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Clinical SupervisionMatthew S. Rofofsky, LCSW
Director of Clinical and Counseling ServicesThe Hetrick‐Martin Institute
Adelphi University School of Social WorkGLSEN – Hudson Valley Chapter
NASW and NYS Society for Clinical Social Work ‐Mid‐Hudson Chapter
October 17, 2014
Our Mission & History
Damien Martin, PhD Emery Hetrick, EdD
• 1979 The Institute for the Protection of Lesbian and Gay Youth is founded in Greenwich Village by Dr. Emery Hetrick, a psychiatrist, and Dr. Damien Martin, a professor at New York University
• 1985 The Harvey Milk School is founded as a GED retrieval school with just over a dozen students from Hetrick‐Martin in collaboration with the New York City Board of Education
• 1992 Hetrick‐Martin and Harvey Milk move into their current location at Astor Place, which, for the first time anywhere, provides an environment specifically designed to support LGBTQ at‐risk youth
• 2003 The school becomes a four‐year, fully accredited NYC Department of Education high school, after a $3.2 million capital expansion
Workshop Objectives:
Gain theoretical and practical understanding of clinical supervision.Understand the impact of diversity on the supervisory relationship.Obtain different viewpoints on self‐disclosure, boundary violations, and ethics.Develop an understanding of the ramifications of transference and countertransference.
Agenda
Intro and HMI’s Model for Clinical SupervisionDefining Clinical Supervision The Nuts and Bolts Components of Clinical Supervision Model 10 Step Model Role of AnxietyApplied Skills Trauma‐Informed SupervisionQ&A
Parking LotOne thing you would like to learn or hear about today?
What is Clinical Supervision?While the relationship is similar in many ways to counseling or
psychotherapy it has a different structure and purpose.
The primary purpose of clinical supervision is to ensure the quality of client care while the trainee or supervisee is learning.
Supervisors must develop separate skills from those required for the practice of counseling or therapy.
History of Clinical Supervision“Tracing the Development of Clinical Supervision” by Janine Bernard based on
presentation at First International and Interdisciplinary Conference on Clinical Supervision, Amherst, NY – 2005.
There have been major developments over the last 25‐30 years.
Recent areas of growth have focused on codifying: Infrastructure of supervision (organizational matters, ethical and legal issues,
evaluation). Variables affecting the supervisory relationship (individual differences, relationship
process). Replication of supervision itself (models of supervision, modalities for conducting
supervision).
Components of a Clinical Supervision ModelPowell (1993)
Contextual Factors
Developmental Level
Descriptive Dimension(Practices)
Philosophical Foundation
What is the State of Clinical Supervision Today?
Common inconsistencies throughout the field of social work/mental health and substance use treatment regarding supervision:
• How clinical supervision is defined?• Whether or not clinical supervision is a priority?• Available resources for self‐care of clinical staff?• The proper assessment, diagnosis and service plan of clients?• The training needs of staff?
Thomas Durham, Ph.d. (2011)
Components of Clinical Supervision
Model of change Environmental factors Ethical and legal concerns Multicultural issues Developmental ability of supervisor and
supervisee Developmental stage of the supervisory
relationship Needs of the client
Model of ChangeProchaska’s transtheoretical approach helps supervisors conceptualize problems
in order to help supervisees select methods and techniques to utilize with clients.
Taken from work with addiction, Prochaska created a six‐stage model to describe the cycle of change that occurs with any problem/challenge:
Pre‐contemplation
Contemplation
Preparation
Action
Maintenance
Termination
Model of Change continued…Transtheoretical approach suggests: that clients engage in therapy or the
social work process at any point in the change cycle.
Practitioners therefore use different methods and techniques to work with clients, depending on where they are in the cycle.
Ex: some psychotherapies, like client‐centered or psychodynamic focus on understanding and insight (contemplation stage).
Ex: CBT and solution focused are more (action) focused.
Model of Change continued… Transtheoretical model frees both supervisor and supervisee to explore
different possibilities since it takes the pressure off the action phase of the work.
*Supervision skills used here are: conceptualization of problems, forming hypotheses and selecting intervention strategies.
Questions: What stage might a youth be in who is considering coming out or transitioning and how might you work with anxious supervisee with little experience around these questions?
