Theoretical Models Of Supervision In A Transcultural Healthcare Practice

 
 

Those of us who have provided supervision other clinicians realize that while a broad supervisory framework (like those reviewed by Bernard and Goodyear (1992)) is imperative to good supervision, it doesn’t really teach us how to provide truly effective and useful supervision. Often the supervision methods and techniques that we learn are only useful in highly specific situations, and may not be as effective in other situations which require, for instance, the generation of awareness or insight in a supervisee. Consider how limited giving feedback or challenging beliefs might be if what our trainee really needs is support and gentle guidance when they are struggling with countertransference or personal reaction to disclosures in psychotherapy?

In order to address the broader need of those engaged in the process of supervision, two methods or approaches to clinical supervision are reviewed. A description of the Supervision Triangle and its structural use is provided first, while the Integrative Development Model and its value in the process of supervision are reviewed second.

 

The Supervision Triangle

The Supervision Triangle is an adaptation of concepts presented originally by Wagner (1957). Wagner suggested that those providing supervision focus on one of three parameters: case management, supervisee responses and challenges, or supervisorial process. The supervision experience can thus be

1. Client-centered: the supervisory dyad focuses their attention on the technical issues of case management
2. Clinician-centered: the supervisory dyad focuses on the trainee’s reactions to the treatment setting and any challenges which may arise or
3. Process-centered: the supervisory dyad attends to the process between focuses on the interaction between client, clinician, and supervisor.patient, practitioner and supervisor.

While the first form of the Supervision Triangle which went into use was a simple illustration of these three parameters, with focus on either client, clinician, or supervisory process. The healthier and more articulate triangular model reminds that supervision is never singularly focused. The process of supervision is at times focused on the client and the treatment setting, at times directed on the trainee’s response to the treatment and client and at times, focused on the interaction between client, clinician and supervisor.

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Application Of The Supervision Triangle

The Supervision Triangle can be applied to the supervisory process in two different ways, ranging from objective to subjective. In the first, more objective, approach, the supervisor utilizes guided reflection. In the second, more subjective, approach self-reflection is employed.

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Guided Reflection

In the more structured, objective approach, the process of supervision is goal-directed and incorporates specific tasks. During each supervisory experience, the dyad engages in four activities. These include:

1. Supervisory goal setting
2. Clinical case presentation and review
3. Evaluation of the supervisory process
4. Revision of supervision as necessary, including the initiation of new contractual agreements

At each phase, the supervisory dyad attends not only to the task at hand but also to the impact of other factors such as ethnic and cultural diversity, on the supervision.
 

1. Supervisory Goal Setting

During the goal setting phase, the Supervision Triangle can remind the dyad to incorporate all relevant areas. By reviewing the trainee’s functioning within each area, the trainee’s needs can easily be identified and attended to (including cultural needs). Some of the areas of competency that must be addressed in the goal setting phase include:

1. Skills/Knowledge
2. Professional Identity, and
3. Sense of Self.
1. Skills / Knowledge: If the supervisor discovers during goal setting that the trainee is inadequately trained in any particular area then additional training experiences can be arranged, or clinical collaborations can be developed (for example, the trainee who has not trained in group therapy can learn these skills by co-leading a group with an experienced clinician- perhaps even the supervisor).
2. Professional Identity: Depending on the phase of professional identity which the trainee has reached, varying degrees of structure or interaction may be employed.
3. Sense of Self: While supervision does not include personal psychotherapy for the trainee, there are personal issues which are triggered during the course of supervision which must be addressed. It is during this phase that the supervisor and supervisee may elect to explore their cultural differences and/or similarities, as well as shared or discrepant values and belief systems.

 

2. Case Presentation And Review

The Supervision Triangle suggests a three-step process for case review:

1. Case description
2. The supervisory dyad reviews the issues that might be relevant to the case within each cell of the Supervision Triangle.
3. The supervisee prioritizes the relevant issues and selects a starting point.

By affording the trainee with the power to direct the supervisory session in these ways, it imbues the trainee with confidence, contributes to his/her self-direction, provides opportunity for the trainee to further his/her clinical conceptualization (and allows the supervisor a chance to evaluate the trainee’s skills in that area), and lowers the trainee’s resistance to the process.

Giger and Davidhizar (1999) and Purnell and Paulanka (1998) both offer models of transcultural models in healthcare practice and may prove useful resources should the trainee desire to explore his/her therapeutic relationship with the client. The incorporation of transcultural models can vastly facilitate and deepen the reflection process, and promote greater insight.
 

