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Models of Supervision - Page 2

Clinical supervision is emerging as the crucible in which counselors acquire knowledge and skills for the substance abuse treatment profession, providing a bridge between the classroom and the clinic. Supervision is necessary in the substance abuse treatment field to improve client care, develop the professionalism of clinical personnel, and impart and maintain ethical standards in the field. In recent years, especially in the substance abuse field, clinical supervision has become the cornerstone of quality improvement and assurance.


Your role and skill set as a clinical supervisor are distinct from those of counselor and administrator. Quality clinical supervision is founded on a positive supervisor–supervisee relationship that promotes client welfare and the professional development of the supervisee. You are a teacher, coach, consultant, mentor, evaluator, and administrator; you provide support, encouragement, and education to staff while addressing an array of psychological, interpersonal, physical, and spiritual issues of clients. Ultimately, effective clinical supervision ensures that clients are competently served. Supervision ensures that counselors continue to increase their skills, which in turn increases treatment effectiveness, client retention, and staff satisfaction. The clinical supervisor also serves as liaison between administrative and clinical staff.


This TIP focuses primarily on the teaching, coaching, consulting, and mentoring functions of clinical supervisors. Supervision, like substance abuse counseling, is a profession in its own right, with its own theories, practices, and standards. The profession requires knowledgeable, competent, and skillful individuals who are appropriately credentialed both as counselors and supervisors.


Definitions


This document builds on and makes frequent reference to CSAT’s Technical Assistance Publication (TAP), Competencies for Substance Abuse TreatmentClinical Supervisors (TAP 21-A; CSAT, 2007). The clinical supervision competencies identify those responsibilities and activities that define the work of the clinical supervisor. This TIP provides guidelines and tools for the effective delivery of clinical supervision in substance abuse treatment settings. TAP 21-A is a companion volume to TAP 21, Addiction Counseling Competencies (CSAT, 2006), which is another useful tool in supervision.


The perspective of this TIP is informed by the following definitions of supervision:

  1. “Supervision is a disciplined, tutorial process wherein principles are transformed into practical skills, with four overlapping foci: administrative, evaluative, clinical, and supportive” (Powell & Brodsky, 2004, p. 11). “Supervision is an intervention provided by a senior member of a profession to a more junior member or members. . . . This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior per-son(s); monitoring the quality of professional services offered to the clients that she, he, or they see; and serving as a gatekeeper of those who are to enter the particular profession” (Bernard & Goodyear, 2004, p. 8).
  2. Supervision is “a social influence process that occurs over time, in which the supervisor participates with supervisees to ensure quality of clinical care. Effective supervisors observe, mentor, coach, evaluate, inspire, and create an atmosphere that promotes self-motivation, learning, and professional development. They build teams, create cohesion, resolve conflict, and shape agency culture, while attending to ethical and diversity issues in all aspects of the process. Such supervision is key to both quality improvement and the successful implementation of consensus- and evidence-based practices” (CSAT, 2007)

Rationale
For hundreds of years, many professions have relied on more senior colleagues to guide less experienced professionals in their crafts. This is a new development in the substance abuse field, as clinical supervision was only recently acknowledged as a discrete process with its own concepts and approaches.
As a supervisor to the client, counselor, and organization, the significance of your position is apparent in the following statements:

  1. Organizations have an obligation to ensure quality care and quality improvement of all personnel. The first aim of clinical supervision is to ensure quality services and to protect the welfare of clients.
  2. Supervision is the right of all employees and has a direct impact on workforce development and staff and client retention.
  3. You oversee the clinical functions of staff and have a legal and ethical responsibility to ensure quality care to clients, the professional development of counselors, and maintenance of program policies and procedures.
  4. Clinical supervision is how counselors in the field learn. In concert with classroom education, clinical skills are acquired through practice, observation, feedback, and implementation of the recommendations derived from clinical supervision.

Functions of a Clinical Supervisor


You, the clinical supervisor, wear several important “hats.” You facilitate the integration of counselor self-awareness, theoretical grounding, and development of clinical knowledge and skills; and you improve functional skills and professional practices. These roles often overlap and are fluid within the context of the supervisory relationship. Hence, the supervisor is in a unique position as an advocate for the agency, the counselor, and the client. You are the primary link between administration and front line staff, interpreting and monitoring compliance with agency goals, policies, and procedures and communicating staff and client needs to administrators. Central to the supervisor’s function is the alliance between the supervisor and supervisee (Rigazio-DiGilio, 1997).


Teacher: Assist in the development of counseling knowledge and skills by identifying learning needs, determining counselor strengths, promoting self-awareness, and transmitting knowledge for practical use and professional growth. Supervisors are teachers, trainers, and professional role models.

  1. Consultant: Bernard and Goodyear (2004) incorporate the supervisory consulting role of case consultation and review, monitoring performance, counseling the counselor regarding job performance, and assessing counselors. In this role, supervisors also provide alternative case conceptualizations, oversight of counselor work to achieve mutually agreed upon goals, and professional gatekeeping for the organization and discipline (e.g., recognizing and addressing counselor impairment).
  2. Coach: In this supportive role, supervisors provide morale building, assess strengths and needs, suggest varying clinical approaches, model, cheer-lead, and prevent burnout. For entry-level counselors, the supportive function is critical.
  3. Mentor/Role Model: The experienced supervisor mentors and teaches the supervisee through role modeling, facilitates the counselor’s overall professional development and sense of professional identity, and trains the next generation of supervisors.

Central Principles of Clinical Supervision


The Consensus Panel for this TIP has identified central principles of clinical supervision. Although the Panel recognizes that clinical supervision can initially be a costly undertaking for many financially strapped programs, the Panel believes that ultimately clinical supervision is a cost-saving process. Clinical supervision enhances the quality of client care; improves efficiency of counselors in direct and indirect services; increases workforce satisfaction, professionalization, and retention (see vignette 8 in chapter 2); and ensures that services provided to the public uphold legal mandates and ethical standards of the profession.
The central principles identified by the Consensus Panel are:

  1. Clinical supervision is an essential part of all clinical programs. Clinical supervision is a central organizing activity that integrates the program mission, goals, and treatment philosophy with clinical theory and evidence-based practices (EBPs). The primary reasons for clinical supervision are to ensure (1) quality client care, and (2) clinical staff continue professional development in a systematic and planned manner. In substance abuse treatment, clinical supervision is the primary means of determining the quality of care provided.
  2. Clinical supervision enhances staff retention and morale. Staff turnover and workforce development are major concerns in the substance abuse treatment field. Clinical supervision is a primary means of improving workforce retention and job satisfaction (see, for example, Roche, Todd, & O’Connor, 2007).
  3. Every clinician, regardless of level of skill and experience, needs and has a right to clinical supervision. In addition, supervisors need and have a right to supervision of their supervision. Supervision needs to be tailored to the knowledge base, skills, experience, and assignment of each counselor. All staff need supervision, but the frequency and intensity of the oversight and training will depend on the role, skill level, and competence of the individual.

The benefits that come with years of experience are enhanced by quality clinical supervision.

  1. Clinical supervision needs the full support of agency administrators. Just as treatment programs want clients to be in an atmosphere of growth and openness to new ideas, counselors should be in an environment where learning and professional development and opportunities are valued and provided for all staff.
  2. The supervisory relationship is the crucible in which ethical practice is developed and reinforced. The supervisor needs to model sound ethical and legal practice in the supervisory relationship. This is where issues of ethical practice arise and can be addressed. This is where ethical practice is translated from a concept to a set of behaviors. Through supervision, clinicians can develop a process of ethical decisionmaking and use this process as they encounter new situations.
  3. Clinical supervision is a skill in and of itself that has to be developed. Good counselors tend to be promoted into supervisory positions with the assumption that they have the requisite skills to provide professional clinical supervision. However, clinical supervisors need a different role orientation toward both program and client goals and a knowledge base to complement a new set of skills. Programs need to increase their capacity to develop good supervisors.
  4. Clinical supervision in substance abuse treatment most often requires balancing administrative and clinical supervision tasks. Sometimes these roles are complementary and sometimes they conflict. Often the supervisor feels caught between the two roles. Administrators need to support the integration and differentiation of the roles to promote the efficacy of the clinical supervisor. (See Part 2.)
  5. Culture and other contextual variables influence the supervision process; supervisors need to continually strive for cultural competence. Supervisors require cultural competence at several levels. Cultural competence involves the counselor’s response to clients, the supervisor’s response to counselors, and the program’s response to the cultural needs of the diverse community it serves. Since supervisors are in a position to serve as catalysts for change, they need to develop proficiency in addressing the needs of diverse clients and personnel.

Clinical Supervision and Professional Development


9. Successful implementation of EBPs requires ongoing supervision. Supervisors have a role in determining which specific EBPs are relevant for an organization’s clients (Lindbloom, Ten Eyck, & Gallon, 2005). Supervisors ensure that EBPs are successfully integrated into ongoing programmatic activities by training, encouraging, and monitoring counselors. Excellence in clinical supervision should provide greater adherence to the EBP model. Because State funding agencies now often require substance abuse treatment organizations to provide EBPs, supervision becomes even more important.


10. Supervisors have the responsibility to be gatekeepers for the profession. Supervisors are responsible for maintaining professional standards, recognizing and addressing impairment, and safeguarding the welfare of clients. More than anyone else in an agency, supervisors can observe counselor behavior and respond promptly to potential problems, including counseling some individuals out of the field because they are ill-suited to the profession. This “gatekeeping” function is especially important for supervisors who act as field evaluators for practicum students prior to their entering the profession. Finally, supervisors also fulfill a gatekeeper role in performance evaluation and in providing formal recommendations to training institutions and credentialing bodies.


11. Clinical supervision should involve direct observation methods. Direct observation should be the standard in the field because it is one of the most effective ways of building skills, monitoring counselor performance, and ensuring quality care. Supervisors require training in methods of direct observation, and administrators need to provide resources for implementing direct observation. Although small substance abuse agencies might not have the resources for one-way mirrors or videotaping equipment, other direct observation methods can be employed (see the section on methods of observation, pp. 20–24).

Guidelines for New Supervisors


Congratulations on your appointment as a supervisor! By now you might be asking yourself a few questions: What have I done? Was this a good career decision?
There are many changes ahead. If you have been promoted from within, you’ll encounter even more hurdles and issues. First, it is important to face that your life has changed. You might experience the loss of friendship of peers. You might feel that you knew what to do as a counselor, but feel totally lost with your new responsibilities (see vignette 6 in chapter 2). You might feel less effective in your new role. Supervision can be an emotionally draining experience, as you now have to work with more staff-related interpersonal and human resources issues.


