Clinical Supervision

Report
Clinical Supervision
Fern Richie, DSN, APRN-BC
[email protected]
What is supervision?

“A disciplined, tutorial process wherein principles
are transformed into practical skills”
◦ “Serves to enhance professional functioning of the
more junior team members”
 (Powell & Brodsky, 2004)

“A social influence process to ensure quality of
clinical care”
 (SAMHSA)

Effective supervisors observe, mentor, coach,
evaluate, inspire and create an atmosphere
that promotes self-motivation, learning, and
professional development
Roles

Teacher
 Assist in the development of counseling skills and knowledge
 Assist in identifying potential countertransference that may be
occurring in the supervisee

Consultant
◦ Provide alternative ways of looking at clinical cases

Coach
◦ Supportive role in which supervisor identifies
strengths and needs, and assesses for burnout

Mentor/Role Model
◦ Supervises through “showing” best practices and selfawareness
Approaches to Supervision

Competency-based
◦ Focus on skills
◦ Set goals that are specific, measurable, attainable, realistic,
timely (SMART)
◦ Use of role playing and demonstration

Treatment-based
◦ Articulate the treatment approach
◦ Acquire skills specific to that treatment approach

Developmental
◦ Supervision addresses needs based on the counselor’s
developmental level

Integrated
◦ Addresses both skills and competency development
Seven Simple (Profound) Truths
Reason for supervision is to ensure quality
client care
 Culture and ethics influence all supervisory
interactions
 Be human and have a sense of humor
 Rely on direct observation of the counselor
 Know your approach and communicate that
to the counselor
 Take care of yourself spiritually, emotionally,
physically (“walk the walk”)
 Remember: It’s all about the relationship

Ethical and Legal Issues
Vicarious liability
 Dual relationships and boundary concerns
 Informed consent
 Confidentiality
 Supervisor ethics

Vicarious Liability

Supervisor is held liable for damages incurred as a
result of negligence in supervision process
◦ Inappropriate advice to the counselor
◦ Failure to listen carefully to comments made about client
◦ Assignment of tasks to inadequately trained counselor

“Did the supervisor make a reasonable effort to
supervise?”
◦ One hour of supervision for every 20-40 hours of clinical
services provided by the counselor
◦ Quality and content of sessions must be evidenced based
◦ Documentation of all supervision sessions
More on Liability

Supervisor is more vulnerable when
◦ Counselor has too many assigned clients
◦ Direct observation of clinical work does not
occur
◦ Supervisor not available to aid staff
Dual Relationships and Boundaries

Two levels
◦ Between supervisor and supervisee
◦ Between counselor and client
Dual relationship transcends professional
relationship
 Key issues

◦ Abusive use of power
◦ Relationship will impair one’s judgment
◦ Risk of exploitation

Most common basis for legal action and
complaints by certification boards against
counselors are boundary violations
Informed Consent

Use of supervision contracts to inform
◦ Process of supervision
◦ Feedback and evaluation criteria
◦ Expectations of supervisor and supervisee
Confidentiality
Client consent to treatment
 Client consent to supervision of case
 Supervisee consent to supervision
 Parameters for confidentiality in
substance abuse treatment are clearly
defined by Federal law 42 CFR and HIPAA

◦ http://www.hipaa.samhsa.gov
◦ http://www.samhsa.gov/about/laws/SAMHSA_
42CFRPART2FAQII_Revised.pdf
Supervision vs. Therapy
Supervision WILL encroach on counselor’s personal
issues
 Goal of supervision is to enhance counselor’s clinical
performance, NOT to resolve personal issues
 Improved self-awareness by counselor may result
from supervision
 When a personal issue emerges

◦ What is the impact of the personal issue on the client and
his/her treatment?
Supervisor must monitor and transfer case to
another counselor if necessary
 Supervisor can encourage counselor to seek outside
counseling

Countertransference
Projecting unresolved personal issues
onto a client or supervisee
 Signs to look for

◦ Feelings of anxiety or dread at prospect of
seeing the client or supervisee
◦ Unexplained anger
◦ Forgetting details about client, appointments
◦ Excessive socializing
Exploring Countertransference with
Supervisee
“How is this client affecting you?”
 “What does working with this client bring up
for you?”
 “What’s going on with you and your life that
may be affecting your counseling with this
client?”
 “What strategies and coping skills can assist
you in your work with this client?”
 “How might you address your own issues?
Have you considered outside counseling?”

