Clinical Supervision_ a Competency

Report
Clinical Supervision: A
Competency-based Approach
Based on Dr. Carol Falender’s January 2011
presentation to the VA Psychology Training
Council
Powerpoint summary by
Evelyn Sandeen, Ph.D. , ABPP
Why do clinical supervision?
• Supervision is required for obtaining a degree
and obtaining licensure
• Greater staff retention among clinicians who
do supervision
• Less burnout among clinicians who do
supervision
• Some research beginning to show positive
impact of supervision on client outcomes
(Bambling et al., 2006; Callahan et al., 2009)
Definition of Clinical Supervision
• Distinct professional activity
• Involves intention to develop scienceinformed practice in the trainee
• Collaborative, interpersonal process
• Involves observation (live, video, or audio)
• Involves feedback
• Facilitates trainee self-assessment
Definition, continued
• Facilitates the acquisition of knowledge and
skills by
– Instruction
– Modeling
– Collaborative problem-solving
Super-ordinate Values embedded in
Clinical Supervision
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Integrity in relationships
Ethical values-based practice
Science-informed, evidence-based practice
Appreciation of diversity
– Diversity of client, of supervisee, and of supervisor
Pillars of Supervision
• Supervisory relationship alliance
– Collaborative relationship
– Respect essential
– Transparency always desirable
– Feedback—frequent and often-- essential
• Educational praxis
– Tailoring learning strategies to the individual
supervisee
Supervision vs. …
• Consultation
– Consultation does not include the power differential
that supervision does
– Consultation does not bring the liability issues for the
supervisor that supervision does
• Psychotherapy
– Some techniques may overlap but domain of interest
is starkly different
• Mentoring
– Advocacy vs. evaluation
Definition of Competence
• Definition of competence in medicine:
• the habitual and judicious use of
communication, knowledge, technical skills,
clinical reasoning, emotions, values, and
reflections in daily practice for the benefit of
the individual and community being served
(Epstein & Hundert, 2002)
Definition of Competence
• APA definition:
• Performing tasks consistent with one’s
professional qualifications, sensitive to
individual and cultural differences, and
anchored to evidence-based practice
• Competency Benchmarks in Professional
Psychology (available on APA website)
Self-Evaluation and Meta-competence
• Self-rated competency is inversely related to
other-rated competency (Kruger & Dunning,
1999; Dunning et al., 2003)
• The more fine-grained the self-assessment,
the better the validity of the self-assessment
• Meta-competence is the ability to reflect on
what we do not know and to compensate for
that (refer, seek information, seek
supervision/consultation or training)
Assessment of Competence in
Professional Psychology
• Competency Toolkit (Kaslow et al., 2009)
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Provides information about and purposes for various assessment methods:
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360-degree evaluation
Rotation performance reviews
Case presentation reviews
Competency Evaluation Rating Forms
Client/patient process and outcome data
Consumer surveys
Live or recorded performance ratings
Objective Structured Clinical Examinations (OSCEs)
Portfolios
Record Reviews
Simulations/Role plays
Self-assessment
Standardized client/patient interviews
Structured oral examination
Written examination
Steps in Competency-based
Supervision
• First, make all steps transparent to the supervisee
• Step 1- Orientation to competency-based
approach
• Step 2- Collaborative identification of
competencies that will be focus of training
• Step 3- Development of the supervision contract
• Step 4- Formative evaluation—every session
• Step 5- Summative evaluations—at regular
intervals
The Supervisory Alliance
• Supervisor must understand the difference
between this alliance and the therapy alliance
• Supervisor has power over the supervisee
• Supervisor has responsibility to hold to
professional standards and evaluate the
supervisee
• Both therapy and supervisory alliances require
respect and collaborative shared purpose
Development of the Supervisory
Alliance
• Make the purpose and the expectations of supervision
explicit (supervision contract may help here)
• Discuss similarities and differences between the client,
the supervisee, and the supervisor each session
• Give and receive two-way feedback in an ongoing and
frequent manner
• Measure the strength of the supervisory alliance
(Appendix B in Falender and Shafranske, 2004)
• Clarify roles if supervisor has more than one role with
supervisee
Development of the Supervisory
Alliance, continued
• Identify relationship strain—This is the
supervisor’s job
– Change in supervisee behavior
– Passive resistance
– Spurious compliance
– Hostility
Functions of the Supervisor in the
Supervisory Relationship
• Identifying and Managing Countertransference
– Help supervisee see emerging patterns
– Give assignments to help balance out the
countertransference
– If this is resisted by supervisee, supervisor must state
that working through countertransference is not
optional, but is a mandate
– Self-disclosure appropriate to understanding and
working with countertransference should be expected
and put in the supervision contract
Diversity Awareness
• Supervisor should start the process by disclosing
his/her own matrix of personal multiple identities
(biases, strengths, assumptions, background
contributing to same)
• May invite supervisee to do the same without
forcing
• Discuss how client’s diversity issues interact with
the biases and assumptions of the supervisee and
the supervisor
Providing Effective Feedback
• Feedback is more effective if it corresponds to
self-assessment (using the Competency
Benchmarks can promote shared language and
behavioral goals)
• Feedback should be specific and behaviorallylinked
• Feedback should be close in time to the
observation of the behavior (video or audio
recording can be very useful here)
• Provide negative feedback in terms of plans,
improvement, and goals
Incorporating Process and Outcome
Data into Supervision
• Review client outcome reports during
supervision (Lambert & Hawkins, 2001)
• Review therapeutic alliance measures during
supervision (e.g., Working Alliance Inventory,
Hatcher & Gillaspy, 2006)
• Utilize satisfaction with supervision forms
(Appendix K in Falender & Shafranske, 2004;
reprinted from unpublished manuscript by
Hall-Marley, 2001)
Ethics
• Supervisors should review the ethical
principles related to the discipline of
whomever they are supervising (Universal
Declaration of Ethical Principles for
Psychologists, 2008; APA Code of Ethics, 2002)
• Make a point to discuss ethics each
supervisory session
• Supervisors should attend to potential ethical
teaching points as they arise
Boundary Issues
• Distinction between boundary crossings vs.
