Supervision
Click on this link for the article:
An overview of ideas and concepts relevant to clinical supervision:
All substance abuse prevention and treatment agencies are systems. A central part of the supervisor’s job is to regulate the system. Supervisors must insure that:
- agency practice is within legal and regulatory boundaries;
- staff development, recruitment, and retention occurs;
- staff skill levels are in line with evidence based practice guidelines;
- each staff member’s knowledge, skills, and abilities are continually enhanced through education and clinical supervision.
Supervisors should utilize state and federal regulation, evidenced based practice models, and context specific guidelines when developing supervision specific policies and procedures.
Isomorphism and Parallel process are frames for understanding the supervisor’s role within the treatment system:
By proxy of their role, agency administrators are the stewards who guide and influence all levels of program functioning. The principles of Isomorphism, systems and “holon” theories provide theoretical constructs for understanding and impacting upon prevention/treatment effectiveness through quality supervision.
Relational process dynamics will also have parallel patterns that both covertly and overtly influence inter and intrapersonal relational dynamics.
The insight gained through understanding ones position of influence within a system is invaluable. Administrators have a responsibility to positively influence and enhance agency functioning through effective supervision.
The definition of clinical supervision is expanded to involve comprehensive insight into the required elements of a supervisory policy.
Supervision Defined
There are three essential elements that a well rounded supervisory policy will address: clinical, administrative, and educational:
- Clinical supervision involves a mentoring process that is designed to insure best practice (prevention/treatment) service delivery. Clinical supervision is expected to involve a transfer of knowledge, skills, and attitudes directly pertinent to working with patients. This element should primarily be addressed through one on one mentoring that ties theory and technique to practice outcomes.
- Administrative supervision involves those activities that insure legal and regulatory compliance. This element can be primarily addressed through a sound quality assurance process.
- Educational supervision involves activities that elevate the supervisee’s knowledge and understanding through a structured learning process. This element can be primarily addressed through a combined group and individual development process.
While it is recognized and expected that there will be overlap between the three elements, each must be addressed for a comprehensive policy to be in place.
Things to remember about supervision
Supervision is not therapy its primary objective is to develop competencies;
Supervision monitors patient care, insures safe conduct and regulatory compliance;
Education in this context is designed specifically to develop competencies, and theoretical understanding as it applies to clinical practice;
There is an evaluative element to supervision;
Supervision should include measurable goals and objectives as part of the supervisee’s individual development plan;
Supervision should be a documented process.
Within the last decade a competency or strengths based approach has emerged departing from the medically modeled tradition that focuses on assessment of deficits or problems and prescribes a remedy to the ailing client by the expert in charge
In order to keep pace with the prevalent strengths based models supervision must employ a similar view.
Pathology or Problem focused Versus Solution Focused
Most traditional supervision paralleled conventional counseling, looking for what the supervisee was doing incorrectly or not doing enough of mostly in the area of technique. Strengths- Based, punctuating what the counselor does well rather than looking for problems.
Competency Development Versus Technique Acquisition
Involves
Modeling
Truax and Carkhuff 1967, suggest modeling is the one of the best methods for supervising. Thus effective supervisors demonstrate empathy, warmth and genuineness.
The primary competency is the attainment of communication and joining skills.
Flattening Hierarchies
In contrast with the hierarchical position strengths based models of supervision attempt to sidestep hierarchy in favor of co-constructing ideas with the supervisee.
A non-hierarchical supervisory relationship is one where there exists a give and take, where the supervisor does not assume to have more correct or privileged knowledge of both the supervisee’s and clients goals, intentions or views, and where the supervisor works intentionally to create a strengths based supervision.
Isomorphic Nature of the Supervisory relationship
Iso meaning same and morph meaning structure
Any two systems that are connected are said to have isomorphic properties
A change in one part of the interconnected system will correspondingly change that part of the other system
In the supervision process this means that what happens at one level (supervision) will likely be repeated at another level ( counseling)
Influence
Isomorphy refers to that part of two or more structures that have a correspondence.
