Presentation on theme: "1 Training package for Psychology Supervisors. A competency based initiative. Yasmina Nasstasia, Wayne Clarke, Chris Wilcox & Katrina Delamothe."— Presentation transcript:
1 Training package for Psychology Supervisors. A competency based initiative. Yasmina Nasstasia, Wayne Clarke, Chris Wilcox & Katrina Delamothe
2 Hunter and Coast ICTN (Rowena Amin) Colleagues from respective Universities including; Craig Gonsalves, Ros Knight, & Kathryn Nicholson Perry. Thank You Acknowledgements to:
3 Module 3: Understanding your development and role as a supervisor.
4 For some time now… in the practice of Psychology, Clinical Supervision has been referred to as a “core competency”. Yet, training of Psychologists in developing this core competency has been patchy in Australia, as it has across our profession internationally.
5 We have witnessed a strengthening of the profession. National Registration has brought with it: the development of standards, an increasing emphasis on fitness to practice, and an intense focus on equipping new graduates for professional practice. By ensuring increasing rigor, by way of close supervision, in the way new Psychologists are entering clinical practice, the practice of Supervision in this context has become a key focus - competency is essential.
6 With guidelines for the Supervision of new graduates well developed, the focus has shifted and broadened so that now the practice and delivery of Supervision generally is beginning to receive the attention it warrants.
7 Whilst across the Psychology profession, Supervision is now an essential element of practice monitoring generally and professional development specifically. There is still no consensus as to what constitutes effective training in Supervision.
8 The view in the past seemed to be that the skill of providing good Supervision was learned by some kind of osmosis… Supervisors knew how to supervise by having been themselves supervised. The majority of Psychologists who provide Supervision have had little training.
9 Consider: How did you learn to supervise? How helpful was this? What if anything was missing? What would you have liked to be different?
10 This set of supervision training modules will, it is anticipated, produce active, involved and committed Supervisors, in whatever context, and across a range of different demands, whose knowledge and awareness of their role will ensure that they avoid the pitfalls of the process.
11 Supervision in Psychology: Current status “Professional practice supervision is a key element in clinical governance. These processes seek to ensure that the individual practitioners are supported in the development of their: Practice knowledge, Skills, Service delivery, Accept responsibility for their professional practice and Are equipped to provide the highest possible levels of care consistent with evolving evidence relevant to that care. (NSW Government – Health Allied Health Professional Practice Supervision).
12 This Policy statement emphasizes that Supervision is aimed at enhancing consumer protection, the safety of care in complex clinical environments, and the Supervisee’s satisfaction in their role. It underscores the risk-averse themes within the public sector generally and the desire to retain staffing resources.
13 “Extensive literature and research indicates that Clinical Supervision brings a range of benefits to practice outcomes for Allied Health Professionals. These benefits are together considered so strong, that Health providers are now recognizing the risks of not supporting and promoting Clinical Supervision in their health professional workforce and many are mandating the practice” (HNELD Pol 13_01) So, in terms of making Supervision a requisite for continuing professional practice, Psychologists are ahead of the game, and have been for some time.
14 The Psychology Board of Australia (PsyBA) regards the experience of Supervision as a component of Continuing Professional Development (CPD) indicating that it is ”… the means by which members of the profession maintain, improve and broaden their knowledge, expertise and competence, and develop personal qualities in their professional lives... “ So that CPD encompasses all aspects of Supervision and ongoing education.
15 Yet, Supervision and mandatory training for Clinical Supervisors is not without its detractors, nor is it without some controversy. When this policy was first introduced by way of discussion paper, two Colleges of the Australian Psychological Society (APS) (Gonsalvez & Milne (2010) “were keen to see more evidence of the effectiveness of Supervisor training” Another “… wanted to see evidence of the effectiveness of Supervisor training programs implemented … in other states”.
16 What is the Supervisory process in Clinical Psychology and what is it meant to achieve? At its heart, Supervision is an interpersonal exchange. In this respect, whatever the aims of the relationship professionally and personally, for both the Supervisor and the Supervisee, the quality of that relationship stands out as being the single most important factor in considering effectiveness in Supervision.
17 Functions of Supervision. Across disciplines, Supervision is aimed at the provision of monitoring, guidance and feedback on matters of personal, professional and educational development in the context of the care of patients. (Kilminister & Jolly (2000) Three functions have been emphasized in the literature about Supervision: that, in essence, it has a: 1. Normative aspect (administrative), 2. Formative aspect (educational) and 3. Restorative function (supportive).
