Guidelines, Maps and Competencies for Clinical Supervision in Health Service

Psychology

Jerry Buchanan, PhD, Janice Pazar, PhD

Leticia Flores, PhD, Roneferiti Fowler, PhD

with thanks to

Amy Farrell, MS

Introduction

Psychologists . . . have been given the privilege of being part of a self-regulated profession, and . . . along with that

privilege comes a responsibility to give back to the profession.

(Baillie, 2014)

• In addition to being a personal responsibility, giving back to the

profession also comes with benefits

• Staying connected to developments within the field

• Learning from trainees

• Enhancing one’s sense of being part of a broader professional

community

Introduction

• Supervision is foundational in the preparation of competent future psychologists

• Underlying assumptions for all supervision

– The supervisor is competent:

· As a professional psychologist

· As a clinical supervisor

• However, minimal attention has been given to defining, assessing, and evaluating supervisor competence

– It is often much easier to identify a lack of competence than it is to define what ‘good’ should look like

(APA, 2014; Bernard & Goodyear, 2014; Falender & Shafranske, 2013; Kitchener, 2000; Ronnestad et al., 1997)

Introduction• What is competence?

– The ability to perform one’s professional role within the standards of practice

– The ability to identify when one is not performing adequately

• Metacompetence

– The ability to know what one does not know and to self-monitor reflectively one’s ongoing performance

• Professional Negligence

– The failure of competence: practicing below a reasonable standard of care for supervision

– Is legally actionable

(APA, 2010; Falender & Shafranske, 2007; Falender & Shafranske, 2014; Hatcher & Lassiter, 2007; Saccuzzo, 2002)

Introduction• Psychology as a profession has adopted supervision as a

distinct professional competency

– This recognition has evolved in the context of an overall focus on competency-based education and training over the past decade

“To be a competent supervisor, an individual possesses and maintains knowledge, skills, and

values/attitudes that comprise the distinct professional competency of clinical supervision as well as general competence in the areas of clinical practice

supervised and in consideration of the cultural contexts.”

-APA, 2014

(APA, 2014; Fouad et al., 2009; Fouad & Gus, 2014; Kaslow et al., 2004)

Health Service Provider Domains of Supervision

• Domain A: Supervisor Competence

• Domain B: Diversity

• Domain C: Supervisory Relationship

• Domain D: Professionalism

• Domain E: Assessment/ Evaluation/ Feedback

• Domain F: Problems of Professional Competence

• Domain G: Ethical, Legal, and Regulatory Considerations

(APA, 2014)

Competence• Competency-based supervision requires supervisors to have

knowledge, skills, and values with respect to:

– Awareness of and attention to one’s interpersonal functioning and professionalism regarding individual and cultural diversity

– Knowledge, Relationships, Attitudes, Skills

• Supervision can occur in a variety of contexts, requiring various competencies:

– Supervision of service delivery by supervisees

– Administrative supervision

– Supervision of research activities conducted by supervisees

– Supervision of individuals related to disciplinary actions

(APA, 2014)

Supervision: Changes Over Time• 19th Century

– Supervision began supportive, reflective space for social workers

– Freud, small, informal groups gathered to discuss and review one another’s clinical work

– In the 1920’s Max Eitington is thought to be the first to make supervision a formal requirement for psychoanalytic training

– The use of supervision was slowly adopted by other helping professions

· Probation

· Teaching

· Advice and welfare programs

· Employee assistance programs

(Carroll, 2007)

Supervision: Changes Over Time

– In the 1950’s, counseling and psychotherapy orientations other than the traditional psychodynamic approach were introduced

– Supervision = Supervisors psychotherapy orientation

– In the 1970’s supervision moved from the “person” to the “work”

– An educational process more than counseling

– Developmental frameworks for supervision became prevalent

– The emphasis from within counseling psychology on the ‘reflective-practitioner’ model influenced supervision toward ‘reflection on practice’

(Carroll, 2007)

Developmental Models of Supervision

• Integrated Developmental Model

– Describes three levels of therapist development

· Level 1 supervisees are generally entry-level students who are high in motivation, yet high in anxiety and fearful of evaluation

· Level 2 supervisees are at mid-level and experience fluctuating confidence and motivation, often linking their own mood to success with clients

· Level 3 supervisees are secure, stable in motivation, have accurate empathy tempered by objectivity, and use therapeutic self in intervention

– Stresses the need for the supervisor to utilize skills and approaches that correspond to the level of the supervisee

