Content Review Information for the Clinical Supervision Domain
DEFINITIONS OF A CLINICAL SUPERVISION
There are many definition of clinical supervision. Lance (1990), from a psychodynamic
perspective, states that supervision is a “therapeutic process focusing on the intra- and
interpersonal dynamics of the counselor and their relationship with clients, colleagues,
supervisors, and significant others.” Blocker (1983), from an educational perspective, defines
supervision as “a specialized instructional process in which the supervisor attempts to
facilitate the growth of a counselor-in-preparation, using as the primary educational medium
of the student’s interaction with real clients for whose welfare the student has some degree
of professional, ethical, and moral responsibility.” This, definitions of clinical supervision are
based upon one’s perspective, seeing it either as an educational, a therapeutic, or a
developmental process, conducted within a specific context whereby principles are
transformed into practical skills and the counselor fashions a personal, integrated,
idiosyncratic style that will sustain him/her throughout their work.
1.
An experienced supervisor/clinician;
2.
Actual clients in clinical settings;
3.
The primary concern should always be the welfare of the client (“first, do no harm”);
4.
Monitoring the counselor’s performance by indirect or direct methods of observation;
5.
The goal of changing the counselor’s behavior to increase/improve clinical skills.
In social work, Kadushin (1992) defines clinical supervision as “an administrative and clinical
process designed to facilitate the counselor’s ability to deliver the best possible service to
clients, both quantitative and qualitative, in accordance with agency policies, procedures,
and in the context of a positive relationship between counselor and supervision.” In addition
to legal and administrative definitions of supervision, clinical definitions include supervision
as counseling (a therapeutic process), supervision as educational, and supervision as
consultation. There are traditionally four models:
1.
Those based on a philosophical model of clinical practice and supervision.
Approximately ninety percent of the definitions and approaches to supervision begin with
defining one’s model of therapy. As an outgrowth of that, one derives their definition and
model of supervision.
2.
Developmental models define the stages through which a counselor grows and, as a
result, defines the tasks and issues of supervision based upon the respective stage of counselor
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development.
3.
Discipline-specific models, that define the tasks and functions of a supervisor based
upon the requirements of the clinician’s discipline.
4.
Generic or competency-based models. This approach states a counselor is a counselor,
regardless of discipline. All counselors need to develop certain generic skills and
competencies. Generic models begin by defining these competencies and methods by which
they will be taught.
THE BLENDED MODELS DEFINITION
The Blended Model defines clinical supervision as a “disciplined tutorial process wherein
principles are transformed into practical skills on four dimensions (or foci): Administrative,
Evaluative, Supportive and Clinical.” It is, first of all, a disciplined process, meaning that it
must be regularly scheduled, with clearly stated goals and objectives, evaluation procedures,
feedback mechanisms, and sanctions if the process is not followed. It is a tutorial, meaning
that it begins with what the counselor needs to know. There are two ways of finding out
what the counselor needs: ask them, and watch them.
Next, it is a process, meaning that it is, first and foremost, based on a trusting relationship
that develops over time. The research on what beings about change in a clinical and/or
supervisory relationship points to four common factors:
1.
The quality of the therapeutic alliance. Does the client of counselor feel listened to,
cared for, supported, a sense of bond, warmth, respect, genuineness, not judged? The quality
of the counselor’s participation in the supervisory relationship is the most important
determinant of outcome. A well-working relationship is the heart of effective supervision.
The non-specific factors that contribute to this alliance include: having a time and place to
talk, feeling understood, a meeting of the minds, a sense of encouragement, coaching, and
teaching. What does not work in supervision is attributing failure to the supervisee, arguing,
passivity, hostility, and negative feelings. The supervisee’s perception of the relationship is
fundamental, not that of the supervisor.
2.
Extratherapeutic factors, which have more to do with what the supervisee brings to
the session than it does with what the supervisor brings. These include the counselor’s
strengths and capacities for growth, the support systems, the setting in which the
supervisor/supervisee work, and the supervisee’s stage of readiness for change. The most
important question a supervisor can ever ask a supervisee is “What do you want, and how
can I help you get there?” There are other extratherapeutic factors contributing to change.
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These are underlying, contributing personality issues, learning and coping styles, supportive
elements in the work environment, such as significant relationships, persistence, faith, a
sense of personal responsibility, career stability and unforeseeable/fortuitous events. The key
is to identify not what the supervisee needs, but what the counselor already has in their life
that can help them to reach their goals.
3.
Hope and expectancy. Hope is how people think about their goals and provides them
with optimism, self-efficacy, and expectancy (Bandura, 1977), the belief that one can
successfully perform a behavior. The supervisor contributes to the placebo/hope effect by
providing the supervisee with support, partnership, empathetic communication,
empowerment, and a “holding environment” where the counselor feels cared for and
supported. Supervision, like treatment, needs to be oriented to the future rather than past, to
solutions as opposed to problems. The supervisor should highlight the counselor’s sense of
personal control. The higher the therapeutic alliance with the supervisor, the more powerful
the placebo/hope effect. What does not work is a sense of hopelessness or ‘nocebo’ effect.
This happens when the supervisor does all the work, is rigidly wedded to a particular
therapeutic paradigm, and focuses on the supervisee’s weaknesses.
4.
Research shows that the models and techniques of the supervisor and counselor have
a relatively small influence on outcome. All approaches seem to have equal efficacy. The
key is matching the right approach to the right person at the right time with the right
amount of help. It is important for a supervisor to choose a model that fits with each
supervisee. The supervisor’s interventions should match the supervisee’s stage of readiness
for change.
In sum, the key factor in measuring a model or definition of clinical supervision is whether is
works to bring about a desired outcome for both the supervisor and the supervisee.
Percentage of Improvement in Psychotherapeutic Relationships
as a Result of Clinical/ Supervisory Relationships
Extratherapeutic Change: 40%
Technique: 15%
Therapeutic Relationship: 30%
Hope: 15%
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DISTINCTION BETWEEN CLINICAL SUPERVISION AND CASE MANAGEMENT
Case Management (Administrative):
• The focus is on the client—what do they need in treatment;
• Issues such a client placement, treatment plans, clinically-observed behaviors;
• What is needed for the client in the continuum of care and after-care;
• In a case management session, a supervisor will review many cases.
