Clinical Supervision: An essential ingredient to enhancing treatment outcome with forensic populations

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Clinical Supervision An essential ingredient
to enhancing treatment outcome with forensic
populations

• Deirdre DOrazio, PhD Charles A. Flinton, PhD

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• http//www.youtube.com/watch?v9ZaLipDgFZQ

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So you want to be a clinical therapist?
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Introduction

• Overview
• Goals of supervision
• Styles of effective (and ineffective) supervision
• Enhancing positive therapeutic outcomes
• Obstacles to supervision
• Transference and counter-transference issues
• Managing the impact of working with difficult
  populations
• Monitoring Supervision

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Who are Supervisees?

• Supervisees can be licensed, pre-licensed,
  pre-doctoral, interns, students counselors, or
  probationary staff.

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What is clinical supervision?

• Supervision is an intervention that is provided
  by a senior member of a profession to a junior
  member or members of that same profession. This
  relationship is evaluative, extends over time,
  and has the simultaneous purposes of enhancing
  the professional functioning of the junior
  member(s), monitoring the quality of professional
  services offered to the clients she, he, or they
  see(s), and serving as a gatekeeper of those who
  are to enter the particular profession.
• Bernard and Goodyear (1998)

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Who supervises forensic therapists?

• A licensed professional with experience providing
  direct services in the field of forensic
  psychology
• A licensed professional with experience providing
  direct services to the population with which the
  intern works
• -Board of Psychology (on supervision)

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APA Laws, Regulations, and Standards

• 1.04 Boundaries of Competence
• b) Psychologists provide services, teach, or
  conduct research in new areas or involving new
  techniques only after first undertaking
  appropriate study, training, supervision, and/or
  consultation from persons who are competent in
  those areas or techniques.
•  
• Maintaining Expertise
• Psychologists who engage in assessment, therapy,
  teaching, research, organizational consulting, or
  other professional activities maintain a
  reasonable level of awareness of current
  scientific and professional information in their
  fields of activity, and undertake ongoing efforts
  to maintain competence in the skills they use.
• APA GUIDELINES

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Sexual Offender Therapist Qualifications

• Has received specialized training regarding
  sexually abusive individuals.
• Currently licensed in a mental health
  profession/medical field.
• Unlicensed clinicians such as interns and
  pre-licensed practitioners must be supervised by
  a qualified, licensed clinician.
• CCOSO Adult Guidelines and Best Practices

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Experience

• A qualified therapist
• 2000 hours of face-to-face clinical experience
  in the assessment and/or treatment of sexual
  offenders.
• Therapists with less than the above-delineated
  education and experience should not have primary
  responsibility for an offender in therapy but may
  provide psychotherapy and other services to
  sexual offenders under supervision of a therapist
  who has such education and experience.
• CCOSO Treatment Guidelines

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Training

• Sexual offender therapists should obtain 30 hours
  of bi-annual sexual offender continuing education
  that is specific to their work with sexual
  offenders.
• CCOSO Treatment Guidelines

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California Sex Offender Management Board (CASOMB)

• Registered interns or psychological assistants
  may provide sex offender specific evaluation or
  treatment services when functioning under the
  supervision of a licensed practitioner who meets
  the established criteria. Such interns or
  psychological assistants may apply to the
  regulatory body for approval and listing.
• -CASOMB Recommendations Report January 2010

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CASOMB continued

• A one-year provisional approval status level
  should be offered to those licensed therapists
  who are pursuing sufficient education, training,
  and experience and provide a sufficient plan to
  correct any deficiencies. A provider with
  provisional approval should not be permitted to
  supervise interns or psychological assistants in
  the area of sex offender treatment until becoming
  qualified as an approved provider. No licensed
  clinical supervisor should supervise more than
  four unlicensed interns or licensed therapists
  with only provisional approval.
• -CASOMB Recommendations Report January 2010

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CASOMB continued 2

• Interns or psychological assistants should
  co-facilitate one hundred hours of direct
  services with an approved licensee before being
  eligible for approved provider status. Treatment
  providers who do not meet the hours of service
  requirement may apply to be listed as approved
  providers if there are reasonable limitations on
  experience hours such as working in rural
  counties with fewer referrals.
• -CASOMB Recommendations Report January 2010

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2913 (d) Board of Psychology Laws and Regs.

