06 September 2009

ANALYZING CLINICAL SUPERVISION PRINCIPLES, TECHNIQUES, AND METHODS

Introduction

Clinical supervision is increasingly seen as a critical component in counselor development across the professional life span; beyond academic training programs and initial counseling positions. Supervisors are inherently and now more directly and openly charged with the responsibility of serving as gatekeepers for the counseling profession. State regulation boards are shifting more and more responsibility to supervisors who must attest to their supervisees’ competencies, and rightfully so. Supervisors’ ultimate responsibility is to clients, and therefore they must ensure that counselors in training are assessing clients’ needs and their counseling progress.

Supervisors also carry a responsibility for the supervisees’ learning and professional identity. Supervisors and their supervises are expected to set measurable goals for the counselor about counseling and case conceptualization that can be presented as summative evaluation to personnel affiliated with university training programs, licensure boards, certification bodies and agency or school system administrators.

Supervision has evolved into a separate process with its own, developing conceptual framework and methodology. However, traditionally there has been a lack of formal training for clinical supervisors, a fact that has been described ass the mental health profession’s “dirty little secret” (Hoffman 23). Historically, the context of clinical supervision was tied to counseling theory. As a result, most supervisors were oriented to the approaches and techniques that evolved from their own or their supervisors’ therapeutic approaches (Boyd 82). Supervision routines, beliefs and practices began emerging as soon as therapists wished to train others.

The focus of the 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 through the rituals of an apprenticeship” (Liddick 1). Currently, supervisor training is considered very important, and a number of authors have presented integrative approaches to supervision developed independently from a specific psychotherapy. The purpose of this article is to explore the import, meaning and application of these emerging clinical supervision principles, techniques and methods for both individual and group counseling constructs.


The Purpose and Importance of Clinical Supervision

Increased development and professionalism in the counseling field is placing greater focus on assessment and measurement of clinical work at all levels. As the field of clinical supervision develops, there is expansion of conceptual models and methodology of practicing supervision. Recent Congressional testimony by the Deputy Director for the US Demand Reduction Office of National Drug Control Policy, specific to substance abuse counseling demands assessment and measurement protocols. “Many health professionals lack the training to identify the symptoms of substance abuse…. Many competent community based treatment counselors lack professional certification” (Schecter 1). Consequently the federal government is working to improve states’ credentialing systems that assess and measure individual treatment providers while they earn professional counseling credentials. The role of the supervisor as gatekeeper is critical in this process.

The critical assessment and measurement of clinical work needed today by the supervisor is true first and foremost at the client level because there is more focus on diagnostic criteria to assess the client and more emphasis on developing specific treatment outcomes and goals, often accompanied by time frames. Insurance companies and managed care panels are requiring diagnoses documented by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) along with specific treatment plans and evaluations.

The second level of need in assessment and measurement is at the counselor level. Clinical supervisors in academic training programs and in the field are required to provide these evaluations. Because supervisors’ ultimate responsibility is to clients, they must ensure that counselors in training are accurately assessing clients’ needs and their counseling progress. As discussed in the introduction to this analysis, regulatory agencies are requiring supervisors to measure and evaluate the competencies of their counselors as a benchmark of their competency.

Lastly, the clinical supervisors’ own competencies are at stake in this issue. The Association for Counselor Education and Supervision’s (ACES) Supervision Task Force on the Establishment of Standards for Credentialing Clinical Supervisors in 1997 issued draft recommendations, which in addition to the Standards for Counseling Supervisors and the Ethical Guidelines for Counseling Supervisors provides the direction and impetus to hold supervisors to a certain level of competency, themselves (Bernard & Goodyear 127; ACES Journal of Counseling and Development 69; ACES Spectrum 53). According to David Powell’s benchmark work, Clinical Supervision in Alcohol and Drug Abuse Counseling, “the consequences of nonexistent or inadequate preparation of supervisors were readily observable in alcohol and drug abuse treatment facilities in the 1970s and beyond. There have been a number of deleterious effects on counselors and supervisors alike” as a result of this lack of competency (Powell xv).