Clinical Supervision (Clinical):
• The focus is on the counselor— what do they need to be proficient;
• Although cases and client care issuer are discusses, the focus remains on what the
counselor needs to know and the skills they need to develop;
• The focus is on counselor skill development;
• Most often, one case will be reviewed at a supervision session; one counselor will
present a case. ‘Live’ material will be incorporated into the supervision session.
PHILOSOPHY OF SUPERVISION
The dominant models of clinical supervision in the 1930’s-1960’s were psychodynamic or
psychoanalytic models. Authors such a Ekstrin & Wallerstein (1972) wrote about these
models. The focus of clinical supervision was upon transference and counter-transference,
and intrapsychic conflicts. It was expected that a therapist in training would be in therapy
him/herself while under clinical supervision.
In the 1950’s, Client-Centered counseling became popular with the work of Rogers (1951),
Truax and Carkhuff (1967). In Client-Centered supervision, the focus remained on personal
growth through non-directive methods. If was expected that a therapist in training would be
in therapy him/herself while under clinical supervision.
In the 1960’s, behaviorism and behavior therapy became popular. Although Skinner and
Watson wrote about behaviorism prior to the 1690’s the popularity of these therapies grew
greatly in the late 1960’s-1970’s in universities and training programs.
Authors such as Krumboltz (1966) wrote about supervision as a process of behavioral
shaping, based on how people learn. ‘Practice, practice, practice’ became the primary means
of supervision and training. If therapy was the performance of a set of skills, then practice
and observation of those skills demonstrated by the counselor was critical.
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In the 1970’s-2000’s, skill-based models of supervision dominated the behavioral health field,
from those of Mead’s Task Model, Munichin’s Structural and Haley’s Strategic Models, to
models that brought in affective as well as cognitive components, such as Kagan’s
Interpersonal Process Recall model.
In the late 1990’s, the behavioral health field moved to blend both affective and cognitive
issues in supervision. This now is how the Blended Model of Supervision emerged.
KEY COMPONENTS OF THE BLENDED MODEL
1.
When defining your approach to supervision, you must begin with an awareness of
your personality, your style of leadership and teaching, and your underlying issues. Thus,
your own self is the first level of the development of any model of supervision.
2.
Second, you must define your concept of health and your core philosophy of change.
3.
Third, the descriptive dimension further defines your approach to supervision.
4.
Fourth, the contextual factors in which supervision is conducted shapes your
approach to supervision (factors such as age, gender, race, ethnicity, recovering/nonrecovering, educational background, types of clients treated, setting of the services, etc.).
5.
Finally, determine the extent to which you will address affective and behavioral
issues in supervision, based upon the stages of counselor development.
DESCRIPTIVE DIMENSIONS
Bascue and Yalof (1991) outlined ten key areas that define what one does in supervision.
Each dimension should be looked at in terms of the stages of counselor development. Where
one ‘places their mark’ on each continuum also depends on the supervisor’s philosophical
underpinnings and the contextual factors in which the supervisor works. Considered
together, these dimensions better ‘fill out the picture’ of one’s model of clinical supervision.
On each dimension, place your mark where you see yourself operating as a clinical
supervisor, taking into account the stages of development of the staff that you supervise and
key contextual factors of yourself and your supervisees.
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DESCRIPTORS
Influential
Are you trying to impact on the supervisee’s affect or cognition, their skills, or their
emotions?
Affective
Cognitive
Emotions
Behaviors
Feelings
Skills
Symbolic
Are you, as a supervisor, more focused on the counselor’s manifest actions (what which is
evident), or their underlying intrapsychic issues? To what extent do you focus on
transference and counter-transference issues in supervision? How much do you delve into
the counselor’s past?
Latent
Manifest
Structural
How do you structure your supervision time? Is it more proactive, with a clearly set agenda
and goals, or is it more reactive, based upon what the counselor presents to you or wishes to
discuss at that time? To what extent if your supervision organized with a clear curriculum?
Proactive
Reactive
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Replicative
Is what happens in the counselor’s private life an issue for you? Is it parallel to what occurs
in session? Is it, instead, separate and discrete, with little effect on session? To what extent
do you stress parallel process or isomorphism in supervision?
Parallel
Discrete
Counselor in Treatment while in Supervision
Do you view therapy for the counselor as an essential part of the counselor’s supervision?
When working with a counselor who is in recovery from addiction, do you place more
emphasis on their ‘walking the walk’ by engaging in their own program of recovery? If the
counselor has had other life experiences which inform their clinical functioning, to what
extent do you address these issues in supervision or expect that these issues will be addressed
in the counselor’s own therapy?
Related
Unrelated
Information Gathering
How do you gather information in supervision—by direct observation, such as the use of a
one-way mirror, videotaping counseling sessions, or through indirect methods, such as
process recordings, review of clinical records only? This dimension is particularly sensitive
to the stage of counselor development.
Direct Methods
Indirect Methods
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Jurisdictional
Who has jurisdiction for the client—the counselor, or the supervisor?
Counselor
Supervisor
Relationship
Is the relationship between the supervisor and the counselor facilitative of hierarchical? Do
you consider yourself to be the expert and the counselor is to mirror your clinical actions?
To what extent are you prescriptive in your supervision?
Facilitative
Hierarchical
Strategy
In supervision, are you trying to impart theory or technique? An insight-oriented approach
to supervision might focus more on the underlying theory of why an intervention is made in
counseling. On the other hand, a skill-based model of counseling and supervision might
focus more on learning the skills and techniques, with little regard to the underlying theory
behind the intervention.
Theory
Technique
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STAGES OF COUNSELOR DEVELOPMENT
Counselors go through a number of stages as they grow professionally in their knowledge
and skills. A number of taxonomies are used. A basic assumption in developmental models
is “a counselor is a counselor is a counselor.” Regardless of one’s discipline, all counselors go
through these stages of development, although perhaps at different rates.
