Supervision Training for CMHC Internship Site Supervisors

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Supervision Training for CMHC Internship Site
Supervisors

• Counseling and Human Services
• Roosevelt University

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Why is Supervision important?

• Macro View
• Society maintains a relationship with our
  profession which allows us to self-regulate, as
  long as we insure that the welfare of clients is
  held above our own self interest.
• As part of this self-regulation, the profession
  is charged with the responsibility of
• controlling who is admitted to practice
  (Gatekeeper)
• establish standards for behavior
• Discipline of incompetent or unethical members.

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Why Is Supervision Important

• Micro View
• To foster the supervisees professional
  development
• A supportive and educational function with
  precise and concrete goals for the supervisee to
  accomplish.
• Derived from combination of supervisors own
  theory or model, supervisees particular
  developmental needs and the supervisees
  expressed wishes.
• To ensure client welfare
• Serving a Restorative Function
• Assist interns to understand burnout and
  compassion fatigue issues and learn appropriate
  self-care techniques.

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Goals of RU Internship Program

• By the time that Interns complete their 600
  hours, they should be able to
• Demonstrate competence in ethical thinking and
  ethical practice.
• Demonstrate awareness of the influence of
  culture, race, gender and sexual orientation on
  the therapeutic process, therapeutic
  relationship, problem formation, maintenance, and
  resolution.
• Demonstrate mastery of basic counseling skills.
• Articulate a coherent theory of change and theory
  of clinical practice.
• Demonstrate their personal theory through
  consistent case conceptualization, case
  presentations and audio/video case demonstrations.

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Defining Supervision

• Association for Counselor Education and
  Supervision (ACES)
• . . . Involves facilitating the counselors
  personal and professional development as well as
  promoting counselor competencies for the welfare
  of the client. Supervisors oversee the
  counselors work through a set of activities that
  include consultation, counseling (if provided for
  by ones model of supervision), training,
  instruction, and evaluation.
• Supervision is a hierarchical and evaluative
  process.
• It is also a collaborative and mentor
  relationship.

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Intern Comments When Asked What Constitutes Good
Supervision.

• Support, Trust, Safety
• Respectful
• Nonjudgmental challenge
• Praise for job well done
• Constructive criticism
• Time, Attention, Concern
• Consistency Accessibility
• Allowed intern to be real and to voice concerns
  and frustrations.
• Good clinical skills

• Understanding of ethics legal aspects.
• Flexibility (able to move from one theoretical
  viewpoint to another)
• Good understanding of diversity issues, special
  populations, etc.
• Able to maintain a big picture view of the
  relationship
• Collegial relationship

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Intern Comments When Asked What Constitutes
Difficult Supervision.

• Cynicism and Burnout (not just in the supervisor,
  but in experienced staff. Supervisor must
  process this information with the intern!)
• Rigidity Inconsistency
• See intern as just another employee (thrown to
  the wolves!)
• Lack of adequate attention to skill development.
• Believe that supervisees will acquire or catch
  needed skills by being exposed to others who are
  doing it. - Germ Theory
• This is the concern with the frequent practice of
  shadowing, without adequate discussion of what is
  actually taking place and why it is taking place.

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Conceptual Model of SupervisionBernard
Goodyear, (2009)
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Credentialing Supervisors

• In the past supervision was carried out by senior
  members of the profession. Today, supervision has
  become a sub-specialty within the counseling
  profession Professional.
• Organizations like AAMFT have included special
  supervisor designations for many years - Approved
  Supervisor
• Many state licensing boards now require higher
  level of credentialing in order to supervise
  post-masters level interns.
• Supervisors must meet certain education and
  experiential requirements.

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Credentialing Supervisors

• No uniformity in credentialing across states.
• General Requirements of State Licensure Boards
• Graduate Degree from Accredited Academic
  Institution or the Equivalent
• Licensure within a specific professional
  discipline (2 or 3 years minimum years of
  licensed practice, with 2 or 3 years of
  pre-licensure clinical experience)
• Specific Training in Supervision
• Completion of a graduate level supervision class
• Clinical Supervisors Course approved by a
  professional organization
• CEU course work in clinical supervision and other
  areas of counselor development (Assessment
  Evaluation, Ethics, Professional Development,
  etc.
• Attestation of having thorough knowledge of
  supervisees practice activities, such as record
  keeping, fiscal management, ethics, etc.

