Conversations Regarding Supervisee-Centred

SupervisionPam Santon MSW RSW

Registered Marriage and Family TherapistRegistered Sex Therapist

Approved Supervisor AAMFT

My Objectives for Our Conversation

• To underline the importance of supporting supervisee’s in their support of clients through competency-based supervisory practices

• To review basics of Supervisory processes• To emphasize the need for Reflective Practice in

promoting the change process of clients • To increase comfort with ‘Person of the Therapist’

methods of Supervision in promotion of the professional development of supervisees

• To allow reflection of supervisory practices

Positioning You in the ConversationReflective Exercise #1

• How many people in the room are currently supervisors?

Please take 5 minutes and talk to 3-4 of your neighbours about the following:

• How does your program currently provide supervision? Who gets supervision and when? Who supervises who? What is it like for supervisors? What is it like for supervisees?

• As you consider your current supervision system, what is working well? How do you know? And what do you think needs change? How do you know?

Positioning Myself in the Conversation

• My own experience of receiving supervision, or not receiving it

• Clinical Director-ASYR 1992-2008: from 4 staff to 4 teams

• Supervisor in private practice since 1996 including the supervision of:

- Individual therapists or a group of therapists working towards Clinical Membership or Approved Supervisor Status with AAMFT

- Social Workers in the Ministry of Long-term Care and a Family Health Team

- Peer Support Counsellors in the Ministries of Labour and Natural Resources

- Students in a 4th Year Practicum Course in Family Relations and Human Development

The Tricky Terrain of Supervision in

the Field of Addictions

Specific Challenges in the Work of Addiction• Clients presentation: Poly-addictions including

Process Addictions, Co-occurring Mental Health issues, Trauma histories

• Visitor and Complainant Status of many clients and frequent no shows

• Family Dynamics of client system and their feelings of powerlessness

• Difficulties of clients with labelling and managing feelings which often results in slow pacing of the work and frequent relapse

• Polarized Models of Interventions• Large caseloads and waiting lists• Marginalization of the clients and their issues; and,

therefore the field and those who work in it: under-serviced, underpaid

Supervising in the Addiction Field• High caseload numbers and long waiting lists to

manage• Staff presenting complicated client issues and the

isomorphic pattern of powerlessness across the levels of the system

• Sometimes less than satisfied, stressed-out staff experiencing compassion fatigue, vicarious trauma and/or burnout

• Responsibility for vacation and sick leave coverage• Own caseload to serve to manage• Managers, Executive Directors and Boards to

appeaseEtcetera

Why ‘Supervisee-Centred’ Supervision

Frontline Staff as the Backbone of the agency!

The Risk of Empathy “After all, it's our gift for empathy

that draws us to our work. And yet, empathy at full throttle--felt and projected 100 percent with our bodies, hearts, and minds--has its risks.”

Babette Rothschild UNDERSTANDING THE KEYS TO VICARIOUS TRAUMA

‘Boundaries Lost’The Burnout Syndrome

• physical and emotional exhaustion as clinicians develop negative self-concept, negative job attitudes, and loss of concern for clients (Pines & Maslach, 1978).

• physical symptoms like fatigue, gastrointestinal irritations, insomnia, and hypertension (Farber, 1990)

• emotional symptoms including despair (Kestnbaum, 1984), boredom and cynicism (Friedman, 1985), withdrawal, and depression (Jayaratne & Chess, 1983).

• interpersonal problems, both in the workplace as well as with family and friends (Kahill, 1988).

Risk Factors• Unrealistic therapeutic expectations• Allowing personal issues to interfere in

professional practice (loss of boundaries)• Working with clients with particularly severe

or traumatic issues• Working in a community agency• Being new to the field • Being male

THE PROTECTIVE FUNCTION

OF SUPERVISION

Supervisors as ‘Back Braces’‘Strengthening the Core Muscles’

Myths of Individual Coping,Realities of Organizational Policy

Kyle Killian 2007

“Stop blaming the victim for lack of life balance”- Agencies to take responsibility for burnout by:Better distribution of caseloads to ensure lower

numbers of trauma clients per counsellorReduced caseloads and more reflective supervisionBetter policies to give frontline staff an increased

sense of control, efficacy & supportClearly defined teams (Borrill 2000)Participation in political advocacy

