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ZUR Institute

Introduction to Supervision II: Advanced Topics, Ethics & Law

Introduction to Supervision II: Advanced Topics, Ethics & Law

By: Sage de Beixedon Breslin, Ph.D.

Table Of Contents

I. Introduction
Supervision In The New Millennium

II. Definitions and Descriptions
Who You Are Makes A Difference
Optimal Qualities In A Trainee
Best Fit In Supervision

III. Supervision Styles & Modes Of Instruction
Supervisor Personal Styles
Modes Of Instruction

IV. Developmental Process In Supervision
Supervisor-Driven
Trainee-Driven

V. Best Practices For Supervision
Case Report Vs. Behavioral Demonstration
Orientation-Driven Supervision
Diversity Training

VI. References

I. Introduction

As has been described in the Introductory course in Supervision, supervision is the process by which a more senior, educated, and experienced clinician guides, teaches and promotes the growth of a clinician with less experience and training. The process is designed to be evaluative, and manages the best interests of both the trainee and the potential client or consumer.

Much has been written about the models of supervision and ways in which supervisory efficacy can be gauged. Less research has been conducted about what makes a good supervisory experience, for both the supervisor and the trainee.

While academic research provides important data for all of us who provide clinical supervision, much of that research finds its best resting place in the Introductory courses in supervision. Within this Advanced course in Supervision, I hope to provide more personal and clinical data to encourage and promote your independent thoughts and inquiries about the experiences you have, or have had, with your trainees. The graduate school curriculum is designed to promote a broad education and understanding of treatment in general, but much of what we have really come to practice as therapists has come through clinical experience. That being said, some general information about Best Practices for Supervision will be shared in this article, then the course will move on to provide up-to-date information about Ethics & the Law with regards to Supervision, as well as clinical vignettes for you to flex the supervisory skills you continue to hone.

Supervision In The New Millennium

Clinical supervisors are in a unique situation these days:

Very few training programs offer courses in supervision, setting up the potential supervisor for disaster unless the clinician has invested time and energy in continuing education in Supervision. Even at that, a single class in Supervision isn’t the same as a semester-long course requiring both academic learning and practical application.
Given the paucity of training in Supervision, potential supervisors rely on their own experience of Supervision as trainees to guide them through the supervisory process.

I remember staring at her wiry, prematurely-graying hair, wondering who she was, and how I came to be assigned to her. I knew that our Clinical Director had made the assignments to these supervisors, but after only a few supervision sessions, I wondered specifically why this woman had been chosen to guide me through my first year of graduate experience.

It was near the end of our third supervision session when her expression seemed to change rather suddenly. She began to ask me questions about my childhood, about which I had always been very private. My responses were not to her liking and her tone became more acid, and her responses more virulent. I held my tears until the hour ended and the building door closed behind me. My only thought as I left the building was, “If my clients ever feel that way, they’ll never come back!” With mounting nausea, it occurred to me that, unlike my clients, I had to go back through that door the following week- my academic career rested on it. I struggled with the supervisor for another few weeks before asking that the Clinical Director reassign me. By then, I’d heard rumors that she’d stopped taking her medication, and that her Schizoaffective Disorder was again in full bloom. The explanation was a godsend for my self-esteem and experience of the process. Otherwise, my model for supervision would have been marred for the remainder of my professional life.
Historically, there have been few standards, qualifications, specified content, and process of evaluation identified for supervision. These are now in the process of development, but remain elemental for the most part.
Supervisors must manage the complexity inherent in assuming multiple roles as teacher, trainer, case manager, psychotherapist, overseer, and mentor. While these dual roles are not likely to pose any ethical dilemmas, the experience can be confusing at the very least for most supervisors.
With the elimination of the oral examination in most states, more emphasis is being placed on long-term supervision and peer consultation, heightening the pressure on supervisors.

II. Definitions and Descriptions

Who You Are Makes A Difference “The Good Enough Mother (oops!) Therapist”

There are optimal characteristics and qualities of therapists in general, but in working dyadically, we must also examine the goodness of fit between supervisor and trainee. It has been often noted in the research that it is the therapeutic alliance that is most salient in any therapy, and is equally important in the supervisory process.

Optimal Qualities And Characteristics Of The Trainee:
When selecting a trainee, select an individual who has as many of these characteristics as possible so that supervision can be predominantly focused on the development of clinical skills.