3. Evaluation

If the supervisory dyad wishes to incorporate evaluation into their supervision (required by most states), then the Supervision Triangle encourages evaluation in all arenas (or cells) of the triangle.
 

4. Review And Re-Contracting

In this phase of clinical supervision, the supervisory dyad has the opportunity to review the work they have done together. They can evaluate the extent to which they have addressed issues in each of the cells in the Triangle during their supervision. The team can identify the biases they have held during the supervisory process and can note which cells or areas have held their attention more than others. This review and recontracting process facilitates change in the focus and process of supervision as the trainee’s skills and professional identity develop.

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Self-Reflection And Self-Monitoring

Self-reflective supervision, due to the specific skills in observation, analysis and action planning that are required, may be more appropriate for the more advanced supervisee. Kolb (1988) and Morrison (2001) both described Stage Models of learning. Review of these models may be useful to the trainee using the Self-Reflective approach, as a well-grounded base of knowledge is required to engage in Self-Reflective supervision.

The structure of the Supervision Triangle can serve as a helpful trigger for content in self-monitoring. Because there are multiple foci in the Triangle, the trainee is cued to check or evaluate each of the areas.

Some of the techniques that may be of use to the supervisee include:

1. Reflection and review about the events that have taken place and the experience of those events (this is a more objective description or observation).
2. Reflection about the experience of what it was like, including feelings and thoughts.
3. Analysis of the experience in light of techniques 1 and 2, and also considering current research; identification of any particular strengths and weaknesses identified during the process.
4. Review of his/her clinical practice in light of techniques 1, 2 and 3, and making any necessary revision or modification in care-giving or clinical service.

EXERCISE: Reflection Activity for the Self-Reflective Supervisee

• Identify a client with whom you have been working, who is culturally different from you
• Visualize presenting this case in your next supervision.
• Using the Supervision Triangle, identify the areas which you would discuss in supervision (for example, cultural assessment, communication, etc)
• Identify the exact questions and issues relevant to this case, which you would want to explore with your supervisor.

Now answer the following questions:

• Did you find this task easy?
• Did the Supervision Triangle help you to focus upon issues for discussio
• Which areas did you cover?
• Will you be able to use the Supervision Triangle in practice?
• How was the issue of culture considered?

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The Integrative Development Model

The second supervision model used for transcultural healthcare practice is the ‘Integrative Development Model’ (IDM) . This model was first described by Stoltenberg et al (1998) and provides a particular useful way to understanding the content and process of supervision. This model poses a three-stage process, which reflects the parallel developmental stages and competence of a trainee.

In Stage One of this model, trainees rely more heavily on the supervisor. In Stage 2, like toddlers moving through Rapprochement, supervisees adventure out and begin an exploratory phase. Finally, in Stage 3, trainees strive for autonomy.

In each of these stages, the supervisee has different needs and requirements of the supervisor and of the supervision experience. Supervisees may simultaneously be in one stage of development in one arena of their professional experience, while existing in another stage in a different arena. As such, the supervisor must have a clear understanding of the trainee’s stengths, weaknesses, and competencies at all times, and must maintain flexibility in his/her supervision style in order to address the ever-changing needs of his/her supervisee.

Stage One: Reliance upon the Supervisor

In Stage One, the influence of the supervisor on the trainee’s stylistic development may be primary. Through role modelling and education, the supervisor is able to facilitate development of the trainee’s values, beliefs, and baseline standards in transcultural health care practice. Should there be insufficient recognition of ethnic and cultural differences between any of the participants in the supervisory triangle (client, clinicians, supervisor), confict may arise.

Because conflict can be destructive if not managed adequately in supervision, both the supervisor and supervisee need to maintain healthy awareness of situations associated with conflict.

Stage Two: The Exploratory Phase

If the trainee has effectively developed a strong and trusting base with his/her supervisor during Stage One, the trainee will be free to explore and develop in a number of ways. The supervisee may attempt to develop new clincial skills, may entertain new ideas and beliefs and may explore different cultural perspectives and experiences. The supervisor must be sensitive to the vulnerability associated with this exploration and must provide the support required for growth, steering clear of any criticism or shaming.

Stage Three: Reaching for Autonomy

While learning is an on-going process, supervisees may experience autonomy is either knowledge acquisition or skill development during Stage Three.

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Conclusion

If you are to supervise, you must first possess adequate clinical knowledge, a strong theoretical model for supervision, and be able to teach an array of clinical interventions. By incorporating the Supervision Triangle into supervisory sessions, you can even more effectively manage goal-setting, case discussion, evaluation and review of the supervisory process.

 
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