– Focuses predominantly on the development of graduate students in training with little application to postdoc supervision

– Limited suggestions for specific supervision methods at each level

(Smith, 2009)

Supervision

PRACTICUM READINESS INTERNSHIP READINESS PRACTICE READINESS

13A. Expectations and Roles

Demonstrates basic knowledge of expectations for supervision

Demonstrates knowledge of, purpose for, and roles in supervision

Understands the ethical, legal, and contextual issues of the supervisor role

13B. Processes and Procedures

No expectation at this level Identifies and tracks progress achieving the goals and tasks of supervision; demonstrates basic knowledge of supervision models and practices

Demonstrates knowledge of supervision models and practices; demonstrates knowledge of and effectively addresses limits of competency to supervise

13C. Skills Development

Displays interpersonal skills of communication and openness to feedback

Demonstrates knowledge of the supervision literature and how clinicians develop to be skilled professionals

Engages in professional reflection about one’s clinical relationships with supervisees, as well as supervisees’ relationships with their clients

13D. Supervisory Practices

No expectation at this level 

Provides helpful supervisory input in peer and group supervision

Provides effective supervised supervision to less advanced students, peers, or other service providers in typical cases appropriate to the service setting

Health Service Provider Domains of Supervision

• Domain A: Supervisor Competence • Domain B: Diversity

• Domain C: Supervisory Relationship

• Domain D: Professionalism

• Domain E: Assessment/ Evaluation/ Feedback

• Domain F: Problems of Professional Competence

• Domain G: Ethical, Legal, and Regulatory Considerations

(APA, 2014)

Domain A: Supervisor Competence• Supervisors strive to be competent in the psychological

services provided to patients by supervisees

– The supervisor seeks to be a role model for the supervisee

– Ensures that supervisees meet competence standards in order to advance to the next level or to licensure

– When supervising in areas in which they are less familiar, they take reasonable steps to ensure competence in their work and to protect others from harm

• Supervisors seek to attain and maintain competence in the practice of supervision through formal education and training

– Didactic seminars

– Continuing education

– Supervised supervision

(APA, 2014; Newman, 2013; Watkins, 2012)

Domain A: Supervisor Competence• Supervisors strive to coordinate with other professionals that

oversee supervisee’s education and training

– Ensure communications and coordination of goals and expectations

– Can assist supervisees in managing multiple roles and responsibilities in addition to supervisory expectations

• Supervisors strive for diversity competence across populations and settings

– Diversity competence is necessary and inseparable from supervision competence

• Supervisors using technology in supervision strive to be competence in its use

– Including but not limited to distance supervision, telehealth, social media, and digital communications

(APA 2013; APA 2014; Fitzgerald, Hunter, Hadjistavropoulos, & Koocher, 2010)

Individual and Cultural Diversity

PRACTICUM READINESS INTERNSHIP READINESS PRACTICE READINESS

2A. Self as Shaped by Individual and Cultural and Context

Demonstrates knowledge, awareness, and understanding of one’s own dimensions of diversity and attitudes towards diverse others

Monitors and applies knowledge of self as a cultural being in assessment, treatment, and consultation

Independently monitors and applies knowledge of self as a cultural being in assessment, treatment, and consultation

2B. Others as Shaped by Individual and Cultural Diversity and Context

Demonstrates knowledge, awareness, and understanding of other individuals as cultural beings

Applies knowledge of others as cultural beings in assessment, treatment, and consultation

Independently monitors and applies knowledge of others as cultural beings in assessment, treatment, and consultation

2C. Interaction of Self and Others as Shaped by Individual and Cultural Diversity and Context

Demonstrates knowledge, awareness, and understanding of interactions between self and diverse others

Applies knowledge of the role of culture in interactions in assessment, treatment, and consultation of diverse others

Independently monitors and applies knowledge of diversity in others as cultural beings in assessment, treatment, and consultation

2D. Applications based on Individual and Cultural Context

Demonstrates basic knowledge of and sensitivity to the scientific, theoretical, and contextual issues related to ICD as they apply to professional psychology. Understands the need to consider ICD issues in all aspects of professional psychology work

Applies knowledge, sensitivity, and understanding regarding ICD issues to work effectively with diverse others in assessment, treatment, and consultation

Applies knowledge, skills, and attitudes regarding dimensions of diversity to professional work

Domain B: Diversity • Supervisors strive to develop and maintain self-awareness

regarding their diversity competence, including attitudes, knowledge, and skills

– Supervisors serve as important role models regarding openness to self-exploration, understanding of one’s own biases, and willingness to pursue education or consultation when needed