This correspondence has the potential of influence. Patterns of behavior and communication are isomorphic
Applying isomorphic process to supervision
Wu- Wei supervision or the stance of not knowing
If one is honest with oneself there is really no knowing
Wu- means not or non
Wei – action –making- doing- striving- straining
Allan Watts—1989
Influence
As there is an interconnection between all systems that are interrelated, this correspondence has the potential of influence. Influence is a matter of the whether the supervisee finds a fit with what is presented by the supervisor.
Isomorphic supervision reflects the notion that the process of supervision also allows for the altering and shaping of supervisees through intentionality.
Intentionality
How does a supervisor establish a non-hierarchical relationship, provide supervision that includes the concept of a non pathological frame of reference, maintain a not knowing and active/ non active stance, and still address or pay attention to the use of isomorphy.
One way is to use their counseling theories as models for supervision.
Non Hierarchical
We deliberately use concepts that reflect a non hierarchical relationship, and co-creation, by situating our ideas in a context that describes where the ideas came from, a solution orientation, and a focus on the utility and strengths, rather than focusing on a fixed set of assumptions and techniques. Thus, techniques take a back seat to issues of respect and mutually co-creating solutions to the problems being presented in supervision.
Techniques
Techniques are suggested as long as placed in the context of interpretations or ideas about possible tasks.
What seems important is the attitude of non-expert, transparency, respect.
For supervision these premises imply that the supervisor is an expert in an exploratory conversational process, in which she or he engages collaboratively with the supervisees in the telling, inquiring, interpreting, and shaping of the supervisee’s narrative. Such a supervisory position implies that the supervisor is not the expert on the supervisees, but that the supervisee is the expert on his or her life and on his or her own narratives, experiences, and knowledge. (Anderson and Swim, 1995)
Parallel process (unconscious dynamics)
Isomorphism suggests that the dynamics of supervisee –client subsystem tend to get reflected in the supervisor-supervisee subsystem as a parallel process
The simultaneous emergence of emotional difficulties in the relationship between the clinician and the patient are similar to the emotional difficulties in the relationship between the supervisor and the supervisee.
The implication is that the difficulties the supervisee experiences with the client is carried into the supervisory session and is reenacted with the supervisor.
Ekstein and Waller 1958 recognized the powerful affective and interpersonal components of the supervisory process. They termed this unconscious dynamic (parallel process). Their model was process oriented with emphasis on the interaction between patient, supervisee and supervisor.
Mattinson (1975)
Transference/ Countertransference
The unconscious operations of transference and countertransference are significant aspects of the parallel process phenomenon. While the client may transfer feelings related to a significant person in the patients past upon the supervisee ( referred to as transference). A strong transference reaction from the patient is characterized by a distorted perception of the supervisee as therapist, through an inappropriate and often repetitive reaction, provoked by the patient’s underlying need to make the relationship with the supervisee fit into the psychodynamic structure of a previous one. Since countertransference is seen to be the reverse of transference, to which the supervisee is in reaction, it is very important for supervisees to determine whether their feelings stem from a personal past relationship and are transferred to the patient or if the feelings are stimulated solely by the client’s behavior or feelings. (Kahn, 1979)
The same dynamics are likely to occur within the supervisee –supervisor relationship as well. The supervisor must be cognizant of transference reactions from the supervisee and vice versa.
Because parallel process is an inevitable component of the supervisory relationship an increased awareness of the dynamics is crucial. To allow the supervisor supervisee to utilize the process as a learning exercise. The most common signs of a parallel process may include inexplicable therapeutic/ supervisory impasses, the supervisee’s sudden change in the transference image of the supervisor and atypical behavior in either the supervisor or the supervisee.
To recognize the parallel process as it occurs the supervisor must be aware of himself / herself in terms of being tuned into what he/she experiences in the supervisory session. The supervisors sensitivity to his/her own process will better enable the supervisor in determining at what relationship level the issues of the parallel process dynamic has originated . The parallel process tends to be an unconscious acting out of what cannot be verbalized. Thus if the supervisor is only dealing with the verbal exchange, dismissing the covert process, the essence of the communication will be lost.