What do you think makes a good (enough) therapist?

Some of the qualities and characteristics of effective therapists include, but are not limited to:
- Cognitive
- Emotional
- Behavioral
- Miscellaneous helpful traits and qualities
Some of these qualities can be developed or learned, but many cannot. Remember, those qualities, traits and characteristics that are not present at the time that you hire the trainee and that cannot be learned, will not develop in the trainee, no matter how hard you work in supervision.

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Best Fit In Supervision
The qualities recommended above for the “optimal trainee” can also be assigned to the supervisor. The qualities are those which make for a good therapist, whether more or less experienced!

In addition to personal qualities and behaviors that can improve both clinical work and supervisory experience, a certain “fit” between supervisor and trainee is also necessary. The ingredients for that “fit” are unique to each dyad, and will be affected by where each of you are in your development as clinicians and especially by where the supervisor is in his/her own development as a supervisor. Some common ingredients that promote optimal supervisory process include:
- Willingness and motivation to participate in the process
- Sufficient education, training, and experience as a mentor, supervisor and clinician
- Open-mindedness to new ideas, orientations and techniques
- Genuine interest and passion for the work
- An open nurturing relationship or alliance
- Strong, assertive communication and structure
- An ability to relate to one another
- Congruence of professional, if not personal, values

III. Supervision Styles & Modes Of Instruction

Once you’ve selected the optimal trainee, the pressure rests on the supervisor to produce the most effective supervisory process!

Supervisors must choose personal styles for conducting supervision, and must also utilize varying modes of instruction.

Supervisor Personal Styles

Supervisors can choose to conduct the supervision in whatever style best suits not only themselves, but also that which is most appropriate for the dyad. The personal style of the supervisor may reflect his/her theoretical orientation, level of comfort with supervision, mood for the day, and may even be dependent on elements posed by the trainee (in any portion of the supervisory hour, or the experience as a whole). Typically, supervisory styles range along a continuum of

relaxed to conservative
open to private
contemporary to traditional and
task-driven to orientation-driven.

In addition, supervisors may elect to assume roles such as teacher, guide, mentor, or senior colleague. These roles may shift during the supervisory hour, as well as from session to session, and throughout the supervisory experience.

Some of these supervisory styles are reviewed by Dr. Robert Rando in Article #2 of this course.

Some Of The Modes By Which Supervisors Train Include:

Didactic: “Say it!”
- Provide instruction and information. Less than 10% of didactic information remains after 48 hours in less specific rehearsal is applied.
Role Modeling: “Show it!”
- Break it down to the simplest components
- Go at your trainee’s pace
- Reinforce all gains made. This is a particularly effective method for training and can be provided in the co-therapy milieu, such as co-leading a group with a trainee.
Experiential: “Sample it!”
- Trainees will be exposed to experiential learning both in the therapy room, and in the supervisory process.
- Just as our clients can only go as far as we have gone clinically, trainees will move to the pace of the functioning of the supervisor.
- For trainees who learn kinesthetically (by physically “doing”), experiential instruction will be the most effective way for them to learn. However, for many trainees, this kind of learning may take far longer to generalize and apply.

All modes of instruction are used in supervision, some more often than not, depending on the developmental level of the supervisory process. Didactic information is generally provided at earlier points in supervision, whereas experiential learning is often reserved for the time when the trainee has already gained a sense of competence and confidence about certain ideas, issues, or situations.

IV. Developmental Process In Supervision
The learning curve – supervision changes as supervision changes!

Nothing remains the same for long! As the training dyad works together, both gain knowledge, skill, and ease in the work together. All of these elements and dynamics alter the process of supervision, as supervision proceeds forward through time and experience. As such, supervisors will need to shift what and how they offer information and learning experiences to their trainees.

Supervisor-Driven

As in all things, supervision has its own developmental process. Not only does a trainee experience the process developmentally, but the supervisor trains developmentally.

As a supervisor, what stages do you go through during the supervisory experience?