– Supervisor’s ability to self-reflect, revise, and update knowledge to advance their skills in diversity

– Modeling these competencies helps to establish a safe environment to address diversity within supervision and in psychology as a whole

(APA, 2014)

Domain B: Diversity • Supervisors develop a plan to enhance their diversity

competence and respectfully address and facilitate the diversity competence of their supervisees

• All supervision can be seen as multicultural, in the same way that all therapy is multicultural

• View diversity as the norm, not the exception, assists supervisors in being sensitive to similarities and differences between themselves and supervisees

(APA, 2010; APA, 2014; Bernard & Goodyear, 2014; Falender, Shafranske, & Falicov, 2014; Pedersen 1990)

The Oncology Setting

Domain B: Diversity

• Cultural competence in oncology initially focused on providing clinical tools for the necessary negotiation of different health beliefs and values in discordant medical encounters

– The main goal was to reduce the conflicts that arise from cultural differences among patients, families, and health care professionals

• Today, cultural competence is increasingly considered a key factor, both at individual and systems levels

– The goal is to eliminate disparities in health care and reduce the burden of unequal cancer treatment

(Surbone, 2009)

Domain B: Diversity • Supervisors recognize the value of and pursue ongoing

training in diversity competence

– Supervisors develop diversity competence as part of professional development as well as life-long learning

– Formal doctoral training in diversity in doctoral program, continuing professional development workshops, programs, and independent study

– Maintain current competence and build knowledge around emerging areas of diversity

• Supervisors aim to be knowledgeable about the effects of bias, prejudice, and stereotyping on therapeutic and supervisory relationships

– When possible, supervisors model client/patient advocacy and change promotion within institutions and systems

(APA, 2003, 2004, 2007a, 2010, 2011a, 2011b; Burnes & Singh, 2010)

Domain B: Diversity • Increasing ethnic diversity in the population makes infusing

and ongoing development of cultural competence particularly important

– Enhances professional credibility with clients

– Facilitates the upholding of professional ethics

· Professional ethics and values are only attainable if psychologists are culturally competent

– Encourages effective relationships in the workplace among practitioners from diverse backgrounds

•

(Smith, 2003)

African Americans

Oncology – African Americans• Beliefs about cancer causation and health maintenance, use of

the lay referral network, use of folk remedies, and the role of family are all important cultural factors that influence cancer treatment

• Barriers to care

– Poverty rates

– Lack of health insurance (transportation, child/elder care)

– Feelings of hopelessness, fatalism, and pessimism often undermine feelings of empowerment in cancer prevention and control

– Among faith communities, God as “the central healer” of disease

– Negative historical experiences with medical research results in distrust

• Researchers are often ignorant to cultural perceptions and beliefs, which often undermines study implementation

(Giuliano et al., 2000)

Domain B: Diversity

– Concept of culture is complex and confusing, particularly the differences among race, ethnicity, and culture

– The relationship of culture to health and illness is multifaceted and still poorly understood

· Most medical literature evaluates the impact of cultural factors using Western standards for comparison

· Particularly in oncology, patients and professionals confront a disease highly charged with physical and psychological suffering for patients and families, as well as metaphorical implications and social stigma in some cultures

· Ineffective communication contributes to frustration, mistrust (challenges with treatment adherence and ultimately outcomes)*

(Surbone, 2009)

Reflective Practice/Self-Assessment/Self-Care

PRACTICUM READINESS INTERNSHIP READINESS PRACTICE READINESS

4A. Reflective Practice

Displays basic mindfulness and self-awareness; engages in reflection regarding professional practice

Displays broadened self-awareness; utilizes self- monitoring; engages in reflection regarding professional practice; uses resources to enhance reflectivity

Demonstrates reflectivity both during and after professional activity; acts upon reflection; uses self as a therapeutic tool

4B. Self-Assessment

Demonstrates knowledge of core competencies; engages in initial self-assessment re: competencies

Demonstrates broad, accurate self-assessment of competence; consistently monitors and evaluates practice activities; works to recognize limits of knowledge/skills, and to seek means to enhance knowledge/skills

Accurately self-assesses competence in all competency domains; integrates self-assessment in practice; recognizes limits of knowledge/skills and acts to address them; has extended plan to enhance knowledge/skills

4C. Self-Care (attention to personal health and well-being to assure effective professional functioning)