Click on the link below for an excellent article that addresses ethical concerns
The Supervision Process: Complications and Concerns
An overview of addictions counselor competencies
Adapted from the work of: William A. Howatt, PhD, EdD, ICADC, a Post Doc at the UCLA School of Medicine, serves on the faculty at Nova Scotia Community College and is Co-editor (with Robert H. Coombs) of the Wiley Book Series on Treating Addictions.
1. Addiction Definitions and Treatment Model
What is your definition of addictive disorders, and what is your treatment model?
2. Addictive Disorders
Define the array of addictive disorders you will be faced with treating.
3. Understanding Motivation for Change
How do you conceptualize the motivation for change, and how does it impact treatment planning?
4. Referral Resources and Case Management
What are your referral procedures? How do you define case management and your typical role in the process?
5. Multicultural Considerations
How do you formally and informally screen for multicultural differences?
6. Counseling Theory
What are your two preferred counseling theories, and why have you chosen them?
7. Counseling Techniques Provide specific examples of techniques that you use to engage the patient.
8. Counseling Techniques
What are your five standard counseling techniques, and why have you chosen them?
9. Addiction Clinical Measures and Screening Tools
What are your three favored addiction measures, and what is your most useful screening tool?
10. Understanding the role of mutual aid groups Provide an overview of the role of mutual aid groups in addictions medicine.
11. Professional and Personal Ethics
How do you define your professional and personal ethics? Explain the role of the CASAC Canon of Ethics in addictions clinical practice.
12. Crisis Intervention
What is your crisis intervention model?
13. Addictions Assessment Protocol
Describe your assessment process from beginning to end. Be specific as to how you assess physical, emotional, spiritual, and mental health.
14. Treatment Planning
What is your treatment planning process, and how do you develop treatment plans?
15. Relapse Prevention
What relapse prevention model are you currently using, and why have you chosen this one?
16. Aftercare Program
How do you design aftercare programs?
17. Addictive Disorder Prevention
What is your addictive disorder prevention model?
1. Addiction Definitions and Treatment Models
- While there is no universally accepted definition for addiction, it is essential to have a clear concept of both addiction disorders and treatment models (e.g., biopsychosocial). It is critical that definitions for addictive disorders be based in clinical research (e.g., the dopamine reward system is becoming recognized as a common link for many addictive disorders).
2. Addictive Disorder
- There are many different addictive disorders. Those most commonly covered in the literature are: alcohol, drugs, gambling, work, sex, interactive, buying, and food
- It is critical that addiction counselors understand both drug classifications and the drugs that require supervised medical detoxification (e.g., alcohol).
3. Understanding Motivation for Change
- The Transtheoretical/Stages of Change model is widely accepted as a critical benchmark for determining a client’s motivation and planning treatment strategies. This six-step model has utility in all aspects of treatment from intake to aftercare planning.
- An effective resource that provides an overview of the Transtheoretical/Stages of Change model is the following journal article: Prochaska, J.O., & DiClemente, C.C. (1982).
4. Referral Resources and Case Management
- Each addiction counselor must have a current list of referral services for their region.
5. Multicultural Considerations
- We live in a multicultural society, and it is paramount that each addiction counselor have a built-in process to screen for multicultural needs. Addiction counselors must challenge any potential prejudices or preconceived notions to be effective with a multicultural population.
- Addiction counselors cannot assume that one treatment or clinical model will fit all.
6. Counseling Theory
- Counselors need a frame of reference that explains why people do what they do from a theoretical perspective. It is important that each addiction counselor develop his or her own unique counseling orientation that is grounded in accepted counseling theory. The top five theoretical constructs utilized in the field of chemical dependency treatment are: Cognitive Behavioral, Rational Emotive, Brief Solution Focused, Transtheoretical Model, Motivational Interviewing.
7. Counseling Process
- Counseling process must have a clearly defined beginning, middle, and end.
8. Counseling Techniques
- A well-developed set of proven counseling techniques is critical to the success of any addiction counselor. Typical addiction counseling techniques include journaling, magic wand, and the triple column technique, which represent merely a sampling of contemporary techniques.
10. Addiction Clinical Measures and Screening Tools
- Addiction counselors must be current in addiction measures, e.g., Substance Abuse Subtle Screening (SASSI) (see www.sassi.com/sassi/index.shtml) and screening tools (e.g., the portable breath alcohol tester, see www.columbialab.com) that are indigenous to their clinical environment.