For all stages of development, there are three factors that determine maturity: self- and
other-awareness, autonomy/dependence, and motivation. As one grows professionally, there
is an increase in awareness, movement towards autonomy and inter-dependence, and stable
motivation. There are also key assumptions regarding the developmental process:
1.
There is a beginning point, but not an end point for learning skills;
2.
Individual learning styles and personalities can be accommodates by developmental
models;
3.
There is a logical sequence to pass;
4.
The order is approximately the same for all counselors;
5.
Advanced counselors have different needs.
LEVEL 1
Level 1 counselors are typically those who have been in the counseling field for one to five
years, according to Stollenberg and Delworth (1991). This group tends to be the most
studied because they are students we see in academic training. The qualities of a Level 1
counselor are that they tend to focus on basic skills, are driven by anxiety and enthusiasm,
follow the supervisor as a role model, and are looking for simple answers. Level 1 counselors
tend to think categorically and have difficulty with probing, confrontation, and selfdisclosure. They want to know the ‘right’ way to counsel and can be highly dependent on
their supervisor and self-focused. They think anecdotally, instead of conceptually as they do
not have much of a repertoire of their or experience. They tend to give the client narrative,
line by line, instead of abstracting the key presenting issues. They use one primary model
and do not know what they do not know.
Level 1 counselors tend to be worried about their lack of confidence/skills in working with
certain clients, lack of life experience, lack of specific skills. They can become stressed by
taking the client problems as their own or may confuse sympathy for vulnerability. They
may want to ‘change clients’ minds’ and struggle with termination issues. They are
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concerned about agency climate. Their motivation will be high along with high anxiety. In
terms of autonomy, they will be highly dependent on their supervisor and need structure,
positive feedback, and minimal direct confrontation. Finally, in terms of awareness, their
self-awareness will be limited, with a high self-focus, evaluation apprehension, and unaware
of strengths/weaknesses.
When transitioning to Level 2, a supervisor will see the supervisee’s motivation change,
which may decrease with new approaches/techniques. The supervisee may show a desire for
more autonomy—sometimes, more than is warranted. Their self- and other-awareness will
begin to grow, toward the client and away from self.
When supervising a Level 1 counselor, the focus should be as follows:
• Exposure to other orientations/models;
• Encourage autonomy/risk-taking;
• Introduce ambiguity;
• Balance anxiety, support, and uncertainty;
• Assist in conceptualizing;
• Give them control;
• Lots of practice and direct observation of their work;
• Build on their strengths;
• Attend to how they learn: locus of control, verbal/written processors, cognitive abilities.
The Level 1 supervision environment should provide structure, keeping anxiety at
manageable levels. The supervisor should be facilitative, yet prescriptive, conceptual, and
catalytic. The supervisor should engage in lots of observation, practice, skills training, roleplay, readings, closely monitoring client behaviors and treatment outcome. The supervisor
needs to address the counselor’s strengths first to aid in their fragility and development of
confidence as a therapist.
LEVEL 2
Level 2 counselors are the problem children, the ‘adolescent’ who will test every boundary
and challenge the supervisor’s authority, competency, and qualifications. They will be
client-focused. Their self-awareness will fluctuate between being fully aware and confused
about who they are and whether they want to work in the field. They may look less skilled
at times than a Level 1 counselor because of this fluctuating awareness. They can become
frustrated with difficult clients. They want to be autonomous but are still dependent.
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They know something is wrong, but lack the skills to fix it. They do not want any longer to
imitate their supervisor and can be more self-assertive. They do not ask for the supervisor’s
recommendations. They have better diagnostic abilities, are more eclectic, and are more
ethically sophisticated.
Level 2 counselors’ motivation fluctuates as increased clinical complexity shakes their
confidence in their abilities. They vacillate between being self-assured and lacking
confidence. Their autonomy fluctuates also between being dependent and autonomous.
They can be quite assertive, pursuing their own agendas, and may only want the supervisor’s
input when requested. They can be evasive in supervision. Their awareness of themselves
and others also fluctuates between better understanding of the client’s viewpoint, but they
can also become enmeshed in the client’s issues.
When transitioning to Level 3, the supervisor should seek to increase the supervisee’s desire
to develop their own, personalized orientation. The supervisor should move the counselor to
more conditional autonomy while still seeking a better understanding of their self-limits.
Finally, the supervisor ought to focus on the counselor’s self-reactions to clients.
When supervising a Level 2 counselor, the supervisor needs to:
• Blend a variety of clients, not giving the Level 2 counselor all of the difficult cases, lest the
motivation decline;
• Be aware that, at this stage of development, supervision can become more like therapy as
counter-transference issues emerge;
• Focus less on technique and more on theory;
• Be ready for confrontation and challenges to their competence;
• Look at transference and counter-transference;
• Seek to move supervision to more of a consultation-type relationship;
• Teach alternatives and encourage independence.
LEVEL 3
Level 3 counselors are the joy of most supervisors. They know their own limits and may
have doubts, but these doubts are not disabling. They have developed their own
idiosyncratic therapeutic style and can function autonomously. Their therapy is an
unfolding from within. They are non-defensive and use self-referential comments well and
blend different approaches well. They understand client diversity and do not pigeonhole
clients into neat categories as do Level 1 counselors. They have well developed ethical
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viewpoints and are able to function well in all three domains: motivation, acceptance, and
autonomy.
Their motivation is stable. Although self-doubts may remain, they are not disabling because
the counselor has developed their own professional identity. In terms of autonomy, they
have a belief in their own autonomy and know when to seek consultation. They can retain
responsibility and accept their strengths/weaknesses. They have a high capacity for empathy
and understanding. They focus on the client, understand process as well as content, and
make therapeutic use of self in counseling.
When supervising a Level 3 counselor, the supervisor should:
• Be facilitative and supportive, treating the supervisee as a colleague. The supervisor is to be
a reality tester for the counselor;
• Share experiences and self-disclosure;
• Nurture wisdom rather than knowledge;
• Stimulate the counselor and nurture continuous growth.
The Level 3 supervision environment is more focused on personal and professional
integration and long-term career decision-making. The supervision can be more facilitative,
moving towards peer or group supervision, and always striving for integration.
