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Clinical Supervision: An essential ingredient to enhancing treatment outcome with forensic populations

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Title: Clinical Supervision: An essential ingredient to enhancing treatment outcome with forensic populations


1
Clinical Supervision An essential ingredient
to enhancing treatment outcome with forensic
populations
  • Deirdre DOrazio, PhD Charles A. Flinton, PhD

2
  • http//www.youtube.com/watch?v9ZaLipDgFZQ

3
So you want to be a clinical therapist?
4
Introduction
  • Overview
  • Goals of supervision
  • Styles of effective (and ineffective) supervision
  • Enhancing positive therapeutic outcomes
  • Obstacles to supervision
  • Transference and counter-transference issues
  • Managing the impact of working with difficult
    populations
  • Monitoring Supervision

5
Who are Supervisees?
  • Supervisees can be licensed, pre-licensed,
    pre-doctoral, interns, students counselors, or
    probationary staff.

6
What is clinical supervision?
  • Supervision is an intervention that is provided
    by a senior member of a profession to a 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 junior
    member(s), monitoring the quality of professional
    services offered to the clients she, he, or they
    see(s), and serving as a gatekeeper of those who
    are to enter the particular profession.
  • Bernard and Goodyear (1998)

7
Who supervises forensic therapists?
  • A licensed professional with experience providing
    direct services in the field of forensic
    psychology
  • A licensed professional with experience providing
    direct services to the population with which the
    intern works
  • -Board of Psychology (on supervision)

8
APA Laws, Regulations, and Standards
  • 1.04 Boundaries of Competence
  • b) Psychologists provide services, teach, or
    conduct research in new areas or involving new
    techniques only after first undertaking
    appropriate study, training, supervision, and/or
    consultation from persons who are competent in
    those areas or techniques.
  •  
  • Maintaining Expertise
  • Psychologists who engage in assessment, therapy,
    teaching, research, organizational consulting, or
    other professional activities maintain a
    reasonable level of awareness of current
    scientific and professional information in their
    fields of activity, and undertake ongoing efforts
    to maintain competence in the skills they use.
  • APA GUIDELINES

9
Sexual Offender Therapist Qualifications
  • Has received specialized training regarding
    sexually abusive individuals.
  • Currently licensed in a mental health
    profession/medical field.
  • Unlicensed clinicians such as interns and
    pre-licensed practitioners must be supervised by
    a qualified, licensed clinician.
  • CCOSO Adult Guidelines and Best Practices

10
Experience
  • A qualified therapist
  • 2000 hours of face-to-face clinical experience
    in the assessment and/or treatment of sexual
    offenders.
  • Therapists with less than the above-delineated
    education and experience should not have primary
    responsibility for an offender in therapy but may
    provide psychotherapy and other services to
    sexual offenders under supervision of a therapist
    who has such education and experience.
  • CCOSO Treatment Guidelines

11
Training
  • Sexual offender therapists should obtain 30 hours
    of bi-annual sexual offender continuing education
    that is specific to their work with sexual
    offenders.
  • CCOSO Treatment Guidelines

12
California Sex Offender Management Board (CASOMB)
  • Registered interns or psychological assistants
    may provide sex offender specific evaluation or
    treatment services when functioning under the
    supervision of a licensed practitioner who meets
    the established criteria. Such interns or
    psychological assistants may apply to the
    regulatory body for approval and listing.
  • -CASOMB Recommendations Report January 2010

13
CASOMB continued
  • A one-year provisional approval status level
    should be offered to those licensed therapists
    who are pursuing sufficient education, training,
    and experience and provide a sufficient plan to
    correct any deficiencies. A provider with
    provisional approval should not be permitted to
    supervise interns or psychological assistants in
    the area of sex offender treatment until becoming
    qualified as an approved provider. No licensed
    clinical supervisor should supervise more than
    four unlicensed interns or licensed therapists
    with only provisional approval.
  • -CASOMB Recommendations Report January 2010