- Addiction counselors need to be familiar with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) as well as with psychological measures that are commonly used by their multi-disciplinary teams (e.g., dual diagnosis clients who are depressed are often monitored by the Beck Depression Inventory®).
12. Professional and Personal Ethics
- Addiction counselors are accountable to both a professional and personal code of ethics.
- Addiction counselors must be aware of organizational policies and procedures, standing orders, local and national laws, and changes in legislation.
13. Crisis Intervention
- Addiction counselors should have an understanding of a crisis intervention model.
- Addiction counselors are advised to have basic skills in first aid, suicide intervention, and self-protection. The wrong time to prepare for a crisis situation is when a crisis occurs.
14. Addictions Assessment Protocol
- Structural assessments are service guides to assess clients that never replace sound clinical judgment. Formal assessments often involve multidisciplinary teams. All assessments of addictive disorders must take into consideration the potential for dual diagnosis.
15. Treatment Planning
- Treatment planning can be facilitated with structured tools described in The Addiction Treatment Planner, 2nd Edition (John Wiley & Sons, 2001) by Robert R. Perkinson and Arthur E. Jongsma, Jr. Treatment planning must include a sound termination strategy that will ensure a smooth transition to aftercare programs.
16. Relapse Prevention
- Relapse prevention must be incorporated into any treatment planning. It is important that relapse prevention be discussed throughout treatment.
17. Aftercare Program
- When a client exits counseling, it is paramount to help the client develop a well thought out aftercare program to assist in relapse prevention. An aftercare plan, to be effective, needs to be a natural extension of the client’s treatment plan.
18. Addictive Disorder Prevention
Addiction counselors must have a clear understanding of addictive disorder prevention target areas. Recent research has provided a clearer picture of what works in prevention. One approach that shows great promise is the Risk and Protection Model, developed at the University of Washington by J. David Hawkins, Richard Catalano, and Janet Miller.
Adapted from the work of: William A. Howatt, PhD, EdD, ICADC, a Post Doc at the UCLA School of Medicine, serves on the faculty at Nova Scotia Community College and is Co-editor (with Robert H. Coombs) of the Wiley Book Series on Treating Addictions.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed., text revision). Washington, DC: Author.
Berghuis, D. J. & Jongsma, Jr., A. E. (2001). The addiction progress notes planner. New York, NY: John Wiley & Sons.
Bissell, L. & Royce, J. E. (1994). Ethics for addiction professionals. Center City, MN: Hazelden.
Coleman, H. L. K. & Pope-Davis, D. B. (Eds.) (1995). Multicultural counseling competencies: Assessment, education and training, and supervision, Vol. 7. Sage Publications.
Coombs, R.H. (Ed.). (2001). Addiction recovery tools: A practical handbook. Thousand Oaks, CA: Sage.
Coombs, R. H. (in press). Addictive disorder: A practical handbook. New York, NY: John Wiley & Sons.
Corsini, R.J. & Wedding, D. (1995). Current psychotherapies (5th edition). Itasca, IL: F. E. Peacock.
Doweiko, H. E. (1996). Concepts of chemical dependency. Pacific Grove, CA: Brooks/Cole.
Egan, G. (1997). The skilled helper. Belmont, CA: Wadsworth Publishing Co.
Gilliland, B. & James, R. (2001). Crisis intervention strategies (4th edition). Pacific grove, CA: Brooks/Cole.
Howatt, B. (2000). The human services counseling toolbox. Pacific Grove, CA: Brooks/Cole.
Meyers, P.L. & Salt, N.R. (2000). Becoming an addictions counselor: A comprehensive text. Boston, MA: Jones & Bartlett.
Palanek, L., Bois, C., Upfold, D., Murray, R., & Gavin, M. (1990). Assessment handbook for addiction treatment programs. Toronto, Ontario: Centre for Addiction Studies and Mental Health.
Perkinson, R. R. & Jongsma, Jr., A. E. (2001). The addiction treatment planner (2nd Edition). New York, NY: John Wiley & Sons.
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-287.