• No licensed psychologist may register, employ, or
  supervise more than three psychological
  assistants at any given time unless specifically
  authorized to do so by the board.
• No board certified psychiatrist may register,
  employ, or supervise more than one psychological
  assistant at any given time.
• No contract clinic, psychological corporation, or
  medical corporation may employ more than 10
  assistants at any one time.
• No contract clinic may register, employ, or
  provide supervision for more than one
  psychological assistant for each designated
  full-time staff psychiatrist who is qualified and
  supervises the psychological assistants. No
  psychological assistant may provide psychological
  services to the public for a fee, monetary or
  otherwise, except as an employee of a licensed
  psychologist, licensed physician, contract
  clinic, psychological corporation, or medical
  corporation.

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4980.45. EMPLOYMENT OR SUPERVISION OF
REGISTRANTS MAXIMUM NUMBER OF REGISTRANTS

• A licensed professional in private practice who
  has satisfied the requirements of subdivision (g)
  of Section 4980.03 may supervise or employ, at
  any one time, no more than a total of two
  individuals registered as either a marriage and
  family therapist intern or associate clinical
  social worker in that private practice.
• An individual supervised after being granted a
  qualifying degree shall receive at least one
  additional hour of direct supervisor contact for
  every week in which more than 10 hours of client
  contact is gained in each setting. No more than
  five hours of supervision, whether individual or
  group, shall be credited during any single week.
• Direct supervisor contact provided in a group
  shall be provided in a group of not more than
  eight (8) supervisees and in segments lasting no
  less than one continuous hour.

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Forensic Psychotherapy as a Specialty

• Sex Offender Management Best Practices
• Collaboration, specialization, education,
  judicial leadership, and buy-in all for victim
  and community safety

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The Containment Model Best Practices
Criminal Justice System (Probation/ Parole
Officer) Polygraph Examiner

Therapist

• The Offender

Supervisee
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Types of Sexual Offender Populations?

• High Moderate Low Risk Sexual Offenders
• Inpatient
• Outpatient
• Group/Individual Therapy
• Pretrial
• Presentencing
• Treatment/Assessment
• Mandated/Voluntary
• Children, Juvenile, Adult, Male, Female, DD etc

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Supervision is NOT Counseling

• Counseling
• Purpose- personal growth, understanding,
  decision-making
• Goal- determined by client need
• Timeframe-self-paced
• Agenda- based on client needs
• Process- an affective process which includes,
  listening, exploring, teaching, supporting

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Types of Forensic Psychology Supervision

• Clinical
• Administrative

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Clinical Supervision

• Purpose- improves clinical skills, professional
  performance and knowledge
• Goal increases knowledge and skills
• Timeframe- is supervisee and task defined
• Agenda- is based on task and skills needed
• Process- includes assessing performance,
  teaching specific skills (e.g., testing,
  theoretical orientation)

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Administrative Supervision

• Purpose assure compliance with agency and
  professional procedures and policies
• Goal- consistent use of approved formats (e.g.,
  documentation, etc)
• Timeframe- ongoing
• Agenda based on agency policy and professional
  guidelines
• Process clarify expectations, policy,
  procedures, and monitoring compliance

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APA Ethics Code

• 7.02 Descriptions of Education and Training
  Programs
• Psychologists responsible for education and
  training programs take reasonable steps to ensure
  that there is a current and accurate description
  of the program content (including participation
  in required course- or program-related
  counseling, psychotherapy, experiential groups,
  consulting projects, or community service),
  training goals and objectives, stipends and
  benefits, and requirements that must be met for
  satisfactory completion of the program. This
  information must be made readily available to all
  interested parties.

