Clinical Supervision

Fern Richie, DSN, APRN-BC [email protected]

What is supervision?

   “A disciplined, tutorial process wherein principles

are transformed into practical skills”

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“Serves to enhance professional functioning of the more junior team members”

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(Powell & Brodsky, 2004) “A social influence process to ensure quality of clinical care”

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(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 self awareness

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

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“How is this client affecting you?”

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“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

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“ How is this counselor affecting you?”

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“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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