With the relationship between supervisor and supervisee being viewed as the key to effective clinical supervision and the supervisor’s behavior and efficacy of supervision as being one of the most important characteristics of the process, there was until the 1990s a considerable lack of evaluation of those characteristics in research literature (Ellis 241; Rich 138). While few studies traditionally made attempts to identify “good” clinical supervisor characteristics, per se that have produced a definitive answer, they have begun to provide insight into the complex issues inherent in the process of competent and effective clinical supervision.

Powell identifies several traits that are required for an effective clinical supervisor that quickly and astutely lead the reader toward the weakest link—the lack of focus on an effective supervisory model. “When it came to supervisory weaknesses, there was agreement on both sides (supervisors and supervisees) that the most significant shortcoming was in exercising managerial authority in decision making and giving constructive feedback” (Powell 35).

Clinical supervision is believed to be capable of minimizing counselors’ feelings of discouragement, emotional exhaustion and burnout (Firth 278; Willkin 33; Faugier 29). However, expectations of supervisees in clinical counseling settings go beyond emotional support, e.g. “models of therapy and supervision fall on a continuum between those that foster a process of insight and understanding (bringing about attitudinal change) and those that emphasize didactic skill training (bringing about behavioral change). This is the fundamental polarity that shapes the practice of counseling and supervision” (Powell 46).

Therefore, regardless of clinical specialty, client group or grade of the clinician, clinical supervision is thought to provide a forum for disseminating good practice, and providing a process of experiences that lead to the acquisition and development of appropriate clinical skills (Bishop 36). Shifting the focus to supervisor competencies in the late 1980s and throughout the 1990s led to the emergence of models or methods of supervision and techniques to be used in implementing effective clinical supervision models which will be discussed in detail in this analysis.


Models for Clinical Supervision

Counseling and supervision begin with a plan for where to go, followed by a method, or a path for getting there” (Powell 45). The clinical supervision model of counselors created by clinical supervisory theorist David Powell, whose seminal works on addiction supervision since the mid-1970s has evolved today to a blending of aspects of several supervision theories is the focus of our analysis. Because Powell’s work builds upon the evolutionary models of clinical supervision that have developed and matured, an overview of these models which are supportive to Powell’s work is in order.

According to the US Department of Health, clinical supervision is “a formal process of formal support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations” (USDH 11). G.M Hart’s seminal work in 1982 took a broad perspective in describing supervision as “an ongoing educational process in which one person in the role of supervisor helps another person in the role of supervisee acquire appropriate professional behavior through an examination of the supervisee’s professional activities” (Hart 12).

Models of supervision have emerged that are associated with leading schools of therapy. Most models of clinical counseling supervision have evolved from individual supervision within these leading schools. Counseling researcher George Liddick explains that as supervision became more purposeful with respect to clinical counseling, three types of models emerged; developmental, integrated and orientation-specific (Liddick 1). G.M. Hart took as broad and similar a perspective when he described three models based upon these leading schools.

With developmental supervision models, it is typical to be continuously identifying new goals for growth. For example, in what Hart terms the skills development model, the goal is to increase supervisees’ skills and conceptual understanding of clients. There is in this model a teaching type of relationship with a focus on the client followed by a focus on the supervisee’s approach to helping the client (37). A thematic analysis with implications for developmental supervision theory published in March 2000 analyzed the impact of such an approach through retrospective phenomenological interviews of four group counseling practicum participants.

The findings suggested that “the skills of members of supervision groups that include fellow novice counselors are more likely to be enhanced that the skills of members of groups that allow novices to interact only with experts” (Starling & Baker 170). These findings suggest that the teacher-novice model may not be completely effective as a sole approach to clinical supervision. Patterns, however, have been observed in research conducted on other developmental supervision models, indicating that as supervisees’ gained experience, behaviors of supervisors regarding their own supervisory efficacy improved (Worthington 206).

Hart also identified a personal growth model, with an identified goal to increase the insight and affective sensitivity of the supervisee. The relationship within this model is more like counseling with a focus on the supervisees’ personal feelings and thoughts about interpersonal relationships with clients (Hart 55). This model is what Powell refers to as the Psychodynamic Model, which was “for decades the cornerstone of the field, (and) is reemerging after having fallen out of favor a generation earlier” (Powell 85). The goal of this model in terms of clinical supervision is in capitalizing upon the dynamics of awareness to effect desired change and improvement. “For psychodynamically oriented supervisors, the primary objective of supervision is not to teach techniques.