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Program/Supervisor Goals (competencies expected
from the program)

• (SFFI example)
• 1.To provide an environment that facilitates
  knowledge of forensic psychology
• 2. To provide an environment that promotes
  collegiality
• 3.To re-enforce empirically supported
  interventions
• 4. To provide the education and support for
  supervisees to gain practical understanding of
  risk assessment and integrate that understanding
  into therapeutic interventions
• (These should be in writing and provided to the
  intern)

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Goals of Supervision(competencies expected of
the supervisor)

• 1. The ability to identify a supervisees
  strengths and growing edges professionally and
  personally.
• 2. The ability to formulate interventions that
  integrate the supervisees abilities and
  strengths with empirically guided interventions.
  (e.g., assist the supervisee in developing a
  personal paradigm for working with forensic
  populations that is also grounded in current/best
  practice).
• 3. The ability to form an appropriate and
  effective helping relationship.
• 4. The ability to identify and address ethical
  issues as they arise.
• 5. The ability and intent to instill amenability
  to growth. (e.g., Give and receive constructive
  feedback without getting defensive.)
• 6. Impart wisdom The ability to pass on lessons
  learned through experience.

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Supervisee Goals(competencies expected of the
supervisee)

• These are goals developed collaboratively between
  supervisee and supervisor.
• Ideal goals are
• Specific - the goal is clearly understood by
  both the supervisor and the trainee
• Realistic - the goal is within the abilities of
  the trainee and the trainee believes that he/she
  can attain the goal
• Challenging - the goal engages the trainee in a
  way that motivates effort
• Measurable/Observable the goal is concrete
  enough that both the supervision and the trainee
  can monitor progress and achieve a sense of
  accomplishment upon attainment

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Establishing Goals

• Goal Relevance
• refers to goals that are pertinent to a
  particular supervisees needs.
• Goal Importance
• works toward identifying goals that are
  personally significant to the supervisee.
• Goal Attainability
• refers to goals that the supervisee believes
  could be achieved.
• Emotional Salience
• refers to setting goals in which the natural
  rewards are obvious to the supervisee.
• -Cullari ,1996

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Formalizing the Goals for Supervision

• Goals of supervised experience should be
  written and signed by both the supervisor and the
  trainee
• Best practices and accepted standards that have
  been developed by the American Psychological
  Association, the Association of Psychology
  Postdoctoral and Internship Centers (APPIC), and
  the California Psychology Internship Council
  (CAPIC).

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• Intern goal and evaluation form hand out

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Goals for Supervision Examples
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Goal Objectives

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RECAPThree Goals of SupervisionPerformance,
Knowledge, Safety

• To provide a safe, supportive, reliable,
  enriching environment
• within which the supervisee will develop
  practical knowledge of the specialty of forensic
  psychotherapy
• and integrate that understanding into applying
  interventions that are supported empirically
• and effectively prevent reoffense
• Easy, right?!

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Exercise
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Enhancing Positive Therapeutic Outcomes

• The Supervisor as Guardian of Public Safety
• Supervision within the sub-niche of psychotherapy
  involving treatment of offenders is unique in
  several ways. Foremost, the over-arching goal of
  the supervisor supervisee relationship is to
  prevent client sexual re-offense. Good
  supervisors attempt to balance liability for
  community safety with the growth of the
  clinician.

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Does Sex Offender Treatment Work?
Hanson et. al, 2009. the Principles of Effective
Correctional Treatment Also Apply to Sexual
Offenders A Meta-Analysis. Criminal Justice and
Behavior, 36, 865-891.
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Yes! Sex Offender Treatment Does WorkBut it has
room to improve

• 1. A meta-analysis examining 129 studies of
  treatment of sex offenders ultimately included
  only 22 studies that met basic study quality
  criteria. Quality was defined per the
  Collaborative Outcome Data Committee guidelines.
• 2. Results
• 22 studies. N3,121 treated sex offenders.
  N3,625 non-treated sex offenders
• 10.9 sexual recidivism for treated group v.
  19.2 for no-treatment
• 43 reduction in sexual recidivism.
• 3. Conclusion
• Risk Need Responsivity principles should be a
  primary consideration in the design and
  implementation of treatment programs for sexual
  offenders.