18 The process of Supervision may take many forms: Supervision as a 1:1 process where the Supervisor is the more experienced practitioner Within a group setting Between two clinicians as peer supervision
19 Supervision may also have different purposes Tutorial or Educational function Training Supervision Managerial Supervision Consultancy Supervision Peer Supervision It is important for the Supervisor to consider the nature of the supervisory contact between the Supervisor and the Supervisee, the parameters for the Supervisory experience, and the boundaries that obtain to these needs.
20 The most common problem occurs when two distinct roles merge: for example when a Supervisory experience becomes a management tool. Also, what aspects of the Supervisory relationship are confidential needs to be considered.
21 In time PsyBA may require more accountability around Supervision by means of recording contacts, and thought will need to be given then to the recording process and what aspects of Supervision can be transparent, as well as those aspects that cannot. Sensitivity is required by the Supervisor, who may have multiple roles with the Supervisee with respect to the risk that Supervision can be overly directive when there are management imperatives that need to be conveyed to the Supervisee.
22 Supervision that has more to do with bureaucratic process, rather than aims such as developing practice knowledge, enhancing skills, and ensuring that service delivery is profession-directed, is management. BUT, there needs to be recognition that, inherent in the Supervision contract, the Supervisor will be seen as having authority. In some instances – with 4+2 candidates, or Post-graduate students on placement – this authority will have a strong, structured evaluative aspect to it.
23 As a general rule, some evaluation always needs to be built into Supervision, simply to reflect upon, at each session, whether the goals of the Supervisee and the Supervisor, have been achieved, before Supervision moves on prematurely to the next issue. (Davys & Beddoe (2010) (p ).
24 Boundaries All relationships have their boundaries. All relationships require boundaries to some degree. In considering the aims of Supervision, following is a useful list of general conditions that provide a sense of how the relationship is constructed and contained:
25 Specification is required with respect to: Aims of Supervision Frequency Duration Cost (if any) Confidentiality (and its limitations) Accountability to professional or registration bodies and organizational policy Interruptions Issues of safety Limits to clinical accountability (particularly if the Supervisor is not from the same profession) Record keeping Preparation Agenda setting Feedback and review Processes for dealing with conflict and complaint Relationship of Supervision to performance management, appraisal and counselling Degree of access the Supervisee has to the Supervisor Missed appointments
26 Contracting in Supervision – Vignette Looking at being open to how the Supervision will work best for the Supervisee, but also how it will meet the goals of the Supervisor: When discussing the Supervision contract, you and James discussed how he would like to receive feedback. He was keen to have his work looked at, but also felt that this would potentially create some difficulty for him. Past experience with Supervision, meant that James could see that feedback about his work, constructive criticism and the like, had created discomfort for him, and contributed to some avoidance. He thought that it might make him defensive to the point of not really listening to your feedback. In discussing this, James felt that the opportunity to be his own critic first might work best for him, so it was agreed that the format would be that you would seek James’ own assessment of the material presented to you before you offered any critique, and that this would be clearly prefaced by a cue for James, such as “now I will give you my thoughts on what you have presented”, to ensure that James was open to input. The decision was to review this structure after six months to see if it was meeting James’ goals,and your goals in terms of the management of the Supervisory relationship.
27 Boundaries in context The context may set up other boundaries, for example, there may be different constraints around Supervision for Psychologists employed within Education, than those in Health. Particular parameters may also apply to Post-graduate students on placement. 4+2 Candidates have quite explicit and rigorous standards which apply to the Supervision they receive.
28 Supervision and Psychotherapy –Vignette Aimed to draw distinctions between the two, but also to see that the decision by Supervisor about what is the material for the Supervision, and what is not, is a difficult one at times: Your Supervisee reports feeling inadequate in his work with clients lately. At the same time, he reports that his life is “falling apart” but implies that this is a ‘no go ‘ area. You notice that, indeed, the Supervisee seems to be coasting with the clients presented, allowing some clients to set the running, and at other times moving clients away from exploring their insights into more general themes. Upon reflection, you feel that you too are coasting with the Supervisee, not addressing the difficulties that he is having, not drawing his attention the possible impact of his personal issues on his psychotherapeutic work, perhaps fearing that he might “fall apart” on you.