Understands the importance of self-care in effective practice; demonstrates knowledge of self-care methods; attends to self-care

Monitors issues related to self-care with supervisor; understands the central role of self-care to effective practice

Self-monitors issues related to self-care and promptly intervenes when disruptions occur

4D. Participation in Supervision Process

Demonstrates straightforward, truthful, and respectful communication in supervisory relationship

Effectively participates in supervision Independently seeks supervision when needed

Domain C: Supervisory Relationship • Supervisors value and seek to create and maintain a

collaborative relationship that promotes the supervisees’ competence

– Supervisors initiate collaborative discussion of the expectations, goals, and tasks of supervision

– They establish a working relationship that values:

· Dignity of others

· Responsible caring

· Honesty and transparency

· Engagement and attentiveness

· Responsiveness

· Humility

· Flexibility

· Professionalism

(APA, 2014; Ellis, Ring, Hanus, & Berger, 2013)

Domain C: Supervisory Relationship • Supervisors aspire to review regularly the process of the

supervisee and the effectiveness of the supervisory relationship and address issues that arise

– The supervisory relationship and the supervisee’s learning needs evolve over time

– The supervisor should work collaboratively with the supervisee to review the supervision goals and tasks

– When disruptions occur in the supervisory relationship, supervisors seek to address and resolve any issues openly, honestly, and in the best interests of client/patient welfare and the supervisee’s development

(APA, 2014; Safran, Muran, Stevens, & Rothman, 2008)

Domain D: Professionalism • Professionalism is synonymous with psychology’s social

responsibility

• The “professionalism covenant” puts the needs and wellbeing of the people being served at the forefront

• Supervisors strive to model professionalism in their own conduct and interactions with others

• Essential components of professionalism:

– Integrity – honesty, personal responsibility, and adherence to professional values

– Deportment – attitude and demeanor

– Accountability

– Concern for others

– Professional identity

(APA, 2014; Grus & Kaslow, 2014; Hodges et al., 2011; Vasquez & Bingham, 2012)

Domain E: Assessment/Evaluation/Feedback • Assessment, evaluation, and feedback occur within a

collaborative supervisory relationship

• Supervisors promote openness and transparency in feedback and assessment

• A major responsibility of the supervisor is monitoring and providing feedback on supervisee performance

– Live observation or review of recorded sessions is the preferred procedure

– Supervisee self-report is the most frequently used source of data on supervisee performance and client/patient progress

· Often, self-report results in a lack of error disclosure because of constrained human memory and information processing as well as supervisee self-protective distortions and biases, resulting in the loss of potentially important clinical data

(APA, 2014; Goodyear & Nelson, 1997; Haggerty & Hilsenroth, 2011; Noelle, 2002; Scott, Pachana, & Sofranoff, 2011)

Supervision of Postdoctoral Fellows

• The goal of a postdoctoral fellowship is to provide the training necessary for the postdoc to achieve intellectual and professional independence and success

• Highest rated supervisors are seen as successfully balancing feedback with an emphasis on personal and professional growth

• Supervisors seen as open and supportive predicts perceived effectiveness of supervision

• Supervisory challenge positively predicts supervisee anxiety

• Though postdoc supervisors have been encouraged to address diversity in past literature, there is often little discussion concerning ethnicity, gender, and/or sexual orientation

• Supervisees report higher satisfaction with supervision when cultural and diversity variables are discussed in the supervisory relationship

(Hicks, 2009; Lizzio, Wilson, & Que, 2009; Murray, 1998)

Need for Post-Doc Opportunities

• Variability in the content, structure, and quality of postdoctoral experiences

– Particularly those that are informal

– Formal programs provide organized, sequential training that includes didactic, supervisory, and experiential components

– Informal opportunities often involve service delivery demands with insufficient education and supervision

• Lack of clarity in the field regarding the tasks to be accomplished during the postdoctoral year

– No consensus of direction regarding benchmark performance in each competency domain

(Kaslow & Webb, 2011)

Domain F: Problems of Professional Competence • Supervisors understand and adhere to the supervisory

contract and to program, institutional, and legal policies and procedures related to performance evaluations.

