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Deirdre D’Orazio, PhD & Charles A. Flinton, PhD

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1 Deirdre D’Orazio, PhD & Charles A. Flinton, PhD
Clinical Supervision: An essential ingredient to enhancing treatment outcome with forensic populations Start 9:05 Deirdre D’Orazio, PhD & Charles A. Flinton, PhD

2 9:06- 9: 20 What did people notice about the supervisee? (Anterior selfish motives) What about the supervisor? Why do you do what you do? Why do you supervise?

3 So you want to be a clinical therapist?
9:20 to 9:30 Why are we here doing this. The ups and downs of being supervisors. Why are people here today? What do you hope to be getting out of the presentation.

4 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 9:22

5 Who are Supervisees? Supervisees can be licensed, pre- licensed, pre-doctoral, interns, students counselors, or probationary staff. 9:23

6 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) 9: 25 Colleagues are those explicitly united in a common purpose and respecting each other's abilities to work toward that purpose.

7 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) 9:27

8 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 9:30

9 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 9:35 Sexual offender therapy is highly specialized and requires special training for those who work with sexually abusive individuals. Therapists performing sexual offender therapy shall be currently licensed in a mental health profession/medical field (i.e. psychiatry, psychology, social work, or marriage and family therapy). Clinicians will adhere to the legal mandates of their licensing agency. Unlicensed clinicians such as interns and pre-licensed practitioners must be supervised by a qualified, licensed clinician. It is expected that the licensed professional adheres to all of the licensure requirements and parameters regarding supervision and the number of individuals he/she is allowed to supervise.

10 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 9:37 ATSA also has 2000 hours

11 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 9:39 ATSA does not have specifics

12 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 9:41

13 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 9:45 This means that new staff members who have not worked with Sos before should not be supervising interns

14 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 9:47

15 § 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. 9:49

A licensed professional in private practice who has satisfied the requirements of subdivision (g) of Section 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. 9;50

17 Forensic Psychotherapy as a Specialty
Sex Offender Management “Best Practices” Collaboration, specialization, education, judicial leadership, and buy-in … all for victim and community safety 9:55 Comment about therapist who do not use current practices

18 The Containment Model “Best Practices”
Criminal Justice System (Probation/ Parole Officer) Polygraph Examiner Therapist The Offender 9:59 Supervisee

19 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 10:01 Need work

20 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 10:06

21 Types of Forensic Psychology Supervision
Clinical Administrative 10:09

22 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) 10:13

23 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 10:16

24 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. 10:20

25 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) 10:25 hand out

26 Goals of Supervision (competencies expected of the supervisor)
1. The ability to identify a supervisee’s strengths and growing edges professionally and personally. 2. The ability to formulate interventions that integrate the supervisee’s 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. 10:27 The importance of the field; professional goals

27 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 10:30

28 Establishing Goals Goal Relevance Goal Importance Goal Attainability
refers to goals that are pertinent to a particular supervisee’s 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 10:34 Goal Relevance refers to goals that are pertinent to a particular offender’s risk factors. For example, most offenders will not state during the early stages of treatment that their goal would be to never offend again (because many assert that they know they will never offend again). Nevertheless, it is appropriate to assert “no offending” as the primary goal. Relevant additions may be to never harm anyone, to abstain from viewing deviant sexual material, and to develop honest, age appropriate relationships. Goal Importance works toward identifying goals that are personally significant to the offender. These goals could relate to dynamic factors that contributed to the offense but are also identified by the offender as goals that would contribute to his personal happiness and stability. A goal such as maintaining a job or establishing a healthy, enduring relationship would fall into this category. Goal Attainability refers to goals that the offender believes could be achieved. Re-establishing a communication with his ex-wife in two weeks and sustaining it for one year is an unrealistic goal for an offender recently released from prison. Developing short-term goal for a pedophile to never think of children in a sexual way again may set the offender up for failure and eventual indifference to treatment goals. Attainable goals would include the development of healthy communication between the offender and his ex-wife. Another attainable goal would be abstaining from masturbating to deviant stimuli and contacting a support person when an urge arises. Emotional Salience refers to setting goals in which the natural rewards are obvious to the offender. For example, does the offender know, or believe, that he will feel good about attaining the goal? If the offender is participating social skill development to address relationship problems, the offender confident that he will have more emotionally fulfilling relationships?

