Clinical Supervisors Autumn Workshop Managing Difficulties on Placement

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Clinical Supervisors Autumn WorkshopManaging
Difficulties on Placement
A workshop for UOW current and prospective
placement supervisors based on the ethical
issues in supervision video developed by the
Leeds clinical psychology training course (UK).
This workshop explores helpful processes and
structures for when things dont go to plan.
Includes 3-way placement contracting, safe
supervision, evaluation monitoring, and useful
models to guide supervisory practice.

• 10am 4pm Friday 20th April 2007
• Group Room Blg 22 (Northfields Clinic) University
  of Wollongong
• FREE Workshop (lunch provided)
• Please contact Helen Kouksenko or Mark Donovan
  for further information or
• to book a place 02 4221 3747 or
  helenko_at_uow.edu.au or mdonovan_at_uow.edu.au

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Managing Placement DifficultiesOUTLINE

• Introductions
• What are placement difficulties?
• Process model of supervision
• Video Due Process
• Prevention strategies
• Evidence base further models of supervision
• Applying ideas to supervisory practice

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What are Placement Difficulties?

• Exercise
• Think about your own placement experiences,
  either as a supervisor or supervisee.
• Write down examples of placement difficulties
  that you have experienced, or might experience,
  on stickies (one per sticky).
• In small groups, collate the stickies into higher
  order factors and provide a name for each of
  these factors

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Process Model - Hawkins Shohet,
1993Seven-eyed supervisor
Supervision matrix
supervisor
6
5
Socio-economic, cultural, political
organisational matrix
4
7
therapist
3
2
Therapy matrix
1
client
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Process Model - Hawkins Shohet Seven-eyed
supervisor

• Mode 1 Session content
• Mode 2 Therapists strategies interventions
• Mode 3 Process relationship between client
  therapist
• Mode 4 Internal experience of therapist
• Mode 5 Here now between supervisor and
  supervisee
• Mode 6 Internal experience of supervisor
• Mode 7 Contextual variables (service, Course,
  cultural)

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Process Model - Hawkins Shohet Seven-eyed
supervisor

• Exercise (pairs)
• Which modes do you tend to focus on as a
  supervisor? (or have you experienced as a
  supervisee?)
• Which modes could you use more? What sort of
  questions might you use in supervision to access
  these modes?

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Video Due Process

• Discuss issues raised by the video based on your
  assigned role (supervisee, supervisor, course
  team, service user)
• What are the issues?
• What might happen next?
• How could these issues have been prevented?
• I Mid-placement review
• II Course meeting
• III Supervisee meeting
• IV Supervisor meeting
• Reflect on your experience of the discussion.
  Consider your assigned role in relation to issues
  of power.

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Preventing Placement Difficulties
Clear procedures for placement failure
Supervisor reflection intuitive alarm bells
Developmentally appropriate challenge
Early identification management of concerns
3-way supervision contract
(clear explicit criteria for what is expected)
Safe supervisory relationship
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Purposes Functions of Supervision

• Function
• (Inskipp Proctor, 1998)
• Formative (learning development)
• Skills of therapist
• Professional/ethical conduct
• Professional identity
• Restorative (support)
• Buffer against stress/impact of work
• Encourage disclosure of issues
• Prevent burn-out
• Normative (managerial)
• Progress of therapist/entry into profession
• Standard of care to clients

• Purpose
• (Carroll, 1996)
• Development of supervisee
• Evaluation gate-keeping

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Responsibilities within Supervision

• The supervisor is responsible for participating
  in and creating the conditions in which learning
  and development can take place, and in which the
  clients needs can best be served...
• ...but...
• ...whether the learning opportunities are grasped
  is the responsibility of the supervisee
• Scaife (2001) p.7

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Purposes Functions of Supervision
Facilitation
Evaluation
Supervisory Relationship
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The Supervisory Relationship
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The Supervisory Relationship

• the relationship between the supervisor and
  supervisee has more impact on the success of the
  process of supervision than any other factor
• Alderfer and Lynch (1987)

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The Supervisory Relationship

• Poor alliance is one of the most frequent reasons
  for non-disclosure in supervision
• (Ladany et al, 1996)
• Perceived trustworthiness of the supervisor has
  been found to account for most variance in
  supervisees judgements of supervision
• (Carey et al, 1988)

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The Supervisory Relationship

• What are the important factors in establishing a
  safe supervisory relationship?