In the Psychodynamic Model, the purpose is to refine the supervisees’ mode of listening and bring about the internalization of a particular attitude about therapy—one that entails a sensitivity to transference, counter-transference, drives and defense mechanisms"”(Powell 85). This model assumes that there are parallel dynamics that link the counselor and the patient and the clinical supervisor and the counselor. In this model, it follows that the ‘self’ is a major emotional force. Perhaps because of this characteristic, as well as problems such as Powell observes when these parallel processes “are played out in the supervisee’s desire to cure himself so as to achieve analytic identity, “the model is less embraced than measurable, skills-oriented approaches to supervision, particularly in the substance abuse arena (Powell 88).

The Skills integration model, as described by Hart, has as a goal for the supervisor to assist the supervisee in integrating acquired skills and personal awareness into effective relationships with clients (Hart 82). This denotes a collaborative relationship with a focus on the supervised client unit of interaction, followed by a focus on the supervisor-supervisee interaction. Also termed simply the “Skills Model” by Powell and others, this model highlights three foci for skills building: process, conceptualization and personalization.

As Powell notes, however, there are many variants to the Skills Model. “A corollary of the behavioral model of therapy that rose to predominance in the 1960s and 1970s, skills-oriented supervision has exerted a correspondingly large influence in its domain. It forms the basis of much work done in substance abuse counselor training, sex therapy supervision, family therapy training and numerous other disciplines” (Powell 96). Perhaps the most prevalent is the task-oriented skills model.

J.M. Bernard’s “Discrimination Model” approach created in 1979 depicts three supervisor roles; that of teacher, therapist and consultant, along with three basic foci process skills; counseling, personalization, and case analysis (Bernard 60-68). Designed to be employed with multiple therapeutic orientations, Bernard’s Discrimination Model is task specific in order to identify issues in supervision, as Liddick observes. “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 to colleagues during co-therapy they might act in a consultant role” (Liddick 2). In this model, as defined initially by D. E. Mead in 1990, the therapist supervisor “is not merely a technician who teachers certain discrete clinical skills that he or she has mastered.

On the contrary the expert must have a “clearly articulated model of counseling drawn from a number of sources and integrated into a consistent approach” (Powell 99). The inherent goal of this model is that the supervisee, however, resemble the supervisor. With the vision of a “computer model” or prototype of an expert system, the supervisor fashions a template that applies theory (whichever theory they use) to determine the information to be collected, the manner in which that information is to be processed and organized and how the information will be used to create treatment plans.

In noting the benefits of the task-oriented skills model, Powell observes that its strength is that it is able to guide across the board, based upon computer systems practicum, task requirements that all supervisors must perform. The task oriented skills model weaves modeling, programmed interventions and feedback into the supervisory program, and in all cases involves direct, live observation of the therapist, capitalizing on experiences and interventions. The question is whether this model is universally applicable. Powell thinks not. “The direct observation of therapy sessions that Mead requires is not employed by some other models of supervision…. Also, there are models (in particular the psychoanalytic) in which the content of training resists being broken down into discrete tasks” (Powell 100).

Researchers Stoltenberg and Delworth framed an integrated developmental model with three levels of supervisees, which Powell also refers to in his seminal work. These levels which may be described as beginning, intermediate and advanced show trends as supervisees move through each level from a beginning phase that is rigid, shallow and imitative to the advanced phase which is characterized by competency, self-assurance and self-reliance. These levels encompass three processes for the supervisee’s growth experience: awareness, motivation and autonomy.

Researchers then identified eight growth component areas for supervisees in this three-phased developmental framework which include intervention, skills competence, assessment techniques, interpersonal assessment, client conceptualization, individual differences, theoretical orientation, treatment goals and plans and professional ethics. The supervisor, then. who is helping supervisees identify their own strengths and growth areas within this construct enables the supervisees to be responsible for their life-long development as therapists” (Liddick 2)

Powell observes that Stoltenberg and Delworth’s model has merit, its applications to the substance abuse field require challenges that may not be present in other traditional clinical settings. “Stoltenberg and Delworth envision a relatively orderly, and by and large, planned sequence of development in the various domains, even if development does not necessarily occur at the same rate in all domains” (Powell 64). The lack of a structured learning environment or “graded” clinical responsibilities based upon supervisees’ skills may make the Stoltenberg-Delworth model a certain challenge for the substance abuse counseling supervisor. “Training takes place mainly on the job, and development occurs most rapidly in the areas where the counselor (out of necessity) gets the most practice. Under these conditions, it is impossible to predict a counselor’s developmental path with any precision” (Powell 64-65).