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The Guiding Principles of Effective
Interventions Risk, Need, Responsivity(Bonta
Andrews, 2007 Hanson et. al, 2009)
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Effective Treatment Targets Criminogenic Needs
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The Purpose of Treatment Need Responsivity

• The objective of treatment is to help the client
  ameliorate Needs.
• This requires creating an environment that
  facilitates treatment engagement so that the
  offender will maximally Respond to treatment.
• Responsivity refers to the environment for
  change.
• The therapeutic landscape must be safe,
  supportive, continual, reliable.
• The supervisory landscape must be safe,
  supportive, continual, reliable.

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The Real Purpose of Treatment

• Change the Structure Function of the Brain
• Good therapy a meaningful experience in a safe
  context that alters the neuronal processing
  template, directly shaping the circuits
  responsible for memory, emotion and
  self-awareness.

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The Neurobiology of Change

• Patterns of energy and information flow within
  the brainand between brains.
• Experience shapes the genetically programmed
  maturation of the nervous system.
• All new input is filtered through this neuronal
  processing template. Changes are use-dependent,
  occurring only in novel or extreme situations.
• Attributing meaning to experience (emotion)
  causes new patterns of connections among nerve
  cells in the brain, at a sub-cortical level. This
  is how memory works.
• Memory is the way past events effect future
  responses.
• Concepts evoke change only when meaning is
  ascribed to experience.
• Good therapists attend to the neurobiology of
  interpersonal experience Human connections shape
  neural connections.
• If it evokes meaning, information from this
  workshopfrom your supervision sessionsfrom your
  supervisees therapy sessions will be encoded,
  stored retrieved by the brain in implicit and
  explicit memory systems.

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Unhealthy Deficits Can Become Healthy Tendencies
Unconscious Incompetence (pre-contemplation) Con
scious Incompetence (contemplation) Conscious
Competence (action) Unconscious Competence
(maintenance)
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RECAP Enhancing Positive Outcomes

• Effective sexual offender therapy, and effective
  sexual offender therapist supervision, can and
  does happen
• It is guided by the goal of preventing victim
  harm
• It includes thorough assessment and targets
  specified and empirically based needs
• Conducted in a relational landscape that
  maximizes brain based change
• Involves making new implicit and explicit memory
  patterns through experience and emotion

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The Therapeutic ProcessEssential to Outcome

• The How is as Important as the What of
  Treatment
• SOT Programs that highlight the therapeutic
  relationship are successful at enhancing positive
  behavior change and reducing recidivism (Marshall
  et al, 2003 2010)
• A convenient overshadowing Strongly manualized
  programs and purely didactic (psychoeducational)
  are inadequate at evoking the kind of change
  needed by offender clients
• Experiential methods are essential for brain
  integration
• Effective therapy, and effective supervision,
  employs positive approaches that motivate change
  and identify strengths, using them to build
  skills while still targeting relevant needs
• Approach goals facilitate treatment engagement,
  disclosure, and prosocial identification

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Supervisors are mindful of what works, and
doesnt work, in therapy with sexual offenders

• Authoritarian and aggressive techniques do not
  work with abusive individuals (i.e.
  confrontation, shock, anger, revenge on behalf of
  victims, demand for change). They elicit
  resistance, argumentativeness, manipulative
  placation, eroded self-esteem, drop-out.
• Effective process facilitates emotion processing
  and regulation. It helps clients regulate the
  affective precursors to offending. Interpersonal
  schemas are changes through emotional expression.
• Many sexual offender clients are particularly
  responsive to therapy process variables because
  they were betrayed by someone in a position of
  trust and they are poised toward suspiciousness.