STAGES OF SUPERVISOR DEVELOPMENT
Level 1 Supervisor:
• Can be mechanical and overly structured
• Wants to be seen as an ‘expert’
• Is highly motivated
• Wants supervisee to use the supervisor’s model
• Has trouble with Level 2 counselors
Level 2 Supervisor:
• Has a mixture of confusion, conflict, anger, and can withdraw from a supervisee
• Gets frustrated easily
• Can be less objective
• Best fit with Level 1 Counselor
Level 3 Supervisor:
• Works autonomously
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• Has a good sense of self and the supervisee
• Sets boundaries and roles
• Has preferred therapists/groups
• Is fully integrated
WHAT TO EXPECT IN SUPERVISION
Indirect methods that a supervisor might use:
• Written or verbal records;
• Reviewing forms/files;
• Observing how the counselor interacts with staff;
• Surveys/client evaluations.
Direct methods that a supervisor might use:
• Audio/video recordings;
• One-way mirror;
• Joint sessions;
• Bug-in-ear;
• Bug-in-eye, whereby a supervisor sits behind a one-way mirror and the counselor sits with
the clients before them. There is a television monitor over the shoulder of the client, and the
supervisor is able to send messages to the counselor about clinical behavior and
interventions.
WHEN TO EXPECT A SUPERVISOR TO INTERVENE AND WHEN NOT TO
Supervisors should only intervene if there is a clear teaching moment, or if there is need to
do so to protect the welfare of the client. Here are some questions a supervisor should ask
him/herself about intervening during a session:
• Urgency—What are the consequences of not intervening?
• Probability of unprompted actions—How likely is it that the counselor will make the
intervention?
• What is the probability of successful implementation of the information provided to the
counselor by the supervisor?
• Dependence—Will the intervention create undue dependence?
• Intrusiveness—Does it detract from the session?
• Do the circumstances truly warrant an intervention?
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DOMINANT METHODS OF SUPERVISION
Nichols (1990) demonstrates the significant decline in the use of indirect methods and major
increases in direct methods of supervision. The availability of technology makes it easier for
supervisors to utilize direct methods of observation. Finally, litigation has required that
supervisors make every effort to supervise counselors.
Munson (1999) ranked the most useful to least useful methods of supervision, as studied
among social work supervisors, and found as follows:
1. Co-facilitation
2. Bug-in-ear
3. One-way mirror
4. Videotape
5. Audiotape
6. Process recordings
7. Case discussion.
ADVANTAGES AND DISADVANTAGES OF FINDIVIDUAL CLINICAL SUPERVISION
The advantages of individual clinical supervision are:
• Confidentiality is less likely to be compromised;
• The counselor often feels safer and more comfortable;
• There is more time to focus on the individual counselor;
• The supervisory relationship is more likely to grow into one that is trusting, deeper, and
more honest.
The disadvantages of individual clinical supervision are:
• Individual supervision can be expensive and time-consuming;
• There is more chance for collusion between counselor and supervisor;
• The counselor and supervisor may be less likely to see his/her ‘blind spots’ as there are
fewer eyes examining his/her work;
• A danger is that the supervisor might hyper-focus on his preferred subjects;
• The relationship can become too cozy and turn into a mutual appreciation society;
• There is greater pressure on the supervisor when dealing with difficult supervisees.
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ADVANTAGES AND DISADVANTAGES OF GROUP CLINICAL SUPERVISION
The advantages of group clinical supervision are:
• It is a more economic use of time, money, and expertise;
• It can be more helpful and less isolating to see others with similar issues;
• The group members learn from one another, allowing for greater parallel processes;
• There is likely to be a wider range of experiences and mixture of individuals;
• There is more opportunity for role-playing, simulations, and trying different strategies.
The disadvantages of group clinical supervision are:
• Each counselor receives less individual time;
• Groups may be intimidating, especially for new counselors;
• Groups can be more revealing of counselor shortcomings to others and, thus, more
threatening;
• Confidentiality can become more of a concern;
• Supervisors need to attend group dynamics:
◦ collusion to prevent effective change,
◦ resist reflection, premature advice,
◦ maintaining status quo, mutual admiration society,
◦ competitive, challenging, and destructive behaviors.
Alternatives to individual and small group clinical supervision are peer supervision and more
of a consultative model of supervision. Group clinical supervision maximizes the limited
time available for supervision, while still maintaining and meeting the legal criteria of
making a reasonable effort to supervise.
CONTENT OF CLINICAL SUPERVISION
We must begin with the basic helping skills as the essential content of supervision:
• Basic helping skills, such as attending, paraphrasing, summarizing, reflecting on feelings,
probing, confrontation, and self-disclosure;
• Affective qualities, such as empathy, genuineness, concreteness, and respect for clients;
• Differential diagnosis skills, particularly in regards to assessing co-occurring disorders;
• Transference, counter-transference, and counter-resistance.
Transference is an irrational attitude manifested by a person in a way that is not evoked by
the realities of the present, but derived from other relationships of experiences. Counter-
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transference is the opposite; the therapist’s tendency to project his/her own unresolved issues
onto the client.
PROBLEMS AND CONCERNS IN SUPERVISION
Working within any system brings with is an array of issues. Where is the line between
supervision and therapy? There are certain key principles that define that line.
1.
The goal of supervision is to help an individual to be a better worker, not necessarily a
better person. In the world of work, is must be clear that a clinical supervisor is there to first
protect the welfare of clients and, second, to ensure that they receive the highest quality of
service.
2.
What a counselor does in their private life is of no concern, unless it interferes in
some way with the clients. Certain situations, such as the counselor being arrested for public
intoxication, etc., are deemed to interfere with the clients as it would impact on the
community’s image of the counselor and the agency.
3.
Supervision looks like therapy, not because a supervisor does therapy with a
supervisee, but because a therapist does supervision. No matter what you do in supervision,
you will likely use the same tools you learned as a counselor. If you are facilitative or clientcentered as a counselor, you will likely be client-centered as a supervisor as well. The skills
of the therapist will spill over into supervision.
Under what circumstances might supervision look like therapy?