Reid, J. (1995). The journey: 52 weeks in recovery. Fort Lauderdale, FL: Abbott-Sterling Publishing.
Smith, R.L. & Stevens-Smith, P. (2000). Substance abuse counseling: Theory and practice (2nd edition). Englewood Cliffs, NJ: Prentice Hall.
Web Site References
Dual Diagnosis Recovery Network, www.dualdiagnosis. org
William Glasser’s Choice Theory and Reality Therapy, www.wglasser.com
Gorski-CENAPS®, www.cenaps.com
Institute of Medicine, www.iom.edu
Portable breath alcohol tester, www.columbialab.com
Sober Recovery, www.soberrecovery.com/links/forprofessionals.html
Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention (CSAP), www.samhsa.gov/csap
Substance Abuse Subtle Screening Institute (SASSI), www.sassi.com/sassi/index.
Outcome Driven Education
A how to guide
The purpose of this document is to empower learners to develop their own competency development plan. Empowerment is actualized by presenting an overview of logic model theory as it applies directly to substance use disorder counselor competency development. Next, logic model concepts are integrated into an addictions practitioner specific competency development framework. Finally, supervision is addressed through an educational matrix.
The logic model provides a step by step recipe for developing competence. The primary value of the process is that it allows the user to conceptualize, actualize, and measure progress toward their self identified learning goals.
Outcome driven is a synonym for the phrase logic model in that they both are primarily focused on the end result. Outcome driven activity involves a continuous connection to what one wants to accomplish. Measurement of progress toward the end result is conducted as each step is completed
A logic model provides direct focus on the process of becoming a competent counselor. This is a developmental process and not an event. Most master level counselors indicate that that they consider themselves to be in a continual state of learning and development. Effective counselors maintain an awareness of both process and content elements. This awareness is equally important for us as students in that there is value in consciously focusing on the educational process as well as the day to day learning content. Focusing on process and content empowers learners by having them own and consciously choose each step toward their self defined goals. The learning that occurs when a person completes a credentialing exam pales in comparison to the years of education that occurred prior to taking the test. Many individuals remain fixated on the final result of becoming credentialed without being aware of their own competency development process. If the individual is only focused on what they need to pass a test, s/he may miss what they need to know most. The model presented here uses a holistic approach; it is one that asks the reader to consider the broad spectrum of educational experience.
Logic models are commonly expected to contain the following elements:
Inputs- resources;
Activities- work;
Outputs-immediately accomplished tasks;
Outcome- the long term goal or goals;
Source: www.uwex.edu/ces/pdande/evaluation/evallogicmodel.html
Outcome-behavioral goal
Begin with a concrete vision of what you would like to accomplish. Your vision will become the outcome or the final result of all of your efforts. The outcome exists as a peripheral aspect; much like becoming sober is a result for patients who we encourage to remain focused on accomplishing the day to day tasks rather than attempting to exist in the future.
Inputs-resources
What do you have to put into the process? Reflect on people who may help you, places where you can go to learn, think of relevant experiences, attitudes, and values that drive your desire to become a counselor. When developing your list of inputs, consider all biological, psychological, social, spiritual, and political areas of your life.
Activities- Macro-process
What are the actions that you will undertake to reach your goal? Conceptualize the process of developing competence. Activities involve the bigger picture of what you intend to do whereas outputs indicates the concrete detail of what you will do. You may wish to draw a diagram that outlines the parts of your learning and development process. Connect your resources to the process elements and list what you will have to do to complete each section. When developing your list of activities consider all biological, psychological, social, spiritual, and political areas of your life.
Judge the relevance of each activity to your final goal.
Outputs-Micro-content- detail
What you will do and how will you know when each task is completed? Break the activities into building blocks or stages that you can complete one by one. How will you know that the task has been satisfactorily completed?
Individualized Instructional Plan:
The theory behind the practice
Anchor:
- If you are not working on improving your competence, then what are you doing?
- As a counselor one of your primary responsibilities is to continually improve your practice. All counseling practices should be grounded in sound reason and empirically validated best practice research;
Three ideas:
- Developing competence should be a systematic process;
- Students are in charge of their own learning and development;
- Every interaction can be measured against your goal of developing competence.
