Clinical Supervision Best Practices to Promote Clinical Competence

Clinical Supervision: Best Practices to Promote Clinical Competence and Professional Integrity Janet L. Muse-Burke, Ph. D. , L. P. C. Marywood University

Disclosures Financial Dr. Muse-Burke is receiving a stipend. She maintains a private practice through which she provides individual clinical supervision for clinicians seeking LPC in PA and co-leads consultation groups for licensed mental health professionals. Non-Financial Dr. Muse-Burke has published book chapters and articles in clinical supervision. She does not receive any compensation for these publications. Dr. Muse-Burke has no other financial or nonfinancial relationships to disclose.

Workshop Objectives Describe the importance of clinical supervision to ensure best practice with clients. Identify ethical and professional guidelines specific to clinical supervision. Describe developmental theory and how it applies to supervisees at different professional phases. Identify qualities of effective versus inadequate or harmful clinical supervisors. List strategies to use with supervisees who demonstrate problems of professional competence.

Workshop Agenda 9: 00 AM 10: 30 AM 10: 45 AM 12: 00 PM 1: 00 PM 2: 30 PM 2: 45 PM 4: 30 PM Importance of Clinical Supervision Ethical Standards and Professional Guidelines for Clinical Supervision Break Developmental Theory of Clinical Supervision Developmental Phases of Mental Health Professionals Lunch Effective versus Inadequate or Harmful Clinical Supervisors Skills for Building a Strong Supervisory Working Alliance Break Strategies for Working with Challenging Supervisees Wrap-up Program Concludes

Importance of Clinical Supervision Ethical Standards and Professional Guidelines for Clinical Supervision

Objectives To discuss the importance of clinical supervision. To review ethical standards relevant to clinical supervision. To describe professional guidelines relevant to clinical supervision.

Importance of Clinical Supervision Clinical supervision is critical to training (Proctor, 1986). Fosters trainee development. Protects client welfare. Ensures competence to serve the profession. Clinical supervision promotes ethical practice (Vasquez, 1992). Imparts knowledge. Teaches skills. Models behaviors. Supervision positively impacts client outcomes (Bambling et al. , 2007).

Importance of Clinical Supervision Growth and development is less valued once basic proficiency is achieved (Wade & Jones, 2015). Learning peaks at competency (Colvin, 2008). Supervision research considers supervised experience as a critical indicator of expertise (Ladany, Marotta, & Muse-Burke, 2001). Clinical supervision is integral to professional development from early training to retirement (Ronnestad & Skovholt, 2003).

Importance of Clinical Supervision Highly Effective Clinicians (Wampold & Brown, 2005) Solicit feedback. Review their performance. Identify actions and strategies for reaching goals. Take responsibility. Supervisors (Wade & Jones, 2015) Provide more objective observation. Challenge capabilities. Encourage cognitive flexibility. Promote self-awareness and self-monitoring.

Ethical Principles The Canadian Psychological Association (CPA, 2009) outlines four ethical principles specific to clinical supervision. The principles apply across clinical, research, education, and administration-based settings. Four Principles Respect for the Dignity of Persons Responsible Caring Integrity in Relationships Responsibility to Society

Respect for the Dignity of Persons Demonstrate respect, courtesy, and understanding. Prevent discrimination. Share in defining the goals and roles. Disclose preferences for theories and practices as well as personal biases, beliefs, and characteristics. Address professional and interpersonal differences with openness. Clearly define parameters of confidentiality. Make reasonable accommodations for crises or unexpected events.

Responsible Caring Be well prepared, make efficient use of time, and be receptive to mutual learning. Keep up to date with standards, guidelines, codes, laws, and regulations specific to the work. Keep competencies in supervision up-to-date. Be aware of professional and personal limitations and be open to and elicit feedback. Maintain records. Ensure availability for supervision. Seek clarification of responsibilities of supervisors when supervision is provided by more than one supervisor.

Integrity in Relationships Address conflict in honest and beneficial ways. Explore personal values. Avoid all forms of exploitation or harmful actions. Strive for the highest level of competence. Avoid dual or multiple relationships. Be aware of professional boundaries. Ensure all relevant parties (e. g. , clients) are informed that services are being supervised. Present accurate evaluations in providing direct feedback and references.