Before your promotion to clinical supervisor, you might have felt confidence in your clinical skills. Now you might feel unprepared and wonder if you need a training course for your new role. If you feel this way, you’re right. Although you are a good counselor, you do not necessarily possess all the skills needed to be a good supervisor. Your new role requires a new body of knowledge and different skills, along with the ability to use your clinical skills in a different way. Be confident that you will acquire these skills over time (see the Resources section, p. 34) and that you made the right decision to accept your new position.
Suggestions for new supervisors:

  1. Quickly learn the organization’s policies and procedures and human resources procedures (e.g., hiring and firing, affirmative action requirements, format for conducting meetings, giving feedback, and making evaluations). Seek out this information as soon as possible through the human resources department or other resources within the organization.
  2. Ask for a period of 3 months to allow you to learn about your new role. During this period, do not make any changes in policies and procedures but use this time to find your managerial voice and decisionmaking style.
  3. Take time to learn about your supervisees, their career goals, interests, developmental objectives, and perceived strengths.
  4. Work to establish a contractual relationship with supervisees, with clear goals and methods of supervision.
  5. Learn methods to help staff reduce stress, address competing priorities, resolve staff conflict, and other interpersonal issues in the workplace.
  6. Obtain training in supervisory procedures and methods.
  1. Find a mentor, either internal or external to the organization.
  2. Shadow a supervisor you respect who can help you learn the ropes of your new job.
  3. Ask often and as many people as possible, “How am I doing?” and “How can I improve my performance as a clinical supervisor?”
  4. Ask for regular, weekly meetings with your administrator for training and instruction.
  5. Seek supervision of your supervision.

Problems and Resources


As a supervisor, you may encounter a broad array of issues and concerns, ranging from working within a system that does not fully support clinical supervision to working with resistant staff. A comment often heard in supervision training sessions is “My boss should be here to learn what is expected in supervision,” or “This will never work in my agency’s bureaucracy. They only support billable activities.” The work setting is where you apply the principles and practices of supervision and where organizations are driven by demands, such as financial solvency, profit, census, accreditation, and concerns over litigation. Therefore, you will need to be practical when beginning your new role as a supervisor: determine how you can make this work within your unique work environment.


Working With Staff Who Are Resistant to Supervision


Some of your supervisees may have been in the field longer than you have and see no need for supervision. Other counselors, having completed their graduate training, do not believe they need further supervision, especially not from a supervisor who might have less formal academic education than they have. Other resistance might come from ageism, sexism, racism, or classism. Particular to the field of substance abuse treatment may be the tension between those who believe that recovery from substance abuse is necessary for this counseling work and those who do not believe this to be true.
In addressing resistance, you must be clear regarding what your supervision program entails and must consistently communicate your goals and expectations to staff. To resolve defensiveness and engage your supervisees, you must also honor the resistance and acknowledge their concerns. Abandon trying to push the supervisee too far, too fast. Resistance is an expression of ambivalence about change and not a personality defect of the counselor. Instead of arguing with or exhorting staff, sympathize with their concerns, saying, “I understand this is difficult.

How are we going to resolve these issues?” When counselors respond defensively or reject directions from you, try to understand the origins of their defensiveness and to address their resistance. Self-disclosure by the supervisor about experiences as a supervisee, when appropriately used, may be helpful in dealing with defensive, anxious, fearful, or resistant staff. Work to establish a healthy, positive supervisory alliance with staff. Because many substance abuse counselors have not been exposed to clinical supervision, you may need to train and orient the staff to the concept and why it is important for your agency.


Things a New Supervisor Should Know


Eight truths a beginning supervisor should commit to memory are listed below:
1. The reason for supervision is to ensure quality client care. As stated throughout this TIP, the primary goal of clinical supervision is to protect the welfare of the client and ensure the integrity of clinical services.


2. Supervision is all about the relationship. As in counseling, developing the alliance between the counselor and the supervisor is the key to good supervision.
3. Culture and ethics influence all supervisory interactions. Contextual factors, culture, race, and ethnicity all affect the nature of the supervisory relationship. Some models of supervision (e.g., Holloway, 1995) have been built primarily around the role of context and culture in shaping supervision.


4. Be human and have a sense of humor. As role models, you need to show that everyone makes mistakes and can admit to and learn from these mistakes. Clinical Supervision and Professional Development 5. Rely first on direct observation of your counselors and give specific feedback. The best way to determine a counselor’s skills is to observe him or her and to receive input from the clients about their perceptions of the counseling relationship.


6. Have and practice a model of counseling and of supervision; have a sense of purpose. Before you can teach a supervisee knowledge and skills, you must first know the philosophical and theoretical foundations on which you, as a supervisor, stand. Counselors need to know what they are going to learn from you, based on your model of counseling and supervision.


7. Make time to take care of yourself spiritually, emotionally, mentally, and physically. Again, as role models, counselors are watching your behavior. Do you “walk the talk” of self-care?


8. You have a unique position as an advocate for the agency, the counselor, and the client. As a supervisor, you have a wonderful opportunity to assist in the skill and professional development of your staff, advocating for the best interests of the supervisee, the client, and your organization.


Models of Clinical Supervision


You may never have thought about your model of supervision. However, it is a fundamental premise of this TIP that you need to work from a defined model of supervision and have a sense of purpose in your oversight role. Four supervisory orientations seem particularly relevant. They include:

  1. Competency-based models.
  2. Treatment-based models.
  3. Developmental approaches.
  4. Integrated models.

Competency-based models (e.g., microtraining, the Discrimination Model [Bernard & Goodyear, 2004], and the Task-Oriented Model [Mead, 1990], focus primarily on the skills and learning needs of the supervisee and on setting goals that are specific, measurable, attainable, realistic, and timely (SMART). They construct and implement strategies to accomplish these goals. The key strategies of competency-based models include applying social learning principles (e.g., modeling role reversal, role playing, and practice), using demonstrations, and using various supervisory functions (teaching, consulting, and counseling).


Treatment-based supervision models train to a particular theoretical approach to counseling, incorporating EBPs into supervision and seeking fidelity and adaptation to the theoretical model. Motivational interviewing, cognitive–behavioral therapy, and psychodynamic psychotherapy are three examples. These models emphasize the counselor’s strengths, seek the supervisee’s understanding of the theory and model taught, and incorporate the approaches and techniques of the model. The majority of these models begin with articulating their treatment approach and describing their supervision model, based upon that approach.


Developmental models, such as Stoltenberg and Delworth (1987), understand that each counselor goes through different stages of development and recognize that movement through these stages is not always linear and can be affected by changes in assignment, setting, and population served. (The developmental stages of counselors and supervisors are described in detail below).


Integrated models, including the Blended Model, begin with the style of leadership and articulate a model of treatment, incorporate descriptive dimensions of supervision (see below), and address contextual and developmental dimensions into supervision. They address both skill and competency development and affective issues, based on the unique needs of the supervisee and supervisor. Finally, integrated models seek to incorporate EBPs into counseling and supervision.


In all models of supervision, it is helpful to identify culturally or contextually centered models or approaches and find ways of tailoring the models to specific cultural and diversity factors. Issues to consider are:

  1. Explicitly addressing diversity of supervisees (e.g., race, ethnicity, gender, age, sexual orientation) and the specific factors associated with these types of diversity;
  2. Explicitly involving supervisees’ concerns related to particular client diversity (e.g., those whose culture, gender, sexual orientation, and other attributes differ from those of the supervisee) and addressing specific factors associated with these types of diversity; and

• Explicitly addressing supervisees’ issues related to effectively navigating services in intercultural communities and effectively networking with agencies and institutions. It is important to identify your model of counseling and your beliefs about change, and to articulate a workable approach to supervision that fits the model of counseling you use. Theories are conceptual frameworks that enable you to make sense of and organize your counseling and supervision and to focus on the most salient aspects of a counselor’s practice. You may find some of the questions below to be relevant to both supervision and counseling. The answers to these questions influence both how you supervise and how the counselors you supervise work:

  1. What are your beliefs about how people change in both treatment and clinical supervision?
  2. What factors are important in treatment and clinical supervision?
  3. What universal principles apply in supervision and counseling and which are unique to clinical supervision?
  4. What conceptual frameworks of counseling do you use (for instance, cognitive–behavioral therapy, 12-Step facilitation, psychodynamic, behavioral)?
  5. • What are the key variables that affect outcomes? (Campbell, 2000) According to Bernard and Goodyear (2004) and Powell and Brodsky (2004),the qualities of a good model of clinical supervision are:
  6. Rooted in the individual, beginning with the supervisor’s self, style, and approach to leadership.
  7. Precise, clear, and consistent.
  8. Comprehensive, using current scientific and evidence-based practices.
  9. Operational and practical, providing specific concepts and practices in clear, useful, and measurable terms.
  10. Outcome-oriented to improve counselor competence; make work manageable; create a sense of mastery and growth for the counselor; and address the needs of the organization, the supervisor, the supervisee, and the client.

Finally, it is imperative to recognize that, whatever model you adopt, it needs to be rooted in the learning and developmental needs of the supervisee, the specific needs of the clients they serve, the goals of the agency in which you work, and in the ethical and legal boundaries of practice. These four variables define the context in which effective supervision can take place.


Developmental Stages of Counselors


Counselors are at different stages of professional development. Thus, regardless of the model of supervision you choose, you must take into account the supervisee’s level of training, experience, and proficiency. Different supervisory approaches are appropriate for counselors at different stages of development. An understanding of the supervisee’s (and supervisor’s) developmental needs is an essential ingredient for any model of supervision.


Various paradigms or classifications of developmental stages of clinicians have been developed (Ivey, 1997; Rigazio-DiGilio, 1997; Skolvolt & Ronnestrand, 1992; Todd and Storn, 1997). This TIP has adopted the Integrated Developmental Model (IDM) of Stoltenberg, McNeill, and Delworth (1998) (see figure 2, p. 10). This schema uses a three-stage approach. The three stages of development have different characteristics and appropriate supervisory methods. Further application of the IDM to the substance abuse field is needed. (For additional information, see Anderson, 2001.)
It is important to keep in mind several general cautions and principles about counselor development, including:

  1. There is a beginning but not an end point for learning clinical skills; be careful of counselors who think they “know it all.”
  2. Take into account the individual learning styles and personalities of your supervisees and fit the supervisory approach to the developmental stage of each counselor.
  3. There is a logical sequence to development, although it is not always predictable or rigid; some counselors may have been in the field for years but remain at an early stage of professional development, whereas others may progress quickly through the stages.
  1. Counselors at an advanced developmental level have different learning needs and require different supervisory approaches from those at Level 1; and
  2. The developmental level can be applied for different aspects of a counselor’s overall competence (e.g.,

  1. of Health and Human Services, 2003, p. 12). Culture shapes belief systems, particularly concerning issues related to mental health and substance abuse, as well as the manifestation of symptoms, relational styles, and coping patterns.
  2. There are three levels of cultural consideration for the supervisory process: the issue of the culture of the client being served and the culture of the counselor in supervision. Holloway (1995) emphasizes the cultural issues of the agency, the geographic environment of the organization, and many other contextual factors. Specifically, there are three important areas in which cultural and contextual factors play a key role in supervision: in building the supervisory relationship or working alliance, in addressing the specific needs of the client, and in building supervisee competence and ability. It is your responsibility to address your supervisees’ beliefs, attitudes, and biases about cultural and contextual variables to advance their professional development and promote quality client care.
  3. Becoming culturally competent and able to integrate other contextual variables into supervision is a complex, long-term process. Cross (1989) has identified several stages on a continuum of becoming culturally competent (see figure 4).
  4. Although you may never have had specialized training in multicultural counseling, some of your supervisees may have (see Constantine, 2003). Regardless, it is your responsibility to help supervisees build on the cultural competence skills they possess as well as to focus on their cultural competence deficits. It is important to initiate discussion of issues of culture, race, gender, sexual orientation, and the like in supervision to model the kinds of discussion you would like counselors to have with their clients. If these issues are not addressed in supervision, counselors may come to believe that it is inappropriate to discuss them with clients and have no idea how such dialog might proceed. These discussions prevent misunderstandings with supervisees based on cultural or other factors. Another benefit from these discussions is that counselors will eventually achieve some level of comfort in talking about culture, race, ethnicity, and diversity issues.
  5. If you haven’t done it as a counselor, early in your tenure as a supervisor you will want to examine your culturally influenced values, attitudes, experiences, and practices and to consider what effects they have on your dealings with supervisees and clients. Counselors should undergo a similar review as preparation for when they have clients of a culture different from their own. Some questions to keep in mind are:
  6. • What did you think when you saw the supervisee’s last name? What did you think when the supervisee said his or her culture is X, when yours is Y? How did you feel about this difference? • What did you do in response to this difference? Constantine (2003) suggests that supervisors can use the following questions with supervisees: What demographic variables do you use to identify yourself? What worldviews (e.g., values, assumptions, and biases) do you bring to supervision based on your cultural identities? What struggles and challenges have you faced working with clients who were from different cultures than your own?