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Supervision Using Supervisee Self-Report

• The grandfather of all supervision and still
  commonly used.
• It is a very difficult form of supervision to
  perform well.
• It is at its best when supervising more
  experienced students.
• Muslin, et al. (1981) found that 50 of the
  important issues evident in videotapes of therapy
  sessions of psychiatric trainees were not
  reported in supervision.
• Some degree of distortion characterized 50 of
  supervisees self-report.
• Inexperienced therapists have a hard time
  comprehending the problems of clients. With
  self-report alone, supervisors are unable to
  actually observe trainees actions as they are
  taking place.

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Supervision Using Supervisee Self-Report

• Self-Report
• As a supervision strategy, it is only as good as
  the observational and conceptual abilities of the
  supervisee and the seasoned insightfulness of the
  supervisor.
• Rogers McDonald (1995) found that when
  supervisors used more direct methods of
  supervision they evaluated their supervisees as
  less prepared for the job than when they used
  self-report.
• Anderson (2000) subjects far more likely to
  consider self-report as representing their worst
  supervision experiences than their best
  supervision experience.

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Supervision Using Audiotape/Videotape

• A picture is worth a thousand words!!!
• During practicum and internship, RU requests
  either audiotaping or videotaping of sessions.
• If at all possible, it would be optimal if site
  supervisors could review tapes with interns
  during individual supervision.
• This allows supervisor to get a more accurate
  overview of supervisees ability.
• Tape review allows the supervisor to
• Highlight the most productive parts of the
  session
• Highlight the most important parts of the session
• Highlight parts of the session where the student
  is struggling.
• Discuss case conceptualization, theoretical
  development, etc.

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Supervision Using Audiotape/Videotape

• More experienced supervisees should be instructed
  to listen to tapes and select specific sections
  to be reviewed.
• Transcribing tapes is a valuable lesson for
  students.
• In this case the supervisee should be prepared
  to
• 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 session.
• Clearly state the specific help desired from the
  supervisor.

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Integrated Developmental Model (Stoltenberg,
McNeil Delworth, 1998)

• Domains representative categories of knowledge
  central to becoming a counselor
• Intervention skills competence The ability to
  implement therapeutic interventions with
  assuredness
• Assessment techniques the ability to utilize
  assessment protocols and devices with assuredness
• Interpersonal assessment the ability to
  theoretically conceptualize a clients
  interpersonal dynamics
• Client conceptualization the ability to
  organize client data into a meaningful diagnostic
  understanding upon which to base clinical
  treatment

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Integrated Developmental Model (Stoltenberg,McNei
l Delworth, 1998)

• Domains Continued
• Individual differences the ability to include
  the influences of diversity and difference into
  the understanding of an individual client
• Theoretical orientation the ability to utilize
  and integrate different clinical theories and
  approaches
• Treatment Plans and Goals the ability to
  contract for change with a client and to
  effectively intervene to achieve therapeutic
  progress
• Professional ethics the ability to coordinate
  professional and personal ethics with standards
  of practice.

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Integrated Developmental Model (Stoltenberg,McNei
l Delworth, 1998)

• Integrated Development Model
• 3 overriding structures that provide markers in
  assessing professional growth.
• Self-Other Awareness
• Where the student is in terms of
  self-preoccupation, awareness of the clients
  world, and enlightened self-awareness
• Motivation
• Reflects the supervisees interest, investment,
  and effort expended in clinical training and
  practice.
• Autonomy
• Reflects the degree of independence that the
  supervisee is manifesting.

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Integrated Developmental Model
(Stoltenberg,McNeil Delworth, 1998)

• Integrated Development Model
• Level 1.
• Supervisees have limited training, or at least
  limited experience in the specific domain in
  which they are being supervised.
• Motivation Both motivation and anxiety are
  high focused on acquiring skills. Want to know
  the correct or best approach with clients.
• Autonomy Dependent on supervisor,. Needs
  structure, positive feedback, and little direct
  confrontation.
• Awareness High self-focus, but with limited
  self-awareness apprehensive about evaluation.

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Integrated Developmental Model
(Stoltenberg, McNeil Delworth, 1998)

• Integrated Development Model
• Level 2
• Supervisees making the transition from being
  highly dependent, imitative, and unaware in
  responding to a highly structured, supportive,
  and largely instructional supervisory
  environment. Usually after 2 or 3 semesters.
• Motivation Fluctuating as the supervisee
  vacillates between being very confident to
  unconfident and confused.
• Autonomy Although functioning more
  independently, he/she experiences conflict
  between autonomy and dependency, much as an
  adolescent. This can manifest as pronounced
  resistance to the supervisor.
• Awareness Greater ability to focus on and
  empathize with client. Balance still an issue.
  Problem can be veering into confusion and
  enmeshment with the client.

