Developing Your Unique Approach to Clinical Supervision: The Contextual-Functional Meta-FrameworkAmerican Mental Health Counselors’ Association, Orlando, FL

Jeff Chang, Ph.D, R.Psych.Assistant ProfessorGraduate Centre for Applied PsychologyAthabasca Universityjeffc@athabascau.ca

Calgary, Alberta, CanadaCalgary, Alberta, Canada

QuestionsQuestionsShow of hands:currently supervising?consider yourself a new-ish supervisor?consider yourself an experienced supervisor?had a course in supervision?read a book on supervision?

Think AboutThink About Your “best” supervisee/supervision experience Your “worst” supervisee/supervision experience Constrains (formal and informal) of your

setting/context Your biggest strength as a supervisor Your biggest weakness as a supervisor How this presentation can help Your best hopes for this presentation

The Contextual-Functional Meta-The Contextual-Functional Meta-Framework: Developing Your Unique Framework: Developing Your Unique

Approach to Clinical SupervisionApproach to Clinical Supervision

Developed inductively over 20 years of supervision practice in different contexts, supervising supervisees of different theoretical orientations, experience levels, and disciplines

Definition of SupervisionDefinition of Supervision

Definition of supervision:Sustained, purposeful interaction between a more

proficient practitioner and a less proficient practitioner undertaken to support the clinical and

professional development of the latter, and directly and indirectly improve clinical

effectiveness. Supervision is a core competency in doctoral

programs in professional psychology, counseling, MFT

I assert that one cannot be a fully effective clinician if one does not master basic administrative tasks

Definition of SupervisionDefinition of Supervision

This definition assumes that clinical and administrative supervision cannot be separated.

Tromski-Klingshirn & Davis (2007): Supervisees generally did not experience it as problematic when clinical and administrative supervision are conducted by the same person.

Those who did mainly said it was a function of the person.

Policies are ethical or accountability needs, operationalized.

Standing on the Shoulders of…Standing on the Shoulders of…I’ve been influenced by several approaches to supervision and therapist development. These

provided ideas that I have used with more or less utility, and that have stimulated reflection.

Developmental/stage models:Developmental/stage models: Most prominent (IDM) (Stoltenberg, 2005) has

focused largely on the student and pre-licensure years

Three developmental stages in pre-licensed therapists, and a “Integrated” level that aggregates a wide range of career stages.

Standing on the Shoulders of…Standing on the Shoulders of…

Summerill (1998) found that supervisors do pretty much the same thing with all supervisees irrespective of supervisees’ purported developmental stage.

Themes and stages of counsellor development (Skovholt & Rønnestad, 1995; Rønnestad & Skovholt, 2003; see also see Goodyear, Wertheimer, Cypers, & Rosemond, 2003).

Take-away: supervisees have different needs over time.

Standing on the Shoulders of…Standing on the Shoulders of…Discrimination Model (Bernard, 1997)Discrimination Model (Bernard, 1997)

Intervention, conceptualization, and personalization skills Teacher, counselor, consultant

Parsimonious Implicitly geared toward the student and

prelicensure years Systemic Approach to Supervision (Holloway, 1995)Systemic Approach to Supervision (Holloway, 1995) Tasks: counseling skill, case conceptualization,

professional role, emotional awareness, self-evaluation

Functions: monitoring/evaluating, instructing/advising, modeling, consulting, supporting/sharing

Standing on the Shoulders of…Standing on the Shoulders of…

addresses the complexity of supervision, and administrative/organizational context

Common factors approachCommon factors approach: : Lambropolis (2002); Morgan & Sprenkle (2007) The latter make three key distinctions:

Clinical competence vs. professional competence (emphasis)

Idiosyncratic vs. general (needs of supervisee or profession)

Collaborative vs. directive (relationship)

Standing on the Shoulders of…Standing on the Shoulders of…

Model-based approachesModel-based approaches Using ideas from one’s chosen model of

therapy has historically been an intuitively- supported modus operandi

Have had their historical moment, this has passed.