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Trustworthiness of supervisor

• Empathic
• Non-judgmental
• Validating and affirming
• Encouraging exploration experimentation
• Worthen McNeil, 1996

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Establishing a Safe Supervisory Relationship

• Authenticity appropriate self disclosure
• Respect for other views
• A flexible curious approach
• Adherence to agreed boundaries
• An empathic and non-judgemental attitude
• A validating and encouraging approach
• Understanding
• Scaife (2001)

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Tips for Establishing a Safe Supervisory
Relationship

• Dont ask the supervisee to do anything that you
  are not prepared to do yourself
• Show your own work to the supervisee openly,
  either live, on tape or by modelling
• Retain the main focus on the client and draw
  everything back to this end
• Always take a respectful approach to clients and
  colleagues so that supervisees know that you will
  not bad mouth them behind their backs
• Dont break confidences
• Dont say one thing and act in a different way

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Tips for Establishing a Safe Supervisory
Relationship

• Discuss how the supervisee can manage you
  should they find their security threatened
• Make sure that challenges are specific and
  related to work
• Comment on areas where you yourself are unsure,
  dont know, or feel you have made an error and
  talk about what can be done next
• Where relevant, talk about your own training
  experiences and how you may differ now from then
• Dont show off your knowledge in the service of
  your own ego

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Tips for Establishing a Safe Supervisory
Relationship

• Be prepared to take responsibility and give
  instructions where client safety is an issue.
  Let supervisees know that they will not be
  allowed to act outside the boundaries that keep
  the system safe
• Share some personal information in a way that you
  might not with clients, in order to allow your
  humanness to show through your professional
  demeanour
• Show interest in the supervisee as a person as
  well as a professional
• Notice the supervisees knowledge and skills
• Scaife (2001)

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Supervision Power

• the supervisors task includes imparting expert
  knowledge, making judgements of trainees
  performance, and acting as a gatekeeper to the
  profession. Formal power, or power attributed to
  the position, rests with the supervisor, and in
  this regard, the supervisory relationship is a
  hierarchical one
• (Holloway, 1995)

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Power Involvement

• the exercise of power cannot be accomplished
  independently, however. The mutually influential
  process of relationship and the ongoing
  interaction between individuals allow for a
  shared influence to emerge. (Holloway,
  1995)
• power is a property of the relationship and not
  of one or other individual.
• (Hinde, 1979, p257)
• Not Power Over (control dominance)
• Power with (involvement mutual influence)

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Social Power

• French Ravens (1960) Types of Power
• Reward Power - Ability resources to mediate
  reward
• Coercive Power - Ability resources to mediate
  punishment
• Legitimate Power - Perceived trustworthiness
• Expert Power - Mastery of knowledge skills
• Referent Power - Interpersonal attractiveness/cha
  risma
• Consider how each of these play out in the
  supervisory relationship

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Power In Supervision

• Invisibility of the role of power in supervision
  can inadvertently lead to a misuse of power
  relations and often give rise to a supervisory
  process characterised not by collaboration but by
  coercion, however subtle and unintentional
• Collaboration is then seen as a key principle
  in developing a supervisory relationship
• Patel (2004) Difference Power in supervision,
  p.109

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Contracting the Supervisory Relationship

• A purpose of the contracting process is to
  facilitate the establishment of a supervisory
  alliance
• Scaife (2001)
• Create a non-judgmental, open relationship where
  anxieties, differences and difficulties can be
  discussed

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Contracting the Supervisory Relationship

• The supervisory contract is seen as important as
  a way of negotiating both goals and tasks but
  also parameters of the relationship. This
  clarifies both content and relational
  characteristics and also establishes mutual
  expectations of the supervisory relationship.
• Beinart, 2003

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Contracting Why is it Important?