boundary violations
• Boundary crossings are unusual but can be
planful and okay ethically
• Boundary violations are never okay
• Should discuss internet and social media
issues with supervisees in terms of ethics
Boundary Issues, cont.
• Around 4% of psychology students experience
sexual contact, pursuit or harrassment by
supervisors/educators
• Attraction to clients—80% of practitioners
admit to this during career yet supervisees
rarely disclose this
• Attraction by client—help supervisee do
functional analysis of the situation and
respond appropriately
Liability
• Supervisors have two types of liability related
to their supervisees
– Direct Liability for negligent supervision
we can control this by
observing supervisee
taking corrective action based on observation
Liability, continued
• Second type of Liability
– Vicarious liability—liability for supervisee’s
behavior
• Not under our control completely
• May be liable simply because of relationship with
supervisee
Supervising the “problem supervisee”
• Competency issues around professional behavior
often are what we mean by “problem
supervisee”
• Papadakis et al. (2005) found correlation
between unprofessional behavior in medical
school and later discipline by state boards
– First type of unprofessional behavior:
• Severely diminished capacity for self-improvement; failure to
respond to feedback
– Second type:
• Severe irresponsibility, unreliability, failure to followup
“Problem Supervisee” continued
• Other categories of problem supervisees:
– Unable/unwilling to integrate professional
standards into their behavior
– Inability to acquire professional skills
– Inability to control personal stress so that it
interferes with professional functioning
Response to “Problem Supervisees”
• In all cases, must have and follow a remediation
procedure
• Observation and feedback must begin early
• Remediation plan itself should be
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Competency based
Items should be observable
Items should be measurable
Plan should have time limits
Examples of Remediation Plans are on VAPTC
sharepoint site
Self-care
• Self-care is not a luxury; it is an ethical
imperative
• Self-care options for psychologists to model
for supervisees:
– Vary work responsibilities
– Use positive self-talk
– Maintain personal/professional balance
– Take vacation time
Self-care, continued
– Maintain professional identity through CE, new
professional tasks, organizations
– Spirituality
– Read literature
– Have control over work responsibilities
– Teach and supervise—protective activities to
prevent burnout
References
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American Psychological Association (2002). Ethical Principles of Psychologists and Code of Conduct
Bambling, M., King, R., Raue, P., Schweitzer, R & Lambert, W. (2006). Clinical supervision: Its
influence on client-rated working alliance and client symptom reduction in the brief
treatment of major depression. Psychotherapy Research, 16 (3), 317-331.
Callahan, J.L., Almstrom, C. M., Swift, J. K., Borja, S. E., Heath, C.J. (2009). Exploring the contribution
of supervisors to intervention outcomes. Training and Education in Professional Psychology,
3(2), 72-77.
Dunning, D., Johnson, K., Ehrlinger, J., & Kruger, J. (2003). Why people fail to recognize their own
incompetence. Current directions in Psychological Science, 12 (3), 83-87.
Epstein, R.M., Hundert, E.M. (2002). Defining and assessing professional competence. Journal of
the American Medical Association, 287(2), 226-235.
Falender, C. A., Shafranske, E. P. (2004). Clinical Supervision: A Competency-based Approach.
American Psychological Association, Washington, D.C.
Hatcher, R. L., Lassiter, K.D. (2007). Initial training in professional psychology: The practicum
competencies outline. Training and Education in Professional Psychology, 1 (1), 49-63.
Hatcher, R.L., & Gillaspy, J.A. (2006). Development and validation of a revised short version of the
working alliance inventory. Psychotherapy Research, 16 (1), 12-25.
References, Cont.
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Kaslow, N.J., Gurs, C.L., Campbell, L.F., Fouad, N.A., Hatcher, R.L., & Rodolfo, E.R.
(2009). Competency assessment toolkit for professional psychology. Training
and Education in Professional Psychology, 3 (4, Suppl), S27-S45.
Kruger, J. & Dunning, D. (1999). Unskilled and unaware of it: How difficulties in
recognizing one’s own incompetence lead to inflated self-assessment.
Journal of Personality and Social
Psychology, 77 (6), 1121-1134.
Lambert, M.J., & Hawkins, E.J. (2001). Using information about patient progress in
supervision: Are outcomes enhanced? Australian Psychologist, 36, 131138.
Papadakis, M.A., Teherani, A, Banach, M.A., Knettler, T.R., Rattner, S.L., Stern, D.T.,
Veloski, J.J., & Hodgson, C.S. (2005). Disciplinary action by medical boards
and prior behavior in medical school. New England Journal of Medicine,
353, 2673-2682.
Universal Declaration of Ethical Principles for Psychologists. (2008). Available from
the International Union of Psychological Science Web site:
http://www.iupsys.org/ethics/univdecl2008.html

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