14
CASOMB continued 2
  • Interns or psychological assistants should
    co-facilitate one hundred hours of direct
    services with an approved licensee before being
    eligible for approved provider status. Treatment
    providers who do not meet the hours of service
    requirement may apply to be listed as approved
    providers if there are reasonable limitations on
    experience hours such as working in rural
    counties with fewer referrals.
  • -CASOMB Recommendations Report January 2010

15
2913 (d) Board of Psychology Laws and Regs.
  • No licensed psychologist may register, employ, or
    supervise more than three psychological
    assistants at any given time unless specifically
    authorized to do so by the board.
  • No board certified psychiatrist may register,
    employ, or supervise more than one psychological
    assistant at any given time.
  • No contract clinic, psychological corporation, or
    medical corporation may employ more than 10
    assistants at any one time.
  • No contract clinic may register, employ, or
    provide supervision for more than one
    psychological assistant for each designated
    full-time staff psychiatrist who is qualified and
    supervises the psychological assistants. No
    psychological assistant may provide psychological
    services to the public for a fee, monetary or
    otherwise, except as an employee of a licensed
    psychologist, licensed physician, contract
    clinic, psychological corporation, or medical
    corporation.

16
4980.45. EMPLOYMENT OR SUPERVISION OF
REGISTRANTS MAXIMUM NUMBER OF REGISTRANTS
  • A licensed professional in private practice who
    has satisfied the requirements of subdivision (g)
    of Section 4980.03 may supervise or employ, at
    any one time, no more than a total of two
    individuals registered as either a marriage and
    family therapist intern or associate clinical
    social worker in that private practice.
  • An individual supervised after being granted a
    qualifying degree shall receive at least one
    additional hour of direct supervisor contact for
    every week in which more than 10 hours of client
    contact is gained in each setting. No more than
    five hours of supervision, whether individual or
    group, shall be credited during any single week.
  • Direct supervisor contact provided in a group
    shall be provided in a group of not more than
    eight (8) supervisees and in segments lasting no
    less than one continuous hour.

17
Forensic Psychotherapy as a Specialty
  • Sex Offender Management Best Practices
  • Collaboration, specialization, education,
    judicial leadership, and buy-in all for victim
    and community safety

18
The Containment Model Best Practices
Criminal Justice System (Probation/ Parole
Officer) Polygraph Examiner

Therapist
  • The Offender

Supervisee
19
Types of Sexual Offender Populations?
  • High Moderate Low Risk Sexual Offenders
  • Inpatient
  • Outpatient
  • Group/Individual Therapy
  • Pretrial
  • Presentencing
  • Treatment/Assessment
  • Mandated/Voluntary
  • Children, Juvenile, Adult, Male, Female, DD etc

20
Supervision is NOT Counseling
  • Counseling
  • Purpose- personal growth, understanding,
    decision-making
  • Goal- determined by client need
  • Timeframe-self-paced
  • Agenda- based on client needs
  • Process- an affective process which includes,
    listening, exploring, teaching, supporting

21
Types of Forensic Psychology Supervision
  • Clinical
  • Administrative

22
Clinical Supervision
  • Purpose- improves clinical skills, professional
    performance and knowledge
  • Goal increases knowledge and skills
  • Timeframe- is supervisee and task defined
  • Agenda- is based on task and skills needed
  • Process- includes assessing performance,
    teaching specific skills (e.g., testing,
    theoretical orientation)

23
Administrative Supervision
  • Purpose assure compliance with agency and
    professional procedures and policies
  • Goal- consistent use of approved formats (e.g.,
    documentation, etc)
  • Timeframe- ongoing
  • Agenda based on agency policy and professional
    guidelines
  • Process clarify expectations, policy,
    procedures, and monitoring compliance

24
APA Ethics Code
  • 7.02 Descriptions of Education and Training
    Programs
  • Psychologists responsible for education and
    training programs take reasonable steps to ensure
    that there is a current and accurate description
    of the program content (including participation
    in required course- or program-related
    counseling, psychotherapy, experiential groups,
    consulting projects, or community service),
    training goals and objectives, stipends and
    benefits, and requirements that must be met for
    satisfactory completion of the program. This
    information must be made readily available to all
    interested parties.