29 The nature of the relationship in Supervision. Clinical supervision is now recognized to be: “ … a designated interaction between two or more practitioners, within a safe and supportive environment, which enables a process of reflective, critical analysis of care, to ensure quality consumer services” (Clinical Supervision Guidelines for Mental Health Services – Queensland: available on the AHPRA website).
30 Supervision, What’s in it for you? 1. Supervisee 2. Supervisor
31 What’s in it for the Supervisee: Professional support An opportunity to off-load and reduce stress An opportunity to enhance knowledge and increase competence An opportunity to experience well-being and enhance professionalism
32 What’s in it for the Supervisor: An opportunity to give back to the profession An opportunity to learn about a fellow professional; the characteristics, insights and style of working of the supervisee; the particular work context of the supervisee; the characteristics of a different client group - that of the supervisee; the assessment skills highlighted with this client group; therapeutic goals for that client group; interventions that apply to this client group; the organizational principles and constraints the supervisee works within. The opportunity to provide knowledge and foster competence The opportunity to promote relevant policies and encourage practice that is evidence-based – through one’s own practice-based evidence The opportunity to promote ethical practice
33 What is the supervisor/supervisee relationship essentially not about: Management Disciplinary process Reportable process … yet Individual Psychotherapy
34 Supervision is NOT psychotherapy, but some very similar conditions apply to the quality of the relationship that is set up between Supervisor and Supervisee when that relationship is going well. Consider the following, with respect to your own experience of good Supervision: What seems to apply and what does not?
35 PSYCHOTHERAPY: Goals: Relief of personal symptoms Self-shifts in attitude Fundamental changes in personality Fundamentals: A working relationship between a trained MH professional and the person needing help to deal with emotional distress and/or poor functioning (relationship, work, social relationships) The professional uses planned interventions according to psychological principles; therapy is aimed at improving self-awareness; therapists give long term emotional and practical support; therapy deals with a crisis or crises; therapies are aimed at improvement, by abolishing specific symptoms
36 What is it? An emotionally charged, confiding relationship: Unlike friendship Expectation that therapist will be dependable and trustworthy Issues raised may be deeply personal, distressing, or embarrassing Therapist will be empathic, but sufficiently detached as to not be overwhelmed by what is raised
37 What is it? It has a shared rationale: Therapist provides an explanation of the problems and the intended methods for dealing with them. This makes sense and is acceptable to the client.
38 What is it? New knowledge is provided: Arises from the relationship and emerges as part of the interchange. Client obtains new information about himself, his situation, his problems and learns of new ways to change or challenge these things.
39 Emotional arousal is facilitated: The process of learning is not a cold, intellectual pursuit. It encourages emotional expression The client gets in touch with his feelings and this enriches the process What is it?
40 What is it? It aims to instill hope: Engagement with the professional raises the client’s hope for a positive outcome. Therapist conveys optimism. A therapeutic alliance is formed around hope and optimism.
41 What is it? Success is experienced: Course of treatment shifts concern Mastery increases and the client no longer feels powerless and/or a victim.
42 What about counselling? Supervision is not a Counselling relationship either, but there are elements that are similar. Consider the following summary of what might constitute a relationship aimed at providing counsel, and consider whether Supervision encompasses some of these elements as well.
43 What is counselling? The aim is to help people make informed decisions about important matters and to assist in dealing with the impact of the decisions taken. Counselling and psychotherapy share many features, but counselling is distinct in that it is directed at assisting people of make critical decisions about their lives. These decisions might be about relationships, marriage, parenting and child management. In the work place, counselling might relate to educational and/or vocational choices, or it might arise from workplace issues and be about work practices. It might have a disciplinary aspect to it, where it is about job performance or training. It might be directed at conflict resolution or it it might deal with the effects of changes in employment or unemployment.
44 As with Psychotherapy, in Supervision, it is the relationship which matters most. For example, those attending workshops some years ago, conducted by Scott Miller, a visiting US psychotherapist and researcher, learned that there is no model or proven technique that guarantees successful outcome in Psychotherapy. Success hinges on the relationship established between therapist and client. The same may said of Supervision.
45 Let us consider further the nature of relationships as they occur in therapy and what we know of them. At the same time, consider that the same elements may apply equally to the relationship that is called Supervision.