Supervisee Transference
Supervisee idealizes the supervisor
 Supervisee resents the supervisee
 Supervisee’s need for acceptance and
approval from supervisor
 Supervisee’s reaction to boundaries the
supervisor might set

The Resistant Supervisee
Arises from many sources
As with the resistant client, supervisee resistance
tells us something
 Must work to identify what is “behind” the
resistance and defensiveness


◦ Fear? Jealousy? Insecurity? Anger?

Next, honor the resistance and what it is telling
you
◦ “I understand this is hard for you. How might we work
together to plan for your professional growth?”


Might use self-disclosure about your previous
experience as a supervisee
REMEMBER – It’s all about the relationship!
Supervisor Countertransference
Supervisor’s need for approval as a
competent supervisor
 Supervisor’s unresolved personal conflicts
are activated by supervisee
 Personal reactions to the supervisee
 Sexual or romantic attraction
 Supervisor also needs to consider outside
counseling if own issues are getting in the
way of effective supervision

Exploring the Supervisor’s
Countertransference
“How is this counselor affecting you?”
 “What does working with this counselor bring
up for you?”
 “What’s going on with you and your life that
may be affecting your supervision with this
counselor?”
 “What strategies and coping skills can assist
you in your work with this counselor?”
 “How might you address your own issues?
Have you considered outside counseling?”

Finding the Time
Develop your supervision plan
 Get administrative buy-in
 Add components one at a time
 Keep in mind that observation of staff can
be brief
 Just start!

Documentation
Both formal supervision sessions and
informal feedback given to counselor
 Content and outcomes of session
 Any risk management issues addressed
(crises, duty to warn, breaches of
confidentiality, etc.)

Methods
Case presentation and review
 Direct observation
 Audio/video taping
 Co-facilitation (modeling)
 Role playing

Facilitating Live Observation
Acknowledge both counselor and client’s
anxiety about observation or taping
 Listen reflectively and normalize the
concerns
 Clearly state the value of direct
observation in terms of improved client
services
 Continue to address concerns and
feelings

Introducing Changes in Practice
Respect staff’s resistance
Respect each counselor and what
experience s/he brings to the agency
 Be clear that change is needed yet allow
time for adjustment and acclimation
 Provide resources to staff to aid in making
changes
 Remember your own days of experiencing
change and resistance to change
 Consider using self-disclosure to address
concerns


Addressing Personal Issues that
Affect Job Performance
Keep the focus on job performance and
client outcomes
 Clarify boundaries of what constitutes
acceptable job performance
 Provide measurable benchmarks by which
staff can assess their own improvement
 Develop a written plan for performance
improvement, with dates set for goals to
be achieved
 Refer for personal assistance/EAP

Issues to Address in Supervision
Clinical decision making skills
 Role of personal values in counseling
 Rapport with clients
 Use of self-disclosure
 How to work with clients who lack
motivation
 Balancing providing tools for recovery with
helping clients make healthy choices

◦ Explore counselor’s use of “advice giving”

Effective use of time
More
Documentation issues
 Concerns about team work
 Positive feedback on what the counselor
is doing well
 Clarify any expectations for change
 Identify resources needed to promote
change and improvement
 Remember: It’s all about the relationship

TIP 52 Resources Posted to
TAADAS Website

“Checklist for Supervisor Competencies”
◦ 5-point rating scale for evaluating the
supervisor

“Evaluation of Counselors and
Supervisors”
◦ 7-point scale for counselor to evaluate the
supervisor

“Counselor Competency Assessment”
◦ Form for documenting counselor competency
Conclusions
Effective supervision will improve client
outcomes
 Both counselor and supervisor must
work to build trust and create a climate
for positive interactions
 Remember: It’s all about the relationship

◦ Never lost sight of where you have been. At some
point, we were all supervisees. Remember what it
felt like to be in that role.
Thank you for your participation!


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