29 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). 10:36

30 Intern goal and evaluation form –hand out

31 Goals for Supervision Examples
Objective: To develop treatment planning skills that integrate actuarially based and clinically judgment based information Objective: To develop professional communication skills Objective: To master court testimony Objective: To develop mastery in test interpretation Objective: To more consistently apply the literature in a the therapy process without losing track of the unique features of the client. Objective: To learn how to build a forensic private practice Objective: To develop scientific/forensic writing skills 10:49 this is real Not a trick

32 Goal Objectives Objective: To develop an objective and genuine stance when working with hostile/argumentative clients. Progress: 10/12/ T.C. discussed treatment plan with a client and agreed to alter the plan because the clt continues to deny the offense. Counter-transference issues interfered with implementation of the presentation. She held back some and colluded. Worked on issues of conflict and confidence. 05/01/ T.C. was able to present intake test data to a resistant, argumentative client without losing track of the material. Appropriate interventions were used to support clts tolerance of disagreement. 10:57

33 RECAP Three Goals of Supervision Performance, 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?!

34 Exercise 10:45 Best and worst supervision experiences

35 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. 10:47

36 Does Sex Offender Treatment Work?
Hanson et. al, the Principles of Effective Correctional Treatment Also Apply to Sexual Offenders: A Meta-Analysis. Criminal Justice and Behavior, 36,

37 Yes! Sex Offender Treatment Does Work …But 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. N=3,121 treated sex offenders. N=3,625 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.

38 The Guiding Principles of Effective Interventions: Risk, Need, Responsivity (Bonta & Andrews, 2007; Hanson et. al, 2009) Principle Tx will be most effective when… Example Risk It treats offenders that are most likely to reoffend Tx mod. or high risk (Static-99R). Don’t mix low & high risk. Don’t exclude high risk Need It targets criminogenic needs, -the changeable characteristics related to sexual reoffending Items on Structured Risk Assessment (SRA, Thornton, 2002) & STABLE 2007 (Hanson & Harris, 2008) Responsivity It creates context for change. It matches the individual’s learning style & ability Staff selected for relationship skills, empathy, warm, genuine, positive regard, able to form relationships with offenders, prosocial direction, “firm but fair”

39 Effective Treatment Targets Criminogenic Needs
FACTOR Structured Risk Assessment STABLE 2007 Items Sexual Interests Sexual Preoccupation Sexual Preference for children Sexualized violence Sex’l preoccupation Sex as coping Deviant sex’l preference Offense Supportive Attitudes Adversarial sex’l attitudes Excessive entitlement Child abuse supportive beliefs Seeing women as deceitful & malicious Machiavellianism Hostility toward women* Emot id w/children* Relational Style Emotional congruence with children Lack of intimate relationships Callousness Grievance thinking Sign. Social Influences Capacity for relat. stability General social rejection Lack of concern for others * Self management Lifestyle impulsiveness Resistance to rules & supervision Poor cognitive problem solving Poor emotional control Impulsive Cooperation w/ supervision Poor cog. problem solving Negative emotionality/ hostility

40 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.

41 11:30

42 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. Lunch ?

43 The Neurobiology of Change
Patterns of energy and information flow within the brain…and 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 workshop…from your supervision sessions…from your supervisee’s therapy sessions will be encoded, stored & retrieved by the brain in implicit and explicit memory systems. 1:15pm

44 Unhealthy Deficits Can Become Healthy Tendencies
Unconscious Incompetence (pre-contemplation) Conscious Incompetence (contemplation) Conscious Competence (action) Unconscious Competence (maintenance)

45 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

46 The Therapeutic Process Essential 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

47 Supervisors are mindful of what works, and doesn’t 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.

48 Good Supervisors Foster Essential Therapist Characteristics
Empathic Genuine Supportive Directive/Reflective

49 Follow the Responsivity Principle
Offender Recovery Begins with Empathy for the Offender “To sense the client’s private world as if it were your own, but without ever losing the "as if” quality—this is empathy, and this seems essential to therapy. To sense the client’s 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 client’s 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 client’s experience of which the client is scarcely aware.” (Carl Rogers, 1957, p.99)

50 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.

51 Obstacles 1:45

52 Indicators of Supervision Strain
Withdrawal Paucity of disclosure Direct expression of criticism/hostility Noncompliance/passive responding Acting in/acting out

53 Obstacles to Supervision Facing 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!

54 The Cycle of Abuse Empathy: A matched vicarious emotional response that depends on the ability to infer another’s 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 1:55 – 2:10

55 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.

56 Cascade Effects of Trauma on the Brain
Left Hemisphere Underdevelopment Deficient Left-Right Hemisphere Integration Limbic Irritability Abnormal Activity in the Cerebellum Hormone Dysfunction 1. Left Hemisphere Underdevelopment verbal perf. (CBT); l. hippocampus growth (cortisol)-low verbal memory & dissociative syx 2. Deficient Left-Right Hemisphere Integration smaller corpus callosum, perceiving/expr language (L) is cut off from processing/expressing negative emotions (R) 3. Limbic Irritability temporal lobe dysf., sensory & autonomic symptoms, sudden affect. 4. Abnormal Activity in the Cerebellum quells electrical irritability of limbic system (affect regulation) by responding to movement; growth is stymied by stress hormones. 5. Hormone Dysfunction Excessive stress hormone response to adversity; heightened fear & adrenaline response; altered metabolism, immune & inflammatory resp; dec. thyroid hormone production & serotonin in the hippocampus; dec. oxytocin (intimacy/monogamy)& incr. vasopressin (sexual arousal)

57 The Cycle of Abuse Trauma Perpetrators, Recipients and Healers IMPACT
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 don’t notice, don’t 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.