46 There are often aspects to the therapeutic relationship which transcend, or perhaps underpin, the processes of history taking, symptom consideration and the formation of strategies These transactional elements relate to: TRANSFERENCE & COUNTERTRANSFERENCE
47 These concepts are drawn from the Psychoanalytic tradition. They provide a way of thinking about relationship formation and development generally, but also specifically, within Supervision. This is of particular relevance to the Supervisory relationship because of the power imbalance, and the traditional nature of Supervision which is hierarchical.
48 What is TRANSFERENCE? A Freudian concept relating to the phenomenon where an adult patient will re-enact or re-experience their childhood experiences of their parents and other authority figures, including siblings, within the therapeutic conversation. Freud noted that some of his patients attributed all kinds of things to him that had no foundation in objective fact. They expressed love or admiration or gratitude which was strangely out of place, or they expressed resentment, ridicule or hostility which was not justified by the therapeutic situation.
49 What is COUNTER-TRANSFERENCE? Respects the reality of transference as a matter of course in most human relationships and acknowledges that the therapist may experience similar feelings, or make similar ascriptions to his patients. So not only it is possible that the patient influences the therapeutic process with attitudes and behaviour’s irrationally based on earlier experiences, so might the therapist with his own. Unless, he is alerted to the problem and able to face his own previously unconscious biases.
50 Working with countertransference in supervision: Supervision provides a great opportunity to sensitize the Supervisee to these components of therapeutic interactions – of all interactions. Hearing the presentation of a case, the objective and detached ears of the Supervisor will pick up instances where the transference is occurring. Processing the case with the Supervisee enables the Supervisor to point out the reactions to the client that come from the Supervisee’s own unconscious. This will alert him to recurrent themes or to “spines” that will be brushed sometimes by some clients in some situations.
51 These two mechanisms can also be found in the Supervisor/Supervisee relationship. There are clear elements of this in the Supervisory relationship, even though it is not a psychotherapy. Some of the other key similarities are: It is regular, structured and 1:1 (mostly) The development of rapport is essential There is disclosure and shared experiences Transference and counter-transference typically occur or emerge, especially because Supervision is often a long-term relationship The power relationship is unequal
52 For these reasons the Supervisor needs to be alert to the ‘vulnerabilities’ inherent in some aspects of the Supervisory relationship/process, and needs to be clear about how to stop the relationship from developing into some form of psychotherapy. This might involve: Being alert to the dynamics and process issues – his/hers as well as yours Talking frankly about Supervision NOT being psychotherapy – recommend psychotherapy to the Supervisee as a helpful process if clear issues needing this kind of exploration have emerged – but, that psychotherapy will not to be with you. Moving session content to less personal areas – presentations, interview material, knowledge-based discussion etc. Discussing issues outside of the Supervision with caution if the alarm bells ringing.
53 Parallel Process Parallel process is a feature unique to the Supervisory relationship - it might be noted from time to time. It is particular to this process because it reflects the ‘supervisory triad’ that is frequently a part of Supervision - that of the client, the Supervisee and the Supervisor. Even though the emphasis is on the dyadic relationship of Supervisor/Supervisor, the other stakeholder in the process is the client, with the Supervisee’s assessment of, reaction to, and relationship with the client being the main subject of much of the Supervision, and the client being one of the beneficiaries of that process.
54 The process is one where the Supervisee unconsciously identifies with the client - what might be noted is that he or she adopts the client’s tone, manner, relating style and/or behaviour. In effect, it might be postulated that the Supervisee is telling the Supervisor what the therapeutic problem is, or how the intervention is being received or felt by the client. However, there may be another dimension to this as well: McNeill and Worthen (1989) quote an earlier study in which it was suggested that parallel process might be seen as a metaphor in which the patient’s problem in therapy may be used to express the Supervisee’s problem in Supervision.
55 On the one hand then, parallel process might relate to an aspect of the Supervision determined by the material brought to the session by the Supervisee, or it might relate to the process of Supervision itself: in this way, it might be seen as two aspects of the same process. Essentially, in broaching the issue, the Supervisor makes use of what is occurring in the therapist-client relationship and the Supervisee-Supervisor relationship to enable the Supervisee to appreciate the emotional difficulties he or she is encountering in receiving assistance in Supervision, to facilitate an understanding of the client’s situation in the therapy.
56 Identifying the phenomenon is thought to have the potential for further advancing the learning and the professional growth aspects of Supervision. It draws upon that part of Supervision that is reminiscent of therapy, as well as upon its didactic elements. Gains are to be made potentially from a process which seeks to highlight and examine the affective problems that the Supervisee experiences with his or her clients, and within the Supervisory relationship, possibly leading to a more complete understanding of self for the Supervisee, and enabling the Supervisee to make greater and freer use of himself or herself in the work with clients.
