though the supervisee may not identify the action as harmful Resultant from supervisor acting inappropriately or with malice supervisor negligence Supervisor clearly violating accepted ethical guidelines and standards of care and practice Occurrence one or more incidents a recurrent pattern within group or individual formats in clinical supervision, supervisor supervision, with one or more supervisors (Dye & Borders, 1990; Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999)

10 sexual improprieties or sexual intimacy with the supervisee (Bartell & Rubin, 1990; Celenza, 2007; Lamb, Catanzaro, & Moorman, 2003) supervisor acting physically, emotionally, or psychologically aggressive and abusive Examples of Harmful Supervision violating the supervisee s boundaries (e.g., emotional intimacy forced upon the supervisee) revealing personal information about the supervisee to his/her clients (Koenig & Spano, 2003) using power for personal gain at the supervisee s expense Ellis (2001)

11 making macro- and microaggressions toward the supervisee e.g., blatant racism, homophobia (Burkard et al., 2009; Sue et al., 2007) publicly humiliating and deriding the supervisee Examples of Harmful Supervision demeaning, critical, and vindictive attitude toward the supervisee engaging in an exploitative multiple relationship that caused the supervisee harm (Gottlieb et al., 2007; Hall, 1988) Ellis (2001) failing to take action resulting in harm to the supervisee or client

12 Psychological trauma (mistrust, fears, excessive shame, guilt, self-derogation) Conspicuous loss of self confidence Harmful Supervision Effects may Functional Impairment (professional or personal) Effects Significant decline in general mental or physical health last a short time persist for months to years persist even following therapy harm clients as well

13 Negating Harmful Treatment Building and enhancing the therapeutic relationship Appropriate application of empirically supported treatment and techniques Prevention and repair of toxic therapeutic relationships and technical process Adjustment of treatment method Adjustment of outcome expectations (tailored to client characteristics and presenting problem) Therapist receiving treatment for unresolved personal problems (Russell-Chapin and Chapin, 2012)

14 93% of counselors receiving inadequate supervision (Ellis, 2014) 35% receiving harmful supervision Of clinical supervisors interviewed 11.8% considered sexual contact with a supervisee as less than totally harmful One third indicated using drugs or getting drunk with a supervisee was not at all harmful to moderately harmful (Ellis, 2014) In the SUD field, supervisors use less effective supervision strategies rarely incorporate strategies for building competence rarely use recorded sessions or live supervision (Ellis et al., 2013, p.436) (Schmidt, Ybanez-Llorate and Lamb, 2013)

15 Performance Observation Planning Reflection Feedback Evaluation (Falender & Shafranske, 2014) Clinical Supervision: Learning Cycle

16 Heavily researched; applied in a variety of contexts Atheoretical Compatible with theoretical and developmental models More inclusive than social role models Concise for feedback/supervision Inherent role of evaluator/monitor Specific concern: interactions within sessions Emphasizes supervisee s immediate learning needs Expands supervisee knowledge base Three distinct foci; three distinct roles Avoids role ambiguity Less senior supervisors can feel overwhelmed (Koltz 2008; Bernard and Goodyear, 2009; Timm 2015)

17 BERNARD AND GOODYEAR S DISCRIMINATION MODEL FOCUS TEACHER COUNSELOR CONSULTANT Intervention (Counseling Performance Skills, Cognitive Counseling Skills, Communication Ability) Conceptualization (Self Awareness, Intention with Interventions) Personalization (Professional Behaviors, Mannerisms)

18 Teacher Counselor Consultant Roles:

19 Identify supervisee s knowledge deficit Roles: teacher Increased responsibility in this role Bring to supervisee s awareness and attention Provide necessary information If supervisee provides group services Determine if knowledge deficits exist with group-specific skills Provide information relevant to the individual level of group interaction Examine interpersonal and group as-a-whole levels of interaction Depending on the supervision format, supervisors may work with one supervisee co-leadership pair or group of supervisees. If the supervisor detects that supervisees lack information regarding how supervisory relationships co-leader relationships or supervision group process may affect supervision outcomes the supervisor may choose to act in the teacher role and provide such information.

20 Roles: counselor Supervisor Identifies and explores how emotional needs impact counseling and supervision process If providing group services Explore the effect of emotional needs upon ability to conceptualize and interact effectively (interpersonal and group-as-a-whole) Group facilitation Necessitates exploration of coleader pairs and supervision group relationships Conceptualized as counselorfacilitator Bernard, 1979

21 Roles: consultant Supervisor encourages and supports Supervisee assumes increasing responsibility for focus of session and learning If supervisee provides group services encourage supervisees to identify a relevant supervision focus identify potential issues within these foci explore their own solutions while also providing needed information, perspectives, and assistance (Bernard, 1979) work with co-leader pairs