Don’t reflect typical community practice; most of our supervisees don’t come to learn a specific (“my”) model, little development in last 15 years.

Standing on the Shoulders of…Standing on the Shoulders of…

Watkins (1995b, p. 570): “Psychotherapy-based models of supervision have generally shown… stability over the last 25-30 years, with… no truly new therapy-based theories of supervision emerging and… existing therapy-based theories showing limited changes or revisions….”

One exception is the narrative approach to training and supervision (Winslade, Crocket, Monk, & Drewery, 2000).

Competency profiles:Competency profiles:

MFTMFT: Nelson, Chenail, Alexander, et al. (2007).

Psychology:Psychology: Kaslow, Grus, Campbell, Fouad, Hatcher, & Rodolfa

(2009); Rodolfa, Bent, Eisman, Nelson, Rehm, & Ritchie (2005)

Counseling:Counseling: CACREP (2009) Task Group for Counsellor Regulation in British

Columbia (2007)

The Meta-FrameworkThe Meta-Framework Orienting to six factors that I believe form the basis of

supervision: We attend to these six factors, explicitly, or implicitly

already. It would be better if we attended to these factors intentionally.

Clarity and intentionality of functions Premise: Clarify how you will operationalize each of

these six factors and you will have your personal approach to supervision

To paraphrase Steve de Shazer:“I’m not here to teach you how to supervise. You’re already

doing it. I’m here to help you be comfortable with, and understand what you’re doing.”

The ModelThe ModelAdministrativeContext

Culture InfusedSupervisoryWorking Alliance

Functions Theory ofChange

The Counselor-Client Supervisor System

Phase ofCounsellorDevelopment

“To whom do Iowe myallegiance”

“Can theSupervisoryRelationshipsupport theintervention?”

“When should I dowhat?

“Is there a clash of ideas, or an ecology of ideas?”

“What are therelational patternsthat affect thesupervisionprocess?

“Where is thesupervisee in thejourney?”

o AGS Commission Model

o With whom have I contracted?

o Who is paying the bill?

o What do they expect me to do?

o Is what I’m doing fall within my primary commission?

Supervisoryworking alliance

o “Stages of Change”

o Visitor, Complainant, Customer

Primary functionso Clinical

educatoro Ethics/risk

management consultant

o Skill development coach

o Catalysto Professional

gate-keepero Admin

supervisoro Professional

mentoro Advocate/

system change agent

o Personal supporter

o How does the supervisee’s theory of change and the supervisor’s theory of change mesh – or not?

o Typically, supervisor’s theory of change is better elaborated.

o Isomorphism o Skovholt & Ronnestad’s themes and stages of counsellor development

Six FactorsSix Factors

Administrative Context Culture Infused Supervisory Working

Alliance Functions Theory of Change The Therapist-Client Supervisor System Stage of Therapist Development

Administrative ContextAdministrative ContextOrienting question: “To whom do I owe my

allegiance?”

AGS Commission Model (Salamon, Grevelius, & Andersson, 1993) Presented commission > hypothetical commission Primary commission vs. secondary commission Secondary commissions must fall within the primary

commission With whom have I contracted? Who is paying the bill? What do they expect me to do? Does what I’m doing fall within my primary

commission?

Administrative ContextAdministrative Context

The AGS Commission Model impacts these areas:

Contracting for supervision goals Informed consent Confidentiality Varying levels of vulnerability A disclosure of interest

While we, as supervisors, are always concerned with the development of supervisees, we must keep in mind where our primary allegiance lies

VignetteVignetteKeenan, a predoctoral intern in clinical psychology, was doing a rotation in a forensic assessment unit, where he was being trained to conduct assessments to ascertain if an accused is competent to stand trial, or make recommendations on sentencing. He felt his therapeutic skills were not being well-used, wanted to do more to develop them. He asked his supervisor, Dr. Law, if he could begin some therapy groups. She told him that that was outside of the mandate of the unit, but she would be happy to work with him to apply his therapeutic skills like engagement and questioning to his assessment work.

Administrative ContextAdministrative Context

Discussion question: Consider a situation in which a supervisee required correction, or even dismissal. How did you balance your obligation to the supervisee, the profession, and your employer?