Beyond self-examination, supervisors will want continuing education classes, workshops, and conferences that address cultural competence and other contextual factors. Community resources, such as community leaders, elders, and healers can contribute to your understanding of the culture your organization serves. Finally, supervisors (and counselors) should participate in multicultural activities, such as community events, discussion groups, religious festivals, and other ceremonies.
The supervisory relationship includes an inherent power differential, and it is important to pay attention to this disparity, particularly when the supervisee and the supervisor are from different cultural groups.

A potential for the misuse of that power exists at all times but especially when working with supervisees and clients within multicultural contexts. When the supervisee is from a minority population and the supervisor is from a majority population, the differential can be exaggerated. You will want to prevent institutional discrimination from affecting the quality of supervision. The same is true when the supervisee is gay and the supervisor is heterosexual, or the counselor is non-degreed and the supervisor has an advanced degree, or a female supervisee with a male supervisor, and so on. In the reverse situations, where the supervisor is from the minority group and the supervisee from the majority group, the difference should be discussed as well.


Ethical and Legal Issues


You are the organization’s gatekeeper for ethical and legal issues. First, you are responsible for upholding the highest standards of ethical, legal, and moral practices and for serving as a model of practice to staff. Further, you should be aware of and respond to ethical concerns. Part of your job is to help integrate solutions to everyday legal and ethical issues into clinical practice.
Some of the underlying assumptions of incorporating ethical issues into clinical supervision include:

  1. Ethical decisionmaking is a continuous, active process.
  2. Ethical standards are not a cookbook. They tell you what to do, not always how.
  3. Each situation is unique. Therefore, it is imperative that all personnel learn how to “think ethically” and how to make sound legal and ethical decisions.
  4. The most complex ethical issues arise in the context of two ethical behaviors that conflict; for instance, when a counselor wants to respect the privacy and confidentiality of a client, but it is in the client’s best interest for the counselor to contact someone else about his or her care.
  5. Therapy is conducted by fallible beings; people make mistakes—hopefully, minor ones.
  6. Sometimes the answers to ethical and legal questions are elusive. Ask a dozen people, and you’ll likely get twelve different points of view.

Helpful resources on legal and ethical issues for supervisors include Beauchamp and Childress (2001); Falvey (2002b); Gutheil and Brodsky (2008); Pope, Sonne, and Greene (2006); and Reamer (2006).


Legal and ethical issues that are critical to clinical supervisors include (1) vicarious liability (or respondeat superior), (2) dual relationships and boundary concerns, (4) informed consent, (5) confidentiality, and (6) supervisor ethics.


Direct Versus Vicarious Liability


An important distinction needs to be made between direct and vicarious liability. Direct liability of the supervisor might include dereliction of supervisory responsibility, such as “not making a reasonable effort to supervise” (defined below). Clinical Supervision and Professional Development.In vicarious liability, a supervisor can be held liable for damages incurred as a result of negligence in the supervision process. Examples of negligence include providing inappropriate advice to a counselor about a client (for instance, discouraging a counselor from conducting a suicide screen on a depressed client), failure to listen carefully to a supervisee’s comments about a client, and the assignment of clinical tasks to inadequately trained counselors.

The key legal question is: “Did the supervisor conduct him- or herself in a way that would be reasonable for someone in his position?” or “Did the supervisor make a reasonable effort to supervise?” A generally accepted time standard for a “reasonable effort to supervise” in the behavioral health field is 1 hour of supervision for every 20–40 hours of clinical services. Of course, other variables (such as the quality and content of clinical supervision sessions) also play a role in a reasonable effort to supervise.
Supervisory vulnerability increases when the counselor has been assigned too many clients, when there is no direct observation of a counselor’s clinical work, when staff are inexperienced or poorly trained for assigned tasks, and when a supervisor is not involved or not available to aid the clinical staff. In legal texts, vicarious liability is referred to as “respondeat superior.”


Dual Relationships and Boundary Issues


Dual relationships can occur at two levels: between supervisors and supervisees and between counselors and clients. You have a mandate to help your supervisees recognize and manage boundary issues. A dual relationship occurs in supervision when a supervisor has a primary professional role with a supervisee and, at an earlier time, simultaneously or later, engages in another relationship with the supervisee that transcends the professional relationship. Examples of dual relationships in supervision include providing therapy for a current or former supervisee, developing an emotional relationship with a supervisee or former supervisee, and becoming an Alcoholics Anonymous sponsor for a former supervisee. Obviously, there are varying degrees of harm or potential harm that might occur as a result of dual relationships, and some negative effects of dual relationships might not be apparent until later.
Therefore, firm, always-or-never rules aren’t applicable. You have the responsibility of weighing with the counselor the anticipated and unanticipated effects of dual relationships, helping the supervisee’s self-reflective awareness when boundaries become blurred, when he or she is getting close to a dual relationship, or when he or she is crossing the line in the clinical relationship.


Exploring dual relationship issues with counselors in clinical supervision can raise its own professional dilemmas. For instance, clinical supervision involves unequal status, power, and expertise between a supervisor and supervisee. Being the evaluator of a counselor’s performance and gatekeeper for training programs or credentialing bodies also might involve a dual relationship. Further, supervision can have therapy-like qualities as you explore countertransferential issues with supervisees, and there is an expectation of professional growth and self-exploration. What makes a dual relationship unethical in supervision is the abusive use of power by either party, the likelihood that the relationship will impair or injure the supervisor’s or supervisee’s judgment, and the risk of exploitation (see vignette 3 in chapter 2).


The most common basis for legal action against counselors (20 percent of claims) and the most frequently heard complaint by certification boards against counselors (35 percent) is some form of boundary violation or sexual impropriety (Falvey, 2002b). (See the discussion of transference and countertransference on pp. 25–26.)
Codes of ethics for most professions clearly advise that dual relationships between counselors and clients should be avoided. Dual relationships between counselors and supervisors are also a concern and are addressed in the substance abuse counselor codes and those of other professions as well. Problematic dual relationships between supervisees and supervisors might include intimate relationships (sexual and nonsexual) and therapeutic relationships, wherein the supervisor becomes the counselor’s therapist. Sexual involvement between the supervisor and supervisee can include sexual attraction, harassment, consensual (but hidden) sexual relationships, or intimate romantic relationships. Other common boundary issues include asking the supervisee to do favors, providing preferential treatment, socializing outside the work setting, and using emotional abuse to enforce power.


Informed Consent


Informed consent is key to protecting the counselor and/or supervisor from legal concerns, requiring the recipient of any service or intervention to be sufficiently aware of what is to happen, and of the potential risks and alternative approaches, so that the person can make an informed and intelligent decision about participating in that service. The supervisor must inform the supervisee about the process of supervision, the feedback and evaluation criteria, and other expectations of supervision. The supervision contract should clearly spell out these issues. Supervisors must ensure that the supervisee has informed the client about the parameters of counseling and supervision (such as the use of live observation, video- or audiotaping). A sample template for informed consent is provided in Part 2, chapter 2

Confidentiality


In supervision, regardless of whether there is a written or verbal contract between the supervisor and supervisee, there is an implied contract and duty of care because of the supervisor’s vicarious liability. Informed consent and concerns for confidentiality should occur at three levels: client consent to treatment, client consent to supervision of the case, and supervisee consent to supervision (Bernard & Goodyear, 2004). In addition, there is an implied consent and commitment to confidentiality by supervisors to assume their supervisory responsibilities and institutional consent to comply with legal and ethical parameters of supervision.

New technology brings new confidentiality concerns. Websites now dispense information about substance abuse treatment and provide counseling services. With the growth in online counseling and supervision, the following concerns emerge: (a) how to main tain confidentiality of information, (b) how to ensure the competence and qualifications of counselors providing online services, and (c) how to establish reporting requirements and duty to warn when services are conducted across State and international boundaries. New standards will need to be written to address these issues.

Supervisor Ethics


Supervisors will:

  1. Uphold the highest professional standards of the field.
  2. Seek professional help (outside the work setting) when personal issues interfere with their clinical and/or supervisory functioning.
  3. Conduct themselves in a manner that models and sets an example for agency mission, vision, philosophy, wellness, recovery, and consumer satisfaction.
  4. Reinforce zero tolerance for interactions that are not professional, courteous, and compassionate.
  5. Treat supervisees, colleagues, peers, and clients with dignity, respect, and honesty.
  6. Adhere to the standards and regulations of confidentiality as dictated by the field. This applies to the supervisory as well as the counseling relationship.

Monitoring Performance


The goal of supervision is to ensure quality care for the client, which entails monitoring the clinical performance of staff. Your first step is to educate supervisees in what to expect from clinical supervision. Once the functions of supervision are clear, you should regularly evaluate the counselor’s progress in meeting organizational and clinical goals as set forth in an Individual Development Plan (IDP) (see the section on IDPs below). As clients have an individual treatment plan, counselors also need a plan to promote skill development.


Behavioral Contracting in Supervision


Among the first tasks in supervision is to establish a contract for supervision that outlines realistic accountability for both yourself and your supervisee. The contract should be in writing and should include the purpose, goals, and objectives of supervision; the context in which supervision is provided; ethical and institutional policies that guide supervision and clinical practices; the criteria and methods of evaluation and outcome measures; the duties and responsibilities of the supervisor and supervisee; procedural considerations (including the format for taping and opportunities for live observation); and the supervisee’s scope of practice and competence. The contract for supervision should state the rewards for fulfillment of the contract (such as clinical privileges or increased compensation), the length of supervision sessions, and sanctions for noncompliance by either the supervisee or supervisor. The agreement should be compatible with the developmental needs of the supervisee and address the obstacles to progress (lack of time, performance anxiety, resource limitations). Once a behavioral contract has been established, the next step is to develop an IDP.

Evaluation of Counselors


Summative evaluation is a more formal rating of the counselor’s overall job performance, fitness for the job, and job rating. It answers the question, “How does the counselor measure up?” Typically, summative evaluations are done annually and focus on the counselor’s overall strengths, limitations, and areas for future improvement.
There has been considerable research on supervisory evaluation, with these findings:
• The supervisee’s confidence and efficacy are correlated with the quality and quantity of feedback the supervisor gives to the supervisee (Bernard & Goodyear, 2004).