Responsibility to Society Be open to considering appropriate roles for promoting social advocacy or social justice. Take into account systemic issues that apply to the area of work. Ensure that issues of ethics, standards, and legal and regulatory requirements are addressed. Strive to achieve the highest quality of learning to use competence to serve public interest.

ACES (2011) Professional Standards Initiating Supervision Ethics Goal-setting Documentation Giving Feedback Evaluation Conducting Supervision Format The Supervisory Relationship The Supervisor Diversity and Advocacy Supervisor Training and Supervision

APA (2016) Professional Standards 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

Developmental Theory of Clinical Supervision Developmental Phases of Clinical Professionals

Objectives To discuss current research on supervisees’ needs at various developmental phases. To review common challenges with supervisees at various developmental phases. To assess the unique needs of supervisors receiving supervision of supervision.

Developmental Supervision Developmental theories indicate as supervisees gain knowledge and experience, the supervisor’s approach should change (Bernard & Goodyear, 2014). Research shows (Worthington, 2006) Supervisors tend to change their approach based on supervisees’ developmental level. The supervisory relationship changes as supervisees gain experience. Supervisors who are not developmentally appropriate might be offering inadequate or harmful supervision (Falender & Shafranske, 2012).

Supervisee Needs (Muse-Burke & Tyson, 2010) Beginning practicum supervisees reported lower estimates of their counseling skills compared to advanced practicum and interns/postdocs. Microskills Counseling Process Dealing with Difficult Clients Cultural Competence Advanced practicum supervisees reported lower estimates for dealing with difficult clients compared to interns/postdocs.

Supervisee Needs (Muse-Burke & Tyson, 2010) For beginning and advanced practicum supervisees, the following contributed to needs being met: Supervision Satisfaction Supervisory Working Alliance - Agreement on Goals Supervisory Working Alliance - Bond For interns and postdocs, the following contributed to needs being met: Supervisory Working Alliance - Agreement on Goals Supervision Satisfaction Counseling Process Dealing with Difficult Clients

Early Practicum: Supervisee Reactions (Muse-Burke, Tyson-Ryba, & Gray Evans , 2014) Worrying about what to do. Feeling pressured to do the “right” thing. Experiencing self-consciousness in session. Worrying about clinical abilities. Feeling discomfort with clinical role. Reacting to clients. Feeling uncertainty about using clinical skills. Managing time in session.

Early Practicum: Supervisor Tasks (Muse-Burke et al. , 2014) Create a safe place for supervisee to cope with anxieties and difficulties. Give support. Provide instruction and be active. Facilitate exploration of Concerns related to becoming a professional. Related personal issues that influence work with clients. Provide specific feedback about what was not going well in session.

Interns: Supervisee Reactions Interns’ cognitive style and theoretical orientation influences preferred supervisory style (Lochner & Melchert, 1997). Human skills competency and an interpersonally sensitive style were best predictors of interns’ needs being met (Eisenhard & Muse-Burke, 2015). Interpersonally sensitive, attractive, and goal-focused supervisors were most likely to meet interns’ needs (Lieber & Muse-Burke, 2012). Interns with training in clinical supervision appeared developmentally advanced (Crook Lyon et al. , 2008).

Interns: Supervisor Tasks (Muse-Burke et al. , 2014) n Process reactions to clients. n Process self in therapy. n Offer encouragement toward self-determination. n Provide professional development. n Attend to self-care and wellness. n Discuss deeper philosophical and meaning-making about professional identity. n Create a collegial relationship. n Provide words of wisdom.

Post-Docs: Supervisee Reactions (Muse-Burke et al. , 2014) Challenges Supervision Difficult supervisees Clinical Work High risk clients Suggestions Utilize a collaborative approach. Empathize. Transference/ countertransference Risk assessment and management Conceptualization Discuss licensure.

Post-Docs: Supervisor Tasks (Hicks, 2013) Assume a mentor/colleague role. Use a process-oriented approach. Provide live supervision. Employ progress evaluation. Discuss hierarchy/power issues. Apply cognitive behavioral theory. Address developmental supervision theory.

Professionals as Supervisees (Morcos & Muse-Burke, 2011) Novice Mental Health Workers Supervisee counseling self-efficacy was related to: Supervisee Disclosure Role Ambiguity Supervisors are urged to: Create a safe, open atmosphere to increase supervisee selfdisclosure. Address the requirements, roles, and responsibilities of supervisees early in supervision.

