Clinical Supervision

Introduction

Supervision is used in counselling, psychotherapy, and other mental health disciplines as well as many other professions engaged in working with people. It consists of the practitioner meeting regularly with another professional, not necessarily more senior, but normally with training in the skills of supervision, to discuss casework and other professional issues in a structured way. This is often known as clinical or counselling supervision or consultation. The purpose is to assist the practitioner to learn from his or her experience and progress in expertise, as well as to ensure good service to the client or patient.

(Wikipedia, the free Encyclopedia, 2008)

Model of Clinical Supervision Explained in Brief

Clinical supervision is the construction of individualized learning plans for supervisees working with clients. The systematic manner in which supervision is applied is called a "model." Both the Standards for Supervision (1990) and the Curriculum Guide for Counseling Supervision (Borders et al., 1991) identify knowledge of models as fundamental to ethical practice.

Supervision routines, beliefs, and practices began emerging as soon as therapists wished to train others (Leddick & Bernard, 1980). The focus of early training, however, was on the efficacy of the particular theory (e.g. behavioral, psychodynamic, or client-centered therapy). Supervision norms were typically conveyed indirectly during the rituals of an apprenticeship. As supervision became more purposeful, three types of models emerged. These were: (1) developmental models, (2) integrated models, and (3) orientation-specific models.

Developemental Models

Underlying developmental models of supervision is the notion that we each are continuously growing, in fits and starts, in growth spurts and patterns. In combining our experience and hereditary predispositions we develop strengths and growth areas. The object is to maximize and identify growth needed for the future. Thus, it is typical to be continuously identifying new areas of growth in a life-long learning process. Worthington (1987) reviewed developmental supervision models and noted patterns. Studies revealed the behavior of supervisors changed as supervisees gained experience, and the supervisory relationship also changed. There appeared to be a scientific basis for developmental trends and patterns in supervision. Stoltenberg and Delworth (1987) described a developmental model with three levels of supervisees: beginning, intermediate, and advanced. Within each level the authors noted a trend to begin in a rigid, shallow, imitative way and move toward more competence, self-assurance, and self-reliance for each level. Particular attention is paid to (1) self-and-other awareness, (2) motivation, and (3) autonomy. For example, typical development in beginning supervisees would find them relatively dependent on the supervisor to diagnose clients and establish plans for therapy. Intermediate supervisees would depend on supervisors for an understanding of difficult clients, but would chafe at suggestions about others. Resistance, avoidance, or conflict is typical of this stage, because supervisee self-concept is easily threatened. Advanced supervisees function independently, seek consultation when appropriate, and feel responsible for their correct and incorrect decisions.

Once you understand that these levels each include three processes (awareness, motivation, autonomy), Stoltenberg and Delworth (1987) then highlight content of eight growth areas for each supervisee. The eight areas are: intervention, skills competence, assessment techniques, interpersonal assessment, client conceptualization, individual differences, theoretical orientation, treatment goals and plans, and professional ethics. Helping supervisees identify their own strengths and growth areas enables them to be responsible for their life-long development as both therapists and supervisors.

Intergrated Models

Because many therapists view themselves as "eclectic," integrating several theories into a consistent practice, some models of supervision were designed to be employed with multiple therapeutic orientations. Bernard's (Bernard & Goodyear, 1992) Discrimination Model purports to be "a-theoretical." It combines an attention to three supervisory roles with three areas of focus. Supervisors might take on a role of "teacher" when they directly lecture, instruct, and inform the supervisee. Supervisors may act as counselors when they assist supervisees in noticing their own "blind spots" or the manner in which they are unconsciously "hooked" by a client's issue. When supervisors relate as colleagues during co-therapy they might act in a "consultant" role. Each of the three roles is task-specific for the purpose of identifying issues in supervision. Supervisors must be sensitive toward an unethical reliance on dual relationships. For example, the purpose of adopting a "counselor" role in supervision is the identification of unresolved issues clouding a therapeutic relationship. If these issues require ongoing counseling, supervisees should pursue that work with their own therapists. The Discrimination Model also highlights three areas of focus for skill building: process, conceptualization, and personalization. "Process" issues examine how communication is conveyed. For example, is the supervisee reflecting the client's emotion, did the supervisee reframe the situation, could the use of paradox help the client be less resistant? Conceptualization issues include how well supervisees can explain their application of a specific theory to a particular case--how well they see the big picture--as well as what reasons supervisees may have for what to do next. Personalization issues pertain to counselors' use of their persons in therapy, in order that all involved are nondefensively present in the relationship. For example, my usual body language might be intimidating to some clients, or you might not notice your client is physically attracted to you.