  1. Ratings of skills are highly variable between supervisors, and often the supervisor’s and supervisee’s ratings differ or conflict (Eby, 2007).
  2. Good feedback is provided frequently, clearly, and consistently and is SMART (specific, measurable, attainable, realistic, and timely) (Powell & Brodsky, 2004).

Direct observation of the counselor’s work is the desired form of input for the supervisor. Although direct observation has historically been the exception in substance abuse counseling, ethical and legal considerations and evidence support that direct observation as preferable. The least desirable feedback is unannounced observation by supervisors followed by vague, perfunctory, indirect, or hurtful delivery (Powell & Brodsky, 2004).

Before formative evaluations begin, methods of evaluating performance should be discussed, clarified in the initial sessions, and included in the initial contract so that there will be no surprises. Formative evaluations should focus on changeable behavior and, whenever possible, be separate from the overall annual performance appraisal process. To determine the counselor’s skill development, you should use written competency tools, direct observation, counselor self-assessments, client evaluations, work samples (files and charts), and peer assessments. Examples of work samples and peer assessments can be found in Bernard and Goodyear (2004), Powell and Brodsky (2004), and Campbell (2000). It is important to acknowledge that counselor evaluation is essentially a subjective process involving supervisors’ opinions of the counselors’ competence.

Addressing Burnout and Compassion Fatigue

Did you ever hear a counselor say, “I came into counseling for the right reasons. At first I loved seeing clients. But the longer I stay in the field, the harder it is to care. The joy seems to have gone out of my job. Should I get out of counseling as many of my colleagues are doing?” Most substance abuse counselors come into the field with a strong sense of calling and the desire to be of service to others, with a strong pull to use their gifts and make themselves instruments of service and healing. The substance abuse treatment field risks losing many skilled and compassionate healers when the life goes out of their work. Some counselors simply withdraw, care less, or get out of the field entirely. Most just complain or suffer in silence. Given the caring and dedication that brings counselors into the field, it is important for you to help them address their questions and doubts. (See Lambie, 2006, and Shoptaw, Stein, & Rawson, 2000.)
You can help counselors with self-care; help them look within; become resilient again; and rediscover what gives them joy, meaning, and hope in their work. Counselors need time for reflection, to listen again deeply and authentically. You can help them redevelop their innate capacity for compassion, to be an openhearted presence for others.
You can help counselors develop a life that does not revolve around work. This has to be supported by the organization’s culture and policies that allow for appropriate use of time off and self-care without punishment. Aid them by encouraging them to take earned leave and to take “mental health” days when they are feeling tired and burned out. Remind staff to spend time with family and friends, exercise, relax, read, or pursue other life-giving interests.


It is important for the clinical supervisor to normalize the counselor’s reactions to stress and compassion fatigue in the workplace as a natural part of being an empathic and compassionate person and not an individual failing or pathology. (See Burke, Carruth, & Prichard, 2006.)


Rest is good; self-care is important. Everyone needs times of relaxation and recreation. Often, a month after a refreshing vacation you lose whatever gain you made. Instead, longer term gain comes from finding what brings you peace and joy. It is not enough
for you to help counselors understand “how” to counsel, you can also help them with the “why.” Why are they in this field? What gives them meaning and purpose at work? When all is said and done, when counselors have seen their last client, how do they want to be remembered? What do they want said about them as counselors? Usually, counselors’ responses to this question are fairly simple: “I want to be thought of as a caring, compassionate person, a skilled helper.” These are important spiritual questions that you can discuss with your supervisees.
Other suggestions include:

  1. Help staff identify what is happening within the organization that might be contributing to their stress and learn how to address the situation in a way that is productive to the client, the counselor, and the organization.
  2. Get training in identifying the signs of primary stress reactions, secondary trauma, compassion fatigue, vicarious traumatization, and burnout. Help staff match up self-care tools to specifically address each of these experiences.
  3. Support staff in advocating for organizational change when appropriate and feasible as part of your role as liaison between administration and clinical staff.
  4. Assist staff in adopting lifestyle changes to increase their emotional resilience by reconnecting to their world (family, friends, sponsors, mentors), spending time alone for self-reflection, and forming habits that re-energize them.
  5. Help them eliminate the “what ifs” and negative self-talk. Help them let go of their idealism that they can save the world.
  6. If possible in the current work environment, set parameters on their work by helping them adhere to scheduled time off, keep lunch time personal, set reasonable deadlines for work completion, and keep work away from personal time.
  7. Teach and support generally positive work habits. Some counselors lack basic organizational, teamwork, phone, and time management skills (ending sessions on time and scheduling to allow for documentation). The development of these skills helps to reduce the daily wear that erodes well-being and contributes to burnout.
  8. Ask them “When was the last time you had fun?” “When was the last time you felt fully alive?” Suggest they write a list of things about their job

Clinical Supervision and Professional Development

they care about and love. List five accomplishments in their professional life. Ask “Where do you want to be in your professional life in 5 years?”
You have a fiduciary responsibility given you by clients to ensure counselors are healthy and whole. It is your responsibility to aid counselors in addressing their fatigue and burnout.


Gatekeeping Functions

In monitoring counselor performance, an important and often difficult supervisory task is managing problem staff or those individuals who should not be counselors. This is the gatekeeping function. Part of the dilemma is that most likely you were first trained as a counselor, and your values lie within that domain. You were taught to acknowledge and work with individual limitations, always respecting the individual’s goals and needs. However, you also carry a responsibility to maintain the quality of the profession and to protect the welfare of clients. Thus, you are charged with the task of assessing the counselor for fitness for duty and have an obligation to uphold the standards of the profession.


Experience, credentials, and academic performance are not the same as clinical competence. In addition to technical counseling skills, many important therapeutic qualities affect the outcome of counseling, including insight, respect, genuineness, concreteness, and empathy. Research consistently demonstrates that personal characteristics of counselors are highly predictive of client outcome (Herman, 1993, Hubble, Duncan & Miller, 1999). The essential questions are: Who should or should not be a counselor? What behaviors or attitudes are unacceptable? How would a clinical supervisor address these issues in supervision?


Unacceptable behavior might include actions hurtful to the client, boundary violations with clients or program standards, illegal behavior, significant psychiatric impairment, consistent lack of self-awareness, inability to adhere to professional codes of ethics, or consistent demonstration of attitudes that are not conducive to work with clients in substance abuse treatment. You will want to have a model and policies and procedures in place when disciplinary action is undertaken with an impaired counselor. For example, progressive disciplinary policies clearly state the procedures to follow when impairment is identified. Consultation with the organization’s attorney and familiarity with State case law are important. It is advisable for the agency to be familiar with and have contact with your State impaired counselor organization, if it exists.


How impaired must a counselor be before disciplinary action is needed? Clear job descriptions and statements of scope of practice and competence are important when facing an impaired counselor. How tired or distressed can a counselor be before a supervisor takes the counselor off-line for these or similar reasons? You need administrative support with such interventions and to identify approaches to managing worn-out counselors. The Consensus Panel recommends that your organization have an employee assistance program (EAP) in place so you can refer staff outside the agency. It is also important for you to learn the distinction between a supervisory referral and a self-referral. Self-referral may include a recommendation by the supervisor, whereas a supervisory referral usually occurs with a job performance problem.


You will need to provide verbal and written evaluations of the counselor’s performance and actions to ensure that the staff member is aware of the behaviors that need to be addressed. Treat all supervisees the same, following agency procedures and timelines. Follow the organization’s progressive disciplinary steps and document carefully what is said, how the person responds, and what actions are recommended. You can discuss organizational issues or barriers to action with the supervisee (such as personnel policies that might be exacerbating the employee’s issues). Finally, it may be necessary for you to take the action that is in the best interest of the clients and the profession, which might involve counseling your supervisee out of the field.


Remember that the number one goal of a clinical supervisor is to protect the welfare of the client, which, at times, can mean enforcing the gatekeeping function of supervision.


Methods of Observation

It is important to observe counselors frequently over an extended period of time. Supervisors in the substance abuse treatment field have traditionally relied


on indirect methods of supervision (process recordings, case notes, verbal reports by the supervisees, and verbatims). However, the Consensus Panel recommends that supervisors use direct observation of counselors through recording devices (such as video and audio taping) and live observation of counseling sessions, including one-way mirrors. Indirect methods have significant drawbacks, including:

  1. A counselor will recall a session as he or she experienced it. If a counselor experiences a session positively or negatively, the report to the supervisor will reflect that. The report is also affected by the counselor’s level of skill and experience.
  2. The counselor’s report is affected by his or her biases and distortions (both conscious and unconscious). The report does not provide a thorough sense of what really happened in the session because it relies too heavily on the counselor’s recall.
  3. Indirect methods include a time delay in reporting.
  4. The supervisee may withhold clinical information due to evaluation anxiety or naiveté.

Your understanding of the session will be improved by direct observation of the counselor. Direct observation is much easier today, as a variety of technological tools are available, including audio and videotaping, remote audio devices, interactive videos, live feeds, and even supervision through web-based cameras.
Guidelines that apply to all methods of direct observation in supervision include:

  1. Simply by observing a counseling session, the dynamics will change. You may change how both the client and counselor act. You get a snapshot of the sessions. Counselors will say, “it was not a representative session.” Typically, if you observe the counselor frequently, you will get a fairly accurate picture of the counselor’s competencies.
  2. You and your supervisee must agree on procedures for observation to determine why, when, and how direct methods of observation will be used.
  3. The counselor should provide a context for the session.
  4. The client should give written consent for observation and/or taping at intake, before beginning counseling. Clients must know all the conditions of

their treatment before they consent to counseling. Additionally, clients need to be notified of an upcoming observation by a supervisor before the observation occurs.

  1. Observations should be selected for review (including a variety of sessions and clients, challenges, and successes) because they provide teaching moments. You should ask the supervisee to select what cases he or she wishes you to observe and explain why those cases were chosen. Direct observation should not be a weapon for criticism but a constructive tool for learning: an opportunity for the counselor to do things right and well, so that positive feedback follows.
  2. When observing a session, you gain a wealth of information about the counselor. Use this information wisely, and provide gradual feedback, not a litany of judgments and directives. Ask the salient question, “What is the most important issue here for us to address in supervision?”
  3. A supervisee might claim client resistance to direct observation, saying, “It will make the client nervous. The client does not want to be taped.” However, “client resistance” is more likely to be reported when the counselor is anxious about being taped. It is important for you to gently and respectfully address the supervisee’s resistance while maintaining the position that direct observation is an integral component of his or her supervision.
  4. Given the nature of the issues in drug and alcohol counseling, you and your supervisee need to be sensitive to increased client anxiety about direct observation because of the client’s fears about job or legal repercussions, legal actions, criminal behaviors, violence and abuse situations, and the like.
  5. Ideally, the supervisee should know at the outset of employment that observation and/or taping will be required as part of informed consent to supervision.