Professionals as Supervisees: Peer Supervision (Muse-Burke & Tyson-Ryba, 2015) Challenges Inconsistencies in commitment Time of day Different developmental levels Creating safety Membership changes Suggestions Establish and maintain group norms. Select day/time when most are available. Allow senior staff to mentor junior staff. Ensure confidentiality. Manage transitions to group: Orientation to new members. Termination for departing members.

Supervisors as Supervisees (Muse-Burke & Tyson-Ryba, 2015) Challenges Training and experience in supervision Willingness to disclose growth edges Openness to feedback Diverse views of training and supervision Diverse theoretical orientations Power differentials Interpersonal style differences

Supervisors as Supervisees (Muse-Burke & Tyson-Ryba, 2015) Suggestions Develop a supervision contract. Provide role induction. Assess supervisors’ competence. Establish goals. Assign key readings or provide training. Address issues related to power and interpersonal process early and often. Document. Receive consultation for supervisor of supervisors. Consider hiring an external supervisor.

Effective versus Inadequate or Harmful Clinical Supervisors

Objectives To describe the characteristics of helpful and effective clinical supervisors versus inadequate and harmful supervisors. To list methods by which institutions might better ensure effective clinical supervision. To identify strategies for supervisees to advocate for effective clinical supervision or address problems with inadequate or harmful supervision.

Competent Supervisors (Falender & Shafranske, 2012) Develop an effective working alliance. Collaborate on developing goals and tasks. Clearly articulate roles and responsibilities. Model self-assessment. Provide feedback to supervisees. Receive feedback from supervisees.

Effective Supervisors (Ladany, Mori, & Mehr, 2013) Encourage autonomy. Strengthen the supervisory relationship. Allow for open discussion. Exhibit positive personal and professional qualities. Demonstrate clinical knowledge and skills. Provide constructive challenge. Offer feedback and reinforcement. Engage in and value supervision.

Ineffective Supervisors (Ladany et al. , 2013) Depreciate supervision. Demonstrate ineffective case conceptualization. Establish a weak supervisory relationship. Exhibit insufficient knowledge and skill. Provide insufficient feedback. Emphasize limitations. Possess negative supervisor characteristics.

Inadequate or Harmful Supervision (Falender & Shafranske, 2012) Imbalanced Developmentally inappropriate Intolerant of differences Inflexible Unethical Untrained

Framework for Evaluating Supervisors (Falender et al. , 2004) Complete a course on supervision. Confirm previous supervision of supervision. Demonstrate evidence of direct observation. Articulate diverse supervisory experiences. Solicit supervisee feedback. Engage in self-assessment. Evaluate supervision outcomes.

Methods of Supervisor Evaluation (Falender & Shafranske, 2004) Qualitative and quantitative evaluation of interactions in supervision. Evaluation of the progress of the supervisee toward supervision goals. Analysis of client-report outcome data. Analysis of critical events in supervision.

Supervisee Needs Index (Muse-Burke & Tyson, 2010) Supervisee self-report 48 items; 7 -point, Likert-type scale Scale Development Qualitative study of trainees’ unmet needs Expert review & pilot study Scale Validation 2 Studies: Psychology (N=311); Counseling, Marriage & Family, and Social Work (N = 201) Cronbach’s alpha =. 976, . 978 1 factor, 50. 92% of total variance

Other Supervision Measures Supervision Satisfaction Questionnaire (Ladany et al. , 1996) Competencies of Supervisor Scale (Borders & Leddick, 1987) Supervisory Styles Inventory (Friedlander & Ward, 1984) Working Alliance Inventory-Trainee Version (Bahrick, 1990) Cross-cultural Counseling Competence Inventory. Revised (La. Fromboise, Coleman, & Hernandez, 1991)

Advocacy for Supervisees (Muse-Burke & Monday, 2016) Consult with trusted others. Peers Supervisors Review the ethics code, supervision guidelines, and supervision literature. Discuss concerns with supervisor. Request a change in supervisor. Consider filing a complaint. Department Institution Professional association Ethics board State licensing board Practice self-care.

Skills for Building a Strong Supervisory Working Alliance

Objectives To define the supervisory working alliance. To describe the conditions necessary to establish a strong supervisory working alliance. To discuss how supervisee nondisclosure, supervisor disclosure, and role induction affect the supervisory working alliance.