•
When harm may be done to a client, it is important for the supervisor to assess the
counselor’s limits and blind spots, so as to protect the welfare of the clients.
•
When there are transitory issues for the counselor who might be impacting on the
counselor’s function and which will quickly be resolved.
•
When the supervisor teaches the counselor emotional awareness and parallel
processes and/or counter-transference.
•
When events are so intense that it is impossible for the supervisor not to respond.
When a supervisor spends more time talking about the counselor’s personal issues, the line
has been crossed. Good questions for a supervisor to continually ask a counselor in
supervision is, “What does this have to do with the client? How is this impacting on your
clinical functioning?” When the line is crossed between supervision and therapy, it is
appropriate to recoup and refer the person for help external to the organization.
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TRAITS OF AN EFFECTIVE SUPERVISOR
The ICRC Role Delineation Study addresses the four key performance domains of a
supervisor. Below are some traits of an effective supervisor:
• clinical knowledge, skills, and experience,
• having been supervised and having supervision of one’s supervision,
• professional education and training,
• food teaching, motivational, and communication skills ,
• a desire to pass on knowledge and skills to others,
• a sense of humor, humility, and balance in one’s life,
• good helping skills, observation skills, and affective qualities,
• ability to create an open, trusting atmosphere,
• respect among peers, colleagues, and supervisees,
• good time-management, executive, and delegation skills,
• familiarity with legal and ethical issues, policies, and procedures,
• cognitive and conceptual abilities,
• concern for the welfare of clients, the agency and the community,
• a non-threatening, non-authoritarian, diplomatic manner,
• decision-making and problem-solving skills,
• crisis-management skills.
These can be simplified into the “Four A’s” of supervision:
• Available—open receptive, trusting, non-threatening,
• Accessible—easy to approach and speak with freely,
• Able—knowledge and skills,
• Affable—pleasant, friendly, and reassuring.
BUILDING A MODEL FOR CLINICAL SUPERVISION
Counseling and supervision begin with a model—a plan for where to go—followed by a
methodology—a path for getting there. A model for supervision should include the
following components:
• A philosophical foundation that describes the underlying viewpoint of the supervisor about
people and hoe they change in counseling and supervision;
• descriptive dimensions, specific characteristics of therapeutic and supervisory practice that
follow largely from the philosophical foundation;
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• The stage of development of the counselor, including the supervisor’s and supervisee’s level
of training, experience, knowledge, and skills.
The Developmental approach to supervision is based on developmental psychology, which
encompasses the description, explanation, and modification of individual behavior over one’s
lifespan. The same concepts of developmental psychology have been applied to the lifespan
of a counselor. Numerous authors have presented developmental approaches to supervision
(Worthington, 1987; Stolsenberg and Delworth, 1987; Grater, 1985; Wiley and Ray, 1986).
Various models use different typologies, or stages of professional development, from Hess;
(1986) four stage system to Stoltenberg and Delworth’s three plus system. We will examine
in depth the latter developmental approach.
There are three basic structures for all counselors, outlined by Stoltenberg and Delworth:
1.
Autonomy, which includes dependence on an authority figure, the ability of the
counselor to function alone, to make independent decisions, the degree of close supervision
required, and one’s sense of self-confidence;
2.
Self- and other-awareness, which includes cognitive and affective components of
focus on self and others;
3.
Motivation, which deals with the understanding of the role of the counselor, the
desire to help people without getting enmeshed, and the learning of one’s own idiosyncratic
model and approach to counseling.
Stoltenberg and Delworth list counselor performance domains, parallel in many ways to the
ICRC 12 Core Functions:
Domains
12 Core Functions
Intervention Skills
Screening
Case Management
Assessment Techniques
Assessment
Orientation
Interpersonal Assessment
Intake
Referral
Client Conceptualization
Counseling
Client Education
Individual Differences
Crisis Intervention
Treatment Planning
Theoretical Orientation
Report and Record Keeping
Treatment Goals and Plans
Consultation with other professionals
Professional Ethics
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LEGAL AND ETHICAL ISSUES FOR CLINICAL SUPERVISORS
A clinical supervisor has legal liability for the actions of a counselor he/she is supervising if
the supervisor has the ability to initiate, change, or terminate treatment of the client. The
supervisor, therefore, has a legal responsibility to make a “reasonable effort to supervise,”
generally seen as one (1) hour of supervision for every twenty (20) hours of client contact.
The key ethical and legal issues faced in supervision is Respondeat Superior, vicarious
liability, which means that the supervisor may be held liable for damages occasioned by the
negligence of a supervisee solely as a result of the supervisory relationship.
SUPERVISORY COMPETENCE
In recent years, the number of professional organizations credentialing clinical supervisors
has grown. The professional organizations that regulate the ethical and legal practices of
supervisors are the National Board of Certified Counselors (NBCC), the National Association
of Social Workers (NASW), and in the alcohol and drug abuse field, the International
Certification and Reciprocity Consortium (ICRC). These organizations and the courts have
posed critical questions in assessing supervisory competence and in defining the range and
scope of clinical supervision. Courts in particular have defined a standard of care and
practice in supervision as a result of malpractice cases by accepting the testimony of experts
in the field.
• Does the supervisor have the skills to perform the requisite supervisory functions?
• Does the supervisor make an adequate effort to supervise?
• Do the supervisor and the agency have a formalized process for providing feedback and
evaluations to counselors?
• Does the supervisor teach the tenets and legal and ethical standards of the profession?
• Does the supervisor maintain adequate documentation of the supervision process?
Court rulings (e.g., Gilmore vs. Board of Psychological Examiners, 1986) have pointed to
several common legal and ethical errors that occur in supervision.
• Confusing supervision with case management;
• Focusing on the client’s needs rather than the supervisee’s development;
• Relying on the supervisor’s clinical skills in supervision, thereby turning supervision into
therapy with a supervisee
• Adopting a laissez-faire attitude with supervision occurring on a sporadic basis;
• Conducting quasi-casual case conference and crisis-management supervision;
• Using one’s supervisory power inappropriately.