Role of Supervisor’s in the Prevention of Burnout

Rosenberg, T. Pace M., PhD 2010• In-service training on burnout• Setting expectations about self-care• Limit-setting around client numbers and

administrative duties• Prioritizing supervision, peer meetings and • support groups• Modeling self-care, case consultation and self

awareness• Including person of the Therapist issues in

supervision including: unresolved FOO issues, therapist’s need to be liked, over-involvement & feeling personally responsible for client-change

General Functions of Supervision The Role of Supervision in Social Work

(An Irish Study 2010 Jeanne Marie Hughes MSW) • Prevent stress and burnout in a profession dedicated to paying attention to someone else’s needs (Hawkins and Shohet 2006)

• Contains or manages anxiety and helps to cope with the demands that the work entails (Brearer 1995)

• Supports reflective practice on the use of discretion and judgment (Gould and Baldwin 2004)

• Educates, supports and manages (Kadushin 1992, Morrison 2003)

• Teaches, guides, counsels and directs (Page/Wosket 1994)

• Facilitates learning, provides an opportunity to plan and evaluate work, supports workers and promotes good standards of practice and protection of the public (McGuiness 1993)

‘Great Supervisors’• Non-judgmental and accepting of the supervisee’s

inexperience and mistakes• Accessible and Available regularly for

conversations (weekly) (answer questions, offer advice and provide feedback)

• Collaborative as well as directive• Trusting of their abilities and potential• Trustworthy and respectful of their information and

learning process• Giving of their expertise and experience• Modeling of professional practices, boundaries and

conduct• Culturally sensitive and Informed

Great Supervisor’s Build Resiliency in Supervisees

• By building trusting, safe relationships• By being present and modeling positive

communication skills• By being open and receptive to mistakes in

themselves and others• By modeling self care• By being reflective and mindful in their

interactions with supervisees

Components of Quality Supervision

• Individual Supervision: 1.5 hours bi-weekly (.5 administration, 1.0 clinical)• Individual Training per learning Goals• Group/Team Supervision• Specific Training as a Team/Agency• Peer Consultation- Formal and Informal• Professional Consultation• Supervision of Supervision• Employee Assistance Program

According to the Literature

Addiction Counselling Competencies (98) The Knowledge, Skills, and Attitudes of Professional Practice, TAP (Technical Assistance Publication) 21 US Dept. of Health and Human Services, SA and MH Services Administration, Centre for Substance Abuse Treatment 2008

Clinical Supervision Handbook A Guide for Clinical Supervisors for Addiction and Mental Health, CAMH, 2008

Clinical Supervision and Professional Development of the Substance Abuse Counsellor TIP ( Treatment Improvement Protocol) 52, US Dept. of Health and Human Services, SA and MH Services Administration, Centre for Substance Abuse Treatment 2009

Competencies for Substance Abuse Treatment Clinical Supervisor TAP 21-A US Dept. of Health and Human Services, SA and MH Services Administration, Centre for Substance Abuse Treatment 2008

The ‘Yin and Yang’ of Supervision

Supervision 101:Roles, Stages, Power,

Relationship, Parallel Process, Reflective Practice

Structuring SupervisionThe Yin/Yang Continuum

(Jay Reeve- www.psychotherapynetworker.org)

Supervisory Practices

Technique- Based Process- Based______________________________________________- New to the field - Focus on clinical or position Experience- Crisis management - Parallel Process- Manualized treatment - Development of Anxiety producing own therapeutic style situations (ethical, SI/HI, policies etc)

Above all else, FLEXIBILITY and RESPONSIVENESS:

In Taoist philosophy, truth does not lie in one pole or the other, in yin or in yang. Instead, the task of the sage is to provide what is lacking for balance and integration..

When they think they know the answers People are difficult to guide When they know that they don't know People can find their own way

Tao Te Ching (S. Mitchell, trans.), Harper Perennial; 1991.

The Many Hats of the Supervisor

General

QuickTime™ and a decompressor

are needed to see this picture.

Idiosyncratic

Directive Collaborative

Isomorphism and Parallel Process in Supervision

• Origins in the psychoanalytic concepts of transference and counter transference

• Transference occurs when the counselor recreates the presenting problem and emotions of the therapeutic relationship within the supervisory relationship

• Counter-transference occurs when the supervisor responds to the counselor in the same manner that the counselor responds to the client.

• Thus, the supervisory interaction replays, or is parallel with, the counseling interaction.