57 The exploration of parallel process, when it emerges in Supervision, aims to enhance the Supervisee’s insight, to add further to self-awareness, and leads to a greater appreciation the complexities generally of the psycho-therapeutic relationship. Indeed, McNeill and Worthen (1989) suggest that examination of the process might be more beneficial to, and better assimilated by, the more advanced Supervisee, with the needs of the beginner more likely to reflect the desire for more concrete and structured types of interventions to reduce anxiety and to enhance basic skills with intervention, rather than an exploration of the more esoteric and nuanced aspects of the supervisory and /or therapeutic relationship.
58 MODULE 3 – Role play Seek the voluntary involvement of two participants to play out the following scenario, to be followed up with questions about the process and its future direction:
59 One of you will be the Supervisor, the other the Supervisee presenting a case in which your have been working with a woman who is in an abusive relationship. Abuse has occurred over the duration of the relationship and has become physical within the last year. There are two young children, who have not been assaulted by the client’s partner, but they are subject to the emotional climate that culminates, more recently, in an assault. The older child has on one occasion placed himself between the parents which has resulted in de-escalation. You (Supervisee) have been seeing the woman for six sessions, and you have presented it twice. You display some agitation in presenting the case and express frustration that the client is not making plans to leave her partner. The client has missed two sessions recently and you raise this as part of the current review. As the Supervisor, you suspect that your Supervisee’s ‘agenda’ is disrupting what was initially a good alliance with the client and you comment on this, referring to the recent breaks in contact.
60 In seeking to further explore the Supervisee’s agenda, the Supervisor points out that it is often difficult for individuals to leave abusive relationships. The Supervisee responds angrily, indicating that he/she views the client’s behaviour as “hopeless” and indicates that she should be putting the children first. The Supervisee indicates that he/she is fed up with “holding the client’s hand” whilst the children continue to live in abject circumstances. What responses might the Supervisor make as part of the Supervisory process? What meaning might be made of the Supervisee’s disclosures: how might this be progressed? Is there a role in checking the Supervisee’s education about domestic violence, resources available, community responses and the like? What is likely to now be most helpful for the client? Should personal material be further explored with the Supervisee: what impact might that have on the Supervisory relationship? What are the chances that this discussion might increase anxiety rather than managing it: how can this risk be avoided?
61 Quality in Supervision – the art of being “good enough!” What are the key ingredients necessary for Supervisees to feel that their experience of Supervision was “good”? (Worthen& McNeill (1996)) An experience that strengthens and affirms Supervisee confidence. Supervisees felt relaxed about presenting material because the Supervisor provided affirmation and reassurance, so that the Supervisee was more venturesome and more open about whatever the material was that was being presented. The experience of Supervision which increased the Supervisee’s capacity for seeing the greater complexity within the issues being presented or being faced in client contact. The feeling expressed was that there was an increased feeling of coherence in the context of complex and confusing circumstances clinically: the likely development of a meta-perspective was enhanced.
62 Supervisees felt, within the experience of Supervision around psychotherapy, an increased ability to work effectively with their client(s). Case conceptualization was felt to have improved, and the formulation of effective interventions followed. Supervisees, as an outcome of good Supervision, developed a new sense of understanding, whether this related to therapeutic practice, or with respect to their professional development. Supervisees reported developing more of an understanding of themselves, of their thinking about their client(s) in relation to this, and as it related to the therapy. Supervisees felt a renewed sense of being able to engage with clients, particularly around therapy and intervention, where there had been struggle. Supervisees reported experiencing a sense of renewal as an outcome of this kind of experience of Supervision, where there was a positive motivation to persist, to try out new strategies, or simply to face challenging and difficult situations with their client(s).
63 The effect of good Supervision events was to strengthen the Supervisee- Supervisor alliance. Trust had developed by way of this positive experience Supervisees felt a renewed sense of being able to engage with clients, particularly around therapy and intervention, where there had been struggle. Supervisees reported experiencing a sense of renewal as an outcome of this kind of experience of Supervision, where there was a positive motivation to persist, to try out new strategies, or simply to face challenging and difficult situations with their client(s). The effect of good Supervision events was to strengthen the Supervisee- Supervisor alliance. Trust had developed by way of this positive experience. Supervisees also experienced a growing impetus for continued advancement in professional development. Good Supervision was a motivating experience, where the Supervisee felt affirmed in having made the career choice for Psychology as a profession, and motivated to further hone their skills around Psychological Practice.