Supervisory Working Alliance (Bordin, 1983) A collaboration for change, which includes: Mutual agreement and understanding between the supervisor and supervisee of the goals of supervision. Mutual agreement and understanding of the tasks of the supervisor and supervisee. The emotional bond between the supervisor and supervisee.

Forming an Effective Supervisory Relationship (Moses & Hardin, 1978) Facilitative conditions ground the relationship in mutual respect and trust. Empathy (e. g. , verbal acknowledgment of the struggles of growing; listening; restatement; focusing on meaning). Respect (e. g. , acceptance of the supervisee as a person; appropriate eye contact and body language; positively identifying supervisee strengths). Concreteness (e. g. , providing specific information to increase self-awareness, maintain effective behaviors, and encourage professional change).

Forming an Effective Supervisory Relationship (Moses & Hardin, 1978) Action-oriented conditions help supervisees understand the profession and act accordingly. Genuineness (e. g. , being oneself with the supervisee; modeling appropriate disclosure; sharing the human side of being a clinician). Confrontation (e. g. , sharing perceptions of the supervisee's incongruent feelings, attitudes, or behaviors to assist the supervisee in gaining a deeper awareness as a professional). Immediacy (e. g. , focusing on the here-and-now interactions of the supervisor and supervisee).

Supervisee Nondisclosures Supervisees must disclose information about clients, themselves, and the clinical and supervisory processes to maximally benefit from supervision (e. g. , Blocher, 1983; Stoltenberg & Delworth, 1987). However, 97. 2% of trainees withhold information from their supervisors (Ladany et al. , 1996). Examples of Nondisclosures: Negative reactions to the supervisor (90%) Clinical mistakes (44%) Countertransference (22%)

Supervisee Nondisclosures (Ladany et al. , 1996) Reasons for Supervisee Nondisclosure Negative feelings (e. g. , "shame” and “embarrassment”) A poor supervisory alliance (e. g. , "mistrust") When core conditions of the supervisory alliance (i. e. , mutual trust, liking, and caring) were not met, the supervisee was less likely to disclose relevant information. Consequently, supervisee advancement and client well-being may have been jeopardized.

Supervisor Self-Disclosures Self-disclosures are personal statements about oneself made to another person (Watkins, 1990). Supervisor self-disclosures produce an environment in which the supervisee is comfortable sharing uncertainties and concerns (e. g. , Norcross & Halgin, 1997). The more frequently the supervisor self-disclosed, the stronger was the supervisory working alliance (Ladany & Lehrman-Waterman, 1999).

Supervisor Self-Disclosures 12% of supervisees said their supervisor made at least one self-disclosure concerning the supervisory relationship (Ladany & Lehrman-Waterman, 1999). Self-disclosure regarding the supervisory relationship could strengthen the alliance or aid in the repair of a troubled relationship. Focusing on the supervisory relationship may create a parallel process and encourage the supervisee to address therapeutic relationship with clients.

Role Conflict & Role Ambiguity (Olk & Friedlander, 1992) Role conflict is when a supervisee is required by the supervisor to either engage in behaviors that are inconsistent with the supervisee's personal convictions or participate in numerous roles that demand conflicting behaviors. Role ambiguity is when a supervisee is uncertain about the expectations of her or his role, the methods required to fulfill those expectations, and the consequences of positive or negative performance.

Role Conflict & Role Ambiguity Supervisees who perceived the supervisory working alliance as strong tended to experience less role conflict and ambiguity (Ladany & Friedlander, 1995). Role conflict within the supervisory relationship had no effect on supervisees' self-statements, anxiety levels, or performance in counseling (Friedlander et al. , 1986).

Strategies for Working with Challenging Supervisees

Objectives To describe the importance of remediation and gatekeeping for clients, supervisees, the community, and the profession. To list various strategies for remediation and gatekeeping. To discuss supervisory skills for use with resistant supervisees demonstrating problems of professional competence.