– Effective management of professional competence problems begins with the supervision contract

– The contract provides:

· Prior written notice of the competencies required for satisfactory performance in the supervised experience

· The process of evaluation

· The procedures that will be followed if the supervisee does not meet the criteria

· Procedures available to the supervisee to clarify or contest the evaluation

(APA, 2014; Goodyear & Rodolfa, 2012; Thomas, 2007)

Domain F: Problems of Professional Competence • Supervisors are competent in developing and implementing

plans to remediate performance problems

• Supervisors are mindful of their role as gatekeeper and take appropriate and ethical action in response to supervisee performance problems

– Supervisors strive to closely monitor and document the progress of supervisees who are taking steps to address problems of competence

– Should a supervisee not meet the stipulated performance levels after agree upon remediation, attending to supervisee due process, supervisors must consider dismissal from the training program.

(APA, 2014; Bodner et al., 2012; Kaslow, Rubin, Forrest, & et al., 2007)

Domain G: Ethical, Legal, & Regulatory Considerations

• Supervisors model ethical practice and decision making and conduct themselves in accord with APA ethical guidelines, guidelines of any other applicable professional organizations, and relevant federal, state, provincial, and other jurisdictional laws and regulations

– Supervisors ensure that supervisees develop the knowledge, skills, and attitudes necessary for ethical and legal adherence

– The supervisor is responsible for understanding the jurisdictional laws and regulations and their application to the clinical setting for the supervisee

• Supervisors serve as gatekeepers to the profession

– Gatekeeping entails assessing supervisee’s suitability to enter and remain in the field

(APA, 2014; Bodner, 2012; Handelsman, Gottlieb, & Knapp, 2005; Knapp, Handelsman, Gottlieb, & VandeCreek, 2013)

Self Rating Supervision Competency

Self-Rating Supervision Competency

• Clinical supervision and therapy have a lot in common, yet

– Use separate and distinct skills

– A “master” clinician may not always become a “master” supervisor without the addition of training and competency in supervisory knowledge and skills

• How do we rate our own competencies and identify areas that need improvement?

(Smith, 2009)

Supervisor Competency Self Assessment

(Falender & Shafranske, 2007)

Supervisor Competency Self Assessment

Rank present from 7 (superior) to 1 (absence of knowledge, skill, value) Signify high priority to enhance competence items in column with “X”)

Knowledge X Present Aspirational

Of area being supervised

Of models theories, modalities and research on supervision

Of professional/supervisee development

Of evaluation, process/ outcome

Awareness of diversity in all forms

Rank present from 7 (superior) to 1 (absence of knowledge, skill, value) Signify high priority to enhance competence items in column with “X”)

Skills X Present Aspirational

Supervision modalities

Relationship skills

Sensitivity to multiple roles: Perform and balance

Provide effective formative and summative feedback

Promote growth and self-assessment in trainee

Conduct own self-assessment

Assess learning needs and developmental level of supervisee

Encourage and use evaluative feedback from trainee

Teaching and didactic skills

Set appropriate boundaries and seek consultation when supervisory issues are outside domain of supervisor competence

Flexibility

Scientific thinking and translation of scientific finding to practice throughout professional development

Rank present from 7 (superior) to 1 (absence of knowledge, skill, value) Signify high priority to enhance competence items in column with “X”)

Values X Present Aspirational

Responsibility for client and supervisee

Respectful

Responsibility for sensitivity to diversity in all forms

Balance between support and challenging

Empowering

Commitment to lifelong learning and professional growth

Balance between clinical and trainingneeds

Value ethical principles

Commitment to knowing and utilizing available psychological science related to supervision

Commitment to knowing one’s own limitations

Rank present from 7 (superior) to 1 (absence of knowledge, skill, value) Signify high priority to enhance competence items in column with “X”)

Social Context Overarching Issues X Present Aspirational

Diversity

Ethical and legal issues

Developmental process

Knowledge of immediate system and expectations within which the supervision is conducted

Creation of climate in which honest feedback is the norm (supportive and challenging)

Training of Supervision Competencies X Present Aspirational

Coursework in supervision includingknowledge and skill areas listed

Has received supervision of supervisionincluding some form of observation (videoor audiotape) with critical feedback

Rank present from 7 (superior) to 1 (absence of knowledge, skill, value) Signify high priority to enhance competence items in column with “X”)

Assessment of Supervision Competencies X Present Aspirational

Successful completion of course on supervision

Verification of previous supervision of supervision document readiness to supervise independently

Evidence of direct observation (e.g., audio or videotape)

Documentation of supervisory experience reflecting diversity

Documented supervisee feedback

Self-assessment and awareness of need for consultation when necessary

Assessment of supervision outcomes—both individual and group

Other to be defined by supervisor/setting X Present Aspirational

Thank you! Gracias!

Discussion

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