Culture Infused Supervisory Working Culture Infused Supervisory Working AllianceAllianceOrienting question: “Orienting question: “Can the supervisory relationship Can the supervisory relationship

support the intervention?”support the intervention?” Conceptualizing the working alliance:

SFT’s ideas of “visiting,” “complainant,” and “customer” relationships… working alliance is the manifestation of an interactional pattern

Prochaska and di Clemente’s Transtheoretical Model of Change (stages of change)

Obtain feedback on the working alliance

Discussion question: Reflect on a supervisee whose motivation was uneven. How did you “hook” his/her motivation? How did you learn what the supervisee was motivated for?

VignetteVignetteLawrence, a clinical social worker, was supervising several licensure interns in a family service agency, using a combination of live supervision from behind a one-way mirror, and case consultation. He noticed that one of his supervisees, Anna, seemed to be simply nodding and agreeing with him a great deal, but did not seem to be engaged in the content of his feedback….

VignetteVignette… Wondering if he was fitting his supervision practice with her needs, he asked her directly how she experienced their supervisory alliance. She replied, “It’s funny you should mention that. I’ve been a little frustrated with supervision lately – you are always so positive, and I need some concrete ideas about what to do a lot of the time.” Lawrence and Anna went on to renegotiate their supervision contract, based on specific skill development needs, including when she would find a call-in during live supervision helpful.

Culture Infused Supervisory Working Culture Infused Supervisory Working AllianceAlliance “Culture-Infused Counselling” approach (Arthur

& Collins, 2010) urges counsellors to: Be culturally self-aware. Appreciate the cultural identity of supervisees Develop a culturally competent working alliance

In this model, culture is not a theoretical abstraction; the rubber meets the road in the supervisory relationship

An ecology of ideas (beliefs and world view) and interaction between supervisor and supervisee

VignetteVignetteDr. Khalil is a Jordanian-Canadian Muslim MFT supervising Kelly, a master’s practicum student. At their initial meeting, Dr. Khalil stood up, placed his hand over his heart, and graciously bowed toward Kelly. He explained that it is contrary to his religious convictions to shake hands with women, and that his gesture is a way for him to express his respect for women. This opened a conversation about how they each position themselves culturally, and conceptualize gender in their respective approaches to therapy.

FunctionsFunctionsOrienting question: Orienting question: “When should I do what?”“When should I do what?” Some functions will not be used with some supervisees:

determined by context. Morgan & Sprenkle’s (2007) three key distinctions:

Clinical competence vs. professional competence (emphasis)

Idiosyncratic vs. general (needs of supervisee or profession)

Collaborative vs. directive (relationship) Not a bad way to think about things, but finer distinctions

are required to ensure that supervisors are clear as to where their primary allegiance lies

FunctionsFunctionsClinical educator:Clinical educator:

Teaching concepts and theories (conceptual skills; Tomm & Wright, 1979)

Assisting supervisees to clarify their theories of counselling and them to make their practice consistent with their theory

Challenging supervisees’ assumptions, deconstructing supervisees’ theories

Teaching supervisees to “know what to look for” (perceptual skills; Tomm & Wright, 1979)

Utilizing ideas outside of “therapy” – art, literature, philosophy

Discussion question: What are some of your best practices to encourage theoretical clarity in your supervisees?

VignetteVignetteLeo, a student in Dr. Jessup’s internship seminar, was a risk of failing because he could not articulate his theory. An addictions counsellor for 25 years before entering a Master’s program, he denigrated the need to identify a theory, proclaiming that he “just wanted to help people.” Rather than “just buying into an established theory,” Leo marched to the beat of his own drum. He seemed unable to connect his clinical work, which seemed to be quite effective when he showed his videos in class, to any coherent way of thinking….