Conversations about Parallel Process• Can increase self awareness and

professional growth• Easier for the more experienced counsellor

because of their confidence in their knowledge and methods of intervention

• Can cross the line into therapy so supervisee permission is always required

• Supervisor should always pay attention to how the therapeutic relationship and client issues are presented by the counselor in the supervisory session and use the awareness as an intervention in facilitating growth in the counselor, thereby helping the client

What Works in Therapy: Project MATCH and the Alliance

Babor, T.F., & DelBoca, F.K. (eds.) (2003). United Kingdom: Cambridge, 113.Treatment Matching in Alcoholism Treatment

• The largest study ever conducted on the treatment of problem drinking:

• Three different treatment approaches studied (CBT, 12 Three different treatment approaches studied (CBT, 12- -step, step, and Motivational Interviewing)

• Difference in outcome between approaches.. The client rating of the therapeutic alliance

was the best predictor of: Treatment participation; Drinking behavior during treatment; Drinking at 12- month follow up

The Clinical Responsibility of the Supervisor

Therefore…. Anything the supervisor can do to reinforce

the therapeutic alliance will improve outcome. Sound clinical supervision, including reflective practice on ‘use of self’ and the person of therapist, needs to be a priority for every clinical setting.

Supervision Chain of Impact

The Supervisory Relationship• The relationship is the key to successful

supervision (Pritchard 1995). • Trust is central to the supervisory

relationship. Supervision cannot proceed in a climate of mistrust. Supervisor and supervisee must work to establish a trusting climate

• Supervisor must be diligent to avoid using information learned in the supervisory process against the supervisee (Munson 2002)

Power in Supervision: Recommendations for Supervisors and Supervisees

Murphy, M. 2005• The results of this study highlight that positive

uses of power can enhance the supervisory relationship.

• “it is imperative for supervisors to model appropriate uses of power for supervisees, so that they will appropriately use power with their clients. - empowerment in the supervisory relationship isomorphically results with empowerment in the therapeutic relationship”

• Open Discussions of power includea) using the term Power in discussions b) talking about power at the first supervision

session, and c) revisiting power as a discussion topic throughout

the supervisory relationship.

Why Be Reflective?• To Improve the quality of services• To avoid clinical responses that can lead to

unintended and negative consequences in sessions

• To replenishes counsellor reserves.• To Avoid robotic practice, decisions,

interventions.• To builds confidence and creativity.• To Strengthen: practice…service…

advocacy…administration• To foster empowerment, thoughtfulness,

respect.

Objectives of Reflective SupervisionModelling Empowering Relationships

• Supervisor and clinician form a trusting relationship• Establish consistent, predictable meetings and times• Ask questions that encourage details about the

emerging relationship and the supervisee’s reactions• Listen, emotionally present, teach/guide,

nurture/support• To Integrate emotion and reason• To foster the reflective process to be internalized by

the supervisee• To explore the parallel process and to allow time for

personal reflection• To attend to how reactions to the content affect the

process

Use of Self Model ‘Use of Self’ and ‘Person of the Therapists’ is a process through which therapists and

counsellors learn how to use their personal emotional and cognitive reactions and knowledge of self in order to:

1) inform conceptualizations of their clients struggles

2) create a therapeutic relationship that is collaborative and conducive to corrective relating with the aim of overcoming difficulties and facilitating personal growth.

Examples of ‘Use of Self’ in Supervision

1) Feeling stuck around a separated couple and wanting them to reconcile.

2) Feeling powerless with a supervisee who wasn’t setting clear boundaries with a client

• Being triangulated in FOO because of cutoffs in own family between siblings

• Inaction on the part of the E.D. to establish a policy around domestic violence

3) Anger at a client for frequent calls between sessions.

4)Dislike of a client for crying repeatedly in sessions.

• Fear of client taking action on professional ethics

• Feeling powerless with emotional pain• Withdrawal as a protective move

How Personal Can Supervision/Training Get?

Aponte 20041. Supervisees present their personal histories and

information about their life circumstances2. Although supervisors may inquire about what they

believe is relevant, Supervisees are free to reveal only what they wish to reveal

3. Supervisees and fellow team/group members are bound by confidentiality for all personal information revealed in the context of supervision.

4. Supervisors and supervisees are not to assume a treatment contract (with all that implies) under the guise of supervision

5. Supervisees may pursue personal treatment outside the context of supervision, and Supervisors may assist in this pursuit as appropriate.

‘To Thy Own Self Be True’-

Building or Revisiting Your Philosophy of Supervision

Beginning with ‘The Self’ of the Supervisor:

Modelling Authenticity

Have a Supervisory Road Map: A Philosophy of Supervision

A template for conducting supervision sessions.

A roadmap of your principles, knowledge and behaviours as they relate to supervision.