Ethical and Legal Concerns
There are two main areas of ethical concern for clinical supervisors:1. The supervisory relationship2. The supervisee’s actions with clients
Clinical supervision can be seen as a 3 tiered relationship with a dual purpose to: 1. Promote the development of the supervisee.2. To monitor the quality of client care.
Contextual issues impacting supervisor’s difficulties when making ethical decision: setting, budget, staff capacity (caseload, etc), licensing rules and legal codes.
Ethical Issues in the Supervisory Relationship
Dual relationships: exist whenever a practitioner has an additional relationship of some kind outside of their primary professional relationship, in this case, as clinical supervisor.
Licensure supervision offered to a new employee as part of their employee contract and their administrator, who is also their “boss”, appointed clinical supervisor.
Peer/colleague who is assigned to another employee seeking licensure as the clinical consultant or clinical supervisor.
Supervising a former peer, friend or intimate partner. Developing a business relationship with a supervisee.
Sherry (1991) suggested three factors that can have great ethical impact: 1. The power differential.2. The therapy‐like quality of the relationship at times.3. The conflicting roles of the supervisor and supervisee (especially with re: to
performance evaluation).
What Can Supervisor Do To Avoid Ethical Misconduct?
1. Seek special training in supervision. Keep knowledge of supervision issues current. Read or attend workshops on a regular basis Join professional organizations that publish current information on ethics and
other content areas.
2. Avoid dual relationships whenever possible. Refer the supervisee to another supervisor if a dual relationship exists. If not
possible, the supervisor should seek personal supervision to maintain objectivity. Be aware of the supervision process becoming to much like therapy. Encourage
supervisee to process personal issues that specifically affect client care. Supervision is the “isomorph” (a near‐replication) of therapy.
Refer/encourage outside therapy to help supervisee keep personal issues separate from client care.
Avoiding Ethical Misconduct, continued…
3. Establish a network of consultants to help with ethical dilemmas.4. Utilize written consent.
Delineate roles, methods of evaluation, issues of confidentiality, areas of expertise and knowledge, availability, methods of feedback, and recourse available to the supervisee should problems arise.
5. Document supervisory activities by keeping a journal or log.
Multicultural Issues
Two important areas in which multicultural differences will play an important role in supervision: In building trust and the working alliance. Evaluation of the supervisee’s competency and ability.
Effective supervisors should consider that multicultural differences affect attitude toward, as well as interactions with supervisees.
It is the responsibility of the supervisor to prevent these biases from negatively affecting the supervisory relationship.
Ex: Variance in age, gender, sexual orientation, race, ethnicity, academic discipline/training between the supervisor and supervisee.
Developmental Level Of Both Supervisor and Supervisee:
Skills and Abilities
Beginning Supervisor
• Concerned with being an expert.• Tends to be structured.
Intermediate –level Supervisor
• Is comfortable with exploration in supervision.
Advanced Supervisor
• Confirmation of identity and role.
Supervisor’s Own Skill Level:
Supervisors face 4 primary issues as they progress through theirstages of development:
Competency vs. incompetence (concern about performance or role). Autonomy vs. dependency (struggle with need for independence). Identity vs. identity diffusion (clarity or confusion about their role). Self‐awareness vs. unawareness (awareness of issues unique to
supervision).
Watkins (1993)
Building a Comprehensive Model of SupervisionA 10‐Step Process
Step 1: Identify personal philosophy of changeStep 2: Identify goals for supervisionStep 3: Define supervision content areasStep 4: Identify expectations for superviseesStep 5: Assess developmental level of superviseeStep 6: Identify developmental level of supervisorStep 7: Identify style of supervisionStep 8: Identify environmental and contextual factorsStep 9: Identify stage of development of supervisory relationshipStep 10: Identify relationship skills, roles, methods, and techniques
necessary to help the supervisee grow and develop
Jane Campbell, Ph.D. (2000)
Step One: Identify Personal Philosophy Of Change That Guides Practice
In Social Work Practice – Proschaska and DiClemente offer model suggesting stages anyone moves through. This model is applicable across contexts. While most known for application in substance use/harm reduction approaches it is just as relevant to apply to desired changes in a relationship or even biting nails!