25
Program/Supervisor Goals (competencies expected
from the program)
  • (SFFI example)
  • 1.To provide an environment that facilitates
    knowledge of forensic psychology
  • 2. To provide an environment that promotes
    collegiality
  • 3.To re-enforce empirically supported
    interventions
  • 4. To provide the education and support for
    supervisees to gain practical understanding of
    risk assessment and integrate that understanding
    into therapeutic interventions
  • (These should be in writing and provided to the
    intern)

26
Goals of Supervision(competencies expected of
the supervisor)
  • 1. The ability to identify a supervisees
    strengths and growing edges professionally and
    personally.
  • 2. The ability to formulate interventions that
    integrate the supervisees abilities and
    strengths with empirically guided interventions.
    (e.g., assist the supervisee in developing a
    personal paradigm for working with forensic
    populations that is also grounded in current/best
    practice).
  • 3. The ability to form an appropriate and
    effective helping relationship.
  • 4. The ability to identify and address ethical
    issues as they arise.
  • 5. The ability and intent to instill amenability
    to growth. (e.g., Give and receive constructive
    feedback without getting defensive.)
  • 6. Impart wisdom The ability to pass on lessons
    learned through experience.

27
Supervisee Goals(competencies expected of the
supervisee)
  • These are goals developed collaboratively between
    supervisee and supervisor.
  • Ideal goals are
  • Specific - the goal is clearly understood by
    both the supervisor and the trainee
  • Realistic - the goal is within the abilities of
    the trainee and the trainee believes that he/she
    can attain the goal
  • Challenging - the goal engages the trainee in a
    way that motivates effort
  • Measurable/Observable the goal is concrete
    enough that both the supervision and the trainee
    can monitor progress and achieve a sense of
    accomplishment upon attainment

28
Establishing Goals
  • Goal Relevance
  • refers to goals that are pertinent to a
    particular supervisees needs.
  • Goal Importance
  • works toward identifying goals that are
    personally significant to the supervisee.
  • Goal Attainability
  • refers to goals that the supervisee believes
    could be achieved.
  • Emotional Salience
  • refers to setting goals in which the natural
    rewards are obvious to the supervisee.
  • -Cullari ,1996

29
Formalizing the Goals for Supervision
  • Goals of supervised experience should be
    written and signed by both the supervisor and the
    trainee
  • Best practices and accepted standards that have
    been developed by the American Psychological
    Association, the Association of Psychology
    Postdoctoral and Internship Centers (APPIC), and
    the California Psychology Internship Council
    (CAPIC).

30
  • Intern goal and evaluation form hand out

31
Goals for Supervision Examples
32
Goal Objectives
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33

RECAPThree Goals of SupervisionPerformance,
Knowledge, Safety
  • To provide a safe, supportive, reliable,
    enriching environment
  • within which the supervisee will develop
    practical knowledge of the specialty of forensic
    psychotherapy
  • and integrate that understanding into applying
    interventions that are supported empirically
  • and effectively prevent reoffense
  • Easy, right?!

34
Exercise
35
Enhancing Positive Therapeutic Outcomes
  • The Supervisor as Guardian of Public Safety
  • Supervision within the sub-niche of psychotherapy
    involving treatment of offenders is unique in
    several ways. Foremost, the over-arching goal of
    the supervisor supervisee relationship is to
    prevent client sexual re-offense. Good
    supervisors attempt to balance liability for
    community safety with the growth of the
    clinician.

36

Does Sex Offender Treatment Work?
Hanson et. al, 2009. the Principles of Effective
Correctional Treatment Also Apply to Sexual
Offenders A Meta-Analysis. Criminal Justice and
Behavior, 36, 865-891.
37
Yes! Sex Offender Treatment Does WorkBut it has
room to improve
  • 1. A meta-analysis examining 129 studies of
    treatment of sex offenders ultimately included
    only 22 studies that met basic study quality
    criteria. Quality was defined per the
    Collaborative Outcome Data Committee guidelines.
  • 2. Results
  • 22 studies. N3,121 treated sex offenders.
    N3,625 non-treated sex offenders
  • 10.9 sexual recidivism for treated group v.
    19.2 for no-treatment
  • 43 reduction in sexual recidivism.
  • 3. Conclusion
  • Risk Need Responsivity principles should be a
    primary consideration in the design and
    implementation of treatment programs for sexual
    offenders.

