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Working with
Resistant Clients
CLIENT ENGAGEMENT
 CLINICAL SUPERVISION
BASICS OF MOTIVATIONAL INTERVIEWING
November 14th, 2011
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CLINICAL SUPERVISION
Roberta C. Churchill M.A.
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Learning Objectives
Participants will be able to:
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Describe benefits of Clinical Supervision as it pertains
both to counseling staff and for clientele
Identify at least three qualities of effective Clinical
Supervision
Describe at least two Ethical Issues that Clinical
Supervision can help address
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What is Clinical Supervision?
“ … a disciplined, tutorial process wherein
principles are transformed into practical skills
on four overlapping foci:
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Administrative
Evaluative
Supportive
Clinical”
Powell & Brodsky (2004)
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Roles of the Clinical Supervisor
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Clinical Supervision
Many of us do a pretty good job of holding back our true feelings …
It may be we are too busy
to express our feelings …
…and we don’t have enough
time to express them …
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Clinical Supervision
At the same time, we also have a difficult time managing stress …
This can unfortunately lead to …
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Compassion Fatigue
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Compassion Fatigue
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Secondary Traumatic Stress
Burnout
Countertransference
Vicarious Traumatization
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Secondary Traumatic Stress
Over time, professionals working with inmates,
substance abusers, and trauma survivors can begin
to change their world view in some concerning
ways:
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The world is a dangerous place
People are not to be trusted
And some trauma survival traits can appear:
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Numbing
Disengagement/Avoidance
Hyper vigilance
Emotionality
Physical Illness
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Burnout
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Related to emotionally demanding work
Emotional/mental exhaustion
Includes a loss of passion
Precipitating Factors:
Workload
 Institutional stress
 Job Role ambiguity
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Countertransference
A counselor’s response to a client
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Positive or negative
Conscious or unconscious
Spoken or unspoken
An emotional reaction to the client
May be caused by an activation of counselor’s
unresolved or unconscious conflicts
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Vicarious Traumatization
Sparked by empathic engagement with a client’s
traumatic experience
Includes:
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A disruption in the counselor’s frame of reference
(loss of identity and spirituality)
Impact on counselor’s personal life and relationships
Reactions and symptoms are similar to those of the client
him/herself
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Effective Clinical Supervision
provides a means for …
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Professional Growth
Greater Self-Efficacy
Improved Client Care
Improved Therapeutic Relationships
Positive Stress Management
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Principles of Clinical Supervision
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Clinical supervision is an essential part of all clinical
programs.
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Clinical supervision enhances staff retention and morale
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Every clinician, regardless of level of skill and experience,
needs and has a right to clinical supervision. In addition,
supervisors need and have a right to supervision of their
supervision.
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Clinical supervision needs the full support of agency
administrators.
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Principles of Clinical Supervision
5.
The supervisory relationship is the crucible in which
ethical practice is developed and reinforced.
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Clinical supervision is a skill in and of itself that has to be
developed.
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Clinical supervision in substance abuse treatment most
often requires balancing administrative and clinical
supervision tasks.
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Culture and other contextual variables influence the
supervision process; supervisors need to continually strive
for cultural competence.
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Principles of Clinical Supervision
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Successful implementation of EBPs requires ongoing
supervision.
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Supervisors have the responsibility to be gatekeepers for
the profession.
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Clinical supervision should involve direct observation
methods.
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Models of Clinical Supervision
Each supervisory relationship will vary according to the
needs and experience of the supervisee, and the style of
the supervisor. Clinical supervision may involve:
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Counseling, teaching and consultation
Personal support and development
Professional support and development
Skills building
A process to provide supervisees’ professional credentials.
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Models of Clinical Supervision
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Competency-based models
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Treatment-based models
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Developmental approaches
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Integrated models
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Models of Clinical Supervision
The qualities of a good model of clinical supervision are:
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Rooted in the individual, beginning with the supervisor’s self, style, and
approach to leadership.
