Clinical Supervision: Models, Role, Legal & Ethical, Cultural Competency, & Transference

Developmental models

We will look at clinical mental health supervision from the point of view of four different models.

The first model we will outline is a relational model in which the relationship between the clinical supervisor and the supervisee are explored related to this supervisee’s developmental stage.

The second model of clinical supervision that we will outline is the six-part mode of Observation, Planning, Teaching, Individual Meetings, Group Training, and Review.

The third models are the type of supervisor observation i.e. video and the behind the mirror.

The fourth model of clinical supervision to be outlined are what I termed "problematic models" sense when these models are used they can create problematic or non efficient/effective communication. These brief examinations or explorations will be followed by more detailed examples of how the developmental model can be applied in actual supervision situations.

So let’s outline the four developmental model of clinical mental health supervision Relational, Six-Part, Observation, and Problematic.

Practitioner's Stage - Relational Developmental Model

Clinical supervision under this model is ‘consultation with a more seasoned practitioner in the field in order to draw on their wisdom and expertise. This model has a focus on the developmental and educative functions and clarifies the different stages that practitioners go through in their professional development– the novice worker, the advanced beginner, competent worker, very experienced worker to expert. This model is used when there is respect for the supervisors’ skill base and ability to impart information for the purposes of learning.

- WA Department of Health. Clinical Supervision Framework for WA Mental Health Services and Clinicians. Department of Health, July 2005, p1-12.

The Six-Part Model for Clinical Supervision

This six-part model includes Observation, Planing, Teaching, Individual Meetings, Group Training, and Review. The six-parts have been adopted State wide in Idaho as the model to be implemented by all provider agencies which provide clinical mental health services on behalf of the State of Idaho through contracts with the Department of Health and Welfare, monitored by Business Psychology Associates (BPA). Clinical Supervision as defined by this model includes:

1) Observing counselors in their work. Observation can be "in person", by video or audio for review by the clinical supervisor. Observations should be recorded on an Observation Sheet or Criteria Sheet.
2) Creating the Professional Development Plan: Professional Development Plans are created for each counselor based on needs indicated from the rubrics, rating forms or from an observation by the clinical supervisor.
3) Teaching, training and mentoring. These activities are needed to assist counselors to improve clinical performance. These activities may be 1:1, group supervision or training/mentoring provided by the clinical supervisor. These activities are reported on Clinical Supervision Progress Notes form.
4) Individual Clinical Supervision Meetings. Each counselor should have a regularly scheduled time for clinical supervision. While the amount of time needed on a weekly or monthly basis may vary depending on the experience and skill of each counselor, each should have clinical supervision on a scheduled basis. Supervision meetings are documented and a copy of the supervisor's summary of that meeting is provided to the counselor.
5) Group Supervision/Training. Group supervision is utilized when there is a common need among counselors which can be addressed in a group meeting. This is a time saving measure and can also be an opportunity for counselors to share information and learning.
6) Reviewing and updating Professional Development Plans: Professional Development Plans must be reviewed at least every three months at which time the plan will either be updated or continued with appropriate supportive documentation. Updating the plan will include selecting new goals with the counselor and agreeing on activities to achieve those goals
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Each of these activities is to be documented on the Clinical Supervision Progress Notes. Professional Development plans are to be created with the counselor and reviewed/updated at least quarterly; more often as needed.

- Porter, John. The "How To" Manual For Clinical Supervision in IDAHO. Idaho Department of Health & Welfare, April 2011, p1-58.

Video and Behind the Mirror Supervision Models

This section will discuss two models of supervision. The two models we will discuss are the video supervision model and the live or "behind the mirror" supervision model. Regarding supervision behind the mirror, we will also discuss group training, sharing information with clients, protecting the supervisee, and gender issues in supervision.

Choosing a Training Model

Supervisors may choose what kind of group they want for a training atmosphere. There are teaching approaches in which the training group is reflective and no one is responsible for failure. This approach is peer supervision. There are also those who believe that training should involve cotherapy, with the supervisor being in the room with the supervisee rather than behind the mirror. Others believe that because ultimately the supervisee must face a client alone, why not begin doing that from the start? What other training methods have you tried? What do you currently believe is the most effective method for supervision training?

Video Supervision Model

Video Supervision vs. Describing
One of the obvious benefits of video supervision is that it allows the supervisor to see the supervisee and client interacting together after the session is over. The benefits of video supervision are that not only is the dialogue and tone of voice preserved, but the body movements and shifting positions of client and supervisee are observable and available for future and perhaps repeated examination. However, I have found that supervisees often prefer to describe an interview they conducted rather than present a videotape of it. The reason, I have found many supervisees prefer describing an interview is, they feel their inadequacies are exposed and on a video recording. Think of a supervisee you are currently with which you are currently working. If you are currently not doing so, would your supervisee be open to videotaping sessions with his or her clients? You might discuss with your supervisee hesitations he or she would have regarding videotaping sessions.

Introduction after the fact
I have found that if I do not introduce the idea of videotaping in the initial training session with the supervisee, they tend to be more uncomfortable with the idea. However, in that first initial session, where roles are outlined, if videotaping is mentioned at that time they accept it as part of the standard process.

Limitations
As valuable as video technology is for clinical supervision, there are, nevertheless, limitations. The supervisor examining a videotaped interview lacks the opportunity to learn how the client would respond to a new technique or intervention. The supervisor cannot, of course, influence past actions. This brings us to an advantage of the live supervision model.