38
The Guiding Principles of Effective
Interventions Risk, Need, Responsivity(Bonta
Andrews, 2007 Hanson et. al, 2009)
39
Effective Treatment Targets Criminogenic Needs
40
The Purpose of Treatment Need Responsivity
  • The objective of treatment is to help the client
    ameliorate Needs.
  • This requires creating an environment that
    facilitates treatment engagement so that the
    offender will maximally Respond to treatment.
  • Responsivity refers to the environment for
    change.
  • The therapeutic landscape must be safe,
    supportive, continual, reliable.
  • The supervisory landscape must be safe,
    supportive, continual, reliable.

41
(No Transcript)
42
The Real Purpose of Treatment
  • Change the Structure Function of the Brain
  • Good therapy a meaningful experience in a safe
    context that alters the neuronal processing
    template, directly shaping the circuits
    responsible for memory, emotion and
    self-awareness.

43

The Neurobiology of Change
  • Patterns of energy and information flow within
    the brainand between brains.
  • Experience shapes the genetically programmed
    maturation of the nervous system.
  • All new input is filtered through this neuronal
    processing template. Changes are use-dependent,
    occurring only in novel or extreme situations.
  • Attributing meaning to experience (emotion)
    causes new patterns of connections among nerve
    cells in the brain, at a sub-cortical level. This
    is how memory works.
  • Memory is the way past events effect future
    responses.
  • Concepts evoke change only when meaning is
    ascribed to experience.
  • Good therapists attend to the neurobiology of
    interpersonal experience Human connections shape
    neural connections.
  • If it evokes meaning, information from this
    workshopfrom your supervision sessionsfrom your
    supervisees therapy sessions will be encoded,
    stored retrieved by the brain in implicit and
    explicit memory systems.

44
Unhealthy Deficits Can Become Healthy Tendencies
Unconscious Incompetence (pre-contemplation) Con
scious Incompetence (contemplation) Conscious
Competence (action) Unconscious Competence
(maintenance)
45

RECAP Enhancing Positive Outcomes
  • Effective sexual offender therapy, and effective
    sexual offender therapist supervision, can and
    does happen
  • It is guided by the goal of preventing victim
    harm
  • It includes thorough assessment and targets
    specified and empirically based needs
  • Conducted in a relational landscape that
    maximizes brain based change
  • Involves making new implicit and explicit memory
    patterns through experience and emotion

46

The Therapeutic ProcessEssential to Outcome
  • The How is as Important as the What of
    Treatment
  • SOT Programs that highlight the therapeutic
    relationship are successful at enhancing positive
    behavior change and reducing recidivism (Marshall
    et al, 2003 2010)
  • A convenient overshadowing Strongly manualized
    programs and purely didactic (psychoeducational)
    are inadequate at evoking the kind of change
    needed by offender clients
  • Experiential methods are essential for brain
    integration
  • Effective therapy, and effective supervision,
    employs positive approaches that motivate change
    and identify strengths, using them to build
    skills while still targeting relevant needs
  • Approach goals facilitate treatment engagement,
    disclosure, and prosocial identification

47
Supervisors are mindful of what works, and
doesnt work, in therapy with sexual offenders
  • Authoritarian and aggressive techniques do not
    work with abusive individuals (i.e.
    confrontation, shock, anger, revenge on behalf of
    victims, demand for change). They elicit
    resistance, argumentativeness, manipulative
    placation, eroded self-esteem, drop-out.
  • Effective process facilitates emotion processing
    and regulation. It helps clients regulate the
    affective precursors to offending. Interpersonal
    schemas are changes through emotional expression.
  • Many sexual offender clients are particularly
    responsive to therapy process variables because
    they were betrayed by someone in a position of
    trust and they are poised toward suspiciousness.