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Court rulings have affirmed the importance of clarifying the roles and expectations of clinical
supervision, correcting these common legal and ethical errors. The two most important legal
issues have been whether the supervisor made a reasonable effort to supervise, and whether
the supervisor is competent to perform the tasks of a supervisor.
SUPERVISORY ACCOUNTABILITY
The legal criterion for malpractice is a breach of duty, that is, of one’s fiduciary responsibility
to protect the welfare of another. The breach may take the form of action or inaction. The
extent to which injury has resulted directly from the dereliction of duty determines the
degree of liability of a counselor or supervisor. There is a growing concern that supervisors
are to be held accountable for the actions of their supervisees.
Vicarious liability occurs when damage to a client results from a dereliction in carrying out
one’s supervisory responsibility for the supervisee’s work, from giving inappropriate advice
to the supervisee to the detriment of the client, from failing to listen carefully to the
supervisee’s report about a client, or from assigning tasks to a counselor who is inadequately
trained to perform those tasks. Falvey (2002) points out a number of landmark cases that
made these distinctions. For example, Jaffee vs. Redmond (1996) established
psychotherapeutic privilege that extended to any licensed practitioners, not differentiating
between disciplines. However, unlicensed supervisees may not be covered under the
regulations for psychological privileging of a licensed supervisor. This is to be determined by
state regulations, and ultimately judges are the interpreters of the scope of privileged
communication. This is significant for the alcohol and drug abuse field because many states
certify but do not license substance abuse counselors. This, they may not be covered under
the regulations of psychological privileging.
Other landmark cases affecting supervisory accountability include Gilmore vs. the Board of
Psychological Examiners (1986), Steckler vs. Ohio State Board of Psychology (1992), Peck vs.
Counseling Service of Addison County, Inc., (1985), and Almonte vs. New York Medical
College (1994).
CONFIDENTIALITY AND ITS LIMITS
The most significant legal and ethical issues affecting supervisors concern client
confidentiality, with breached of confidentiality as one of the top five charges in successful
suits against psychotherapists. Pope and Bajt (1988) provide startling data: 57% of senior
psychologists acknowledged violating legal and/or ethical mandates concerning
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confidentiality at least once in the interest of a client’s welfare; 21% divulged confidential
information; and 27% refused to carry out a duty to report child abuse or to warn a victim of
a dangerous situation. Most strikingly, 75% stated that, at times, caregivers should violate
formal legal and ethical standards.
Roe vs the State Board of Psychology (1995) rejected the claim of lack of adequate training
on confidentiality as a defense in the case of a supervisee’s violation. The court determined
that it was the supervisor’s responsibility to train the supervisee in the limits of
confidentiality. On the other hand, courts have also affirmed a client’s right to privacy by
insisting that the supervisee inform the client of the limits of confidentiality at the start of
counseling. This is termed ‘the psychological Miranda warning’.
Tarasoff vs. Regents of the University of California (1976) has been used by several states as
the standard for duty to warn. Most states place at least symbolic value on this landmark
case in defining the duty to warn and, thereby, to protect identified victims of threatened
violence. Jablonski vs. the United States (1983) also addressed the predictability of violent
acts based on the patient’s psychological profile. Pesce vs. J. Sterling Morton High School
(1987) lays out guidelines for mandatory child abuse reporting, while taking into account the
child’s safety, cultural differences in child rearing, the age of the child, and the type of abuse.
In 2003 the federal government, through regulations implementing the Health Insurance
Portability and Accountability Act (HIPPA), established new guidelines that limit
confidentiality. The guidelines specify that each provider must issue a “Notice of Privacy
Practices” that makes explicit with whom medical information may be shared and how it
may be used. The United States Department of Health and Human Services (DHHS) has
been given unrestricted access to medical records to monitor compliance. The new
regulations have been challenges in the courts by privacy advocates. It is imperative that
supervisors become familiar with these HIPPA guidelines and other DHHS regulations and
with the court decision in the area of patient rights, for these developments will dramatically
impact the therapeutic and supervisory relationships.
Juxtaposed to the HIPPA regulations are DHHS regulations that allow the federal
government and law enforcement to examine an individual’s medical records without their
knowledge or consent. This policy likewise portends great changes in the doctor-patient
relationship as traditionally understood and practices. Clinicians and patients’-rights
advocates have voiced grave concerns to the effect that patients will withhold information
physician and therapists need for proper diagnosis and treatment. Even when patients do
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volunteer sensitive information, clinicians may not enter it into the records, which thus are
left incomplete. According to a study by the Association of American Physicians and
Surgeons, 78% of physicians surveyed withheld information from a patient’s records because
of concerns about privacy. Moreover, 87% reported that the patient requested the
withholding of information from their medical records (Falvey, 2002).
CLINICAL OVERSIGHT: DANGEROUS LIAISONS
Court rulings have emphasized that supervisees must know the qualifications of their
supervisor, critical patient information related to the performance of their clinical duties, the
logistics of treatment, insurance reimbursement procedures, required record keeping, and
the risks and benefits of alternatives to treatment.
Simmons vs. the United States (1986), Pesce vs. J. Sterling Morton High School, District 201
(1987), Jablonski vs United States (1983), and Andrews vs. United States (1984) made clear
the supervisor’s responsibility to oversee the counseling relationship between a supervisee
and a client. Ignorance of the nature of that relationship no longer is an acceptable excuse
for a supervisor. The courts further expect the supervisor to confront the supervisee about
any allegations of impropriety, document the recommendations and actions taken, and place
a critical incident report in the supervisee’s file pending resolution. Courts have also upheld
that the supervisor must question the client wherever feasible and clinically viable, consult
with colleagues about the alleged impropriety, and monitor the supervisee’s cases. Finally,
supervisors are expected to report the allegation to investigate services, state boards, and
relevant ethics committees.
A growing concern in supervision is non-disclosure of information be a supervisee to the
clinical supervisor. Falvey (2002) points to a study by Welfel (1998) that 97% of supervisees
withheld information from their supervisors, 60% withheld personal information relevant to
their counseling practice, 90% withheld negative feelings about the supervisor, 44%
withheld information about their clinical mistakes, 36% withheld counter-transference
information, and 9% withheld the fact of their attraction to at least one client. Dues to the
prevalence of non-disclosure of information, it is imperative that supervisors establish an
open and trusting atmosphere so that supervisees will be more likely to share such
information.