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Good Supervisors Foster Essential Therapist
Characteristics

• Empathic
• Genuine
• Supportive
• Directive/Reflective

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Follow the Responsivity Principle Offender
Recovery Begins with Empathy for the Offender
To sense the clients private world as if it
were your own, but without ever losing the "as
if qualitythis is empathy, and this seems
essential to therapy. To sense the clients
anger, fear, or confusion as if it were your own,
yet without your own anger, fear, or confusion
getting bound up in it, (is empathy). When the
clients world is this clear to the therapist,
and he moves about in it freely, then he can both
communicate his understanding of what is clearly
known to the client and can also voice meanings
in the clients experience of which the client is
scarcely aware. (Carl Rogers, 1957, p.99)
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Obstacles to Effective Supervision

• Strains in supervision can be brought about by
  the challenges inherent in clinical practice,
  conflicts in the goals and/or tasks, inadequate
  attention to the values modeled by the supervisor
  and/or the essential therapist characteristics,
  inadequacies in technical competence, boundary
  crossings, problematic supervisee behavior, and
  negative transference, countertransference, and
  parallel process phenomena.

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Obstacles
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Indicators of Supervision Strain

• Withdrawal
• Paucity of disclosure
• Direct expression of criticism/hostility
• Noncompliance/passive responding
• Acting in/acting out

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Obstacles to SupervisionFacing the Shadow

• Negative attitudes and beliefs about offenders
  leads to inappropriate therapeutic style and
  negative outcomes
• What is the societal context within which we
  provide sexual offender treatment?
• How might the common societal view of sexual
  offenders impact a therapist?
• Impact you?
• Beware the temptation to participate in the
  cycle of abuse!

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The Cycle of Abuse

• Empathy A matched vicarious emotional response
  that depends on the ability to infer anothers
  cognitive and affective state. It is mediated by
  egocentrism (a continuum of self to other focus)
• Trauma leads to a personal distress state,-
  excessive self focus with goal of immediate
  relief
• Acute distress yields to general wounded-ness
• Reactive versus receptive
• Common symptoms self-regulation deficits (affect
  tolerance/ modulation), shame, secrecy, negative
  self-evaluation, depression, social/intimacy
  deficits, avoidance behaviors (dissociation,
  denial, distraction, externalization

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Cascade Effects of Trauma on the Brain

• Inability to regulate strong emotions wires the
  brain to survive in a world of constant danger.
• When unknown or threatening sensory input is
  matched against the existing processing template,
  the brain activates a fight or flight response
  before the signal can get to the cortex.
• The brain becomes programmed to irritability,
  impulsivity, suspiciousness.

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Cascade Effects of Trauma on the Brain

• 1. Left Hemisphere Underdevelopment
• 2. Deficient Left-Right Hemisphere
  Integration
• 3. Limbic Irritability
• 4. Abnormal Activity in the Cerebellum
• 5. Hormone Dysfunction

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The Cycle of Abuse Trauma Perpetrators,
Recipients and HealersIMPACT

• Recipients
• Trauma taxes expectation system leading to
  failure to manage fear and integrate trauma.
• Perpetrators
• Ongoing wounded-ness keeps abusive individuals
  self-focused and reacting to a hostile world.
  Empathy deficits prevail. They dont notice,
  dont care, or misinterpret cues from others.
  Significant impact on Risk, Needs Responsivity.
• Healers
• What the patient says in group is more of an
  intelligence test. It is what he says to other
  patients, our reading between the lines that
  tells us the degree of internalized change.
  Therapist lack of confidence steals the reserves
  necessary to perceive what is really going
  on.-Liam Marshall, 2011.

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Empathy is Related to.