Build a dynamic ‘Philosophy of Supervision’ that clarifies your values, insights and beliefs in this moment and review and update annually.

Components of a Philosophy of Supervision

• Influence• Isomorphism• Change and Components of Supervision• Developmental Stages of Supervision• Gender issues• Accountability• Ethical Issues• Self of the Supervisor

Using a ‘Collage’ to defineYour Philosophy of Supervision

“I suggest that (Supervisees) avoid reifying human predicaments into symptoms…. All of this is mostly a matter of cleaning out enough psychological "debris" so that supervisees can sit comfortably, listen carefully, and think creatively. When I supervise, I give example after example of interventions that challenge clients' suppositions and help them explore new terrain. Then I hope for the best. Perhaps Marsha Linehan, the inventor of Dialectical Behavior Therapy, put it best when she advised new students to stop trying to act like therapists: "If they would act like themselves, they would be better off. . . . All you are trying to be is simply one human being trying to help another human being. That's all this is." Unfortunately, the(diagnostic) category obscures that fact.”Jay Efran, Ph.D., Temple University.

Supervisee-Centred Supervision Robert Taibbi: Clinical Director and Supervisor for 30 years

www.psychotherapynetworker.org

“The administrative stuff plays second fiddle to your real job though: helping the supervisee--from scared beginners to confident (sometimes overconfident) pros to burned-out timeservers--figure out what they need and how to weave together their strengths, skills, and personalities into a unique and personal clinical style.

Obviously, you need good supervisory skills, but you must apply those skills in creative ways at different times with different staff because one size definitely doesn't fit all in this work.

It's the relationship between supervisor and supervisee (rather than a set of skills, per se) that's the key to helping him or her learn what it really means to be a therapist and practice therapy.”

Using a ‘Collage’ to defineYour Philosophy of Supervision

“I suggest that (Supervisees) avoid reifying human predicaments into symptoms…. All of this is mostly a matter of cleaning out enough psychological "debris" so that supervisees can sit comfortably, listen carefully, and think creatively. When I supervise, I give example after example of interventions that challenge clients' suppositions and help them explore new terrain. Then I hope for the best. Perhaps Marsha Linehan, the inventor of Dialectical Behavior Therapy, put it best when she advised new students to stop trying to act like therapists: "If they would act like themselves, they would be better off. . . . All you are trying to be is simply one human being trying to help another human being. That's all this is." Unfortunately, the(diagnostic) category obscures that fact.”Jay Efran, Ph.D., Temple University.

My Personal Supervision Philosophy

• Collaborative- power to as opposed to power-over• Accountable to the client system and the agency• Reflective in that the supervisee needs to be centred

and grounded in their ‘use of self’• Necessary- frontline staff as the backbone of the

service• Developing of the Unique Talents of the ‘professional

part’ of the clinician• Informed by client feedback and the literature• Empowering of ‘the Person’ of the Clinician• Strength-based- building on talents and abilities • Mistake Friendly- aware that we learn through trial

and error

Exercise #2‘The Person’ of the Supervisor

In groups of 3 or 4, identify the following:

a) The major models of therapy, counselling or change process that you value.

b) A life experience that you have had that informs your experience of supervision.

b) 2-3 Personal Strengths you bring to your Supervisory Role

c) 5- 8 adjectives that best describe your values in regard to your supervisory practices.

The Methods and Tools of the ‘Yang’

of Supervision

Methods and Tools of Reflective, ‘Use of Self’,

‘The Person of’ Supervision

CONTENT

• Learning Contract*• Feedback Forms*• Evaluation Tools*• Genogram* • Cultural Genogram*• Professional Genograms*

PROCESS

• Mindfulness • Self Supervision• Reflective Conversations• Supervision of Supervision• Outside Supervision, Consultation and Training

Mindfulness and Supervision Mindfulness is intentionally being aware of

what really is in the current moment Jon Kabat-Zinn

The aim of supervision of clinical work ought to be supervision of the therapist’s own self-supervision.

As Confucius said, Give a man a fish and you feed him for a day; teach him to fish and you feed him for a hundred years

(O’Hanlon & Wilk, 1987).