64 A host of researchers and writers about Supervision have set out the essential elements as markers for success or failure within the Supervisory relationship: SUPPORT – when it’s there and when it’s not TRUST – when it’s there and when it’s not AVAILABILITY – when it’s there and when it’s not RESPECT – when it’s there and when it’s not EXPERIENCE AND KNOWLEDGE – when it’s there and when it’s not PERSONAL CONNECTION – when it’s there and when it’s not CHALLENGING – when it’s there and when it’s not FEEDBACK AND COMMUNICATION – when it’s there and when it’s not
65 When is supervision working well? Agenda – shaping and directing the session Preparation – organized case presentation Reading and sharing an article relevant to the process, or to a past issue. Illustration or example(s) drawn from the Supervisor’s experience “with-ness” – doing something together Supportiveness and non-judgmental approaches Helpful self-disclosure can be useful Outcome evaluation: did it work, why, how can we show it to have worked Group supervision – case presentation, think-tank approach to clinical problems
66 When is Supervision not working well? Dysjunction – differences of approach that seem to be irreconcilable No choice of supervisor – the feeling of being stuck with each other. Contact becomes limited in frequency or duration when there is poorness of fit. Supervision which turns into Performance Appraisal or a tool of management. Expert or non-expert – difference in perception The feeling of being overwhelmed especially by the “expertness” of the very experienced clinician.
67 Phases of learning for New Supervisors (handout)
68 What makes a good Supervisee? One who is committed to establish a solid Supervisory relationship One is who is clear about and who actions the contract for Supervision One who responds to empathy and support One who is seeking greater professional autonomy One who is positive with respect to continuing professional development One who respects and maintains boundaries – all boundaries One who is comfortable with having sessions recorded, monitored and reviewed. One who is punctual and who arrives prepared for Supervision One who is able to accept feedback.
69 What makes a good Supervisee? See supervision as a positive even if mandated – choose supervision. Has a genuine desire to learn. Openly and honestly present their work and know how to present their work. Are willing to look inwards to what is happening to you as you do the work. Are willing to be accountable for their work.
70 Non-disclosure in the Supervisory Relationship
71 Group Exercise/Discussion: Supervision is facilitated or limited by disclosure. What, as Supervisors, we told or shown by our Supervisees determines to a great extent agenda for any supervisory session. As a group experienced in having been Supervisees, can you reflect on your experiences and share with the rest of us, situations where you have not been as open with your Supervisor as you might have been. Consider also you motives for holding back on information, for not declaring your own thoughts and feelings, and/or for your doubts about the Supervisory process at that time. What was happening at that time in the Supervision? What made you decide to leave information out of the content of the session?
72 Non-disclosure in the Supervisory Relationship Exploration of non-disclosure with respect to what Supervisees share with their Supervisor further exposes, and adds weight to, important elements in the Supervisory relationship already outlined. Ladany et al. (1996) suggest that the power imbalance, together with the evaluative nature or implications of Supervision, and the way that these are played out, acknowledged and confronted, is at the heart of the matter.
73 The power imbalance may influence the Supervisee’s willingness to be open, to experience confidence, or to demonstrate and feel trust in the process. Because evaluation is explicit or implied, the Supervisee may seek to minimize any negative impression that he or she might make, at the same time attempting to maximize the potential to be viewed – and judged– positively.
74 The choice of what is disclosed in Supervision is up to the Supervisee. No matter how full and complete the presentation of a case, or a session with a client, information about the Supervisee himself or herself, his or her own processes, his or her reactions to the therapy, are for him or her to share – or not - with the Supervisor.
75 Indeed, as Ladany et al. (1996) hypothesise that “… Supervisees would leave more things unsaid in Supervision than clients would in therapy because of the evaluative consequences and the involuntary nature of Supervision” (p10-11). Withholding information may be the only way that the power imbalance can be redressed, so that it may be the Supervisee’s only means to exert some control in this skewed relationship.
76 In a study of more than 100 by Ladany et al. (1996), Supervisees, detail the wide range of forms that non-disclosure can take. They examine the reasons given by Supervisees for their decision to hold back in the supervisory conversation, and they provide some useful suggestions for how the Supervisor might encourage more openness in Supervision. A total of 13 categories were identified to describe aspects of the alliance, or the circumstances of the interaction, where Supervisees withheld information from Supervision.