In instances where there is overwhelming anxiety regarding observation, you should pace the observation to reduce the anxiety, giving the counselor adequate time for preparation. Often enough, counselors will feel more comfortable with observation equipment (such as a video camera or recording device) rather than direct observation with the supervisor in the room. Clinical Supervision and Professional Development


The choice of observation methods in a particular situation will depend on the need for an accurate sense of counseling, the availability of equipment, the context in which the supervision is provided, and the counselor’s and your skill levels. A key factor in the choice of methods might be the resistance of the counselor to being observed. For some supervisors, direct observation also puts the supervisor’s skills on the line too, as they might be required to demonstrate or model their clinical competencies.


Recorded Observation

Audiotaped supervision has traditionally been a primary medium for supervisors and remains a vital resource for therapy models such as motivational interviewing. On the other hand, videotape supervision (VTS) is the primary method of direct observation in both the marriage and family therapy and social work fields (Munson, 1993; Nichols, Nichols, & Hardy, 1990). Video cameras are increasingly commonplace in professional settings. VTS is easy, accessible, and inexpensive. However, it is also a complex, powerful and dynamic tool, and one that can be challenging, threatening, anxiety-provoking, and humbling. Several issues related to VTS are unique to the substance abuse field:

  1. Many substance abuse counselors “grew up” in the field without taping and may be resistant to the medium;
  2. Many agencies operate on limited budgets and administrators may see the expensive equipment as prohibitive and unnecessary; and
  3. • Many substance abuse supervisors have not been trained in the use of videotape equipment or in VTS. Yet, VTS offers nearly unlimited potential for creative use in staff development. To that end, you need training in how to use VTS effectively. The following are guidelines for VTS:
  4. Clients must sign releases before taping. Most programs have a release form that the client signs on admission (see Tool 19 in Part 2, chapter 2). The supervisee informs the client that videotaping will occur and reminds the client about the signed release form. The release should specify that the taping will be done exclusively for training purposes and will be reviewed only by the counselor, the

supervisor, and other supervisees in group supervision. Permission will most likely be granted if the request is made in a sensitive and appropriate manner. It is critical to note that even if permission is initially given by the client, this permission can be withdrawn. You cannot force compliance.

  1. The use and rationale for taping needs to be clearly explained to clients. This will forestall a client’s questioning as to why a particular session is being taped.
  2. Risk-management considerations in today’s litigious climate necessitate that tapes be erased after the supervision session. Tapes can be admissible as evidence in court as part of the clinical record. Since all tapes should be erased after supervision, this must be stated in agency policies. If there are exceptions, those need to be described.
  3. Too often, supervisors watch long, uninterrupted segments of tape with little direction or purpose. To avoid this, you may want to ask your supervisee to cue the tape to the segment he or she wishes to address in supervision, focusing on the goals established in the IDP. Having said this, listening only to segments selected by the counselor can create some of the same disadvantages as self-report: the counselor chooses selectively, even if not consciously. The supervisor may occasionally choose to watch entire sessions.
  4. You need to evaluate session flow, pacing, and how counselors begin and end sessions.

Some clients may not be comfortable being videotaped but may be more comfortable with audio taping. Videotaping is not permitted in most prison settings and EAP services. Videotaping may not be advisable when treating patients with some diagnoses, such as paranoia or some schizophrenic illnesses. In such cases, either live observation or less intrusive measures, such as audio taping, may be preferred.


Live Observation


With live observation you actually sit in on a counseling session with the supervisee and observe the session first hand. The client will need to provide informed consent before being observed. Although one-way mirrors are not readily available at most agencies, they are an alternative to actually sitting in on the session. A videotape may also be used either from behind the one-way mirror (with someone else operating the videotaping equipment) or physically located in the counseling room, with the supervisor sitting in the session. This combination of mirror, videotaping, and live observation may be the best of all worlds, allowing for unobtrusive observation of a session, immediate feedback to the supervisee, modeling by the supervisor (if appropriate), and a record of the session for subsequent review in supervision. Live supervision may involve some intervention by the supervisor during the session.

Live observation is effective for the following reasons:

  1. It allows you to get a true picture of the counselor in action.
  2. It gives you an opportunity to model techniques during an actual session, thus serving as a role model for both the counselor and the client.
  3. Should a session become countertherapeutic, you can intervene for the well-being of the client.
  4. Counselors often say they feel supported when a supervisor joins the session, and clients periodically say, “This is great! I got two for the price of one.”
  5. It allows for specific and focused feedback.
  6. It is more efficient for understanding the counseling process.
  7. It helps connect the IDP to supervision.

To maximize the effectiveness of live observation, supervisors must stay primarily in an observer role so as to not usurp the leadership or undercut the credibility and authority of the counselor.
Live observation has some disadvantages:

  1. It is time consuming.
  2. It can be intrusive and alter the dynamics of the counseling session.
  3. It can be anxiety-provoking for all involved.

Some mandated clients may be particularly sensitive to live observation. This becomes essentially a clinical issue to be addressed by the counselor with the client. Where is this anxiety coming from, how does it relate to other anxieties and concerns, and how can it best be addressed in counseling?
Supervisors differ on where they should sit in a live observation session. Some suggest that the supervisor sit so as to not interrupt or be involved in the session. Others suggest that the supervisor sit in a position that allows for inclusion in the counseling process.
Here are some guidelines for conducting live observation:

  1. The counselor should always begin with informed consent to remind the client about confidentiality. Periodically, the counselor should begin the session with a statement of confidentiality, reiterating the limits of confidentiality and the duty to warn, to ensure that the client is reminded of what is reportable by the supervisor and/or counselor.
  2. While sitting outside the group (or an individual session between counselor and client) may undermine the group process, it is a method selected by some. Position yourself in a way that doesn’t interrupt the counseling process. Sitting outside the group undermines the human connection between you, the counselor, and the client(s) and makes it more awkward for you to make a comment, if you have not been part of the process until then. For individual or family sessions, it is also recommended that the supervisor sit beside the counselor to fully observe what is occurring in the counseling session.
  3. The client should be informed about the process of supervision and the supervisor’s role and goals, essentially that the supervisor is there to observe the counselor’s skills and not necessarily the client.
  4. As preparation, the supervisor and supervisee should briefly discuss the background of the session, the salient issues the supervisee wishes to focus on, and the plans for the session. The role of the supervisor should be clearly stated and agreed on before the session.
  5. You and the counselor may create criteria for observation, so that specific feedback is provided for specific areas of the session.
  6. Your comments during the session should be limited to lessen the risk of disrupting the flow or taking control of the session. Intervene only to protect the welfare of the client (should something adverse occur in the session) or if a moment critical to client welfare arises. In deciding to inter

Clinical Supervision and Professional Development

vene or not, consider these questions: What are the consequences if I don’t intervene? What is the probability that the supervisee will make the intervention on his or her own or that my comments will be successful? Will I create an undue dependence on the part of clients or supervisee?
• Provide feedback to the counselor as soon as possible after the session. Ideally, the supervisor and supervisee(s) should meet privately immediately afterward, outlining the key points for discussion and the agenda for the next supervision session, based on the observation. Specific feedback is essential; “You did a fine job” is not sufficient. Instead, the supervisor might respond by saying, “I particularly liked your comment about . . .” or “What I observed about your behavior was . . .” or “Keep doing more of . . . .”
Practical Issues in Clinical Supervision


Distinguishing Between Supervision and Therapy


In facilitating professional development, one of the critical issues is understanding and differentiating between counseling the counselor and providing supervision. In ensuring quality client care and facilitating professional counselor development, the process of clinical supervision sometimes encroaches on personal issues. The dividing line between therapy and supervision is how the supervisee’s personal issues and problems affect their work. The goal of clinical supervision must always be to assist counselors in becoming better clinicians, not seeking to resolve their personal issues.

The boundary between counseling and clinical supervision may not always be clearly marked, for it is necessary, at times, to explore supervisees’ limitations as they deliver services to their clients. Address counselors’ personal issues only in so far as they create barriers or affect their performance. When personal issues emerge, the key question you should ask the supervisee is how does this affect the delivery of quality client care? What is the impact of this issue on the client? What resources are you using to resolve this issue outside of the counseling dyad? When personal issues emerge that might interfere with quality care, your role may be to transfer the case to a different counselor. Most important, you should make a strong case that the supervisee should seek outside counseling or therapy.
Problems related to countertransference (projecting unresolved personal issues onto a client or supervisee) often make for difficult therapeutic relationships. The following are signs of countertransference to look for:

  1. A feeling of loathing, anxiety, or dread at the prospect of seeing a specific client or supervisee.
  2. Unexplained anger or rage at a particular client.
  3. Distaste for a particular client.
  4. Mistakes in scheduling clients, missed appointments.
  5. Forgetting client’s name, history.
  6. Drowsiness during a session or sessions ending abruptly.
  7. Billing mistakes.
  8. • Excessive socializing. When countertransferential issues between counselor and client arise, some of the important questions you, as a supervisor, might explore with the counselor include:
  9. How is this client affecting you? What feelings does this client bring out in you? What is your behavior toward the client in response to these feelings? What is it about the substance abuse behavior of this client that brings out a response in you?
  10. What is happening now in your life, but more particularly between you and the client that might be contributing to these feelings, and how does this affect your counseling?
  1. In what ways can you address these issues in your counseling?
  2. • What strategies and coping skills can assist you in your work with this client? Transference and countertransference also occur in the relationship between supervisee and supervisor. Examples of supervisee transference include:
  3. The supervisee’s idealization of the supervisor.
  4. Distorted reactions to the supervisor based on the supervisee’s reaction to the power dynamics of the relationship.
  5. The supervisee’s need for acceptance by or approval from an authority figure.
  6. • The supervisee’s reaction to the supervisor’s establishing professional and social boundaries with the supervisee. Supervisor countertransference with supervisees is another issue that needs to be considered. Categories of supervisor countertransference include:
  7. The need for approval and acceptance as a knowledgeable and competent supervisor.
  8. Unresolved personal conflicts of the supervisor activated by the supervisory relationship.
  9. Reactions to individual supervisees, such as dislike or even disdain, whether the negative response is “legitimate” or not. In a similar vein, aggrandizing and idealizing some supervisees (again, whether or not warranted) in comparison to other supervisees.
  10. Sexual or romantic attraction to certain supervisees.
  11. Cultural countertransference, such as catering to or withdrawing from individuals of a specific cultural background in a way that hinders the professional development of the counselor.

To understand these countertransference reactions means recognizing clues (such as dislike of a supervisee or romantic attraction), doing careful self-examination, personal counseling, and receiving supervision of your supervision. In some cases, it may be necessary for you to request a transfer of supervisees with whom you are experiencing countertransference, if that countertransference hinders the counselor’s professional development. Clinical Supervision and Professional Development

Finally, counselors will be more open to addressing difficulties such as countertransference and compassion fatigue with you if you communicate understanding and awareness that these experiences are a normal part of being a counselor. Counselors should be rewarded in performance evaluations for raising these issues in supervision and demonstrating a willingness to work on them as part of their professional development.


