Clinical Supervision: A Competency-based Approach

1. Clinical Supervision: A Competency-based Approach Based on Dr. Carol Falender’s January 2011 presentation to the VA Psychology Training Council Powerpoint summary by Evelyn Sandeen, Ph.D. , ABPP

2. Why do clinical supervision? • Supervision is required for obtaining a degree and obtaining licensure • Greater staff retention among clinicians who do supervision • Less burnout among clinicians who do supervision • Some research beginning to show positive impact of supervision on client outcomes (Bambling et al., 2006; Callahan et al., 2009)

3. Definition of Clinical Supervision • Distinct professional activity • Involves intention to develop science-informed practice in the trainee • Collaborative, interpersonal process • Involves observation (live, video, or audio) • Involves feedback • Facilitates trainee self-assessment

4. Definition, continued • Facilitates the acquisition of knowledge and skills by • Instruction • Modeling • Collaborative problem-solving

5. Super-ordinate Values embedded in Clinical Supervision • Integrity in relationships • Ethical values-based practice • Science-informed, evidence-based practice • Appreciation of diversity • Diversity of client, of supervisee, and of supervisor

6. Pillars of Supervision • Supervisory relationship alliance • Collaborative relationship • Respect essential • Transparency always desirable • Feedback—frequent and often-- essential • Educational praxis • Tailoring learning strategies to the individual supervisee

7. Supervision vs. … • Consultation • Consultation does not include the power differential that supervision does • Consultation does not bring the liability issues for the supervisor that supervision does • Psychotherapy • Some techniques may overlap but domain of interest is starkly different • Mentoring • Advocacy vs. evaluation

8. Definition of Competence • Definition of competence in medicine: • the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflections in daily practice for the benefit of the individual and community being served (Epstein & Hundert, 2002)

9. Definition of Competence • APA definition: • Performing tasks consistent with one’s professional qualifications, sensitive to individual and cultural differences, and anchored to evidence-based practice • Competency Benchmarks inProfessional Psychology (available on APA website)

10. Self-Evaluation and Meta-competence • Self-rated competency is inversely related to other-rated competency (Kruger & Dunning, 1999; Dunning et al., 2003) • The more fine-grained the self-assessment, the better the validity of the self-assessment • Meta-competence is the ability to reflect on what we do not know and to compensate for that (refer, seek information, seek supervision/consultation or training)

11. Assessment of Competence in Professional Psychology • Competency Toolkit (Kaslow et al., 2009) • Provides information about and purposes for various assessment methods: • 360-degree evaluation • Rotation performance reviews • Case presentation reviews • Competency Evaluation Rating Forms • Client/patient process and outcome data • Consumer surveys • Live or recorded performance ratings • Objective Structured Clinical Examinations (OSCEs) • Portfolios • Record Reviews • Simulations/Role plays • Self-assessment • Standardized client/patient interviews • Structured oral examination • Written examination

12. Steps in Competency-based Supervision • First, make all steps transparent to the supervisee • Step 1- Orientation to competency-based approach • Step 2- Collaborative identification of competencies that will be focus of training • Step 3- Development of the supervision contract • Step 4- Formative evaluation—every session • Step 5- Summative evaluations—at regular intervals

13. The Supervisory Alliance • Supervisor must understand the difference between this alliance and the therapy alliance • Supervisor has power over the supervisee • Supervisor has responsibility to hold to professional standards and evaluate the supervisee • Both therapy and supervisory alliances require respect and collaborative shared purpose

14. Development of the Supervisory Alliance • Make the purpose and the expectations of supervision explicit (supervision contract may help here) • Discuss similarities and differences between the client, the supervisee, and the supervisor each session • Give and receive two-way feedback in an ongoing and frequent manner • Measure the strength of the supervisory alliance (Appendix B in Falender and Shafranske, 2004) • Clarify roles if supervisor has more than one role with supervisee

15. Development of the Supervisory Alliance, continued • Identify relationship strain—This is the supervisor’s job • Change in supervisee behavior • Passive resistance • Spurious compliance • Hostility

16. Functions of the Supervisor in the Supervisory Relationship • Identifying and Managing Countertransference • Help supervisee see emerging patterns • Give assignments to help balance out the countertransference • If this is resisted by supervisee, supervisor must state that working through countertransference is not optional, but is a mandate • Self-disclosure appropriate to understanding and working with countertransference should be expected and put in the supervision contract

17. Diversity Awareness • Supervisor should start the process by disclosing his/her own matrix of personal multiple identities (biases, strengths, assumptions, background contributing to same) • May invite supervisee to do the same without forcing • Discuss how client’s diversity issues interact with the biases and assumptions of the supervisee and the supervisor

18. Providing Effective Feedback • Feedback is more effective if it corresponds to self-assessment (using the Competency Benchmarks can promote shared language and behavioral goals) • Feedback should be specific and behaviorally-linked • Feedback should be close in time to the observation of the behavior (video or audio recording can be very useful here) • Provide negative feedback in terms of plans, improvement, and goals