77 Negative reactions to Supervisor - unpleasant; disapproving; critical thoughts Personal issues - thoughts about self; privacy about context of own life and ‘non- public’ issues Clinical mistakes – perceived errors or feelings of inadequacy as a therapist Evaluation concerns – uneasiness/uncertainty about Supervisor’s assessment General client observations – comments about client behaviour, diagnosis, interventions Negative reaction to client – disapproving or critical thoughts about the client Countertransference – therapist’s identification with the client, reaction to the client Client-therapist attraction – feeling drawn to the client, interested in a sexual or personal sense Positive reactions to Supervisor – perceived approval from Supervisor, with a desire to maintain this kind of contact Supervision setting concerns – feeling unsupported in the placement Supervisor appearance – disapproval of dress, language and aspects of Supervisor’s presentation Supervisee-Supervisor attraction – drawn to the Supervisor in a sexual or physical sense Positive reactions to client – approving thoughts or comments (Reflect upon which of these emerged from the Group exercise)
78 These categories are listed in descending order of the frequency reported, and possible importance, from the responses of Supervisee’s participating in the Ladany et al (1996) study. Of main significance was the Supervisee’s negative reaction to the Supervisor. Some of the perception had to do with the feeling that that the Supervisor lacked skill or expertise In other instances, Supervisees indicated that the power imbalance led to a reluctance to challenge or question the Supervisor Fear of being seen negatively, or of committing “political suicide’ was often reported. Deferring to the Supervisor,or to self-consciously acting to reduce the risk of being negatively evaluated, were also cited.
79 Personal issues were not disclosed by a large number Supervisees. Some of this may have related to perfectionism, some to concerns around career choice. However, as the study authors point out, Supervision is not psychotherapy, and some degree of reticence to introduce personal matters into Supervision might be quite an “appropriate” and a “healthy” choice (p18). It is where this might have implications for client contact and/or psychotherapy that this category of non- disclosure might be an issue that the Supervisor might sense and further explore with the Supervisee.
80 Clinical errors and the concerns about evaluation seem to be linked, and occurred in this study in equivalent number. The difficulty is that concerns about the adequacy of performance, the desire to promote a positive appearance in Supervision, and the non- disclosure of clinical errors or mistakes may exert a negative impact on client care. Undisclosed aspects of client’s presentation, the client’s behaviour during a session, and/or the Supervisee’s specific reactions to clients, were of significance where diagnostic implications, or decision-making about the direction of intervention were involved in the Supervisory process. This was critical where the Supervisee’s inability or empathise with or connect to the client compromised interaction and/or therapy.
81 Ladany et al. (1996) also provide an analysis of the reasons behind the decision of Supervisees to withhold information: 10 were clearly identified: Perceived unimportance – information thought to be irrelevant, unnecessary or not worth discussing Too personal – private, undesirable to discuss about self in Supervision Negative feelings – embarrassment, shame or discomfort related to raising a topic Poor alliance with the Supervisor – negative feelings about Supervisor- Supervisee interaction Deference – considered by Supervisee to be no part of their role, it might hurt or offend, it might cause a negative reaction in the Supervisor Impression management – concern about being perceived, viewed, or labelled negatively Supervisor agenda – perceived orientation, views, beliefs of the Supervisor Political suicide – negative consequence perceived or feared with respect to future activities Pointlessness – a perception that raising an issue would change nothing, or that the issue is out of the control of the Supervisor or Supervisee Supervisor is not competent – Supervisor perceived as being inadequate or unavailable
82 Ladany et al (1996) propose that a poor alliance, either at the time or in the context of the Supervisory relationship was a main in theme in determining that Supervisee’s made the choice not to disclose content that might have had some relevance to the session of Supervision. The notion of mutual trust, liking, and caring between the Supervisor and Supervisee seemed to be the key components. When these conditions were not present, it is proposed that Supervisees will disclose less information.
83 In terms of how the non-disclosure occurred, the authors determined that there were three principal mechanisms used. The most common was taking a passive approach: if the Supervisor did not raise an issue, or ask a question, the information was not spontaneously volunteered. A diversionary approach was employed as another strategy: the Supervisee launched into a discussion of something else as a way to avoid disclosing information. The least used strategy was a more direct approach: Supervisees indicated that they did not wish to discuss, elaborate or go further into issues raised in the Supervision.