The Model of Supervision Behind the Mirror

Reflection of Therapy Focus
I have found that the behavior of the supervisor towards the supervisees behind the mirror may parallel what happens in the therapy room. For example, if the supervisor focuses on the supervisees’ feelings, the supervisees will then be more likely to explore the feelings of clients. In contrast, if the supervisor treats the supervisees like equals or "pals", the supervisees may find it difficult to be skilled in therapy sessions with clients, whom they are consequently also treating as equals or pals.

One example of this would be if the supervisee is trying to help parents be firm with a violent child. For this to occur, the supervisor must first take charge as the expert behind the mirror. By "taking charge", I simply mean that the supervisor needs to know his or her therapeutic stance when training supervisees so that the supervisee may become an expert in helping clients. This is, of course, necessary even in training programs where there is no actual mirror. Do you agree that behavior in a therapy session may be a reflection of what has happened behind the mirror?

Group Training Supervision Model

Rules for Behavior
When supervisees are first brought together, it may be helpful if the supervisor briefly discusses the rules for behavior behind the mirror. One rule may be that supervisees not comment on each other’s interviews unless they have a positive suggestion to make. This is a grey area. One school of though is, insightful interpretations given from one supervisee to another supervisee may produce bad feeling between supervisees. What is wanted, of course, is a feeling of support within the supervisee group. For example, it is appropriate to say, "Perhaps that man’s behavior would change if you brought in his mother." It is not helpful to say, "Have you avoided bringing his mother in because you are afraid of the potential conflict?"

Ask yourself, if you have group supervisee meetings, how do you set the stage for a positive supportive attitude among supervisees? Also, remember that the role you play as supervisor may be reflected in the therapy stance the supervisee takes with his or her clients. Do you feel you were more of a "pal" with your last supervisee group? Did you notice your supervisees being more of a pal with their clients?

An Obvious Ethics Violation
Ethically, of course, a supervisor clearly needs to discourage supervisees from making jokes about, or ridiculing, the clients being observed behind the mirror. If a supervisor ignores such comments, supervisees may lose respect for the therapy approach. Have you found, like I, that if a supervisee makes a joke about a client they may be attempting to gain a sense of superiority for themselves? How do you respond to such inappropriate behavior?

Observation Prep
I find to avoid this from even happening I need to prep the observing supervisees by explaining that clients who are motivated to schedule a therapy session usually have deep personal issues. We all have deep personal issues, and just as your supervisees would not appreciate someone making light of their situations, neither would the client being observed. If your supervisees find in their self-talk that they are making light of the client's situation, or judging them, you can use this strategy as a tool for personal growth.

Competition Among Supervisees
Competition among supervisees needs to be directed towards the goal of seeing who can be the most kind and competent therapist. I feel it needs to be clear to the members of a training group that the supervisor is in charge. Ideas and suggestions go to the supervisor and from there to the supervisee being observed. That is, when a supervisee comes out of the therapy room needing a plan, supervisees should not express their ideas directly to him or her with ideas. Instead, the model I use is having the supervisor communicate directly with the supervisee.

I have found that one problem with the supervisor opening up the discussion so that everyone can contribute is that the comments and suggestions from the other supervisees can be disorganized, judgmental, and overwhelming. This may create a defeatist attitude for the supervisee who has conducted the session. Since clearly you can’t control ahead of time what is going to transpire in a group discussion, I find it most effective for comments to be made to the supervisor and then edited and communicated to the supervisee.

Model for Working with Experienced Supervisees
When a supervisee has had previous training in clinical therapy, it may be difficult for them to adjust their interpretations in a group setting. Part of the problem is that experienced therapists are asked to become students again, a position that is awkward for many of them. However, the presence of such a supervisee can encourage the supervisor to address practical aspects of therapy to educate beginners in the group; the supervisee, meanwhile, must be persuaded to learn the principles of brief therapy and to reserve judgment until after observing them in practice. As you read the following example of a supervisee I worked with, Mary, think of how you would deal with the difficulties presented.

Mary, age 51, had previously been in private practice in another state for a number of years, and joined me in a training program to meet our state licensure requirements. Due to her relative experience in private practice, Mary disagreed with me on ideology and interview techniques. However in contrast, Mary was placed as a beginner in conducting sessions with more than one person, since in private practice she only dealt with individuals and never with couples, family members, etc. How would you deal with a supervisee in this scenario?

Friendly versus Strict versus Reaction Models for Supervisors

Regarding therapy supervision, do you agree that supervision should be structured, focused, and educational in nature? This portion of the course will expand on methodology to do this. In addition, both the supervisor and supervisee are responsible for the content and structure, although the recommended structure of the supervision session is similar to a cognitive therapy session. I have found that during a typical weekly supervision session, which is usually 60 minutes in length, at least one client that your supervisee is working with should be discussed in depth.

How do you acknowledge your limitations as a supervisor? Here is an exercise to think about your possible limitations as a supervisor regarding three problematic approaches. These three problematic approaches are the Friendly Supervisor, the Strict Supervisor, and the Reaction Supervisor. As I clarify each of these, ask yourself which one of the three categories, if any, do you fall into? To clarify, the Friendly Supervisor is amiable and easygoing, but as a consequence, may not provide substantial feedback to the supervisee. Do you find yourself having the need to be liked by your supervisee? Secondly, the Strict Supervisor is rigid and believes in "my way or the highway". Do you feel you may be too authoritarian with your supervisee? Finally, the Reaction Supervisor focuses too much on the supervisee’s personal feelings about his or her client. Do you feel you are too much in a therapy role with your supervisee?

QUESTION 1
What are the three problematic approaches?
To select and enter your answer go to Test.