Precise, clear, and consistent.
Comprehensive, using current scientific and evidence-based practices.
Operational and practical, providing specific concepts and practices in clear,
useful, and measurable terms.
Outcome-oriented to improve counselor competence; make work
manageable; create a sense of mastery and growth for the counselor; and
address the needs of the organization, the supervisor, the supervisee, and
the client.
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Direct Observation
Issue: What is happening behind the
closed door?
Assumption: Practice conforms to
policy, procedure, and clinical protocol
Verification: Rarely happens
Reality: Clinicians lack performance
feedback and mentoring
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Direct Observation
Direct observation of counselors is the
only way to see the whole picture
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Direct Observation
Recorded vs. Live Observation
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Due to secure nature of correctional facilities, it is difficult to
audio / videotape group and individual sessions with offenders.
It may be possible for Clinical Supervisor to observe through
security monitors or other two-way mirrors.
Although time consuming, live observation is easier and more
widely used in corrections and criminal justice settings.
It is important to remember that
direct observation is part of the Clinical Supervision process
and NOT part of an administration evaluation process.
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Developmental Stages of Counselors
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Developmental Stages of Counselors
There are several important general principles about
counselor development, including:
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There is a beginning but not an end point for learning clinical skills; you can
never “know it all.”
Effective Clinical Supervision takes into account the individual learning styles
and personalities of the supervisees and fits the supervisory approach to
the developmental stage of each counselor.
There is a logical sequence to development, although it is not always
predictable or rigid; some counselors may have been in the field for years
but remain at an early stage of professional development, whereas others
may progress quickly through the stages.
The developmental level can be applied for different aspects of a
counselor’s overall competence (e.g., Level 2 mastery for individual
counseling and Level 1 for group counseling).
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Cultural and Contextual Factors
Culture shapes belief systems, particularly concerning issues
related to mental health and substance abuse, as well as the
manifestation of symptoms, relational styles and coping
patterns.
Cultural competence refers to the ability to honor and respect
the beliefs, language, interpersonal styles, and behavior of
individuals and families receiving services, as well as staff who
are providing such services.
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Cultural and Contextual Factors
“Cultural competence is a dynamic, ongoing,
developmental process that requires a commitment
and is achieved over time”.
(U.S. Department of Health and Human Services, 2003)
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Cultural and Contextual Factors
Becoming culturally competent and able to integrate other
contextual variables into supervision is a complex, long-term
process.
It is the clinical supervisor’s responsibility to help supervisee’s
build on the cultural competence skills they already possess as
well as to focus on their cultural competence deficits. It is
important to initiate discussion of issues of culture, race,
gender, sexual orientation and the like in supervision.
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Ethical Issues
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Ethical decision-making is a continuous, active process.
Ethical standards are not a cookbook. They tell you what to do, not always
how.
Each situation is unique. Therefore, it is imperative that all personnel learn
how to “think ethically” and how to make sound legal and ethical decisions.
The most complex ethical issues arise in the context of two ethical behaviors
that conflict; for instance, when a counselor wants to respect the privacy
and confidentiality of a client, but it is in the client’s best interest for the
counselor to contact someone else about his or her care.
Therapy is conducted by fallible beings; people make mistakes—hopefully,
minor ones.
Sometimes the answers to ethical and legal questions are elusive. Ask a
dozen people, and you’ll likely get twelve different points of view.
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Ethical Issues
Direct vs. Vicarious Liability
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Direct liability of the supervisor might include
dereliction of supervisory responsibility.
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Vicarious liability might include being held
liable for damages incurred as a result of
negligence in the supervision process.
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Ethical Issues
Dual Relationships and Boundary Issues
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Be aware of both of these at two levels: between Clinical
Supervisor and treatment staff AND treatment staff and client /
inmate.