48
Good Supervisors Foster Essential Therapist
Characteristics
  • Empathic
  • Genuine
  • Supportive
  • Directive/Reflective

49
Follow the Responsivity Principle Offender
Recovery Begins with Empathy for the Offender
To sense the clients private world as if it
were your own, but without ever losing the "as
if qualitythis is empathy, and this seems
essential to therapy. To sense the clients
anger, fear, or confusion as if it were your own,
yet without your own anger, fear, or confusion
getting bound up in it, (is empathy). When the
clients world is this clear to the therapist,
and he moves about in it freely, then he can both
communicate his understanding of what is clearly
known to the client and can also voice meanings
in the clients experience of which the client is
scarcely aware. (Carl Rogers, 1957, p.99)
50
Obstacles to Effective Supervision
  • Strains in supervision can be brought about by
    the challenges inherent in clinical practice,
    conflicts in the goals and/or tasks, inadequate
    attention to the values modeled by the supervisor
    and/or the essential therapist characteristics,
    inadequacies in technical competence, boundary
    crossings, problematic supervisee behavior, and
    negative transference, countertransference, and
    parallel process phenomena.

51
Obstacles
52
Indicators of Supervision Strain
  • Withdrawal
  • Paucity of disclosure
  • Direct expression of criticism/hostility
  • Noncompliance/passive responding
  • Acting in/acting out

53
Obstacles to SupervisionFacing the Shadow
  • Negative attitudes and beliefs about offenders
    leads to inappropriate therapeutic style and
    negative outcomes
  • What is the societal context within which we
    provide sexual offender treatment?
  • How might the common societal view of sexual
    offenders impact a therapist?
  • Impact you?
  • Beware the temptation to participate in the
    cycle of abuse!

54
The Cycle of Abuse
  • Empathy A matched vicarious emotional response
    that depends on the ability to infer anothers
    cognitive and affective state. It is mediated by
    egocentrism (a continuum of self to other focus)
  • Trauma leads to a personal distress state,-
    excessive self focus with goal of immediate
    relief
  • Acute distress yields to general wounded-ness
  • Reactive versus receptive
  • Common symptoms self-regulation deficits (affect
    tolerance/ modulation), shame, secrecy, negative
    self-evaluation, depression, social/intimacy
    deficits, avoidance behaviors (dissociation,
    denial, distraction, externalization

55
Cascade Effects of Trauma on the Brain
  • Inability to regulate strong emotions wires the
    brain to survive in a world of constant danger.
  • When unknown or threatening sensory input is
    matched against the existing processing template,
    the brain activates a fight or flight response
    before the signal can get to the cortex.
  • The brain becomes programmed to irritability,
    impulsivity, suspiciousness.

56
Cascade Effects of Trauma on the Brain
  • 1. Left Hemisphere Underdevelopment
  • 2. Deficient Left-Right Hemisphere
    Integration
  • 3. Limbic Irritability
  • 4. Abnormal Activity in the Cerebellum
  • 5. Hormone Dysfunction

57
The Cycle of Abuse Trauma Perpetrators,
Recipients and HealersIMPACT
  • Recipients
  • Trauma taxes expectation system leading to
    failure to manage fear and integrate trauma.
  • Perpetrators
  • Ongoing wounded-ness keeps abusive individuals
    self-focused and reacting to a hostile world.
    Empathy deficits prevail. They dont notice,
    dont care, or misinterpret cues from others.
    Significant impact on Risk, Needs Responsivity.
  • Healers
  • What the patient says in group is more of an
    intelligence test. It is what he says to other
    patients, our reading between the lines that
    tells us the degree of internalized change.
    Therapist lack of confidence steals the reserves
    necessary to perceive what is really going
    on.-Liam Marshall, 2011.