• To clarify desires and expectations
• Prompts supervisees to think of their needs for
  support and to learn
• To share knowledge/ experiences of supervision
  and to establish a common framework
• To explore the evaluative role of the supervisor
• To identify the responsibilities of each party in
  the contract to the other involved stakeholders

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Setting up the Contract

• Timing Induction and practicalities first
• Responsibility rests with the supervisor
• Base discussions around the formal written
  contract

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What to Include? Ground Rules for Supervision

• Timing, frequency, location
• Availability at other times/Informal contact
• Boundaries between personal and professional
  relationship
• Clarify who has overall responsibility for
  clinical work

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What to Include? What is to be learned and how

• Different therapeutic models
• Number and type of cases
• Strengths and areas of weakness
• Gaps in experience
• What has helped them to learn

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What to Include? Heading off Problems

• Process for giving evaluative feedback
• What action to take if the supervisee feels their
  needs are not being met
• How to approach differences of opinion
• Highlight probable ethical dilemmas
• (e.g., child protection, suicide risk,
  confidentiality issues)

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Mini-Contracting

• Prepare an agenda for each session
• What do I/you wish to achieve as a result of
  todays supervision?
• How shall we go about accomplishing that?

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Evidence Base for Supervision

• Limited!
• Models and practice tend to draw upon existing
  knowledge of psychotherapy models transferable
  therapeutic relationship skills
• Ellis et al (1996) critique of 144 studies from
  1981-1993
• Not based on theory
• Did not test clear hypotheses
• Used unvalidated measures

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Evidence Base for Supervision

• Milne James (1999) systematic review of
  clinical supervision showed clear and beneficial
  effects for
• Feedback
• Discussion
• Written/verbal instructions prompts
• Modelling (live/video)
• Role play
• Professional self-management skills
• Paper pencil exercises
• Homework assignments
• Behavioural rehearsal of skills
• Live supervision

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Evidence Base for Supervision

• Pratt (1999) ideal wish list of attributes and
  skills for supervision
• Clear and explicit theory/practice links
• Constructive feedback
• Observation of supervisee/supervisor, use of
  tapes
• Containment
• Two-way relationship
• Caseload management
• Manage power relationship

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Evidence Base for Supervision

• Beinart (2004) study of interns/2 yrs post-qual.
  Emerging themes from qualitative analysis
• Boundaried
• Supportive
• Respectful
• Open relationship
• Committed
• Collaborative
• Sensitive to needs
• Educative
• facilitative

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Evidence Base for Supervision

• Helpful supervisory relationships seem to be
  rather similar to other good relationships and
  are based on mutual trust and respect
• Supervisees do not necessarily find expert
  supervision the most effective, they perceive
  boundaried and collaborative supervisory
  relationships to be most helpful and most
  psychologists are good at these.
• Beinart, 2004

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What doesnt work!

• Unhelpful supervisors
• Limit autonomy
• Dont provide adequate direction and clarity
• Are cold, aloof hostile
• Contribute to supervisee stress
• Act as therapists explore supervisee personal
  issues
• Lack empathy, tolerance and interest in
  supervisee
• Are discouraging and defensive
• Neufeldt et al, 1997 Watkins, 1997

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Other Useful Supervision Models
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Psychological Distance Micholt (1992)
Great Powers (organising agents,
requester) Clinical Psychology Training Course
Psychological distance is the perceived closeness
(or distance) and clarity in the relationship
between the three parties
Facilitator Group/Participants Consultant Manage
rs Supervisor Supervisees
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Developmental Model - Stoltenberg, McNeil
Delworth (1998)

• Stage 1 Dependency
• Anxious, insecure about role and ability to
  fulfil it (survival), self-focussed, lacking
  insight but highly motivated
• Supervisor needs to provide a clearly structured
  and containing environment including positive
  feedback and encouragement
• Stage 2 Dependency-Autonomy Conflict
• Fluctuation between dependence autonomy
  over-confidence v over-whelmed client-focussed
  but less aware of counter-transference may feel
  angry towards supervisor as encounter
  complexity/loss of early confidence
• Supervisor needs to be less structured, allowing
  trainee to learn from mistakes. Need to contain
  ambivalent emotions.