19. Incorporating Process and Outcome Data into Supervision • Review client outcome reports during supervision (Lambert & Hawkins, 2001) • Review therapeutic alliance measures during supervision (e.g., Working Alliance Inventory, Hatcher & Gillaspy, 2006) • Utilize satisfaction with supervision forms (Appendix K in Falender & Shafranske, 2004; reprinted from unpublished manuscript by Hall-Marley, 2001)

20. Ethics • Supervisors should review the ethical principles related to the discipline of whomever they are supervising (Universal Declaration of Ethical Principles for Psychologists, 2008; APA Code of Ethics, 2002) • Make a point to discuss ethics each supervisory session • Supervisors should attend to potential ethical teaching points as they arise

21. Boundary Issues • Distinction between boundary crossings vs. boundary violations • Boundary crossings are unusual but can be planful and okay ethically • Boundary violations are never okay • Should discuss internet and social media issues with supervisees in terms of ethics

22. Boundary Issues, cont. • Around 4% of psychology students experience sexual contact, pursuit or harrassment by supervisors/educators • Attraction to clients—80% of practitioners admit to this during career yet supervisees rarely disclose this • Attraction by client—help supervisee do functional analysis of the situation and respond appropriately

23. Liability • Supervisors have two types of liability related to their supervisees • Direct Liability for negligent supervision we can control this by observing supervisee taking corrective action based on observation

24. Liability, continued • Second type of Liability • Vicarious liability—liability for supervisee’s behavior • Not under our control completely • May be liable simply because of relationship with supervisee

25. Supervising the “problem supervisee” • Competency issues around professional behavior often are what we mean by “problem supervisee” • Papadakiset al. (2005) found correlation between unprofessional behavior in medical school and later discipline by state boards • First type of unprofessional behavior: • Severely diminished capacity for self-improvement; failure to respond to feedback • Second type: • Severe irresponsibility, unreliability, failure to followup

26. “Problem Supervisee” continued • Other categories of problem supervisees: • Unable/unwilling to integrate professional standards into their behavior • Inability to acquire professional skills • Inability to control personal stress so that it interferes with professional functioning

27. Response to “Problem Supervisees” • In all cases, must have and follow a remediation procedure • Observation and feedback must begin early • Remediation plan itself should be • Competency based • Items should be observable • Items should be measurable • Plan should have time limits • Examples of Remediation Plans are on VAPTC sharepoint site

28. Self-care • Self-care is not a luxury; it is an ethical imperative • Self-care options for psychologists to model for supervisees: • Vary work responsibilities • Use positive self-talk • Maintain personal/professional balance • Take vacation time

29. Self-care, continued • Maintain professional identity through CE, new professional tasks, organizations • Spirituality • Read literature • Have control over work responsibilities • Teach and supervise—protective activities to prevent burnout

30. References • American Psychological Association (2002). Ethical Principles of Psychologists and Code of Conduct   • Bambling, M., King, R., Raue, P., Schweitzer, R & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16 (3), 317-331. Callahan, J.L., Almstrom, C. M., Swift, J. K., Borja, S. E., Heath, C.J. (2009). Exploring the contribution of supervisors to intervention outcomes. Training and Education in Professional Psychology, 3(2), 72-77. • Dunning, D., Johnson, K., Ehrlinger, J., & Kruger, J. (2003). Why people fail to recognize their own incompetence. Current directions in Psychological Science, 12 (3), 83-87. • Epstein, R.M., Hundert, E.M. (2002). Defining and assessing professional competence. Journal of the American Medical Association, 287(2), 226-235. • Falender, C. A., Shafranske, E. P. (2004). Clinical Supervision: A Competency-based Approach. American Psychological Association, Washington, D.C. Hatcher, R. L., Lassiter, K.D. (2007). Initial training in professional psychology: The practicum competencies outline. Training and Education in Professional Psychology, 1 (1), 49-63. • Hatcher, R.L., & Gillaspy, J.A. (2006). Development and validation of a revised short version of the working alliance inventory. Psychotherapy Research, 16 (1), 12-25.

31. References, Cont. • Kaslow, N.J., Gurs, C.L., Campbell, L.F., Fouad, N.A., Hatcher, R.L., & Rodolfo, E.R. (2009). Competency assessment toolkit for professional psychology. Training and Education in Professional Psychology, 3 (4, Suppl), S27-S45. • Kruger, J. & Dunning, D. (1999). Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessment. Journal of Personality and Social Psychology, 77 (6), 1121-1134. • Lambert, M.J., & Hawkins, E.J. (2001). Using information about patient progress in supervision: Are outcomes enhanced? Australian Psychologist, 36, 131- 138. • Papadakis, M.A., Teherani, A, Banach, M.A., Knettler, T.R., Rattner, S.L., Stern, D.T., Veloski, J.J., & Hodgson, C.S. (2005). Disciplinary action by medical boards and prior behavior in medical school. New England Journal of Medicine, 353, 2673-2682. • Universal Declaration of Ethical Principles for Psychologists. (2008). Available from the International Union of Psychological Science Web site: http://www.iupsys.org/ethics/univdecl2008.html