Balancing Clinical and Administrative Functions


In the typical substance abuse treatment agency, the clinical supervisor may also be the administrative supervisor, responsible for overseeing managerial functions of the organization. Many organizations cannot afford to hire two individuals for these tasks. Hence, it is essential that you are aware of what role you are playing and how to exercise the authority given you by the administration. Texts on supervision sometimes overlook the supervisor’s administrative tasks, but supervisors structure staff work; evaluate personnel for pay and promotions; define the scope of clinical competence; perform tasks involving planning, organizing, coordinating, and delegating work; select, hire, and fire personnel; and manage the organization. Clinical supervisors are often responsible for overseeing the quality assurance and improvement aspects of the agency and may also carry a case-load. For most of you, juggling administrative and clinical functions is a significant balancing act. Tips for juggling these functions include:

  1. Try to be clear about the “hat you are wearing.” Are you speaking from an administrative or clinical perspective?
  2. Be aware of your own biases and values that may be affecting your administrative opinions.
  3. Delegate the administrative functions that you need not necessarily perform, such as human resources, financial, or legal functions.
  4. Get input from others to be sure of your objectivity and your perspective.

There may be some inherent problems with performing both functions, such as dual relationships. Counselors may be cautious about acknowledging difficulties they face in counseling because these may affect their performance evaluation or salary raises.
On the other hand, having separate clinical and administrative supervisors can lead to inconsistent messages about priorities, and the clinical supervisor is not in the chain of command for disciplinary purposes.


Finding the Time To Do Clinical Supervision


Having read this far, you may be wondering, “Where do I find the time to conduct clinical supervision as described here? How can I do direct observation of counselors within my limited time schedule?” Or, “I work in an underfunded program with substance abuse clients. I have way too many tasks to also observe staff in counseling.”
One suggestion is to begin an implementation process that involves adding components of a supervision model one at a time. For example, scheduling supervisory meetings with each counselor is a beginning step. It is important to meet with each counselor on a regular, scheduled basis to develop learning plans and review professional development. Observations of counselors in their work might be added next.Another component might involve group supervision. In group supervision, time can be maximized by teaching and training counselors who have common skill development needs.

As you develop a positive relationship with supervisees based on cooperation and collaboration, the anxiety associated with observation will decrease. Counselors frequently enjoy the feedback and support so much that they request observation of their work. Observation can be brief. Rather than sitting in on a full hour of group, spend 20 minutes in the observation and an additional 20 providing feedback to the counselor.
Your choice of modality (individual, group, peer, etc.) is influenced by several factors: supervisees’ learning goals, their experience and developmental levels, their learning styles, your goals for supervisees, your theoretical orientation, and your own learning goals for the supervisory process. To select a modality of supervision (within your time constraints and those of your supervisee), first pinpoint the immediate function of supervision, as different modalities fit different functions. For example, a supervisor might wish to conduct group supervision when the team is intact and functioning well, and individual supervision

when specific skill development or countertransferential issues need additional attention. Given the variety of treatment environments in substance abuse treatment (e.g., therapeutic communities, intensive outpatient services, transitional living settings, correctional facilities) and varying time constraints on supervisors, several alternatives to structure supervision are available.


Peer supervision is not hierarchical and does not include a formal evaluation procedure, but offers a means of accountability for counselors that they might not have in other forms of supervision. Peer supervision may be particularly significant among well-trained, highly educated, and competent counselors. Peer supervision is a growing medium, given the clinical supervisors’ duties. Although peer supervision has received limited attention in literature, the Consensus Panel believes it is a particularly effective method, especially for small group practices and agencies with limited funding for supervision. Peer supervision groups can evolve from supervisor-led groups or individual sessions to peer groups or can begin as peer supervision. For peer supervision groups offered within an agency, there may be some history to overcome among the group members, such as political entanglements, competitiveness, or personality concerns. (Bernard and Goodyear [2004] has an extensive review of the process and the advantages and disadvantages of peer supervision.)


Triadic supervision is a tutorial and mentoring relationship among three counselors. This model of supervision involves three counselors who, on a rotating basis, assume the roles of the supervisee, the commentator, and the supervision session facilitator. Spice and Spice (1976) describe peer supervision with three supervisees getting together. In current counseling literature, triadic supervision involves two counselors with one supervisor. There is very little empirical or conceptual literature on this arrangement.
Individual supervision, where a supervisor works with the supervisee in a one-to-one relationship, is considered the cornerstone of professional skill development. Individual supervision is the most labor-intensive and time-consuming method for supervision. Credentialing requirements in a particular discipline or graduate studies may mandate individual supervision with a supervisor from the same discipline

.
Intensive supervision with selected counselors is helpful in working with a difficult client (such as one with a history of violence), a client using substances unfamiliar to the counselor, or a highly resistant client. Because of a variety of factors (credentialing requirements, skill deficits of some counselors, the need for close clinical supervision), you may opt to focus, for concentrated periods of time, on the needs of one or two counselors as others participate in peer supervision. Although this is not necessarily a long-term solution to the time constraints of a supervisor, intensive supervision provides an opportunity to address specific staffing needs while still providing a “reasonable effort to supervise” all personnel.


Group clinical supervision is a frequently used and efficient format for supervision, team building, and staff growth. One supervisor assists counselor development in a group of supervisee peers. The recommended group size is four to six persons to allow for frequent case presentations by each group member. With this number of counselors, each person can present a case every other month—an ideal situation, especially when combined with individual and/or peer supervision. The benefits of group supervision are that it is cost-effective, members can test their perceptions through peer validation, learning is enhanced by the diversity of the group, it creates a working alliance and improves teamwork, and it provides a microcosm of group process for participants. Group supervision gives counselors a sense of commonality with others in the same situation. Because the formats and goals differ, it is helpful to think through why you are using a particular format. (Examples of group formats with different goals can be found in Borders and Brown, 2005, and Bernard & Goodyear, 2004.)


Given the realities of the substance abuse treatment field (limited funding, priorities competing for time, counselors and supervisors without advanced academic training, and clients with pressing needs in a brief-treatment environment), the plan described below may be a useful structure for supervision. It is based on a scenario where a supervisor oversees one to five counselors. This plan is based on several principles:
• All counselors, regardless of years of experience or academic training, will receive at least 1 hour of supervision for every 20 to 40 hours of clinical work.

Clinical Supervision and Professional Development

  1. Direct observation is the backbone of a solid clinical supervision model.
  2. Group supervision is a viable means of engaging all staff in dialog, sharing ideas, and promoting team cohesion.

With the formula diagramed below, each counselor receives a minimum of 1 hour of group clinical supervision per week. Each week you will have 1 hour of observation, 1 hour of individual supervision with one of your supervisees, and 1 hour of group supervision with five supervisees. Each week, one counselor will be observed in an actual counseling session, followed by an individual supervision session with you. If the session is videotaped, the supervisee can be asked to cue the tape to the segment of the session he or she wishes to discuss with you. Afterwards, the observed counselor presents this session in group clinical supervision.


When it is a counselor’s week to be observed or taped and meet for individual supervision, he or she will receive 3 hours of supervision: 1 hour of direct observation, 1 hour of individual/one-on-one supervision, and 1 hour of group supervision when he or she presents a case to the group. Over the course of months, with vacation, holiday, and sick time, it should average out to approximately 1 hour of supervision.


Documenting Clinical Supervision


Correct documentation and recordkeeping are essential aspects of supervision. Mechanisms must be in place to demonstrate the accountability of your role. (See Tools 10–12 in Part 2, chapter 2.) These systems should document:

  1. Informal and formal evaluation procedures.
  2. Frequency of supervision, issues discussed, and the content and outcome of sessions.
  3. Due process rights of supervisees (such as the right to confidentiality and privacy, to informed consent).
  4. Risk management issues (how to handle crises, duty-to-warn situations, breaches of confidentiality).

One comprehensive documentation system is Falvey’s (2002a) Focused Risk Management Supervision System (FoRMSS), which provides templates to record emergency contact information, supervisee profiles, a logging sheet for supervision, an initial case review, supervision records, and a client termination form.
Supervisory documents and notes are open to management, administration, and human resources (HR) personnel for performance appraisal and merit pay increases and are admissible in court proceedings. Supervision notes, especially those related to work

with clients, are kept separately and are intended for the supervisor’s use in helping the counselor improve clinical skills and monitor client care. It is imperative to maintain accurate and complete notes on the supervision. However, as discussed above, documentation procedures for formative versus summative evaluation of staff may vary. Typically, HR accesses summative evaluations, and supervisory notes are maintained as formative evaluations.


An example of a formative note by a supervisor might be “The counselor responsibly discussed countertransferential issues occurring with a particular client and was willing to take supervisory direction,” or “We worked out an action plan, and I will follow this closely.” This wording avoids concerns by the supervisor and supervisee as to the confidentiality of supervisory notes. From a legal perspective, the supervisor needs to be specific about what was agreed on and a timeframe for following up.


Structuring the Initial Supervision Sessions


As discussed earlier, your first tasks in clinical supervision are to establish a behavioral contract, get to know your supervisees, and outline the requirements of supervision. Before the initial session, you should send a supportive letter to the supervisee expressing the agency’s desire to provide him or her with a quality clinical supervision experience. You might request that the counselor give some thought to what he or she would like to accomplish in supervision, what skills to work on, and which core functions used in the addiction counselor certification process he or she feels most comfortable performing.


In the first few sessions, helpful practices include:

  1. Briefly describe your role as both administrative and clinical supervisor (if appropriate) and discuss these distinctions with the counselor.
  2. Briefly describe your model of counseling and learn about the counselor’s frameworks and models for her or his counseling practice. For beginning counselors this may mean helping them define their model.
  3. Describe your model of supervision.
  4. State that disclosure of one’s supervisory training, experience, and model is an ethical duty of clinical supervisors.
  1. Discuss methods of supervision, the techniques to be used, and the resources available to the supervisee (e.g., agency inservice seminar, community workshops, professional association memberships, and professional development funds or training opportunities).
  2. Explore the counselor’s goals for supervision and his or her particular interests (and perhaps some fears) in clinical supervision.
  3. Explain the differences between supervision and therapy, establishing clear boundaries in this relationship.
  4. Work to establish a climate of cooperation, collaboration, trust, and safety.
  5. Create an opportunity for rating the counselor’s knowledge and skills based on the competencies in TAP 21 (CSAT, 2007).
  6. Explain the methods by which formative and summative evaluations will occur.
  7. Discuss the legal and ethical expectations and responsibilities of supervision.
  8. • Take time to decrease the anxiety associated with being supervised and build a positive working relationship. It is important to determine the knowledge and skills, learning style, and conceptual skills of your supervisees, along with their suitability for the work setting, motivation, self-awareness, and ability to function autonomously. A basic IDP for each supervisee should emerge from the initial supervision sessions. You and your supervisee need to assess the learning environment of supervision by determining:
  9. Is there sufficient challenge to keep the supervisee motivated?
  10. Are the theoretical differences between you and the supervisee manageable?
  11. Are there limitations in the supervisee’s knowledge and skills, personal development, self-efficacy, self-esteem, and investment in the job that would limit the gains from supervision?
  12. Does the supervisee possess the affective qualities (empathy, respect, genuineness, concreteness, warmth) needed for the counseling profession?
  13. Are the goals, means of supervision, evaluation criteria, and feedback process clearly understood by the supervisee?
  14. Does the supervisory environment encourage and allow risk taking?