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Integrated Developmental Model
(Stoltenberg, McNeil Delworth, 1998)

• Integrated Development Model
• Level 3
• Supervisee focusing more on a personalized
  approach to practice and on using and
  understanding of self in therapy.
• Motivation Consistent occasional doubts about
  ones effectiveness will occur, but without being
  immobilizing.
• Autonomy A solid belief in ones own
  professional judgment developed as the supervisee
  moves into independent practice. Supervision
  tends to be collegial as differences between
  supervisor and supervisee expertise diminish.
• Awareness Supervisees return to being
  self-aware, but with a very different quality
  than at Level 1. Able to remain focused on the
  client while also stepping back to attend to
  their own personal reactions to the client and
  then to use this in decision making about the
  client.

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Integrated Developmental Model
(Stoltenberg,McNeil Delworth, 1998)

• Integrated Development Model
• Level 3i (Integrated)
• Occurs as supervisee reaches Level 3 across
  multiple domains
• Including treatment, assessment, case
  conceptualization.
• Characterized by a personalized approach to
  professional practice across domains and the
  ability to move easily across them.
• Supervisee has strong awareness of his or her
  strengths and weaknesses.

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Discrimination Model (Bernard, 1997)

• Developed by Janine Bernard in 1970s as a
  teaching tool.
• A-theoretical and A-cultural model for training
  novice therapists.
• It is parsimonious and versatile.
• Implies that the supervisor will tailor their
  responses to the particular needs of the
  supervisee.
• Supervisor roles and foci will change throughout
  each supervision session.
• Three supervisory roles Three Focus Areas
• Teacher - Intervention skills
• Counselor - Conceptualization skills
• Consultant - Personalization skills

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Discrimination Model (Bernard, 1997)

• Supervision Foci Intervention skills
• Focus on what the counselor does in the therapy
  session, from start to finish. Focus on what is
  observable.
• Focus on implementation skills, rather than on
  the planning or anticipation of them.
• May include
• The ability to open an interview smoothly
• Competent use of reflections, probes,
  restatements, summaries, and interpretations
• Understanding of nonverbal communication to
  enhance verbal communication
• Achieving interview closure.

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Discrimination Model (Bernard, 1997)

• Supervision Foci Conceptualization skills
• Addresses a counselors ability to sort out the
  essential information presented by the client to
  identify themes and to develop a working
  understanding of the clients life situation.
• Reflects on deliberate thinking and case analysis
  by trainees.
• It is important to note that a counselor's
  philosophy or theory of counseling directly
  influences how he or she understands and
  diagnoses the clients concerns.
• May include
• Understand what clients are saying
• Identify themes in clients messages
• Recognize appropriate and inappropriate goals for
  clients
• Choose strategies appropriate to clients
  expressed goals
• Recognize event subtle client improvements.

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Discrimination Model (Barnard, 1997)

• Supervision Foci Personalization Skills
• Involves trainee use of aspects of self as they
  relate to the counseling experience.
• May include
• Comfort in assuming some authority in the
  counseling relationship and taking responsibility
  for their specialized knowledge and skills.
• Hearing challenges by clients and feedback from
  supervisors without becoming overly defensive
• Comfort with their own feelings, values, and
  attitudes as well a those of their clients
• Fundamental respect for their clients.

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Discrimination Model (Bernard, 1997)
Supervisor Role Focus of Supervisor Teacher Counselor Consultant
Intervention Skills
Conceptualization Skills
Personalization Skills
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Legal and Ethical IssuesinSupervision
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Ethical Principles

• We have all had ethics classes and we are all
  aware of the principles stated below
• Autonomy patients have the right to be self
  directed.
• Beneficence we are to work for the health
  welfare of out client.
• Justice fair and equal treatment
• Nonmalfeasance refrain from intentionally
  inflicting harm
• Fidelity keeping promises in the
  client/therapist relationship
• Unfortunately, therapists, interns, and
  supervisors sometimes act in ways that violate
  these principles and initiate legal response.
• Whether the actions are intentional or
  unintentional, the liability is no less
  significant.
• Ignorance is clearly not a mitigating
  circumstance!