Both during the supervision hour, and throughout the supervision process, learning occurs in developmental stages or waves. The stages repeat as necessary at different layers of the supervision. The stages include:

Prescriptive training: Teach it!
Initially, trainees must be told what to do it, if they have no clinical experience. As trainees gain experience and skill, they will require less “teaching” or didactic instruction. However, there will be situations during which more prescriptive training will be required. For instance, when the supervisory time is shortened for any reason, there may only be time for case report and prescriptive training. In addition, during clinical emergencies, supervision may be constrained to prescriptive training.
Catalytic instruction: Trigger it!
As trainees gain competence and skill, it is imperative that the supervisor promote independent thought and action in the trainee. Within this developmental layer, the supervisor works to solicit the thinking of the trainee, so that the trainee learns to make his or her own decisions and interventions in the therapy hour. The trainee learns to multi-track successfully during this phase.
Reflective guidance: Treasure it!
As the trainee gains independence in all ways, s/he will think, act, and report in supervision all that we, as clinicians, would. This stage development requires only reflective guidance and encouragement to enhance the self-esteem and confidence of the trainee. This final stage of supervision is for fine tuning.

As noted previously, these stages or waves can occur both during the supervisory hour as well as throughout the supervisory process. After teaching and triggering, consider treasuring what the trainee can teach you. While we often incorporate the opportunity for feedback in the final evaluation of our trainees, sometimes we miss golden opportunities throughout the process to connect and hear from our trainees about our instructional skills and styles.

Consider using the last 10 minutes of the supervision hour to ask some of the following questions of your trainee:

How was supervision for you today?
Did you get what you needed?
What worked best for you?

Trainee-Driven

The developmental process of supervision is also driven by the trainee’s style of learning and the skills they need to acquire.

By combining both opportunities for both cognitive and experiential learning, the trainee gains a more comprehensive understanding and grasp of the clinical process. Sultanoff (2006) describes the process of conceptual integration in supervision as occurring in four stages:

Unconscious ineffectiveness: Prior to the gathering of information and experience, the trainee may be less than skilled in certain areas. In the therapy room, the new trainee may have little skill, and may also be unaware of how ineffective s/he is being with the client. The trainee may even need to “unlearn” certain things.
Conscious ineffectiveness: During this stage of cognitive and practical development, the trainee has a heightened awareness of what s/he can’t yet do. In treatment, the trainee becomes more and more conscious of his/her actions and their impacts. When interventions or interactions flail or fail, the trainee is clear that additional skills are needed!
Conscious effectiveness: As the trainee gains clarity and acumen, s/he is both aware of and able to implement skills through practice. With clients, the trainee follows a clinical protocol, meting out therapy according to certain rules, guidelines, and plans. The therapy is effective and predictable.
Unconscious effectiveness: During this “autopilot” stage, the trainee no longer needs conscious effort to perform effectively. Therapy is a smoother process in which the trainee responds to the actions of the client as they are produced. Interactions become more fluid and interventions become spontaneous and creative.

With each new skill to be acquired, the trainee will reenter each of the four stages, and proceed through the learning process. As the trainee recognizes the similarities between skills to be acquired, it is likely that the acquisition of new skills will proceed more and more rapidly over time.

In addition, as the trainee begins to feel confident in his or her performance, s/he will also begin to experience clinical intuition. Highly trained therapists often report getting “a sense” of what to do during a therapy hour, and follow their “hunches” to terrific clinical results. As trainees reach this stage of heightened awareness with their clients, it is imperative that we remind our trainees to mediate behaviors and interventions generated by intuition with sound clinical skills and judgment.

Not only do trainees learn developmentally, their skills are acquired according to the stage of development they are in at the time. Trainees first learn “micro-skills” such as responding and non-verbal listening, and then acquire “macro-skills” such as the application of theory to practice, as well as broad conceptualization and multi-tracking.

1. Micro-skill development
In order to generate independent thought about clinical style as well as the micro-skills needed in treatment room, you might ask your trainee,

“What does a clinician do in therapy to help a client? If I watched a highly-effective therapist through a one-way mirror, what would I see during the session?”

During this stage of the supervisory process, trainees must learn to:

Use open-ended questions with their clients
Listen reflectively, until active listening is more appropriate
Limit self-disclosure unless it promotes the therapeutic goals set out in the treatment plan
Learn what to do when stuck (rather than just reverting to earlier stages of functioning)

2. Macro-skill development
As trainees shift into the acquisition of macro-skills, less didactic instruction will be required, and more solicitation of independent thinking and action will be necessary by the supervisor. At this stage, the training dyad may find themselves in a more colleagueal relationship, exchanging ideas about the application of theory and orientation to treatment with particular populations and disorders.