Clinical Supervision and Professional Development

Administrative Supervision


As noted above, clinical and administrative supervision overlap in the real world. Most clinical supervisors also have administrative responsibilities, including team building, time management, addressing agency policies and procedures, recordkeeping, human resources management (hiring, firing, disciplining), performance appraisal, meeting management, oversight of accreditation, maintenance of legal and ethical standards, compliance with State and Federal regulations, communications, overseeing staff cultural competence issues, quality control and improvement, budgetary and financial issues, problem solving, and documentation. Keeping up with these duties is not an easy task!
This TIP addresses two of the most frequently voiced concerns of supervisors: documentation and time management. Supervisors say, “We are drowning in paperwork. I don’t have the time to adequately document my supervision as well,” and “How do I manage my time so I can provide quality clinical supervision?”


Documentation for Administrative Purposes


One of the most important administrative tasks of a supervisor is that of documentation and recordkeeping, especially of clinical supervision sessions. Unquestionably, documentation is a crucial risk-management tool. Supervisory documentation can help promote the growth and professional development of the counselor (Munson, 1993). However, adequate documentation is not a high priority in some organizations. For example, when disciplinary action is needed with an employee, your organization’s attorney or human resources department will ask for the paper trail, or documentation of prior performance issues. If appropriate documentation to justify disciplinary action is missing from the employee’s record, it may prove more difficult to conduct the appropriate disciplinary action (See Falvey, 2002; Powell & Brodsky, 2004.)
Documentation is no longer an option for supervisors. It is a critical link between work performance and service delivery. You have a legal and ethical requirement to evaluate and document counselor performance. A complete record is a useful and necessary part of supervision. Records of supervision sessions should include:

  1. The supervisor–supervisee contract, signed by both parties.
  2. A brief summary of the supervisee’s experience, training, and learning needs.
  3. The current IDP.
  4. A summary of all performance evaluations.
  5. Notations of all supervision sessions, including cases discussed and significant decisions made.
  6. Notation of cancelled or missed supervision sessions.
  7. Progressive discipline steps taken.
  8. Significant problems encountered in supervision and how they were resolved.
  9. Supervisor’s clinical recommendations provided to supervisees.
  10. • Relevant case notes and impressions. The following should not be included in a supervision record:
  11. Disparaging remarks about staff or clients.
  12. Extraneous or sensitive supervisee information.
  13. Alterations in the record after the fact or premature destruction of supervision records.
  14. Illegible information and nonstandard abbreviations.

Several authors have proposed a standardized format for documentation of supervision, including Falvey (2002b), Glenn and Serovich (1994), and Williams (1994).

Time Management


By some estimates, people waste about two hours every day doing tasks that are not of high priority. In your busy job, you may find yourself at the end of the week with unfinished tasks or matters that have not been tended to. Your choices? Stop performing some tasks (often training or supervision) or take work home and work longer days. In the long run, neither of these choices is healthy or effective for your organization. Yet, being successful does not make you manage your time well. Managing your time well makes you successful. Ask yourself these questions about your priorities: Clinical Supervision and Professional Development .

  1. Why am I doing this? What is the goal of this activity?
  2. How can I best accomplish this task in the least amount of time?
  3. What will happen if I choose not to do this?

It is wise to develop systems for managing time-wasters such as endless meetings held without notes or minutes, playing telephone or email tag, junk mail, and so on. Effective supervisors find their times in the day when they are most productive. Time management is essential if you are to set time aside and dedicate it to supervisory tasks.

Vignette Overview


This vignette illustrates how a clinical supervisor can justify a system of supervision, along with time and resource allocations, to agency administrators in the light of recent pressures from the administration to increase billable hours. (Clinical supervision is not a billable expense at this agency.)


Background


Ella, a Level 2 supervisor, was recently hired to be the clinical supervisor of this agency, overseeing the work of six counselors. Jonathan is the agency’s CEO and Ella’s immediate boss. Jonathan has directed Ella to maintain supervisory functions “the way your predecessor did.” Jonathan does not want to introduce any significant tasks into the workload, especially those that are not billable or revenue generating.


Ella, on the other hand, recently attended a 30-hour class on clinical supervision and is seeking her certification as a clinical supervisor. During the class she learned the importance of “making a reasonable effort to supervise,” and the legal and ethical obligations of the agency to supervise. She learned about her and the agency’s vicarious liability for the actions of the clinical staff. In the class, Ella was given the 20-to-1 guideline: for every 20 hours of client contact, staff should receive a minimum of 1 hour of clinical supervision.


Until now, staff has received primarily consultation and support with case management. To justify more in-depth clinical supervision, Ella needs the support and endorsement from Jonathan of the new supervision system. Given his emphasis on billable hours and reducing nonreimbursable activities, Ella knows that introducing these changes in the agency will not be easy, but she comes to Jonathan with her plan for supervision, asking for his endorsement.


Learning Goals

  1. To describe the benefits and rationale of clinical supervision.
  2. To design a system of supervision that is efficient and effective, without greatly increasing staff and supervisory time and resources.
  3. To explore a system in which the supervisor can balance management and administrative duties, maintain a clinical caseload, conduct training, and perform other duties as assigned.

[The vignette begins with a meeting between Jonathan and Ella to discuss her supervisory tasks and her plan. After a short introduction in which Ella discusses her feeling of being overwhelmed by her tasks, the dialog continues.]


JONATHAN: The last time we met you were to look at how to improve the quality of our counseling and design a new plan for supervision. What did you come up with?
ELLA: Well, first I looked at what makes us a quality agency: our strengths and skills and our weaknesses and liabilities. We want to be the best agency possible. There are four issues that came to me. First, after the client suicide last year, concerns were raised about our liability as an agency. Even though we took the right action, we need to be mindful of our vicarious liability for what our staff does. I think we’re both concerned about that issue.


Second, we’re now required by the State to eventually have all counseling staff be certified addiction counselors. Our accrediting body is pushing us to provide better quality assurance systems with more clinical supervision. Third, I know our organizational development plan calls for us to expand services in the near future. We need to attract high-quality counselors. That’s difficult in a highly competitive market, with many agencies vying for good staff. We’ve had significant staff turnover in recent years for several reasons. I found that the average tenure of a counselor in our agency is 2 years, which, by the way, is consistent with the national average. We know from the exit interviews that the majority of staff who leave complain that we didn’t provide as many good training and supervision opportunities as other agencies do to support their learning and self-care needs. It’s costing us a lot of money to have such high staff turnover.


Finally, we need to increase our billable hours. Research tells us that the better the supervision, the better staff morale and in turn, the better the client services. This has a direct impact on our bottom line if we retain clients in treatment longer.
[Ella gives Jonathan copies of various studies she’s compiled from her training on the cost of staff turnover, the CSAT Manpower Study (CSAT, 2003), and a synopsis on staff development issues from the agency’s development plan.]


Master Supervisor Note: Notice how Ella is well prepared for her presentation to Jonathan, providing a rationale in language and terms that appeal to administrators: concerns about liability, credentialing of personnel as mandated by the State, staffing needs and turnover, and billable hours. When presenting a proposal for a clinical supervision system to senior administrators, it is wise to:


1. Use terms and language that apply and appeal to administrators
2. Be prepared with facts and figures (e.g., the CSAT Manpower Study)
3. Be clear, direct, and succinct; most administrators value clarity, directness, and results-oriented presentations
4. State clearly the goals, objectives, timelines, and costs for the system and have the data to support them


JONATHAN: Wow, I’m impressed. You’ve done your homework. So, what is it you’re suggesting? You know money is a key issue right now.


ELLA: Money is an important issue. I’m suggesting that we look at our current supervision system and that we design and offer a new system that will help counselors become credentialed, meet the requirements of our accreditation body, reduce our high turnover rates, protect our liability concerns, improve morale, and in turn, bring more money into the agency.


JONATHAN: That’s a tall order. And you’re going to do this without spending any money? [Laughing.] Let me go back to what you said. I thought after last year’s suicide that we beefed up our oversight.


ELLA: Yes, we trained staff on how to deal with suicidal ideation and what actions to take. We were really sensitive to suicidal symptoms and documentation of issues. We have done a good job addressing that issue. However, I have concerns about our liabilities in general. What is going on right now that we don’t know about? What are our counselors actually doing behind closed doors? Is there another legal issue waiting for us that we don’t know about? That’s what I mean by our vicarious liability. Without a sound, consistent system of supervision, it will feel like we’re constantly putting our fingers in the dike. Master Supervisor Note: When conceptualizing, justifying, and implementing a new comprehensive supervision program each level of staff—agency administration, supervisory staff, counselors providing direct services, and support staff—have unique concerns about the needs and effects of clinical supervision. Administrative staff are most likely to be concerned about some of the issues noted below:


1. Legal and ethical requirements for supervision, such as vicarious liability, scope of competence and practice requirements, and recent court rulings requiring clinical supervision. It is useful to stress the agency’s fiduciary responsibility to ensure the quality of services provided.
2. Relevant Federal, State, and credentialing or accreditation requirements for supervision.
3. Staffing costs, such as personnel retention and turnover rates, hiring costs and expenses associated with retraining of personnel, and impact on staff morale. It is useful to provide any research data available in the field or from your agency.
4. Costs associated with implementing a supervision system, such as material and time costs and the impact on billable hours.
5. The cost benefit for implementing a supervision system, addressing: “What’s in it for the agency? Why should we do this? What are the ramifications and costs if we don’t?”
6. A timeline for implementation, with dates and deliverables, including benchmarks to measure success.
It is important that support in the form of data or relevant resource materials supplement these points.


JONATHAN: I agree. Are you telling me we’re not doing our job? That our supervisors are not supervising?


ELLA: Our counselors are working very hard. We have fine staff here. Yet, we’ve got to give them more tools to do a better job, to continue to enhance their skills, and to ensure they recognize what they don’t know. And, as we grow, the skills needed by staff will also grow.


JONATHAN: We’re not doing that now? We have money in the budget for training. We send people to summer institutes every year. We have weekly training sessions. Isn’t that supposed to address those issues?


ELLA: It does, but only partly. Much of what we do in these sessions is administratively oriented, addressing new policies, procedures, and paperwork, compliance issues, and personnel concerns. We’re not doing clinical supervision.


JONATHAN: I’m confused. Maybe I don’t have a good understanding of what clinical supervision is. I thought that’s what we were doing. Are we better off than we were a year ago? I need to assure the board of directors that we’re doing a better job, that the legal concerns of last year have been addressed.


[Ella presents a brief and clear description of what clinical supervision is and how it differs from what they have been doing, which is primarily case management.] ELLA: We’ve made significant progress. You can assure the board of that. We’ve minimized some of our legal risk. We’ve addressed compliance issues. That’s good! When you asked me to look at a quality assurance plan, it was clear our weekly staff meetings and training sessions only address some of the needs. We must increase our clinical oversight of staff. That’s not just administrative in nature. In the course on clinical supervision you sent me to, I found a definition that I think really makes my point. First, clinical supervision is a process where counseling principles are transformed into practical skills. Second, there are four focuses in clinical supervision: administrative, evaluative, supportive, and clinical/educational. We’ve addressed the administrative aspects of supervision well. We now need to increase the amount of evaluation we give staff, support them in their clinical duties, and train them by watching them work with our clients more closely.