58
Empathy is Related to.
  • Healthy
  • Accurate perspective taking
  • Affect identification, tolerance modulation
  • Attachment , Intimacy Social Interest
  • Prosocial behavior abuse abatement
  • Conscience development
  • Feeling understood, validated, supported
  • Unhealthy
  • Cognitive distortions
  • Criminal thinking
  • Less visual processing
  • Affective Dysregulation(PD)
  • Communication deficits
  • Intimacy deficits callousness
  • Abusive behavior
  • Psychopathy

59
Unconscious Challenges to Supervision
  • Transference
  • Unconscious redirection of a client's feelings
    for a significant person to the therapist. Common
    manifestations of transference erotic
    attraction, rage, hatred, mistrust,
    parentification, over-dependence, idealization.
    I.e. A man transfers hatred of his mothers
    infidelities to other women, and his female
    psychotherapist.
  • Counter-transference
  • A jointly created phenomenon between the
    treater and the client. The client pressures the
    treater through transference into playing a role
    congruent with the clients internal world. The
    specific dimensions of that role are colored by
    treaters own personality. I.e. The female
    therapist, feeling dismissed and disliked,
    attends more to other clients in group therapy.

60
Vicarious Traumatization
  • The cumulative transformative effect upon the
    trauma therapist of working with survivors of
    traumatic life events.It is a process through
    which the therapists inner experience is
    negatively transformed through empathic
    engagement with clients trauma material
  • Pearlman Saakvitne, 1995

61
Monitoring Managing Therapist Impact
  • Repeated exposure to stories of perpetration and
    predation tempt us to participate in the cycle of
    abuse. Supervisors help therapists access and
    treat the wounds of clients, while identifying
    impact to the therapist and managing the
    therapists wounds

62
Cultivate the Nymph in Supervisees!
  • The goal is an integrated brain. Focus on the
    How along with the What of the work they do,
    and the work you do together.
  • 2. Therapist Style Empathy, Genuineness,
    Supportiveness, Directiveness.
  • 3. Treatment planning begins with the clients
    world view. They wont develop empathy until we
    do.
  • 4. Get comfortable with working at the foot of a
    volcano! Tolerate and transform pain and fear.
  • Willing Awareness commit to showing up
    physically and psychologically to experience
    that which is.
  • 6. Beware the temptation to participate in the
    cycle of abuse.

63
My Vow to Care for the Helper
  • Internal
  • I will expect counter-transference
  • In session I will practice willing awareness
  • External
  • I will prioritize my personal life
  • I will incorporate my best qualities
  • I will find a passion in my professional life
  • I will be aware of personal signs of burnout
  • I will allow myself my own therapy
  • I will utilize debriefing consultation
  • I will connect with other professionals in the
    field

64
Care for the Healer
  • Practice the treatment in your own life.
  • Self empathy sells empathy!
  • Beware of vicarious traumatization.
  • Commit to lifelong learning, consultation,
    collaboration.
  • Put your work into perspective.
  • Appreciate your colleagues.

65
(No Transcript)
66
  • Supervision types, process, and techniques

67
Types of Supervision Styles
  • Authoritarian supervision
  • Laissez Faire supervision
  • Companionable supervision
  • Collaborative supervision

68
Authoritarian Supervision
  • Cognitive stance of the supervisor
  • Supervisees require constant attention because
    they are often undependable or immature (e.g.,
    they will attempt to work as little as possible
    unless someone monitors them carefully).
  • Supervisees cannot be trusted to fulfill their
    tasks, the supervisor must check on them
    frequently. The supervisor is ultimately
    responsible for supervisees performance.
    Consequently, close observation is an essential
    part of the supervisors responsibilities.

69
Laissez Faire Supervision
  • Cognitive stance of the supervisor
  • Give supervisees the freedom to use their talents
    and skills in accomplishing job responsibilities.
    Hire good people and then get out of their way.

70
Companionable Supervision
  • Cognitive stance of the supervisor
  • Supervision is a friendship-like relationship.
    Supervisors should seek to be liked and create
    harmonious relationships. The focus should be on
    being buddies with the supervisees and avoid
    confronting them about poor job performance or
    mistakes in judgment.