A “Systems Model” that surfaced in 1995 describes the clinical supervision tasks of helping the supervisee with counseling skill, case conceptualization, professional role, emotional awareness, self evaluation and the supervision functions of monitoring and evaluation, advising and instructing, modeling, consulting, and supporting or sharing (Holloway 22-25). A four-stage process of supervision unveiled as well in 1995 delineated the clinical supervisor as teacher, guide, gatekeeper and finally, consultant (Taibbi 311-315). According to Powell, “the systems model of supervision is defined as the application of systems technology to the process of supervision” as a “disciplined way of analyzing as precisely as possible an existing situation by determining the nature of the elements which combine and relate to make the situation what it is, establishing the interrelationships among the elements and synthesizing a new whole to provide means of optimizing systems outcomes” (Powell 107).

In this model, it is the subsystems that are the foci, the interrelated components that are viewed organizationally as working to attain a specific objective. The clinical supervision model, for example, could be comparable to family systems theory, which views the network of relationships among family members as subsystems. As Powell explains, “By working with the counselor to keep this big picture always in view, the supervisor seeks to elicit the creative, innovative and problem-solving potentials of the counselor and supervisor” (Powell 108).

This model is not for the faint of will, or heart, however, as it incorporates complex and involved applications including but not limited to communication and learning theories, systems analysis techniques including synthesis and flow chart modeling. Powell observes, “It imports so much technology from outside the clinical professions than an attempt… to describe the functions of a counselor in systems terms—such as designing and pilot-testing a counseling prototype-—sounds more like the process of producing an airplane” (Powell 108). While acknowledging, however, that the results, when applied, are remarkable, Powell’s observation of the complexity of the system as applied to clinical supervision is worthy of note.

Powell’s Clinical Supervision Model and Techniques

In each of these descriptions of the supervision process, the primary focus is on devising a system that improves the competencies of the supervisee, not the supervisor. Powell offers a blended model that combines the best attributes of each of the models discussed thus far and frames the blended model for the alcohol and drug abuse field. This model is developmental in nature, and addresses descriptive dimensions of clinical supervision issues, including influence, therapeutic strategy, symbolic, structural, replicative, counselor in treatment, information gathering, jurisdiction, and relationship. The supervisor moves back and forth along these descriptive continua according to the counselor’s placement along the continua in his or her development (Powell 135).

The Powell model borrows significantly from the structural, or strategic model, with a skills-oriented approach, and insight-oriented approaches. While leaning toward a non-hierarchical relationship, “the type of relationship formed in counseling or supervision is contingent on setting variables, treatment approaches, and client factors” (Powell 133). In this model, Powell outlines issues specific to addictions counseling and supervision, arguing that clinical supervision is sorely needed in this arena. “At present, practitioners must glean material from a limited number of sources, none of them definitive” (Powell 117).

As to how Powell’s model applies specific to substance abuse counseling, there is a parallel with the therapeutic community under treatment. For example, substance abuse programs typically begin with strong directive approaches, and in the early stages of recovery a client is told what to do and when to do it. As the substance abuse client gains experience, power is conferred to the client and the program becomes less directive, less hierarchical, Powell explains, the counselor-supervisor relationship parallels this progress (133). In this sense, counselors adopting this form of substance abuse therapy for clients are supervised according to true adherence to therapy practices.

Powell’s blended model targets basic supervisory techniques that, while specific to the field of substance abuse counseling are consistent with and applicable to assumptions and principles of the model that can be applied overall in the arena of clinical supervision. What methods of observation, for example, would be employed using Powell’s model? “Live observation is recommended whenever possible,” Powell urges. “The choice of methods and techniques in any given situation will depend on the need for fidelity of information, the availability of technical equipment, the ability to intervene, the immediacy of the supervisory debriefings, and the counselor’s skill level” (Powell 150).