VignetteVignette… Dr. Jessup saw Leo’s promise and thought he was a sensitive, effective, and intuitive counselor, but could not pass him in the internship seminar unless Leo articulated a coherent approach to counselling. He challenged Leo to develop the “Leo Smith model.” Dr. Jessup supported Leo to figure out, inductively, “why he was doing what, when” in his sessions via videotape review and live supervision. He was able to articulate a coherent approach to counseling, and even sheepishly admitted that he was “a cross between CBT and reality therapy, with a little bit of inner child work thrown in” by the end of the internship.

FunctionsFunctionsEthics/Risk Management ConsultantEthics/Risk Management Consultant Supporting the application of ethical principles in

practice Moving beginning supervisees from “ethics as a

theoretical abstraction” to applied practice outcomes.

Supporting novice supervisees from a fear-based perspective to a realistic outlook.

Warning supervisees of risky situations Moving supervisees from a risk management,

defensive practice outlook to an aspirational outlook

Discussion question: How do ethical the dilemmas your supervisees face change as they develop?

FunctionsFunctions

Skill Development Coach:Skill Development Coach: Demonstrating and giving feedback on

supervisee skills (executive skills; Tomm & Wright, 1979):

Generic (e.g., attending, questioning, reflecting, summarizing, information-giving, structuring)

Model-specific: How to use generic skills in the service of the specific procedures in accord with a theory of counselling

Encouraging self-observation of skills development

Discussion question: What are some favorite ways to teach and/or model specific skills?

VignetteVignetteKelsey is a Master’s student in counselling who has previously worked as a rehabilitation worker, developing behavior management plans for children diagnosed with autism. She had had extensive training in applied behavior analysis. She was pleased to have obtained a practicum in a local clinic that was well known for solution-focused training. Her supervisor, Liz, found that Kelsey’s skill at asking for specific behavioral descriptions and sequences could be easily transferred to the process of shaping her solution-focused questioning skills.

FunctionsFunctions

Catalyst:Catalyst: Tracking patterns of supervisee response to particular

client situations (“countertransference”). Raising these patterns with the supervisee Supporting the supervisee to find the correct (for

him/her) way to manage the issue The supervisee’s view will depend on the theory of

counselling he/she espouses, and personal beliefs/values

Discussion question: How can we nudge at supervisees’ “blind spots” without bashing them over the head?

VignetteVignetteSandy is a divorced 46-year-old MFT working in a community counselling agency. She has young adult children and a mother in failing health, who was struggling to stay in her own home. Sandy referred to herself as a “sandwich generation” woman, and spent many hours supporting her mother’s independence. Her supervisor, Carol, knew of her personal circumstances….

VignetteVignette… At one of their regular supervision sessions, Sandy mentioned to Carol that her work with Amy, who had a similar life circumstance, but had moved her widowed father into a nursing home, was not going well. Sandy admitted she thought Amy had not tried hard enough to keep her father at home. They seemed to be talking in circles. Carol wondered whether the therapeutic impasse was related to Sandy’s personal situation. She gingerly self-disclosed how she felt stuck, or less than objective, occasionally at different points in her life journey, and asked if this might be behind Sandy’s therapeutic impasse with Amy.

FunctionsFunctionsProfessional gatekeeper:Professional gatekeeper:

Entering, formative, and summative evaluation Monitoring and giving feedback to supervisees re:

educational program policies and licensing requirements

Reporting to educational programs and licensing boards

Resolving performance issues, if present Out-counselling supervisees unsuitable for the

professionDiscussion question: Have you ever had to out-

counsel a supervisee? Describe the experience.

FunctionsFunctionsOrganizational/administrative supervisorOrganizational/administrative supervisor: Ensuring compliance with policies and procedures Addressing performance issues, if present Policies are ethical or accountability needs,

operationalized. Supporting supervisees with time and workflow

management Clinical record-keeping and time management are

often the first indications of therapist impairment.Discussion question: How is administrative

performance related to clinical competence?

FunctionsFunctions

Personal supporterPersonal supporter Listening respectfully to events/struggles in

supervisees’ personal lives Providing personal support, within the bounds of

professional boundaries NOT THERAPY: performance vs. personalDiscussion question: When providing personal support

to a supervisee, what indicates to you that you should make a referral for therapy?