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SUPERVISORY CONTRACTING
Ray vs. Delaware (1997) and Steckler vs. Ohio State Board of Psychology (1992) defined the
standards of supervision and the limits of supervision with an unlicensed counselor. From
these rulings, it is clear that some form of written supervisory contract signed by supervisor
and supervisee is imperative. This contract should include:
• An individualized training plan for the supervisee;
• The schedule, format, duration, roles, responsibilities, goals, and objectives of supervision;
• Information on the supervisor’s training and model of supervision;
• Emergency and crisis-management procedures, including the availability of 24/7 coverage
in the event of a clinical emergency;
• Clarification of roles of an academic supervisor, if applicable;
• A ratio of the number of clients to the number of supervision hours;
• Formative and summative evaluation procedures;
• Disciplinary procedures, due process, rights of the supervisee, and sanctions.
Peck vs. Counseling Services of Addison County, Vermont (1985) defined the need for a
formal crisis-management policy. Agencies should have a crisis plan that states how crises
and duty-to-warn situations will be handled. What mechanisms are in place for responding
to crises, especially after normal working hours? Who is ‘on call’ after hours and how
quickly is information concerning lethality of a clinical situation to be reported to the
supervisor and management of the agency? What policies and procedures are in place to
handle crisis situations? How will duty-to-warn procedures be enacted after normal work
hours?
SUPERVISEE SELECTION, ASSIGHMENTS, AND DOCUMENTATION
Few supervisors identify client screening as an aspect of supervision, despite court rulings
that supervisors can be held liable if they do not determine the supervisee’s competence
before assigning responsibilities. It is imperative that the supervisor protect the welfare of
the clients by:
• Knowing the clinical competencies and limitation of their supervisees;
• Assessing the complexity of client issues prior to assigning cases to a supervisee;
• Determining whether the supervisee is adequately trained to assume the case;
• Ensuring that the supervisee does not have too many cases to be able to provide proper
services to clients;
• Protecting the supervisee from having too many difficult cases in their caseload;
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• Identifying and resolving learning and personal problems that may compromise the
supervisee’s effectiveness;
• Ensuring that there is sufficient supervision time for the cases assigned.
According to a number of court rulings (Almonte vs. New York Medical College, 1994; Hill
vs. Kokosky, M.D., 1990; Emory University vs. Porubiansky, 1981), the supervisor should
review the résumés of all employees, assess their areas of strength and areas in which
additional training is needed, and require formal training and close supervision for the deficit
areas. Falvey (2002) provides a workbook of appropriate forms to document clinical
supervision. The use of these forms is highly recommended. Documentation should review
emergency procedures and the supervisee’s employment profile. Records of all clinical
supervision sessions should be maintained. Documentation of all cases discussed in
supervision should be documented in the supervisory log. The written and mutually signed
supervision contract should be maintained.
SUGGESTED REFERENCES/BIBLIOGRAPHY
The following references are recommended as study tools for clinical supervision
information. Note, however, that this is not a comprehensive list of all references used as a
basis for the examination.
Bascue, L. O., and J. A. Yalof. 1991. “Descriptive Dimensions of Psychotherapy Supervision.”
Clinical Supervisor 9 (2), 19-30.
Edelwich, J. and A. Brodsky. 1991. Sexual Dilemmas for the Helping Professional. New
York: Brunner/Mazel.
Ekstein, R. and Wallerstein R. S. 1972. The Teaching and Learning of Psychotherapy,
Madison, CT: International Universities Press.
Falvey, J. E. 2002. Managing Clinical Supervision: Ethical Practice and Legal Risk
Management. Pacific Grove, California: Brooks/Cole.
Hart, G. M. 1982. The Process of Clinical Supervision. Baltimore: University Park Press.
Hubble, M. A., B. L. Duncan, and S. D. Miller. 1999. The Heart and Soul of Change: What
Works in Therapy. Washington, DC: American Psychological Association.
Kadushin, A. 1992. Supervision in Social Work, New York: Columbia University Press.
SE/ad – Adapted by Brighter Tomorrows Consulting, LLC, from materials originally authored and arranged by
Dr. David Powell, DLC, LLC, 2008.
Krumboltz, J. D. 1966. “Behavioral Goals for Counseling.” Journal of Counseling
Psychology 13, 153-159.
Munson, C. E. 1999. Clinical Social Work Supervision, New York: Haworth Press.
Nichols, W. C., D. P. Nichols, and K. V. Hardy. 1990. “Supervision in Family Therapy: A
Decade Restudy.” Journal of Marital and Family Therapy 16, 275-285.
Pope, K. S., and Bajt, T. R. “When laws and values conflict: A dilemma for psychologists.”
American Psychologist, 43. 828-829, 1988.
Powell, D. J. 2004. Clinical Supervision in Alcohol and Drug Abuse Counseling,
San Francisco: Jossey-Bass.
Rogers, C. R. 1951. Client-Centered Therapy: Its Current Practice, Implications and Theory.
Boston: Houghton Mifflin.
Stoltenberg, C. D., Delworth, U., and McNeill, B. 1991. IDM Supervision: An Integrated
Developmental Model for Supervising Counselors and Therapists, San Francisco: Jossey-Bass.
Truax, C. B., and R. R. Carkhuff. 1967. Towards Effective Counseling and Psychotherapy:
Training and Practice. Chicago: Aldine.
Van Ooijen, Els. 2000. Clinical Supervision: A Practical Guide. London: Churchill
Livingstone.
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Dr. David Powell, DLC, LLC, 2008.
PREPARATION AND REVIEW SAMPLE EXAMINATION
For each of the following, select the response that best answers the question.
1.
Effective counselor/supervisor relationships would NOT include which of the
following?
a. the supervisor assessing the counselor’s ability to take a stand
b. ongoing feedback
c. a climate conducive to feedback
d. a standardized, objective format
2.