The Discrimination Model is primarily a training model. It assumes each of us now have habits of attending to some roles and issues mentioned above. When you identify your customary practice, you can then remind yourself of the other two categories. In this way, you choose interventions geared to the needs of the supervisee instead of your own preferences and learning style.

Orientation-Specific Models

Counselors who adopt a particular brand of therapy (e.g. Adlerian, solution-focused, behavioral, etc.) oftentimes believe that the best "supervision" is analysis of practice for true adherence to the therapy. The situation is analogous to the sports enthusiast who believes the best future coach would be a person who excelled in the same sport at the high school, college, and professional levels. Ekstein and Wallerstein (cited in Leddick & Bernard, 1980) described psychoanalytic supervision as occurring in stages. During the opening stages the supervisee and supervisor eye each other for signs of expertise and weakness. This leads to each person attributing a degree of influence or authority to the other. The mid-stage is characterized by conflict, defensiveness, avoiding, or attacking. Resolution leads to a "working" stage for supervision. The last stage is characterized by a more silent supervisor encouraging supervisees in their tendency toward independence. Behavioral supervision views client problems as learning problems; therefore it requires two skills: 1) identification of the problem, and (2) selection of the appropriate learning technique (Leddick & Bernard, 1980). Supervisees can participate as co-therapists to maximize modeling and increase the proximity of reinforcement. Supervisees also can engage in behavioral rehearsal prior to working with clients.

Carl Rogers (cited in Leddick & Bernard, 1980) outlined a program of graduated experiences for supervision in client-centered therapy. Group therapy and a practicum was the core of these experiences. The most important aspect of supervision was modeling of the necessary and sufficient conditions of empathy, genuineness, and unconditional positive regard.

Systemic therapists (McDaniel, Weber, & McKeever, 1983) argue that supervision should be therapy-based and theoretically consistent. Therefore, if counseling is structural, supervision should provide clear boundaries between supervisor and therapist. Strategic supervisors could first manipulate supervisees to change their behavior, then once behavior is altered, initiate discussions aimed at supervisee insight.

Bernard and Goodyear (1992) summarized advantages and disadvantages of psychotherapy-based supervision models. When the supervisee and supervisor share the same orientation, modeling is maximized as the supervisor teaches--and theory is more integrated into training. When orientations clash, conflict or parallel process issues may predominate.

Summary

Are the major models of supervision mutually exclusive, or do they share common ground? Models attend systematically to: a safe supervisory relationship, task-directed structure, methods addressing a variety of learning styles, multiple supervisory roles, and communication skills enhancing listening, analyzing, and elaboration. As with any model, your own personal model of supervision will continue to grow, change, and transform as you gain experience and insight.

Effective Supervision

By Meir Stolear (2008)
  1. Effective supervision can best be offered in a context in which supervisors are aware of professional bodies' and institutions' requirements.
  2. Supervisors and supervisees work together towards a good outcome that will improve the service to the client and improve the supervisees' professional development.
  3. Supervisors and supervisees frequently give each other constructive criticism and feedback in an open and respectful manner.
  4. Supervision is best structured, where regular timetables for meetings are agreed. The content of supervision meetings to be agreed and learning objectives determined at the beginning of the supervisory relationship. Supervision contracts can be useful tools, in which detail regarding frequency, duration and content of supervision; appraisal and assessment; learning objectives and any specific requirements, is included.
  5. Good supervision best covers the following: clinical management; teaching and research; management and administration; pastoral care; interpersonal skills; personal development and reflection.
  6. The quality of the supervisory relationship will strongly affect the effectiveness of the supervision process (i.e. there is more to gain from a supervision session where the supervisor and the supervisee have developed a good professional alliance).
  7. Good training for supervisors needs to include some of the following: understanding teaching learning processes; assessment skills; counselling skills; appraisal skills; unbiased feedback; careers advice skills and interpersonal skills.

Summary: supervisors and supervisees can work well together if they understand and agree on the following:

  1. Helpful supervisory behaviour includes giving direct guidance on clinical work, linking theory to practice, engaging in joint problem-solving tasks, offering feedback and reassurance, and providing role models.
  2. Ineffective supervisory behaviour will include the following: rigidity; low empathy; failure to offer support; failure to deal with supervisees' concerns; not teaching LFT; being indirect, intolerant and emphasising the negative aspects of the practice being evaluated.
  3. In addition to supervisory skills, effective supervisors need to have good interpersonal skills, good teaching skills and be clinically competent.

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