Benefits of Mindful PracticeMindfulness and Supervision

AAMFT Supervision Bulletin 2010

• Reduces anxiety and increases calm demeanor

• Increases ability to be present and in the moment

• Reduces internal ‘chatter’ and negative self talk

• Increases self reflection and boundary setting• Allows easier transitioning between clients or

supervisees• Increases clients/supervisee’s experience of

being heard, validated and responded to

Goal: to increase therapeutic presence

Regular practice of mindfulness meditationwith MFT supervisees resulted in significantimprovement of in-session skills- Increased patience- Increased ability to attend to the client’s

experience- Increased ability to attend to one’s own

experience- Reduced reactivity and judgment- Better handling of challenges

Methods of Mindfulness Meditation:Practices that bring the clinician’s awareness

fully into the present without judging or evaluating that experience

• Meditation• Body Awareness: Body Scan- what is

your body telling you • Body Movement: dance, walk• Journaling• Art

Observation Active Listening

Clarify Reception

Discover supervisee‘s point of view

Explain your point of view

Discuss the alternatives

Co-construct new ideas

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The Reflective Supervisory Conversation (Leonardo daVinci Institute, The Netherlands 2008)

Prompting Phrases for Reflecting Practice

• “I’m wondering…”• “Can we explore for a

moment…”• “What are your thoughts

on…”• “How would you

approach…”• “What are the

possibilities you see in…”

• “How will your strengths…”

• “Can you tell me (a little more) about…”

• “How would you describe…”

• “What would happen if you tried…”

• “How do you understand/Can you help me understand…”

• “If you viewed this from ________’s perspective, what would you see…”

• “What do you need from me today to feel supported…”

BASIC USE OF THE GENOGRAM

• Chronicle families and major elements of their histories over a minimum of three generations(McGoldrick&Gerson,1985)

• Provide graphic annals of families membership, characteristics, and interpersonal relationships

• Reflect the transmission of family patterns from generation to generation (Kuehl, 1995) and provide a provisional blueprint for change (Lieberman, 1979, p. 57).

Reflective Exercise #3 The Cultural Genogram

Constantine 2003

• In your small groups, discuss the demographic variables you use to identify yourself culturally including SES, race, ethnicity, religion, gender/sexual identity, education etc.

• What worldviews (e.g., values, assumptions, and biases) do you bring to supervision based on your cultural identities?

• What struggles and challenges have you faced working with supervisees who were from different cultures than your own?

Cultural Awareness Continuumin Supervision Cross,1989

• Cultural Destructiveness- superiority of dominant culture and inferiority of other cultures; active discrimination

• Cultural Incapacity- Separate but equal treatment- passive discrimination

• Cultural Blindness- Sees all cultures and people as alike and equal; discrimination by ignoring culture

• Cultural Openness (Sensitivity)- Basic understanding & appreciation of importance sociocultural factors in work with minority populations

• Cultural Competence- Capacity to work with more complex issues and cultural nuances

• Cultural Proficiency- Highest capacity for work with minority populations; a commitment to excellence and proactive effort

Culturally Responsive Supervision

• Inclusive of the multiple awareness of self and other

• Multi-cultural competence as a stated mutual goal of supervision

• Strong working alliance in supervisory dyad supports trust and respect vital for risk-taking, development of self-awareness and multicultural sensitivity

• Self awareness is a prerequisite for multi cultural competency (Richardson&Molinaro 1996)

Teaching Multicultural CompetenceEncourage - acceptance and respect for cultural differences in

supervisor/ therapist/client relationships- adaptation of supervisory/therapeutic approaches to fit

socio-cultural contexts - self-awareness regarding the impact of values,

attitudes, biases and cultural differences - acquisition of cultural knowledge and sensitivity- a multicultural experience in the world- provision of services to accommodate diversity in

culture and socioeconomic status- reflection on beliefs and behaviors related to age,

gender, ethnicity, power, religion/spirit uality, context, etc.

- Seek factual knowledge when faced with new cultural situations

• Develop an open and sensitive working alliance with your supervisee

• Practice Mindful awareness and teach it• Be aware that matching of supervisor and

supervisee personal characteristics does not seem to be crucial in the creation of meaningful relationships

• Recognize that the ability of the supervisor to discuss similarities and differences seems to be the critical dimension

The Professional GenogramMagnuson (2000)

• to examine influences of professional mentors, authors, and theorists.

• parallel the family genogram structure • feature a chronology of direct professional mentors,

influential theorists and philosophies above participant symbols

• lines can be added to illustrate relationships between the persons, philosophies, and entities that are symbolized

• provides a forum for examining assumptions that inform the person-of the-professional

Reflective Exercise #4

With 3-4 other participants discuss what methods of Reflective Clinical Supervisory practice you are currently using and find helpful.

What other method or tool will you try next week?