• Former / future counselor
• Former / future AA/NA sponsor
• Former / future emotional relationship
• Former / future administrative
supervisor
• Former / future sexual relationship
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Ethical Issues
Informed Consent
 The key to protecting the counselor and/or supervisor
from legal concerns
The supervisor must inform the supervisee about:
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The process of supervision
The feedback and evaluation criteria
Any other expectations of supervision - the supervision
contract should clearly spell out these issues
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Ethical Issues
Confidentiality
“In supervision, regardless of whether there is a written or
verbal contract between the clinical supervisor and supervisee,
there is an implied contract and duty of care because of the
supervisor’s vicarious liability. Informed consent and concerns
for confidentiality should occur at three levels:
 client consent to treatment
 client consent to supervision of the case
 supervisee consent to supervision.”
(Bernard & Goodyear, 2004)
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Ethical Issues
Supervisor Ethics
In general, supervisors adhere to the same standards and ethics as substance abuse
counselors with regard to dual relationship and other boundary violations.
Supervisors will:
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Uphold the highest professional standards of the field.
Seek professional help (outside the work setting) when personal issues interfere with
their clinical and/or supervisory functioning.
Conduct themselves in a manner that models and sets an example for agency
mission, vision, philosophy, wellness, recovery, and consumer satisfaction.
Reinforce zero tolerance for interactions that are not professional, courteous, and
compassionate.
Treat supervisees, colleagues, peers, and clients with dignity, respect, and honesty.
Adhere to the standards and regulations of confidentiality as dictated by the field
and security of the institution. This applies to the supervisory as well as the
counseling relationship.
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Benefits of Clinical Supervision
Clinical supervision has a range of benefits for clinicians
and the organization:
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Availability of support for supervisees, and a forum to discuss clinical issues
Maintenance of clinical skills and quality practice
Promotion of standardized performance of core skills across the
organization and / or field
Improvement and / or attainment of complex clinical skills
Increased job satisfaction and self confidence
Improved communication amongst workers
Improved worker retention
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Benefits of Clinical Supervision
Clinical supervision can address a number of recognized
contributors to stress and burnout. For instance, clinical
supervision may help with issues such as:
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Stressful events. Clinical supervision may help the supervisee to develop
coping strategies
Role ambiguity. Clinical supervision may help to clarify the roles and
responsibilities of the job
Career development. Clinical supervision can facilitate career progression
by helping supervisees to enhance clinical skills and experience and by
providing (in some cases) the required credentials for registration with
professional bodies
Skill use. Skill variety, task identity, task significance, autonomy and
feedback are recognized contributors to job satisfaction, which in turn can
impact on worker wellbeing. Clinical supervision can help to expand
supervisees’ repertoire of clinical and interpersonal skills.
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Benefits of Clinical Supervision
REMEMBER
Every clinician, regardless of level of skill and experience,
needs and has a right to clinical supervision.
This is difficult work – take care of yourself if you want to
continue doing it effectively and with compassion.
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References
Center for Substance Abuse Treatment. Clinical Supervision and Professional
Development of the Substance Abuse Counselor. Treatment Improvement Protocol
(TIP) Series 52. DHHS Publication No. (SMA) 09-4435. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2009.
Center for Substance Abuse Treatment. Competencies for Substance Abuse Treatment
Clinical Supervisors. Technical Assistance Publication (TAP) Series 21-A. DHHS
Publication No. (SMA) 08-4243. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2007; reprinted 2008.
Neumann, D.A. and Gamble, S.J. 2009. Issues in the professional development of
psychotherapists: Countertransference, and vicarious traumatization in the new trauma
therapist. Pyschotherapy, 32 (2), 341-347.
http://community.nicic.gov/blogs/mentalhealth/archive/2011/03/11/vicarioustraumatization-a-guide-to-recognizing-responding-to-and-preventing-a-seriousconsequence-of-providing-mental-health-care-in-jails-prisons-and-communitycorrections.aspx
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