VignetteVignetteJohn, a pre-licensure psychologist in a private practice, was uncharacteristically late getting assessment reports completed. Most of these were parenting assessments done at the request of the local child protective service (CPS), necessitating postponement of court dates. CPS workers were calling John’s clinical supervisor and the owner of the private practice, Dr. Kelly, to complain. When Dr. Kelly asked John about this, he tearfully blurted out that his wife had been having an extramarital affair, which preoccupied him day and night. He felt unable to concentrate on work, and profusely apologized for letting things slip….

VignetteVignette… Dr. Kelly listened carefully and empathically to John. Together, they negotiated a plan to manage the incomplete and late work, and address the concerns of the CPS workers, who were a prime referral source for the practice. They also negotiated a reduction in John’s workload so that he could manage adequately, including John’s request to decline any marital therapy cases from an EAP contract the practice served. Dr. Kelly and John also discussed whether John required a referral to therapy, and what modality (couple or individual). Finally, Dr. Kelly recommended some readings on therapist impairment.

FunctionsFunctions

Professional mentor:Professional mentor: Providing advice and support about:

Further graduate education or continuing education

Self-care and workload management Research vs. practitioner track Starting or enhancing a private practice Work-life balance

VignetteVignetteDr. Kennedy, an MFT, had supervised Lana, a licensed counsellor, for eight years. Dr. Kennedy had supervised Lana as a licensure intern, and was her administrative supervisor at the family service agency where they both worked. Although they were still required to review cases, the vast majority of the time, Dr. Kennedy found that Lana’s clinical work was excellent, and Dr. Kennedy’s ideas were mostly enhancements of sound treatment plans that Lana developed on her own….

VignetteVignette… Lately, the conversation had turned to Lana’s desire to return to school for a doctorate. They discussed what discipline (psychology, counselor education, or MFT) would provide the best fit for Lana, whether she wanted to seek a leadership position or an academic one after the completion of her degree, and various options of how she would balance family, work, and school.

FunctionsFunctions

Advocate/system change agent:Advocate/system change agent: Advocating for policies, organizational

structures, and clinical practices, etc., that make the delivery of services more effective.

VignetteVignetteCraig was contracted by a children’s mental health agency to provide clinical supervision to licensure interns and licensed clinicians. He found that, to a person, they felt overwhelmed with paper work and case management demands that they did not feel were useful. They were either working overtime (unpaid) to keep up, or dropping necessary documentation, thus exposing the agency to liability…

VignetteVignette… Craig carefully worked his way into to position of trust with both the clinical staff and the senior management of the agency. He suggested some modest changes to reduce the duplication of forms, some small tokens of appreciation the agency could make to improve staff morale. He also explained to the clinical staff how documentation would help treatment consistency and were legally and ethically necessary.

Theory of ChangeTheory of Change

Orienting question: “Orienting question: “Is there a clash of Is there a clash of ideas, or an ecology of ideas?”ideas, or an ecology of ideas?”

Supervisor and supervisee must the clear about: How clients change in counselling How supervisees change in supervision

Not just counselling theory, but implicit beliefs and world view

Almost all the time, the supervisor’s view is better elaborated than the supervisee’s view

Theory of ChangeTheory of Change The supervisor’s primary model of therapy will always

“leak out.” Gregory Bateson: “Your epistemological slip is always

showing” Not indoctrination, but clarification and deconstruction When theories are too divergent… The limits of competenceDiscussion question: What is the philosophy of your

setting/you when it comes to theory of client change? Do you take a position of teaching or assimilating a supervisee’s theoretical approach, or accommodating it?

VignetteVignetteLenora, a MFT master’s student, was quite taken with emotionally focused therapy (EFT), but became quite worried when she ended up being supervised by Consuelo, who was well-known for practicing narrative therapy. Lenora privately confided to a fellow student her worry that “narrative would be shoved down my throat.” Consuelo, who had an adequate understanding of EFT, invited Lenora to think in a way that was consistent with EFT’s assumptions and practice….