Powell specifies, however, that clear goals must be set to determine why, when and how live observation is to take place. Citing the use of videotaped sessions, Powell notes that one-hour of a videotaped session can provide hours of supervisory discussion, if it is utilized within the proper context. “The therapeutic tasks assigned and the videotapes recorded should be derived from the IDP. Whenever possible, both the supervisee and the supervisor should review tape segments for selection prior to the supervision session” (Powell 152).

As a more direct technique, Powell recommends cofacilitation as a live observation technique, preferable over one-way mirror or videotape viewing. Why? “First it allows a supervisor to get a true understanding of the counselor in action. Second, cofacilitation gives the supervisor an opportunity to model counseling techniques during an actual session, thus serving as a role model for both counselor and clients. Third, should a session become counter-therapeutic or destructive to the client, the supervisor can intervene for the wellbeing of the client” (Powell 154). Moreover, the bond that is forged in the spirit of teamwork between the supervisor and the supervisee has definitive advantages, building role, confidence and flexibility skills for both.

There are detriments to cofacilitation, however, which Powell cautions must be considered. It can cause performance anxiety for the supervisee, it is obtrusive to the client, and represents only one slice of a “fluid” dynamic between the counselor and client with which the supervisor makes his or her observations. Supervisors must curtail their tendencies to take control of counselor sessions. Cofacilitation is also time-consuming, with each hour of live observation requiring at least one more hour of processing, if the experience is to be beneficial for the supervisee. Still, Powell believes the advantages of this technique far outweigh the disadvantages. In a group setting, Powell cautions that the supervisor should sit within the group, while in the individual setting, the supervisor should sit alongside the counselor. “Sitting outside the circle undermines the human connection between the supervisor and the participants by giving the impression that the supervisor is conducting an inspection” (Powell 155).

Group supervision and peer supervision, as well as case presentations are also techniques discussed by Powell in the blended model approach. “The key to making peer supervision effective is to structure the training with clear, measurable learning objectives,” Powell explains. He recommends that it be done by counselors at level three efficacy, which in the blended model represents an adaptation of Stoltenberg and Delworth’s model that encompasses three processes for the supervisee’s growth experience: awareness, motivation and autonomy as they move from beginning to intermediate and advanced phases of development.

Powell notes that with beginning counselors who have skills deficiencies and a lack of confidence, “inexperienced overzealous staff may seek to impose philosophical conformity in the guise of professional standards” (Powell 160). A powerful alternative for less advanced supervisees might be the group supervision approach, combined with individual one-on-one supervision sessions or observations. “Group supervision differs from supervision on a one-on-one basis in the same way that group therapy differs from individual therapy,”

Powell explains. “Group supervision involves two or more individuals who see themselves bonded together with a common focus and goals and who are interdependent in pursuit of learning and goal attainment.” (Powell 161). In this scenario, the supervisor, as with a therapist in a group setting, “facilitates the development of knowledge and skills and addresses interpersonal dynamics of the supervisees” (Powell 161). In order to facilitate effective implementation of the blended model, Powell recommends a series of innovative measures the supervisor may employ that work in conjunction with the model, including a foundational questionnaire that helps identify the philosophical preferences of supervisees, solution rather than failure focused supervision, the employment of open-ended, effective questions that create clarity instead of anxiety for “incorrect” answers, the setting of realistic goals that focus on how they will be achieved rather than when, and in vivo supervision.

The latter involves didactic and experiential elements of supervision achieved with a rotation between live observation of the supervisor and/or supervisee in action; a group discussion of the therapy session “with the client observing (a unique concept), and a 15-minute debriefing between the therapist and the client” (Powell 211). Through these techniques, Powell’s blended model offers an original contribution to clinical supervision not only as it applies to substance abuse counseling, but to the overall the great number of issues related to the clinical supervision process that are similar across different types of counseling.

In conclusion, Powell’s seminal work reveals common ground between major models of clinical supervision before considered to be mutually exclusive of one another. Derived from the major models analyzed in this report, and drawn from a developmental approach to supervision, Powell has successfully synthesized a new, blended model that fills the gaps between clinical supervision model theories methods and practices, In summary, the Powell model provides a viable template for implementing the effective techniques of day-to-day clinical supervision.


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