71
Collaborative Supervision
  • Cognitive stance of the supervisor
  • A cooperative effort between the supervisor and
    supervisee that facilitates a joint effort to be
    greater than the sum of their individual
    contributions.
  • Supervision in this approach has a dual focus 1)
    the accomplishment of the organizations goal and
    2) support staff in the accomplishing their
    personal and professional development goals.
  • Supervision emphasizes the identification of
    potential problems early the supervisor and
    supervisee then jointly develop strategies to
    prevent or ameliorate issues and attain goals.

72
Effective Supervision Styles
  • Ineffective
  • Concrete feedback-
  • directive, critical, asking irrelevant
    questions
  • Effective
  • Abstract feedback
  • feeding questions that are information
    seeking, information giving and guiding.
    Expertise was also held back at times to enhance
    discovery.
  • -P. Grimmet (1998)

73
Characteristics of Effective Supervisors
  • Empathetic
  • Supportive
  • Flexible
  • Interested in supervision
  • Track supervisees effectively
  • Link theory with practice
  • Engage in joint problem-solving
  • Interpretative
  • Respectful
  • Focused
  • Practical
  • Knowledgeable

74
Characteristics of Ineffective Supervisors
  • Rigid
  • Low empathy
  • Low support
  • Failure to consistently track supervisee concerns
  • Failure to teach or instruct
  • Indirect intolerant
  • Closed
  • Lack respect for differences
  • Non-collegial
  • Lacking in praise encouragement
  • Sexist
  • Emphasize evaluation, weaknesses, deficiencies

75
The Process of Supervision
  • The Trans Theoretical Model (TTM) and Supervision

76
Trans Theoretical Model of Change (Per Ryan E.
Gillespie)
77
Precomtemplation Stage
  • Supervisees are unaware of (or not focused on)
    the possibility for change (resistant, unaware,
    etc)
  • Maybe acquiescent in order to pursue secondary
    gain
  • Maybe defensive to feedback

78
Contemplation Stage
  • Thinking but not doing (Baldwin, 1991)
  • Supervisees may experience anxiety about change
  • Supervisees may experience feelings/beliefs of
    incompetence
  • Supervisees begin to intellectually consider
    change but do not take action

79
Action Stage
  • Supervisees may experience distress (due to
    incongruence between their awareness and
    readiness to change)
  • Supervisees express a commitment to professional
    development
  • Supervisors may overestimate supervisees skills
    (Supervisors must supervisees in staying focused
    and not regress to previous stages)

80
Maintenance Stage
  • Professional autonomy is building
  • Supervisees more readily seek assistance in
    honing skills
  • Failures may cause regression

81
Termination Stage
  • Change has occurred when skills become more
    automatic and forced conscious attention is not
    required to maintained skills
  • Consultation is natural

82
Structured Interventions
  • Structure (at least initially)
  • Homework
  • Video/Audio Taping
  • Document Review
  • Case Conferences/Presentations
  • Topic Presentations

83
TTM Specific Interventions
  • Experiential Processes
  • Consciousness raising
  • E.g. Socratic dialog
  • Dramatic Relief
  • Role play
  • Self-reevaluation
  • Affective and cognitive assessment of how the
    supervise thinks they are doing
  • Environmental Reevaluation
  • Assessing and correctly attributing influences of
    change

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Interventions
  • Stimulus control
  • Removing negative stimuli (e.g. shame)
  • Counter-conditioning
  • Developing alternative ways of behaving,
    thinking, feeling, and interacting with their
    clients.
  • Contingency management
  • Based on the principles of reinforcement
  • Social liberation
  • Maintaining collegial relationships
  • Helping relationships
  • Trust in the supervisory relationship

85
  • ..supervisees reported that supervision
    mentoring relationships had more influence on
    their professional development than academic
    preparation.
  • Greig, T. C. (1998). Supervisor mentoring and
    psychotherapist professional development An
    exploratory qualitative study. Dissertation
    Abstracts International, 59(04), 1851B. (UMI No.
    9830593)

86
EXCERCISE
87
APA Ethics Code
  • 7.04 Student Disclosure of Personal Information
  • Psychologists do not require students or
    supervisees to disclose personal information in
    course- or program-related activities, either
    orally or in writing, regarding sexual history,
    history of abuse and neglect, psychological
    treatment, and relationships with parents, peers,
    and spouses or significant others except if (1)
    the program or training facility has clearly
    identified this requirement in its admissions and
    program materials or (2) the information is
    necessary to evaluate or obtain assistance for
    students whose personal problems could reasonably
    be judged to be preventing them from performing
    their training- or professionally related
    activities in a competent manner or posing a
    threat to the students or others.