58 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

59 ‘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 mother’s 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 client’s internal world. The specific dimensions of that role are colored by treater’s own personality. I.e. The female therapist, feeling dismissed and disliked, attends more to other clients in group therapy.

60 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 therapist’s inner experience is negatively transformed through empathic engagement with clients’ trauma material” Pearlman & Saakvitne, 1995

61 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 therapist’s wounds

62 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 client’s world view. They won’t 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.

63 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

64 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.


66 Supervision types, process, and techniques
Who was your best supervisor? why

67 Types of Supervision Styles
Authoritarian supervision Laissez Faire supervision Companionable supervision Collaborative supervision

68 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 supervisor’s responsibilities.

69 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.” As a result, members view supervision as an admission to failure; that is, as something to submit to when they encounter a situation they are unable to handle on their own.

70 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. UNTIL ITS TOO LATE

71 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 organization’s 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. Supervision is dedicated to assisting all members to enhance their knowledge and skills, which can lead to advancement within the organization and profession.

72 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)

73 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

74 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

75 The Process of Supervision
The Trans Theoretical Model (TTM) and Supervision

76 Trans Theoretical Model of Change (Per Ryan E. Gillespie)
Termination Maintenance Action Contemplation Precontemplation

77 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

78 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

79 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)

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

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

82 Structured Interventions
Structure (at least initially) Homework Video/Audio Taping Document Review Case Conferences/Presentations Topic Presentations Initially supervisees that are highly anxious may benefit from a high level of structure in supervision sessions They need supervisors to provide specific direction on working with clients, assessment, case notes and case conceptualizations. Supervisors can assign trainees homework to practice their skills. Level two: Trainees gain confidence as a therapist and the focus shifts more to the client than their own process. Supervisors assess the trainee’s skills and, when appropriate, allow trainees more autonomy and encourage more independent decision-making in terms of interventions. Level three: Trainees increasingly empathize with the client and reflect on what they know about theory and research in a given situation. As the supervisory relationship becomes more collaborative, supervisors may introduce other perspectives to broaden their view and might be more willing to provide negative feedback.

83 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

84 Interventions Stimulus control Counter-conditioning
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

85 “…..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 )

86 EXCERCISE Consider doing exercise here of group breakout with half describing their best and worst experiences as a supervisee; other half their best and worst experiences as a supervisor. Consider flip chart exercise comparing roles of offender therapist to non-offender therapist

87 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.

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

89 Case Example

90 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”. Most psychologists are reluctant to say” do it because I said so”.

91 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 (11:19 am to 11:20) 1 minutes Working together with other professionals help builds the frame- offenders are masters at splitting and undermine an environment that is conducive to change.

92 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

93 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 Regardless of the model supervisors use and trainees' level of experience, Stoltenberg emphasizes the use of supportive and facilitative interventions, in which supervisors provide support and encourage the development of the trainee through praise and attentive listening. However, some feedback may be harder to give than others, especially in situations when it's based on personality or professional issues, such as situations in which the feedback concerns a supervisee's behavior outside of supervision with other interns, Hoffman says. Indeed, research has shown that many supervisors report withholding feedback from trainees, such as negative reactions to trainees' counseling and professional performance. In particular, supervisors report it is difficult to provide feedback when clinical issues are subjective, when they are uncomfortable with imposing their opinions on trainees and when the feedback concerns something outside the supervisory relationship, according to a January 2005 study in the Journal of Counseling Psychology (Vol. 52, No. 1, pages 3-13). For example, the study, which was conducted by Hoffman, Clara Hill, PhD, Stacey Holmes, PhD, and Gary Freitas, PhD, found that supervisors had difficulties deciding whether supervision should include discussing a supervisee's personality characteristics that might affect the trainee's clinical or professional success. The study included interviews with 15 counseling center supervisors about their feedback to intern trainees.

94 Documenting Supervision
It is important to document supervision sessions because: You are legal responsible for supervisee’s 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 supervisee’s case were to go to court (for any reason) it is imperative that supervision notes indicate that your were providing close and adequate supervision.

95 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

96 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

97 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.

98 Discussion

99 Deirdre D’Orazio, PhD Charles A. Flinton, PhD
Central Coast Clinical and Forensic Psychology Services Charles A. Flinton, PhD San Francisco Forensic Institute

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