VignetteVignette… to be “the best emotionally focused therapist you can be.” In supervision, Consuelo asked Lenora about “what EFT would guide you to do” in specific situations. She also invited to Lenora to deconstruct the discourses behind EFT’s assumptions. When Lenora was stuck and asked for help, Consuelo would often take a one-down position, apologizing for “only being able to think in narrative” before suggesting ideas. By the end of the school year, Lenora noted that Consuelo’s approach helped her to “really understand EFT and opened my eyes up to narrative.”

The Service Delivery SystemThe Service Delivery SystemOrienting question:Orienting question: “What are the relational “What are the relational

patterns affecting the supervision process?patterns affecting the supervision process? Larger context: agency, environment “Parallel process”: material from the therapeutic

relationship replicates itself in supervision, thought to occur when the training analyst unconsciously identified with the patient and reenacts the patient's defensive behavior in supervision.

“isomorphism” is a systemic reworking of the notion of parallel process, used mainly by family systems therapists: how family dynamics affect the therapy process

Therapist-Client Supervisor SystemTherapist-Client Supervisor System

Isomorphism as an interventive stance: Liddle (1988).

Isomorphic sequences are opportunities for intervention; supervisee can alter the sequence in supervision with the goal of altering the supervisee's in-session behavior accordingly.

VignetteVignetteAndre was working as the clinical supervisor in an employee assistance program (EAP). Once the local factory, which was the EAP’s main corporate client, closed, rumors were rife that the EAP would be the next to go. The rumors and worry were affecting client service. Andre raised the issue with management, who gave him the unreassuring news that lay-offs were likely. Armed with definitive information, Andre could support the staff to hold it together, support them to be present for clients, and minimize the effects of the chaotic workplace on client service.

Phase of Counsellor Development Phase of Counsellor Development

Orienting question:Orienting question: “Where is the supervisee in the “Where is the supervisee in the journey? What are the supervisee’s journey? What are the supervisee’s developmental needs?”developmental needs?”

Themes and stages of counsellor development (Skovholt & Rønnestad, 1995; Rønnestad & Skovholt, 2003; see also see Goodyear, Wertheimer, Cypers, & Rosemond, Michelle, 2003).

Eight dimensions: time period central task

Stage of Counsellor DevelopmentStage of Counsellor Development

predominant affect sources of influence role and working style conceptual ideas learning process measures of effectiveness and satisfaction… Manifested differently in six distinct stages of

counsellors’ careers.

VignetteVignetteKendrick had been a licensed MFT for 24 years, and was employed by a family service agency. He had the idea that there was “nothing new under the sun” in the world of therapy. He had seen many trends and “flavors of the month” come and go since he entered graduate school almost 30 years earlier. In the last few years, Kendrick had reignited a passion for theatre – he had been in several high school and college productions -- and for the past three years was acting in community theatre….

VignetteVignette… His studies of characters in plays in which he acted was melding with his clinical experience, and inviting him to think about his work in new ways. He frequently spoke in case review meetings about how a character he was getting ready to play helped him understand a particular client. His clinical director, Dr. Cohen, was a midcareer psychologist who practiced CBT, and initially did not understand where Kendrick was “coming from,” but knew Kendrick to be a sound, if somewhat unorthodox, therapist. Dr. Cohen listened carefully in case reviews, and was able to support Kendrick’s new direction in his clinical work.

PotentialsPotentials

Real world relevance Systemic: considers the context of which service

delivery and supervision, culture, and the interactional patterns in which the client, counsellor, and supervisor participate

Orienting and organizing supervision efforts -- remind supervisors to attend to, and weigh, multiple aspects of supervision at one time we have to walk, chew gum, breathe, look where

we’re going, talk to the person we’re out walking with, and smell the flowers at the same time.

PotentialsPotentials

Transtheoretical and cross-disciplinary applicability

Supervision as career-long process To clarify relationships of accountability,

and thus provide a protective factor from inappropriate dual relationships and other ethical issues

Further DevelopmentFurther Development Further feedback and conceptual

development Piloting a training curriculum for

supervisors (our program and interested community agencies)

Evaluation of training Partnerships for research and conceptual

development