22 Personalization Conceptualization Intervention FOCI:

23 Personalization Supervisor s role and responsibilities Supervisee s focus=identifying and utilizing self more effectively in the counseling session Provides supervisee opportunities to discuss affective responses and defenses Includes mannerisms used in interaction, body language, voice intonation Increase skill in recognizing own feelings, reactions, behaviors, and attitudes surfacing during sessions Consider potential impact upon clients Assists supervisees in identifying values and situating themselves within respective cultural background Typically this will involve the counselor role by the supervisor Emphasis placed on building the supervisee s ability to effectively & ethically manage their feelings, reactions, behaviors, and attitudes. Personalization issues can be challenging to address as this may prove satisfying or uncomfortable to supervisee (Polanski, 2003)

24 Refers to supervisee being able to identify and organize essential information presented by client (Bernard, 1979) generate intervention options from this understanding identify patterns or themes from the session content determine what information is the most important intentionally determine how to proceed Conceptualization To conceptualize issues, supervisor may use counseling theories human development theories diagnostic criteria As supervisee becomes more reflective change in perception change in counseling practice increased ability to help client make meaning of their experiences (Neufeldt, Karno and Nelson, 1996) Often in supervision, conceptualization issues result when supervisees feel stuck and unsure how to proceed with clients.

25 Refers to observable and purposeful skills utilized by the supervisee in the session witnessed by the supervisor (Bernard, 1979; Bernard & Goodyear, 2004) Intervention the most structured approach the ability to open an interview minimal encouragement communication and interaction with client OARS= open-ended questioning, affirmation, empathy and other forms of support, reflecting feelings, and paraphrasing content accurately, and competent use of summaries. (Polanski, 2003; Bernard & Goodyear, 1998; Ivey, 1973; Lieberman, Yalom, & Miles, 1973). Examination of supervisee s choice, rationale, and execution of skills in therapeutic sessions Supervisor often engages in teaching the new skills or enhancing an existing set of skills Anxiety for supervisee may be observable

26 SUPERVISOR ROLE FOCUS OF SUPERVISION Teacher Counselor Consultant INTERVENTION Supervisee would like to use guided relaxation with a client however has never used the technique. Supervisor teaches the supervisee relaxation techniques, and other stress reduction methods. Supervisee can demonstrate a variety of process skills, but with one client uses question asking as primary style of interaction Supervisor assists supervisee determine the effect of this client that limits use of skills in therapy sessions. Supervisee finds clients reacting well to stories/analogues, and requests additional methods with metaphor. Supervisor works with supervisee to identify different uses of counseling metaphors and to practice. CONCEPTUALIZATION Supervisee is unable to recognize themes and patterns of client thought, either during or after sessions. Supervisee is unable to establish realistic goals for client who requests skill development with assertiveness. Supervisee would like to use a different mode for case conceptualization. Supervisor uses session transcripts to teach supervisee to identify thematic client statements (e.g. playing the victim, blaming, dependence, etc.) Supervisor helps supervisee relate personal discomfort to inability to be assertive in several personal and professional relationships. Supervisor discusses several models for supervisee to consider. PERSONALIZATION Supervisee is unaware that preference for a close seating arrangement reflects own cultural background and intimidates client. Supervisee is unaware that a female client has feelings of attraction. Supervisee would like to feel more comfortable working with elderly clients. Supervisor assigns the reading of literature about cultural boundaries and physical closeness. Supervisor attempt to assist the supervisee to confront own sexuality and any blind spots to recognizing sexual cues from others. Supervisor and supervisee discuss developmental tasks, needs, and concerns of older individuals.

27 Evidence-based Clinical Supervision Refers to specific practices (skills) supported by evidence as well as systematic analysis of efficacy Provides normative inclusion of outcome assessment in clinical supervision Determines & studies input to the supervision process Requires requisite training, and outcomes of supervisee competence and client symptom reduction. (Milne, Sheikh, Pattison, &Wilkinson, 2011) Includes client self-report of outcomes in supervision session (Reese et al., 2009)

28 In a review of dissemination & implementation of evidence-based practices in child and adolescent mental health, supervision and fidelity were the factors with greatest empirical support (Novins, Green Legha, & Aarons, 2013)

29 Creating Changes in Supervision Be respectful of biases and opinions Refrain from arguing or threatening Privilege supervisee s background and experience Vary flexibility versus structure Use TTM in determining readiness Remember a past experience when you were in supervisee s role and your response Consider use of self disclosure emphasizing response

30 Clinical Supervision Work to establish and maintain a solid working supervisory relationship Use basic communication skills and active listening Expect and maintain interpersonal boundaries Use an informed consent document and establish a contract Seek supervision and consultation Work to bridge service and practice Provide empathy and support Give feedback Read clinical supervision literature Provide empathy and support Strive to empower Foster professional development Focus on competencies instead of impairment Use a validated review form (beginning, monthly and for remedial actions) Document what happens, including data tracking per diagnosis and supervisee Learn and use supervisory skills Participate in research (Ellis, 2010; Schmidt, Ybanez-Llorate, and Lamb, 2013)

31 Clinical Supervision If supervisee provides group services Don t Don t neglect diversity issues forget the gatekeeper role Don t Neglect group therapy theory, group process and dynamics, group development and therapeutic factors Don t (Ellis, 2010) avoid confronting fears and anxiety re: being in a position of power and authority Don t Don t remain in the expert role provide inadequate or harmful supervision