• Healthy
• Accurate perspective taking
• Affect identification, tolerance modulation
• Attachment , Intimacy Social Interest
• Prosocial behavior abuse abatement
• Conscience development
• Feeling understood, validated, supported

• Unhealthy
• Cognitive distortions
• Criminal thinking
• Less visual processing
• Affective Dysregulation(PD)
• Communication deficits
• Intimacy deficits callousness
• Abusive behavior
• Psychopathy

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Unconscious Challenges to Supervision

• Transference
• Unconscious redirection of a client's feelings
  for a significant person to the therapist. Common
  manifestations of transference erotic
  attraction, rage, hatred, mistrust,
  parentification, over-dependence, idealization.
  I.e. A man transfers hatred of his mothers
  infidelities to other women, and his female
  psychotherapist.
• Counter-transference
• A jointly created phenomenon between the
  treater and the client. The client pressures the
  treater through transference into playing a role
  congruent with the clients internal world. The
  specific dimensions of that role are colored by
  treaters own personality. I.e. The female
  therapist, feeling dismissed and disliked,
  attends more to other clients in group therapy.

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Vicarious Traumatization

• The cumulative transformative effect upon the
  trauma therapist of working with survivors of
  traumatic life events.It is a process through
  which the therapists inner experience is
  negatively transformed through empathic
  engagement with clients trauma material
• Pearlman Saakvitne, 1995

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Monitoring Managing Therapist Impact

• Repeated exposure to stories of perpetration and
  predation tempt us to participate in the cycle of
  abuse. Supervisors help therapists access and
  treat the wounds of clients, while identifying
  impact to the therapist and managing the
  therapists wounds

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Cultivate the Nymph in Supervisees!

• The goal is an integrated brain. Focus on the
  How along with the What of the work they do,
  and the work you do together.
• 2. Therapist Style Empathy, Genuineness,
  Supportiveness, Directiveness.
• 3. Treatment planning begins with the clients
  world view. They wont develop empathy until we
  do.
• 4. Get comfortable with working at the foot of a
  volcano! Tolerate and transform pain and fear.
• Willing Awareness commit to showing up
  physically and psychologically to experience
  that which is.
• 6. Beware the temptation to participate in the
  cycle of abuse.

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My Vow to Care for the Helper

• Internal
• I will expect counter-transference
• In session I will practice willing awareness
• External
• I will prioritize my personal life
• I will incorporate my best qualities
• I will find a passion in my professional life
• I will be aware of personal signs of burnout
• I will allow myself my own therapy
• I will utilize debriefing consultation
• I will connect with other professionals in the
  field

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Care for the Healer

• Practice the treatment in your own life.
• Self empathy sells empathy!
• Beware of vicarious traumatization.
• Commit to lifelong learning, consultation,
  collaboration.
• Put your work into perspective.
• Appreciate your colleagues.

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• Supervision types, process, and techniques

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Types of Supervision Styles

• Authoritarian supervision
• Laissez Faire supervision
• Companionable supervision
• Collaborative supervision

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Authoritarian Supervision

• Cognitive stance of the supervisor
• Supervisees require constant attention because
  they are often undependable or immature (e.g.,
  they will attempt to work as little as possible
  unless someone monitors them carefully).
• Supervisees cannot be trusted to fulfill their
  tasks, the supervisor must check on them
  frequently. The supervisor is ultimately
  responsible for supervisees performance.
  Consequently, close observation is an essential
  part of the supervisors responsibilities.

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Laissez Faire Supervision

• Cognitive stance of the supervisor
• Give supervisees the freedom to use their talents
  and skills in accomplishing job responsibilities.
  Hire good people and then get out of their way.

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Companionable Supervision

• Cognitive stance of the supervisor
• Supervision is a friendship-like relationship.
  Supervisors should seek to be liked and create
  harmonious relationships. The focus should be on
  being buddies with the supervisees and avoid
  confronting them about poor job performance or
  mistakes in judgment.