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Ethical and Legal Issues

• Ethics and legal matters are often related, but
  each has a distinct purpose.
• Ethical standards are a call to ethical
  excellence.
• Generally broad in nature and open to
  interpretation.
• They are a statement from the profession to the
  general public regarding what we stand for.
• The law is specific in nature.
• Not focused on excellence, but on minimal
  standards.
• For a professional to be considered liable, it is
  generally accepted that he/she acted outside the
  bounds of accepted practice.

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Ethical Issues for Clinical Supervision

• Due Process
• A legal term for procedure that ensures that
  notice and hearing must be given before an
  important right can be removed.
• Substantive Due Process procedures that govern
  a training program must be applied consistently
  and fairly.
• Procedural Due Process has to do with the
  rights of the individual to be notified.
• Supervisee-student should be apprised of the
  academic and performance requirements and program
  regulations, receive notice of any deficiencies,
  be evaluated regularly, and have an opportunity
  be heard if their deficiencies have let to a
  change in status.
• Most supervision literature focuses on procedural
  due-process!

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Ethical Issues for Clinical Supervision

• Due Process
• When full due process procedures are followed
• Supervisee is guaranteed a respectful review of a
  situation and the expert opinions of
  professionals, in addition to that of the person
  initiating the complaint.
• By following this procedure, the institution is
  equally protected form the accusation that its
  action was capricious or arbitrary.

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Ethical Issues for Clinical Supervision

• Informed Consent
• Best defense against a charge of malpractice for
  practitioners.
• For supervisors, there are 3 levels of
  responsibility
• Supervisor must determine that clients have been
  informed by the supervisee regarding the
  parameters of therapy.
• Supervisor must also be sure that clients are
  aware of the parameters of supervision that will
  affect them.
• Supervisor must provide the supervisee with the
  opportunity for informed consent.

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Ethical Issues for Clinical Supervision

• Informed Consent with Clients
• It is essential that clients understand and agree
  to the procedures of therapy prior to its
  beginning.
• Factors that constitute necessary and sufficient
  informed consent
• Risks and benefits of treatment
• Logistics of treatment, including length of
  sessions, costs, opportunities for telephone
  contact, etc.
• Info on the type of counseling to be provided
• What is expected of the client (homework, family
  involvement, etc.)
• Preferred alternatives to the type of treatment
  being offered
• Risks of receiving no treatment

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Ethical Issues for Clinical Supervision

• Informed Consent Regarding Supervision
• Client must also be aware of supervision
  procedures.
• Will the sessions be taped?
• Who will be watching?
• How intrusive is the supervision?
• Are their emergency procedures? Is therapist
  available via telephone?
• Supervisees place themselves in a position to be
  sued if they dont tell the family that they are
  going to discuss the case with a supervisor.
• It is vitally important that a student not
  mislead the client regarding the fact that they
  are in training!!!
• May be exposed to charges of fraud,
  misrepresentation, deceit, etc.

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Ethical Issues for Clinical Supervision

• Informed consent with trainees
• Trainees must be informed of evaluative criteria.
• Must be informed of the conditions that dictate
  their success or advancement.
• Must also be clear what their responsibilities
  are and what the supervisors responsibilities
  are.
• If there is a possibility that personal
  counseling will be recommended for any trainees
  in a given program, all trainees should be
  cognizant of this practice upon entering the
  program.
• Supervisees should be included in the choice of
  supervisors, the form of supervision, the
  expectations of the supervisor, the theoretical
  orientation of the supervisor.

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Ethical Issues for Clinical Supervision

• Dual Relationships
• Most flagrant type of dual relationships are
  sexual relationships between therapists and
  clients.
• Sexual exploitation of a client is grounds for
  the automatic revocation of licensure or
  certification.
• It is the responsibility of the supervisor to be
  certain that supervisees understand the
  definition of a dual relationship.
• Problematic dual relationships with supervisees
  can include intimate relationships, therapeutic
  relationships, work relationships, and social
  relationships.
• What makes a dual relationship unethical is
• The likelihood that it will impair the
  supervisors judgment
• The risk to the supervisee of exploitation

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Ethical Issues for Clinical Supervision

• Dual Relationships
• Preventing Supervisee Ethical Transgressions.
• Preventive education and honest discussion
  between supervisors and trainees about the
  possibility, if not the probability, of
  occasional sexual attraction to clients,
  supervisees, or supervisors.
• It is important that the supervisor accept
  responsibility for raising the topic.
• Ethical supervision is embedded in a clearly
  articulated supervisor-student relationship that
  monitors misuse of power and boundary crossings,
  yet is capable of deeply personal discourse
  (Bridges, 1999)

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Ethical Issues for Clinical Supervision

• Dual Relationships between Supervisor and
  Supervisee
• Intimate Romantic Relationships
• Sexual relationships that grow our of supervisory
  relationships, in which both parties experience
  positive, caring feelings are relatively common.
• If both are adults and both are consenting, then
  is is difficult to label as inappropriate.
• The issue is how to prevent it from becoming
  unethical.
• Should sever the supervisory relationship.