In Drug and Alcohol Recovery, this model is popular to help patients understand their pending journey or the journey they have made to the current point.
In psychotherapy (and when clinically appropriate), this model can be used to show clients who have been discouraged about their “failure” or lack of progress in some of their desired changes that progress has been made.
How To Implement Change Theory
Model can be used to show client where client was prior to coming to therapy –
sometimes at Precontemplation due to not having a direction at the start, at the Contemplation stage due to realizing that there is a problem, or at the Action stage due to wanting support on the action that they wish to embark upon.
Worker might reflect on their Actions and reflect on the achievements that they have made to graduate to Maintenance. Recognition can be offered for making it to the Contemplation stage and being self‐aware that they Relapsed.
Empowerment comes from helping the client to reflect on what did not work in the Maintenance stage and helping them to correct that when taking Action. Building resiliency should be stressed (including a support system and healthy coping mechanisms) is a very important task during the Action stage.
Step 2: Identify Goals For Supervision
Which competencies must an effective and ethical practitioner possess in a particular discipline and setting?
Important for supervisor to know where they are going in order to plan how to get there.
Make a list of competency areas required for the supervisee (knowledge, practice skills, personal comportment)
Clearly describe the content of each area Refer to requirements described for the state license Consider needs of setting and discipline
Step 3: Define Specific Content Areas for Supervision
Establishing ethics Assessment techniques Intervention strategies Group and individual skills Crisis intervention Conceptualization of client problems Record keeping Intake Procedures
Ex: if supervisee lacks experience in working with the LGBTQ population this is an area to prioritize.
Step 4: Identify Expectations For Supervisees In Each Content Area Depending On Developmental Level.
What are the expectations for supervisees at the beginning of their career versus those more experienced?
Example: Under the content area of ethics, post‐degree may expect the beginning
supervisee to already have a knowledge base of ethical guidelines for the supervisee’s discipline.
Application of these guidelines may however, become the hallmark of post‐degree supervision.
Example: At the advanced level, a supervisor can expect the supervisee to be more aware
of limits of professional expertise, be able to identify challenges in the work and be able to ask for assistance around these cases.
Reference: “Using Rubrics for Documentation of Clinical Work Supervision” (Hanna & Smith, 1998).
Step 5: Assess Developmental Level Of Supervisee
Knowledge of 1:1, group, family and/or child/adolescent counseling skills; communication and relationship skill
Conceptualization skills Assessment or diagnostic skills Knowledge/experience with different
methods of counseling Knowledge of a variety of
intervention techniques Written skills
Knowledge and understanding of systems and the interaction between the 1:1, family, environmental factors and presenting problem(s)
Awareness of the role of multicultural and contextual issues and ability to respond to those issues
Understanding of the role of developmental factors in client problems
Step 6: Identify The Developmental Level Of The Supervisor
Knowledge of the role and functions of clinical supervisors
Knowledge of the models, methods and techniques of clinical supervision
Ability to articulate a personal model and structure of supervision. Understand the importance of the supervisory relationship and be able to facilitate this relationship
Knowledge about the role of systems, cultural issues and environmental factors
Knowledge of legal and ethical issues unique to clinical supervision
Familiar with methods of evalution of supervisee’s competency and ability to apply them throughout supervision
Awareness of requirements and procedures for licensure or certification
Step 7: Identify Preferred Style Of Supervision
Factors that should be considered when selecting a preferred style of supervision:
Personality characteristics Leadership style Work values Learning style
Many models and tools exist to help supervisors examine style preferences.
Ex: Supervisor Emphasis Rating Form – Revised (SERF‐R)By Lanning & Freeman (1994)‐ looks at choice of supervisory style from aspects such as: professional behavior, use of process and conceptual skills, personalization (sharing of one’s personal beliefs and feelings).
Step 8: Identify Environmental and Contextual Factors That Influence Supervision
Availability of rooms Time Number of clients on caseload Budgeting Setting Populations served Licensing requirements
Brainstorming with peers and problem‐solving methods are recommended to address difficulties in the environment.
Effective Supervisors must be realistic about environmental factors in supervision and be cautious not to engage in patterns of negative thinking.
Step 9: Developmental Stage of the Supervisory Relationship
Research has shown that quality of the supervisory relationship is most crucial variable in clinical supervision.