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Developmental Model - Stoltenberg, McNeil
Delworth (1998)

• Stage 3 Conditional Dependency
• Increased professional self-confidence. Able to
  see client in a wider context and reflect on
  clients problems and the interaction during the
  session.
• Supervisor can adopt more enquiring framework,
  process-centred and reflective.
• Stage 4 Master Professional
• Personal autonomy, insightful awareness, able to
  confront personal professional issues
• More likely to be collegial or peer supervision
  context

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Stages Model - Inskipp Proctor (1993)
Unconscious Incompetence
Conscious Incompetence
Conscious Competence
Unconscious Competence
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UOW Policies Procedures for Placement
Difficulties/Failure

• Supervision contract to be completed within first
  2 weeks of placement
• Encourage low threshold for concerns
• Intern /or supervisor can contact practicum
  coordinator/clinic director (Chris Allan) or
  supervision coordinator (Mark Donovan) at any
  time for initial discussion of issues (problem
  solving)
• In the first instance, intern/supervisor
  encouraged to attempt resolution of the concerns
  through the supervisory relationship

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UOW Policies Procedures for Placement
Difficulties/Failure

• Mid-placement review to identify/review concerns
  (general principle of no surprises at MPR)
• Clear, measurable (behavioural) goals identified
  for intern to achieve in order to meet criteria
  for passing placement
• Course Director (Brin Grenyer) involved when
  appropriate, as well as certain Clinical
  Committee members

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NSW Psychologists Registration BoardSupervisor
Training

• 1 2 day workshops available
• Workshop notes can be downloaded, including a
  section on Managing Problems
• Legal requirements for Due Process
• Early notification of concerns
• Document required improvements
• Negotiate a remediation plan
• Provide support to implement the plan

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Applying Ideas to Supervision

• Think back over the Due Process video. Any
  further ideas on how to manage this situation?
• Review the list of placement difficulties. How
  could you tackle these difficulties using the
  ideas discussed in this workshop?

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References on Supervision

• Alderfer, C. Lynch, B (1987) Supervision in Two
  dimensions. Journal of Strategic and Systemic
  Therapies, 5, 70-73
• Bernard,J. Goodyear,R. (1992) Fundamentals of
  Clinical Supervision. Boston Allyn Bacon.
• Carey, J.C., Williams, K.S. Wells, M. (1988)
  Relationship Between Dimensions of supervisors
  influence and counsellor Trainees performance.
  Counsellor Education and Supervision, 28, 130-139
  
• Dobson K S Shaw B F (1993) The training of
  cognitive therapists What have we learned from
  treatment manuals? Psychotherapy 30 573-577
• Fleming,I. Steen,L. (2004) Supervision and
  Clinical Psychology Theory, Practice and
  Perspectives. Hove Brunner-Routledge.
• Hawkins,P Shohet,R. (1993) Supervision in the
  Helping Professions. Milton KeynesOpen
  University Press.
• Holloway,E. (1995) Clinical Supervision A
  systems approach. London Sage.
• Holloway E Neufeldt S (1995) Supervision Its
  contribution to treatment efficacy Journal of
  Consulting and Clinical Psychology 63 207-213
• Inskipp,F Proctor,B. (2001) Making the most of
  Supervision (2nd Edition). London Cascade.

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References on Supervision

• Liese B S Beck J S (1997) Cognitive therapy
  supervision. In Watkins C. (ed) Handbook of
  Psychotherapy Supervision Chichester Wiley.
• Nelson M L Holloway E L (1990) Relation of
  gender to power and involvement in supervision.
  Journal of Counselling Psychology 37 473- 481
• Page,S. Wosket,V. (1998) Supervising the
  Counsellor a cyclical model. London Routledge.
• Scaife,J. (2001) Supervision in the the Mental
  Health Professions A practitioners guide. Hove
  Brunner-Routledge.
• Shanfield S, Matthews K Hetherly V (1993) What
  do excellent psychotherapy supervisors do?
  American Journal of Psychiatry 150 1081-1084
• Watkins C E (1997) Handbook of Psychotherapy
  Supervision Chichester Wiley.
• Worthen, V. McNeil, B.W. (1996) A
  phenomenological Investigation of good
  supervision events. Journal of Counselling
  Psychology, 43, 25-34