88
4980.55. DISCLOSURE OF COUNSELORS
QUALIFICATIONS
  • As a model for all therapeutic professions, and
    to acknowledge respect and regard for the
    consuming public, all marriage and family
    therapists are encouraged to provide to each
    client, at an appropriate time and within the
    context of the psychotherapeutic relationship, an
    accurate and informative statement of the
    therapist's experience, education, specialties,
    professional orientation, and any other
    information deemed appropriate by the licensee.
  • -Board of Behavioral Sciences

89
Case Example
90
Monitoring
  • As a supervisor, you are required to assume FULL
    RESPONSIBILITY for the work product of your
    supervisee.
  • Remember that the supervisorial relationship is
    a hierarchical one. Teach and lead.

91
The Frame
  • The frame defined as any aspect of the
    supervision program intended to create an
    environment in which learning and growth are is
    possible.
  • Interventions
  • Structure

92
APA Ethics Code
  • 7.06 Assessing Student and Supervisee Performance
  • (a) In academic and supervisory relationships,
    psychologists establish a timely and specific
    process for providing feedback to students and
    supervisees. Information regarding the process is
    provided to the student at the beginning of
    supervision.
  • (b) Psychologists evaluate students and
    supervisees on the basis of their actual
    performance on relevant and established program
    requirements

93
Giving Difficult Feedback
  • Most supervisors admit withholding feedback due
    to concern about negative reactions from
    supervisees. -Stoltenberg (2005)
  • -Provide specific examples, and if possible, use
    of audio or video, observation
  • -Be aware of your own discomfort and monitor body
    language and eye contact.
  • -Anticipate concerns

94
Documenting Supervision
  • It is important to document supervision sessions
    because
  • You are legal responsible for supervisees
    actions
  • You will have a clearer perception of how the
    supervisee is progressing in terms of addressing
    crisis issues, adhering to the treatment plan,
    and diagnosing the client.
  • If the supervisees case were to go to court (for
    any reason) it is imperative that supervision
    notes indicate that your were providing close and
    adequate supervision.

95
Supervision Contracts
  • Supervisor and supervisee rights and
    responsibilities
  • Content and Context of Supervision
  • Scope of practice under supervision
  • Length of contract period
  • Roles and Expectations of Supervisee and
    Supervisor
  • Learning activities, processes, supervisor and
    supervisee responsibilities, feedback, mutually
    defined goals and tasks
  • Legal/Ethical Parameters
  • Informed consent Confidentiality

96
Supervision Contracts continued
  • Adherence to agency/practice requirements and
    rules
  • Include specific reference to ethical codes,
    licensing statutes, and laws
  • Reference to agency/site personnel practices
  • Performance Expectations
  • Specific knowledge, skills, values
  • Modes of formative and summative evaluation

97
Risk Management
  • Ensure that the clients and referral agents know
    the status of the supervisee (e.g., that they are
    unlicensed and/or an intern) in writing
  • APA code 10.01, Informed Consent to Therapy
  • c) When the therapist is a trainee and the legal
    responsibility for the treatment provided resides
    with the supervisor, the client/patient, as part
    of the informed consent procedure, is informed
    that the therapist is in training and is being
    supervised and is given the name of the
    supervisor.

98
Discussion
99
  • Deirdre DOrazio, PhD
  • Central Coast Clinical and Forensic Psychology
    Services
  • drdorazio_at_cccfpsych.com
  • 805-903-2446
  • Charles A. Flinton, PhD
  • San Francisco Forensic Institute
  • caflinton_at_sffi.us
  • 415-391-7171
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