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Collaborative Supervision

• Cognitive stance of the supervisor
• A cooperative effort between the supervisor and
  supervisee that facilitates a joint effort to be
  greater than the sum of their individual
  contributions.
• Supervision in this approach has a dual focus 1)
  the accomplishment of the organizations goal and
  2) support staff in the accomplishing their
  personal and professional development goals.
• Supervision emphasizes the identification of
  potential problems early the supervisor and
  supervisee then jointly develop strategies to
  prevent or ameliorate issues and attain goals.

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Effective Supervision Styles

• Ineffective
• Concrete feedback-
• directive, critical, asking irrelevant
  questions
• Effective
• Abstract feedback
• feeding questions that are information
  seeking, information giving and guiding.
  Expertise was also held back at times to enhance
  discovery.
• -P. Grimmet (1998)

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Characteristics of Effective Supervisors

• Empathetic
• Supportive
• Flexible
• Interested in supervision
• Track supervisees effectively
• Link theory with practice
• Engage in joint problem-solving
• Interpretative
• Respectful
• Focused
• Practical
• Knowledgeable

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Characteristics of Ineffective Supervisors

• Rigid
• Low empathy
• Low support
• Failure to consistently track supervisee concerns
• Failure to teach or instruct
• Indirect intolerant
• Closed
• Lack respect for differences
• Non-collegial
• Lacking in praise encouragement
• Sexist
• Emphasize evaluation, weaknesses, deficiencies

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The Process of Supervision

• The Trans Theoretical Model (TTM) and Supervision

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Trans Theoretical Model of Change (Per Ryan E.
Gillespie)
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Precomtemplation Stage

• Supervisees are unaware of (or not focused on)
  the possibility for change (resistant, unaware,
  etc)
• Maybe acquiescent in order to pursue secondary
  gain
• Maybe defensive to feedback

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Contemplation Stage

• Thinking but not doing (Baldwin, 1991)
• Supervisees may experience anxiety about change
• Supervisees may experience feelings/beliefs of
  incompetence
• Supervisees begin to intellectually consider
  change but do not take action

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Action Stage

• Supervisees may experience distress (due to
  incongruence between their awareness and
  readiness to change)
• Supervisees express a commitment to professional
  development
• Supervisors may overestimate supervisees skills
  (Supervisors must supervisees in staying focused
  and not regress to previous stages)

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Maintenance Stage

• Professional autonomy is building
• Supervisees more readily seek assistance in
  honing skills
• Failures may cause regression

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Termination Stage

• Change has occurred when skills become more
  automatic and forced conscious attention is not
  required to maintained skills
• Consultation is natural

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Structured Interventions

• Structure (at least initially)
• Homework
• Video/Audio Taping
• Document Review
• Case Conferences/Presentations
• Topic Presentations

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TTM Specific Interventions

• Experiential Processes
• Consciousness raising
• E.g. Socratic dialog
• Dramatic Relief
• Role play
• Self-reevaluation
• Affective and cognitive assessment of how the
  supervise thinks they are doing
• Environmental Reevaluation
• Assessing and correctly attributing influences of
  change

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Interventions

• Stimulus control
• Removing negative stimuli (e.g. shame)
• Counter-conditioning
• Developing alternative ways of behaving,
  thinking, feeling, and interacting with their
  clients.
• Contingency management
• Based on the principles of reinforcement
• Social liberation
• Maintaining collegial relationships
• Helping relationships
• Trust in the supervisory relationship

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• ..supervisees reported that supervision
  mentoring relationships had more influence on
  their professional development than academic
  preparation.
• Greig, T. C. (1998). Supervisor mentoring and
  psychotherapist professional development An
  exploratory qualitative study. Dissertation
  Abstracts International, 59(04), 1851B. (UMI No.
  9830593)

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EXCERCISE
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APA Ethics Code

• 7.04 Student Disclosure of Personal Information
• Psychologists do not require students or
  supervisees to disclose personal information in
  course- or program-related activities, either
  orally or in writing, regarding sexual history,
  history of abuse and neglect, psychological
  treatment, and relationships with parents, peers,
  and spouses or significant others except if (1)
  the program or training facility has clearly
  identified this requirement in its admissions and
  program materials or (2) the information is
  necessary to evaluate or obtain assistance for
  students whose personal problems could reasonably
  be judged to be preventing them from performing
  their training- or professionally related
  activities in a competent manner or posing a
  threat to the students or others.