V. Best Practices For Supervision

Beyond the nuts and bolts of the developing supervision, there are a few areas that all training dyads must address. Thus far, we’ve described the parties that comprise the supervisory dyad, and have noted the process by which they will interact. It is also imperative that the dyad choose how they will share supervisory experiences.

Case Report Vs. Behavioral Demonstration: The Story Vs. The Study

While it may seem to require far more effort to directly observe a trainee, this style of supervision provides great instructional experience as well as healthy risk management.

Case report can provide just as accurate presentation of case detail as can behavioral observation. Supervisors can quickly question and promote learning with case report, while they may have to wait for such opportunities when involved in direct observation. While trainees may not provide an accurate description of interventions used in the treatment room when providing case report, there is no such error in recall during direct observation because the supervisor is able to view the interventions him- or herself.

For best risk management, it is important to attempt direct observation on a monthly basis if not more frequently. With challenging or complex cases, direct observation of the treatment is necessary on a consistent and frequent basis. While you may feel as if this level of supervision requires more of your effort and attention than you signed on for, know that you significantly reduce your risk, and that of your trainee’s clients, by providing more direct supervision on a consistent basis, especially for those particularly difficult cases.

Orientation-Driven Supervision

Those that conduct supervision in the orientation being acquired by the trainee promote “in vivo” exposure to the process. This can be a highly effective way for the trainee to “learn” an orientation, without the “educational” delay inherent in direct observation. This style of supervision will near psychotherapy and must be conducted with the utmost care for the trainee’s vulnerability and exposure.

Remember that you must be competent in the orientation in which you are providing supervision in order to uphold your best ethics.

Diversity Training

In addition to having clarity about the ways in which supervision will be conducted, it is imperative that you ensure that your trainee develops sufficient cultural sensitivity to work with the clinicians and clients in your environment.

According to the “APA Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations,” clinicians:

need a sociocultural framework to consider diversity of values, interactional styles, and cultural expectations in a systematic fashion. They need knowledge and skills for multicultural assessment and intervention, including abilities to:

recognize cultural diversity;

understand the role that culture and ethnicity/race play in the sociopsychological and economic development of ethnic and culturally diverse populations;

understand that socioeconomic and political factors significantly impact the psychosocial, political and economic development of ethnic and culturally diverse groups;

help clients to understand/maintain/resolve their own sociocultural identification; and understand the interaction of culture, gender, and sexual orientation on behavior and needs.

Multicultural sensitivity can be broadened to include, but is not limited to, sensitivity to differences in age, gender, physical ability or limitation, socioeconomic status, sexual orientation, and religious affiliation. Being able to recognize and appreciate both differences and unique qualities of each of these groups is elemental to multicultural sensitivity.

Basic training in multicultural sensitivity requires review of at least four areas:

Self-awareness
The supervisor must provide opportunities for the trainee to examine and explore his or her own cultural identity. Not only does this allow the clinician to explore impacts of his/her own culture on both the therapy and the supervision process, but it is also likely to improve the trainee’s ability to explore and appreciate the client’s cultural elements.

Other-awareness
Through this learning process, the trainee comes to value all that they learn about their clients. The client’s cultural identity may gravely impact the treatment process, so it is imperative that the trainee access this rich source of information about the client.

Self-management
According to Sultanoff (2006), “in order to help diverse populations, one must be able to cope with ambiguity, confusion, lack of clarity, alternative points of view and uncertainty and discomfort that differences trigger.” While experienced trainees may handle this with ease and grace, less experiences trainees may need didactic instruction about how to best manage treatment with a culturally different client.

Relationship management
Because our cultural differences can affect how we perceive and communicate with others, trainees must learn to conduct treatment with their culturally different clients in ways that are both suitable and effective. Clear communication with the client is at the foundation of culturally-sensitive treatment.

References

APA. “APA Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations.” https://www.apa.org/pi/oema/resources/policy/provider-guidelines.aspx Retrieved 2/13/06.

Falendar, C. and Shafranske, E. (2004). Clinical Supervision: A Competency-Based Approach. Washington, D.C.: APA Books.

Rando, R. (2007). “Adaptive Supervision in Counselor Training.” https://ccvillage.buffalo.edu/Village/ElecProj/Rando.htm Retrieved 2-22-07.

Sultanoff, S. (2006). Clinical Supervision: Best Practices. Private communication 9/25/06.

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