Learning Defined:
Learning does not occur when someone is sitting passively in a class room; it occurs when the student actively engages in the process of applying the material to their everyday life.
Evidence of learning;
- Learning is present when individuals integrate what they are experiencing into their practice thus demonstrating a transfer of relevant knowledge, skills, and attitudes.
The best assessment is seeing something done.
Learning without a plan is like flying without guidance from a control tower.
Learning activities process model:
- Envision- Develop a statement of purpose;
- Clarify- List the competencies that you would like to develop;
- Identify- List learning resources;
- Apply- Write an action statement;
- Measure- Write a statement of how you would know that you were moving toward your goal.
Elements found in every profession
If you want to join a profession than you must gain an ability to address each of these standardized elements:
A function specific jargon;
A scope of practice;
A canon of ethics that guides practice;
A specific area of practice;
A body of empirical knowledge that guides practice;
A standardized education process.
Develop your learning goal
Use the elements that define a profession to develop your specific learning goals.
Next, brain storm and write down:
- Theories that you want to learn about;
- Skills that you would like to develop;
- Attitudes, values, and philosophies that will ground your practice.
The goal is to develop mastery in knowledge, attitudes and skills as it applies to each core competency.
Knowledge, Skill, and Attitude defined
Knowledge-The intellectual function -how one acquires and classifies information;
The theory behind the practice
Skills -are expressive functions and how one demonstrates what has been learned;
- Skills are often recognized as behaviors
- Skills may be further defined as:
A learned action or an observable competence
You will know that you have gained an understanding when you can explain something to others in a way that they understand.
Attitudes-Are personality functions that affect how we perceive and interact;
Base beliefs Values
Emotions Opinions
Self esteem Philosophy
Apply the model by developing your own individualized competency development plan
The practice that flows from the theoretical foundation
Envision
Operationalize your vocational goal into a statement of purpose.
What would you have to do to move to the next level of competence?
For example:
I want to be an expert substance use disorder counselor.
Clarify
Identify the specific knowledge, skills, and attitudes that area associated with your vocational goal. Technical Assistance Publication 21 is one source that illustrates addiction counseling competencies:
| Technical Assistance Publications (TAP 21): Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice. www.nattc.org/respubs/tap21/tap21.pdf |
Identify
List resources that you will use in your quest for competence:
- Supervision
- Course work
- Peer supervision
- Feedback from patients
Apply
Now that you have decided what you want to do – what tools you will need-and who will help you – Identify what you will be doing and where you will be doing it.
- I will apply this to my group practice
- I will apply this in my supervision process
Measure
If you were doing it right how would you know?
- What would you be feeling, seeing, doing, experiencing?
- How would people be responding to you?
Use the process model to get the most out of supervision
Educational supervision matrix
Measuring progress toward intended goals
Assessment loop
The assessment loop is a mechanism whereby the learner continuously returns to the theories, values, and skill sets that ground h/her practice as a means of concretely measuring this practice against a standard. The core competencies also provide practice standards that may be used as guides for measuring practice improvement. It is expected that novice practitioners will follow these guides by rote as they are building a competence foundation. Advanced or exemplary practitioners should demonstrate an ability to explain and blend various aspects of the theories underlying their practice.
Continually comparing one’s activity against a standard is prudent as it allows insight and comparison between intent and action.
Core competencies
Knowledge –Skills- Attitudes
Assessment of competency
Novice- Master
Identify and list strengths
as well as opportunities for improvement
Collaborate-
Identify –and agree on learning outcomes
What you would like to accomplish
Develop a plan to reach the identified goals
Establish a trajectory
In your plan:
Provide dates, times and deliverables for each party involved
Provide measurable objectives for both the counselor and the supervisor
Supervisor’s responsibility
Provide feedback and other mechanisms that will assess the student’s process.
References:
Program Development and Evaluation University of Wisconsin Extension Web Resource (2008, April 22) Retrieved August 21, 2008 fromwww.uwex.edu/ces/pdande/evaluation/evallogicmodel.html
Technical Assistance Publications (TAP 21): Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice.(2006,December 7) Retrieved August 21, 2008 from
www.nattc.org/respubs/tap21/tap21.pdf