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4980.55. DISCLOSURE OF COUNSELORS
QUALIFICATIONS

• As a model for all therapeutic professions, and
  to acknowledge respect and regard for the
  consuming public, all marriage and family
  therapists are encouraged to provide to each
  client, at an appropriate time and within the
  context of the psychotherapeutic relationship, an
  accurate and informative statement of the
  therapist's experience, education, specialties,
  professional orientation, and any other
  information deemed appropriate by the licensee.
• -Board of Behavioral Sciences

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Case Example
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Monitoring

• As a supervisor, you are required to assume FULL
  RESPONSIBILITY for the work product of your
  supervisee.
• Remember that the supervisorial relationship is
  a hierarchical one. Teach and lead.

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The Frame

• The frame defined as any aspect of the
  supervision program intended to create an
  environment in which learning and growth are is
  possible.
• Interventions
• Structure

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APA Ethics Code

• 7.06 Assessing Student and Supervisee Performance
• (a) In academic and supervisory relationships,
  psychologists establish a timely and specific
  process for providing feedback to students and
  supervisees. Information regarding the process is
  provided to the student at the beginning of
  supervision.
• (b) Psychologists evaluate students and
  supervisees on the basis of their actual
  performance on relevant and established program
  requirements

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Giving Difficult Feedback

• Most supervisors admit withholding feedback due
  to concern about negative reactions from
  supervisees. -Stoltenberg (2005)
• -Provide specific examples, and if possible, use
  of audio or video, observation
• -Be aware of your own discomfort and monitor body
  language and eye contact.
• -Anticipate concerns

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Documenting Supervision

• It is important to document supervision sessions
  because
• You are legal responsible for supervisees
  actions
• You will have a clearer perception of how the
  supervisee is progressing in terms of addressing
  crisis issues, adhering to the treatment plan,
  and diagnosing the client.
• If the supervisees case were to go to court (for
  any reason) it is imperative that supervision
  notes indicate that your were providing close and
  adequate supervision.

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Supervision Contracts

• Supervisor and supervisee rights and
  responsibilities
• Content and Context of Supervision
• Scope of practice under supervision
• Length of contract period
• Roles and Expectations of Supervisee and
  Supervisor
• Learning activities, processes, supervisor and
  supervisee responsibilities, feedback, mutually
  defined goals and tasks
• Legal/Ethical Parameters
• Informed consent Confidentiality

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Supervision Contracts continued

• Adherence to agency/practice requirements and
  rules
• Include specific reference to ethical codes,
  licensing statutes, and laws
• Reference to agency/site personnel practices
• Performance Expectations
• Specific knowledge, skills, values
• Modes of formative and summative evaluation

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Risk Management

• Ensure that the clients and referral agents know
  the status of the supervisee (e.g., that they are
  unlicensed and/or an intern) in writing
• APA code 10.01, Informed Consent to Therapy
• c) When the therapist is a trainee and the legal
  responsibility for the treatment provided resides
  with the supervisor, the client/patient, as part
  of the informed consent procedure, is informed
  that the therapist is in training and is being
  supervised and is given the name of the
  supervisor.

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Discussion
99

• Deirdre DOrazio, PhD
• Central Coast Clinical and Forensic Psychology
  Services
• drdorazio_at_cccfpsych.com
• 805-903-2446
• Charles A. Flinton, PhD
• San Francisco Forensic Institute
• caflinton_at_sffi.us
• 415-391-7171