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Ethical Issues for Clinical Supervision

• Confidentiality
• Confidentiality violations are the most common
  violations for trainees.
• Supervisor must be sure that trainee keeps
  confidential all client information except for
  purposes of supervision.
• In group supervision the supervisor must be
  especially careful with the identify of patients
  being discussed in front of multiple trainees.
• Must be sure that all trainees maintain
  information overheard in supervision meetings as
  confidential.
• Finally, it is the responsibility of the
  supervisor to maintain the confidentiality of the
  trainees, when they have shared confidential
  information.

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Ethical Issues for Clinical Supervision

• Confidentiality, Privacy, Privileged
  Communication
• Confidentiality involves professional ethics
  rather than any legalism and indicates an
  explicit promise to reveal nothing about the
  client without consent.
• Privacy is the other side of confidentiality. It
  is the clients right not to have private
  information divulged without informed consent,
  including information divulged in therapy.
• Privileged communication is a legal concept and
  is the result of state statute. Refers to the
  right not to have the confidential communication
  used in open court without their consent.
• Although all privileged communication is
  confidential, not all confidential information is
  privileged.

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Legal Ramifications of Clinical Supervision

• Malpractice
• The difference between a claim of an ethical
  violation and a claim of malpractice is
  determined whether the aggrieved chose to bring
  the complaint to a regulatory body or civil
  court.
• There are far more claims to regulatory bodies
  than there are lawsuits.
• Reasons being the cost of litigation is
  prohibitive.
• Legal complaints are restricted by tort law.
  Defendant must be able to prove that the
  negligence claimed resulted in harm. Most cant
  meet this burden of truth.
• Must also prove that the intention of the
  therapist is to cause harm.

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Legal Ramifications of Clinical Supervision

• Malpractice
• 3 elements must be proved for a plaintiff to
  succeed in a malpractice claim.
• A fiduciary relationship with the therapist must
  have been established. Within supervision, this
  means that the supervisor is working in the best
  interest of the supervisee and the supervisees
  clients hand not in his or her own interest.
• Therapists or supervisors conduct must have
  been improper or negligent and fallen below
  standards.
• The client or supervisee must have suffered harm
  or injury
• A causal relationship must be established between
  the injury and the negligence or improper conduct.

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Legal Ramifications of Clinical Supervision

• Duty to Warn Tarasoff v. Regents of the
  University of California
• Example of a legal precedent becoming an
  influence on ethical codes.
• Now a legal standard for all mental health
  professionals and has become a law in many
  states.
• It is imperative for supervisors to inform
  supervisees of conditions under which it would be
  appropriate to implement the duty to warn. For
  the protection of intended victims.
• Two issues are embedded
• Assessing the level of dangerousness of the
  client
• Identification of a potential victims.
• Legal experts seem to lean in favor of client
  privilege unless there is clear evidence that a
  client is immediately dangerous and there is an
  identifiable victim.

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Supervisor Liability

• Direct Liability - When the actions of the
  supervisor are the cause of harm.
• failure to complete supervision adequately,
• suggests an intervention that is determined to be
  harmful.
• Very rare for supervisors
• Vicarious Liability - When the supervisor is held
  liable for the actions of the supervisee or by
  virtue of the relationship with the supervisee.
• Is the supervisee working under the direct
  control of the supervisor?
• Was the supervisee working within the defined
  scope of tasks permitted by the supervisor?
• Does the supervisor have the power to control and
  direct the supervisees work?

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Roosevelt UniversitySupervisor Orientation

• Roosevelt University Counseling and Human
  Services program provides orientation information
  for site supervisors when our students begin
  their practicum and internship experience.

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Questions?

• If you have any questions, please feel free to
  contact the university instructor or Field
  Placement Liaison for your students campus
• Chicago Dr. Kristina Peterson,
  kpeterson_at_roosevelt.edu 312-853-4779
• Schaumburg Dr. Bruce Dykeman, bdykeman_at_roosevelt.
  edu 847-619-8822