Developmental process serves as a catalyst for the supervisee’s personal growth and professional development.
May contribute to the choice of method and techniques for supervision.
Step 10: Identify Relationship Skills, Roles, Methods and Techniques Necessary To Foster Growth In
Supervisee Relationship skills and roles speaks to the effective supervisory behaviors and
personal qualities and characteristics that engender a positive relationship (see handout).
Method of supervision generally refers to format for the supervisory process (Ex: 1:1, group, peer and team).
Methods may include: case consultation (most common in social work practice), written activities, in some fields of counseling perhaps audio and videotapes, and cotherapy.
Focus of supervision may move from specific interventions (times of crises perhaps) or immediately prior to a session with a client to conceptualization if meeting after said session.
Role Of Anxiety In The Supervisory Relationship
Anxiety is a natural response to supervision and may play a significant role in shaping the working alliance and quality of the relationship.
Supervisors need to consider its impact on the relationship and how to work with it.
Commonly referred to as performance anxiety
Bernard and Goodyear suggest two other categories: Approval Anxiety – desire to be seen as competent. Dominance Anxiety – supervisee’s response to the power and
authority of the supervisor.
Theoretical Interpretations of the Meaning of Anxiety
Karen Horney – a well‐known psychodynamic theorist is known for an interesting model that may be helpful in understanding the prevalence of anxiety.
Individuals take one of three positions in order to structure and handle anxiety: moving away, moving towards and moving against.
The reaction to “move toward” people may take the form of socially desired behavior such as compliance with others’ wishes, agreement, or in extreme forms, acting helpless.
The “moving away” reaction may take the form of acting distant or detached in order to avoid becoming hurt or abandoned.
The “moving against” reaction may be observed in aggressive, dominating behavior like using arguing, criticizing, and disagreeing as a means to gain control of their anxiety.
Family Systems Theory on Anxiety Responses In Supervisees:
Triangulation: drawing another person into a relationship to cope with anxiety.
Over‐functioning: acting overly responsible for another person.
Under‐functioning: acting helpless and inadequate.
Pursuit and Distancing: moving closer or moving from a person as a result of anxiety.
The Supervisory Relationship as a Multi‐Person System: Transference & Counter‐Transference
Clinicians and supervisors who view supervision from a relational perspective recognize supervisory (as well as therapeutic) action involves the co‐construction of new relationships.
Article: “Transference Enactments in Clinical Supervision” suggests that supervision: Increases supervisees’ understanding of latent content Promotes empathy Improves clinical skills Enhanced ego functioning Expands relational capacity
Explore with group: if you are LGBTQ identified but your supervisor is not, how might this play out in supervision? Between supervisee and clients?
Applied Skills When Addressing Anxiety and Transference Enactments in Clinical Supervision
Analyzing parallel process: denotes the fact that problems the supervisee is having with clients will be reflected in the relationship with the supervisor.
Transference and Counter‐transference: supervisor offers a “containing” experience for worker struggling with thoughts/feelings.
Moving from the general to the specific: especially useful for beginning supervisees – can be used in times when supervisee becomes legitimately frustrated with clients.
I‐focus questions: “What was it like for you when the client said that?” –Brings the material into the here and now.
Asking for and reflecting meaning Brainstorming and solution‐focused questions Scaling questions
Self‐Disclosure As Applied Supervisory Skill
Tyber (1997) discussed two types of self‐disclosure:
Self‐disclosure statements: Giving examples of similar problems from one’s own training “I know it was very difficult for me when my supervisor corrected me or gave me suggestions…”
Self‐involving statements:Self‐disclosing one’s feelings in the here and now “I am experiencing difficulty giving you feedback – what can I do? “How do you want to hear this from me?”
Trauma‐informed Supervision
Supervision framework focusing on vicarious trauma Creating a safe and supportive environment for supervisees Supervisor provides “container” for what supervisees are holding from
their work with clients Premium placed on self‐care
Conclusion“But at the end of the day, supervision was, is, and will be defined by the realization of our supervisees that they understand the
therapeutic process and themselves at least a tad better than when they entered
supervision, and our own realization that we have been players in the professional
development of another. It is as simple and as profound as this”
J. Campbell