Importance of Gatekeeping - a means of preventing unsuitable supervisees from entering the profession (Ziomek-Daigle & Christensen, 2010). Remediating to correct supervisees’ deficits. Steering unfit supervisees toward other professions. Reasons to Gatekeep Ethical mandates (e. g. , ACA, 2014; APA, 2002) Professional standards (e. g. , ACES, 2011; APA, 2015) Protection of the community (Bernard & Goodyear, 2014) Safeguard other trainees (Rosenberg et al. , 2005; Shen-Miller et al. , 2015; Veilleux et al. , 2012)

Standards and Competencies Knowledge Coursework Assessments Standardized Licensure/Certification Tests Skills Evaluations by Supervisors Evaluations by Clients Dispositions Characteristics of Effective Psychotherapists Index (CEPI; Muse-Burke & Surace, 2014)

Necessary Dispositions (Reick & Callahan, 2013; Sperry, 2000; Wampold & Budge, 2012) Warm Friendly Confident Experienced Honest Open Alert Flexible Supportive Empathic Attending Facilitates expression of affect Accurately interprets Explores feelings Genuine Respectful Emotionally Intelligent

Problematic Dispositions (Brear & Dorrian, 2010; Oliver et al. , 2004; Rosenberg et al. , 2005; Shen-Miller et al. , 2011) Limited self-awareness Poor professionalism Insensitive Interpersonal deficits Poor rapport building skills Insufficient insight Judgmental Low awareness of emotions Limited empathy Psychopathology Failure to apply ethical and legal principles Immaturity Poor communication Limited critical thinking

Standards for Gatekeeping (Johnson et al. , 2008) Prepare supervisors and educators for evaluating students. Ensure familiarity with all ethical guidelines. Ensure competence in identifying deficits and providing feedback. Acknowledge competence is neither dichotomous nor static. Attempt to separate dual roles.

Standards for Gatekeeping (Johnson et al. , 2008) Prevent inflation of evaluation based on likeability and alliance. Provide timely and accurate feedback using summative and formative evaluations. Develop standard methods that are valid and reliable for measuring competence. Utilize formal and informal methods to establish cooperation between training programs, internship sites, and licensing boards.

Gatekeeping Practices (Kaslow et al. , 2007; Muse-Burke et al. , in press; Russell et al. , 2007; Veilleux et al. , 2012) Consult with other faculty/staff Talk with supervisee about concern Increase informal communication and interaction with supervisee Assign readings related to improving skills Complete a plagiarism tutorial and test Submit papers for plagiarism check Review professionalism DVDs or webinars Observe master clinician DVDs Write a personal conduct statement Write a paper Transcribe a portion of client sessions and provide alternative responses Increase supervision of supervisee Increase direct observation of supervisee Obtain tutoring

Gatekeeping Practices (Kaslow et al. , 2007; Muse-Burke et al. , in press; Russell et al. , 2007; Veilleux et al. , 2012) Provide a referral for personal counseling Require to repeat practicum Provide a referral for psychological or psychiatric assessment Develop a written remediation plan Reduce course load Assign a peer mentor Shift client caseload Assign a co-clinician Require to repeat coursework Require to complete extra coursework Write a letter of concern Put on probation Require a leave of absence Counsel out of the program or field Dismiss from the program File a complaint with an ethics committee

Barriers to Gatekeeping (Elman et al. , 1999; Falender & Shafranske, 2004; Forrest et al. , 2013; Hoffman et al. , 2005; Robiner et al. , 1993; Russell et al. , 2007; Strom-Gottfried, 2000) Procedural Factors Establishing and evaluating necessary competencies Being proactive (instead of reactive) Protecting against legal repercussions Personal Factors Social loafing Discomfort and conflict Institutional Factors Enrollment/Vacancies Institutional reputation Accreditation Support from colleagues and administrators Departmental culture (i. e. , avoidance, individualistic attitudes, multicultural competence)

Strategies with Resistant Supervisees Provide remediation and gatekeeping initiatives in a supportive atmosphere; acknowledge supervisees’ strengths and successes (Ladany et al. , 2016). Spend more time than might be typical building trust (Kress et al. , 2015). Use relational and reflective strategies initially and move towards more challenging approaches as time progresses (Grant et al. , 2012). Collaborate with supervisees in developing the remediation plan (Bernard & Goodyear, 2014).

For more information: Janet L. Muse-Burke, Ph. D. , L. P. C. Department of Psychology & Counseling jlmuse-burke@maryu. marywood. edu 570 -348 -6211 ext. 2367 Private Practice janetmuseburkephd@gmail. com 570 -589 -0303 www. janetmuseburkephd. com