Master Supervisor Note: In many agencies, administrators may not have a clinical background and thus may not understand the differences between case management and clinical supervision. A skillful supervisor patiently educates administrators about the distinction and stresses clinical concerns.


JONATHAN: I think I understand the difference. I’m not a clinician so I am not always familiar with terminology. So what are you proposing we do?


ELLA: I need your endorsement and support for a system of supervision involving direct observation of counseling staff, so we shift the balance of our supervision from mostly administrative to include a clinical focus, too. The supervision will address each counselor’s skills, what competencies they need to develop further, and how each can best address the needs of the clients.


How To Demonstrate the Importance of Administrative Support for Clinical Supervision


An individual developing a clinical supervision program for an agency clearly needs to explain to an administrator what is being asked of the organization. It is essential that administrators understand and support the supervision system. Without that endorsement, supervision systems will not be successful. Critical steps in this process include:


1. The endorsement of supervision to all staff should be both verbal and in writing.
2. Clinical supervision systems need the support of staff at all levels of management and in a manner they will understand: how it will benefit them, the agency, and the clients.
3. Staff should hear a consistent message about supervision over time, lest they see the supervision system as the current “flavor of the month,” and believe “this will pass as soon as another priority comes along.” Staff need to hear that administrators have a long-term commitment to a consistent program of quality assurance in their supervision program.
4. It is essential that administrators understand that systemic change takes time.

Although some immediate results will be seen, long-term results can best be measured over the long term. Many staff have settled into their ways of doing counseling and might take time to adjust to receiving clinical supervision and make noticeable improvements in their skills. JONATHAN: This is making me nervous. It’s sounding like money. [Laughing.] You know the pressure we’re under to increase billable hours and decrease activities that don’t generate revenue. Now you seem to be adding more activities and expenses. Where’s the time coming from to do this?


ELLA: I understand the concern about increasing expenses. There are two answers. Remember the oil commercial years ago, that went something like: “Pay me now or pay me later, but you’re eventually going to pay me.” We’re paying a lot for staff turnover and decreased productivity because people are feeling unsupported by administrators. Staff morale is lower, too. If we can provide better training and supervision, we can save the agency considerable expense. Second, if we can train our staff better, we can perhaps increase both the quality of our care and the number of clients we can serve. That goes right to the bottom line.


JONATHAN: Are you sure you didn’t get an M.B.A. somewhere along the way? You sound like a business person. Are you saying we’re not as productive as we might be? Isn’t that an administrative issue if people are not doing their jobs?


ELLA: If we support them further, they could do an even better job. Our counselors are excellent at what they do. They work very hard and for long hours. Often that leads to burnout and eventually staff turnover. If we reduced that burnout through supervision, we’d keep them here longer, and their treatment of clients would improve. That would help our credibility in the community and eventually lead to more services and revenue. “Pay me now or pay me later.” The choice is up to you.


JONATHAN: Okay. So what are you proposing, and what will it cost?


ELLA: For an agency our size, with only a few counselors, two clinical supervisors can do the job. At the same time, they can attend to some administrative issues too, in addition to their own clinical work. At the training, I learned of a system where a supervisor would spend about 3 hours a week supervising her counselors. Some of the time is observation, and the rest is individual and group supervision. I can show you the matrix we’d use to do this. Each counselor would be observed in action with a client at least once a month. The supervisor would meet with the team every week and review the case presented by the counselor of the week. We’d use videotape of counseling sessions to demonstrate the counselor’s skills and actions. The group would view sections of the videotape, and we’d have an hour-long discussion of the tape. In some cases, instead of videotaping (it may not be appropriate to videotape some clients), the supervisor would sit in on the actual session and observe. They’d then follow the same individual in small group supervision discussion. To do this, I need you to provide funds to purchase video cameras, tripods, and DVDs. We need $1,000 for this purchase. That will ensure we’re making a reasonable effort to supervise and will significantly increase our clinical supervision system here. What do you think?


How To Implement a Clinical Supervision System


To clarify the above statement by Ella, if a supervisor oversees the work of one to five counselors, it typically requires 2–3 hours per week (see Figure 3 on p. 11). This entails relying on group clinical supervision and direct observation through audio- or videotaping or live supervision. Supervisors might need to provide additional time for close supervision of trainees, interns, or counselors needing specific attention. The critical aspects in rolling out a clinical supervision system include:


1. Administrative support. This should be in the form of both written and oral communication to all personnel showing administrators’ support for clinical supervision.
2. Training of supervisors. Credentialing organizations require a certain number of hours of training to be certified as clinical supervisors. Simply because a person is a good counselor does not qualify them to be a supervisor. It requires another body of knowledge and skills to be a supervisor.
3. Educating staff about what quality supervision is and what to expect in the new system. A session for clinical staff should be held (1–2 hours duration), explaining the rationale for supervision, the policies, procedures, techniques, and expectations of supervision.
4. A system of supervision of supervision, monitoring the progress of supervisors in implementing the system, and providing feedback on how they are doing. This is sorely lacking for most supervisors, at least initially. This can be done through internal supervisors overseeing other supervisors, peer supervision of supervisors, or externally by contracting with a master supervisor to oversee the work of supervisors.
5. Consistency of the message that supervision is here to stay and that clinical supervision is a requirement of the agency.
6. Time to implement the system, acknowledging and working through staff resistance to change. Attitudes and behaviors about supervision change slowly. Thus, administrators need to understand that it takes time to work with personnel, to be clear about what’s expected of them, and to overcome staff resistance.


JONATHAN: We can do that. That’s a modest expense we can afford. How do I sell this to the board?

ELLA: What did the potential law suit cost us last year in legal fees? Surely more than the cost of three cameras. What does it cost us to train a new counselor when someone leaves? Surely more than the time we’re investing in their training. Perhaps you could tell that board that if we can retain a staff member for 6–12 months longer, we’ll save the agency far more than you’ve invested in supervision. By being careful, by providing quality supervision, in the long run, it will in fact save us money by being preventive.

JONATHAN: What else can I tell the board about this supervision system?

ELLA: You can tell them that when a counselor leaves, clients react and the quality of their care decreases. The board is interested in client satisfaction and treatment outcome. This supervision system will help with that.

JONATHAN: Okay, I’m sold. What’s next?

ELLA: First, I want to submit to you this plan I’ve developed for the supervision system. I’d ask that you read it and next time we meet, if we concur, I’d like a written statement from you endorsing the plan. I’d also like you to introduce the program at our next all-staff meeting. How does that sound so far?

JONATHAN: That’s fair. Then what?

ELLA: Second, we need funding for the equipment. Third, we need to identify potential supervisory candidates from within the organization. If none can be found, we will have to look outside the agency to recruit a qualified supervisor. Fourth, we will begin to train our supervisors in this model of supervision. This can be done through a number of low-cost media. Fifth, we will provide an in-service training for all staff on the supervision system. We need to be clear with staff that we’re going to be observing them with videotape and/or direct observation. Some won’t like that. Some staff will be quite resistant to the change. This will take time—likely about a year for everybody to be on board. You and I have to be consistent over time, reinforcing the message that this is how we’re doing clinical supervision here, regardless of staff’s credentials or years of experience.

There’s going to be a learning curve. Master Supervisor Note: Again, it is important to be prepared for this presentation with a clear statement of funding requirements, training needs, mechanisms of how these needs will be met, and benchmarks for success. Further, it is essential to get a firm commitment to the plan from administrators before the supervisor proceeds. The supervisor should also stress the barriers and obstacles to be overcome and how those will be addressed.

JONATHAN: Some of the distinction between case management and clinical supervision will hopefully become clearer to me and staff as we implement the system. You’re going to have to continue to educate me about it. I’d like to meet regularly with you, perhaps once a week during the roll-out, to discuss how we’re doing. Since the State now requires our counselors to eventually be certified, will this help in that process?

ELLA: Absolutely. As you might recall, to be certified as an addiction counselor, the person must be supervised by a certified supervisor. This system will meet that requirement. It will help our counselors to be certified.


[Jonathan and Ella summarize the advantages of a model for clinical supervision that includes workforce development and a means to implement evidence-based practices, address risk-management issues and vicarious liability, create consistency within the agency, minimize reactivity, address accreditation issues, and support counselor wellness.]

JONATHAN: Can you bring me a budget for what this will cost in person hours and hardware by next week? Talk to our accountant if you need costing data. How are we going to train our supervisors? What will that cost? What’s the most cost-effective way of conducting the staff and supervisor training? I’d like to see a 3-, 6-, and 12-month implementation and financial plan for this. Can you provide projections as to potential cost offsets and savings on the other end? Can you have that for me by next week?

ELLA: Yes, I can do that by next week. I’ll also give ideas as to how supervisors can balance management and administrative duties, maintain a caseload, and perform other duties as assigned.

 

Resources


The following are resources for supervision:

  1. Code of Ethics from the Association of Addictions Professionals (NAADAC; http://naadac.org).
  2. International Certification & Reciprocity Consortium’s Code of Ethics (http://www.icrcaoda.org).
  3. Codes of ethics from professional groups such as the American Association for Marriage and Family Therapy (http://www.aamft.org), the American Counseling Association (http://www.counseling.org), the Association for Counselor Education and Supervision (http://www.acesonline.net), the American Psychological Association (http://www.apa.org), the National Association of Social Workers (http://www.socialworkers.org), and the National Board for Certified Counselors (NBCC; http://www.nbcc.org).
  4. ACES Standards for Counseling Supervisors; ACES Ethical Guidelines for Counseling Supervisors (http://www.acesonline.net/ethical_guidelines.asp); and NBCC Standards for the Ethical Practice of Clinical Supervision.

TAP 21-A provides detailed appendices of suggested reading and other resources (CSAT, 2007). Additionally, Part 3 of this document provides a literature review and bibliographies (available online only at http://www.kap.samhsa.gov). The following are examples of online classroom training programs in clinical supervision in the substance abuse field:

  1. http://www.attcnetwork.org/midatlantic, Clinical Supervision for Substance Abuse Treatment Practitioners Series.
  2. http://www.attcnetwork.org/midatlantic,

Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency.

  1. http://www.attcnetwork.org/northeast, Clinical Supervision to Support the Implementation, Fidelity and Sustaining Evidence-Based Practices.
  2. http://www.attcnetwork.org/northwestfrontier,

Clinical Supervision, Part 2: What Happens in
Good Supervision.


Other training programs are given in professional graduate schools, such as New York University School of Social Work; Smith College School for Social Work; University of Nevada, Reno, Human and Community Sciences; and Portland State University Graduate School of Education.
For information about tools to measure counselor competencies and supervisor self-assessment tools, along with samples, see the following:

  1. David J. Powell and Archie Brodsky, Clinical Supervision in Alcohol and Drug Abuse Counseling, 2004.
  2. L. DiAnne Borders and Lori L. Brown, The New Handbook of Counseling Supervision, 2005
  3. Jane M. Campbell, Becoming an Effective Supervisor, 2000.
  4. Janet Elizabeth Falvey, Managing Clinical Supervision: Ethical Practice and Legal Risk Management, 2002.
  5. Carol A. Falender and Edward P. Shafranske,

Clinical Supervision: A Competency-Based
Approach, 2004.
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