In supervisory intervention, supervisors’ remarks which promote self-exploration,
conceptualization, and more inclusive integration of methods are described as:
a. catalytic
b. facilitative
c. confrontive
d. conceptual
3.
Which of the following is NOT a model of clinical supervision?
a. influential
b. structural
c. rational-emotive
d. symbolic
4.
According to David Powell and Archie Brodsky in Clinical Supervision in Alcohol
and Drug Counseling, there are four overlapping foci of effective supervision. Which of the
following is NOT one of those foci?
a. supportive
b. clinical
c. evaluative
d. didactic
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Use the following frequency distribution to answer questions 5 and 6.
5.
Score
Frequency
48
1
49
0
50
3
51
6
52
9
53
11
54
12
55
8
56
7
The median is:
a. 51
b. 53
c. 54
d. 55
6.
Rounded to the nearest hundredth, the mean is:
a. 52.00
b. 53.37
c. 51.64
d. 52.73
7.
The general approach to analysis is case studies based on interview and literature data
where content analysis is used may be best characterized as:
a. objective
b. positivist
c. qualitative
d. quantitative
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8.
To estimate the degree to which two sets of scores derived from the same sample
carry together, you would calculate:
a. a correlation coefficient
b. the standard deviation
c. a t-statistic
d. an f-statistic
9.
ASAM adolescent admission criteria for Level IV medically managed intensive
inpatient treatment lists several biomedical conditions and complications. Which of the
following is NOT one of them?
a. disulfiram-alcohol reactions
b. biomedical evidence of a co-existing serious injury or biomedical illness, newly
discovered or ongoing
c. recurrent or multiple seizures
d. substance use that greatly complicates of exacerbates previously diagnosed medical
conditions
10.
A client who is suffering from alcohol hallucinosis and is presenting for treatment
exhibiting auditory hallucinations and delusions of persecution:
a. does not warrant emergency medical attention
b. can readily provide an in-depth history of the amount of alcohol consumed
c. should be hospitalized immediately and prescribed antidepressants
d. cannot easily be evaluated to determine an accurate history of the exact amount of
consumption
11.
Which of the following would NOT be considered a cognitive risk factor for relapse?
a. overconfidence
b. positive moods and feelings of success
c. difficulty overcoming negative moods
d. belief that addiction is not a disease
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12.
According to a study conducted by J. E. Helger on controlled drinking modality, what
percentage of alcohol users maintain at a social drinking level?
a. 2%
b. 12%
c. 22%
d. 32%
13.
Harold has a dual diagnosis and has developed side effects from a drug involving the
extrapyramidal motor system. What drug has Harold most likely been taking?
a. lithium carbonate
b. an antidepressant
c. an anti-inflammatory drug
d. a major tranquilizer
14.
Post-acute withdrawal syndrome is a neurological consequence of alcoholism which
predisposes a person to:
a. delirium tremens
b. complete recovery
c. contentment
d. relapse
15.
Which of the following is NOT a description of a cognitive-behavioral model of
therapy?
a. empathic relationship between counselor and patient, relaxation training, and
homework assignments
b. daily thought record (DTR), role playing, and imagery
c. activity monitoring and scheduling, exercise, and stimulus control
d. Education, focus on family of origin issues, and confrontation of belief system
16.
The term supervisor has its roots in Latin; it means:
a. “looks over”
b. “takes charge”
c. “works harder”
d. “has knowledge”
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17.
The focus of __________ is on the status of the client and the client’s needs. The
focus of __________ is on the knowledge, skills, and emotional needs of the counselor.
a. counseling; clinical supervision
b. clinical supervision; clinical practice
c. the client-counselor relationship; clinical proficiency
d. service coordination; clinical supervision
18.
The generally agreed upon definition of responsibility for clinical supervision is:
a. one hour of clinical supervision for every twenty hours of client contact
b. two hours of clinical supervision each week
c. thirty minutes of clinical supervision each day
d. eight hours of clinical supervision each month
19.
The goal of supervision is:
a. to promote the proper method of recovery from addiction
b. to insure that a counselor adheres to the policies and procedures of the program
c. to impact on the counselor’s clinical behavior
d. to provide a model of behavior in all clinical as well as all personal skills
20.
The dominant models of clinical supervision in the 1930’s-1960’s were:
a. Psychodynamic or Psychoanalytic models
b. Developmental models
c. Philosophy-based or Approach-based models
d. Client-centered models
21.
Based on the work of Stoltenberg and Delworth, Level 1 counselors are typically
those who have been in the counseling field:
a. for less than six months
b. for less than one year
c. for one to two years
d. for one to five years
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22.
You are supervising a counselor who comes to work one day noticeably distraught.
She reports that she had a fight with her husband and states, “I’m so mad at him that I’ve
started to think about divorce.” As her supervisor, which of the following should you NOT
do?
a. talk to the supervisee about how their personal issues affect client care
b. seek consultation yourself (supervision of the supervision) to ensure objectivity
c. remove the counselor from active casework and begin counseling her to resolve
the problem
d. refer the counselor to the EAP for an assessment and document that you made the
referral, in the event that disciplinary action may be necessary in the future
23.
According to ________, positive and negative feedback must be paired together.
a. Abraham Maslow
b. Carlo DiClemente
c. Irvin Yalom
d. Carl Rogers
24.
The facilitative model of supervision was based on which of the following models of
psychotherapy?
a. Freud’s analytically oriented approach
b. Rogers’ client-centered therapy
c. Ellis’ cognitive therapies
d. Mead’s task-oriented model
25.
A sociogram can be used as an effective supervision technique for evaluating a group
counseling session, mapping where the interactions and interchanges occur. If an arrow goes
from one member into the center of the group, what does it mean?
a. It indicates that a member of the group was providing feedback about themselves.
b. It indicates that a member of the group was the focus of the discussion at that time.
c. It indicates a comment to the group as a whole.
d. It indicates an exchange of information between a group member and the
counselor.
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ANSWER KEY
1. A
2. A
3. C
4. D
5. B
6. B
7. C
8. A
9. B
10. D
11. B
12. A
13. D
14. D
15. D
16. A
17. D
18. A
19. C
20. A
21. D
22. C
23. A
24. B
25. C
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