84 An important finding in the Ladany et al (1996) study was the extent to which non-disclosure in Supervision was counterbalanced in some way by Supervisee’s sharing this information with others. This was often peers and work colleagues who were perceived as being important to the Supervisee’s function as a therapist. This suggests that informal Supervision may occur involving those who have considerably less Supervisory experience than the nominal Supervisor. It points to a need to share and to express, and a desire to do so in a less pressured, less evaluative and more open context.
85 Group Exercise-Discussion Having considered the nature of non-disclosure in Supervision – the content and the reasons for this conscious or unconscious decision made by Supervisees – consider what you, as a Supervisor, need to look out for and what steps you might take to maximize openness and trust in Supervision relationships.
86 Ladany et al. (1996) have drawn some suggestions for Supervisor consideration or action to limit the extent of non-disclosure: Supervisee anxiety about evaluation and the evaluative aspect of Supervision needs to be addressed, normalised, and acknowledged as part of the Supervision process. Supervisors need to reflect upon their approach to Supervision to counter the effects of non- disclosure: Supervisees are more likely to be disclosing if the process is perceived to be open and collaborative Deference may reflect the Supervisee’s heightened awareness of the power differential and may be particularly salient for beginning Supervisees. Discussions in Supervision are often one-side or involve feedback: this may be more critical and ego-threatening than positively reinforcing Supervisors may need to indicate that some personal issues may relate to Supervision around client contact, and suggest that discussion may be important to the Supervisee’s growth as a therapist Revelation of mistakes made by the Supervisor in discussion with the Supervisee will increase the chances of mistakes being shared more openly in the Supervision Foster in the Supervisee that all aspects of the client’s presentation, behaviour during the contact and the Supervisee’s reaction to these and to other aspects of client presentation have a potential bearing on the course of the assessment of, and the intervention with, that client The largest number of complaints against Psychologists involve inappropriate sexual intimacies. Supervisors need to be aware that the dynamics of both psychotherapy and Supervision hold this potential: they need to be alert to the potential for damage to client outcome, as well as to the damage that might apply to either or both participants in Supervision.
87 “Supervisors could disclose their own mistakes and struggles to make it safe for supervisees to disclose. They could normalize mistakes by sharing their own humanness and growth, communicating that mistakes will not erode their impression of the supervisee.” Ladany et al. (1996) (p 22). Finally, Ellis (2010) provides an excellent snap-shot of the processes involved in learning about and providing Supervision. The article ends with Ellis providing some twenty “do’s” of Clinical Supervision. There is a strong emphasis on : Constructing a relationship that empowers the Supervisee, One that encourages openness in the interaction, and transparency in its evaluative aspects. Encouraging the Supervisor to use his own processes “ …we do not have to do Supervision in isolation” (p111).
88 References Davys, A & Beddoe, L (2010). Best Practice in Professional Supervision. London. Jessica Knight Ellis, M V (2010). Bridging the Science & Practice of Clinical Supervision: Some Discoveries, Some Misconceptions The Clinical Supervisor 29(1), Falender, C A & Shipanske, E P (2007). Competence in Competency-Based Supervision Practice: construct and application Professional Psychology: Research and Practice38(3), Gonsalvez, C J & Milne, D L (2010). Clinical supervisor training in Australia: a review of current problems and possible solutions Australian Psychologist. 45(4), Hawkins, P & Shohert, R (2000). Supervision in the Helping Professions. Philadelphia. Open University Press. Kilminster, S M & Jolly, B C (2000). Effective supervision in clinical practice: a literature review. Medical Education34, Ladany, N; Hill, C E; Corbett, M M; & Nutt, E A (1996). Nature, Extent, and Importance of What Psychotherapy Trainees Do Not Disclose to Their Supervisors. Journal of Counseling Psychology 43(1), McNeill, B M & Worthen, V (1989). The Parallel Process in Psychotherapy Supervision Professional Psychology: Research and Practice 20 (5), Milne, D E; Sheikh, A I; Pattinson, S & Wilkinson, A (2011). Evidence-based Theory for Clinical Supervisors: a systematic review of 11 controlled studies The Clinical Supervisor 30(1), NSW Government Health (2013). Allied Health Professional Practice Supervision. Doc HNELHD Pol13_01 NSW Government Health (2010). Continuing Professional Development for Psychologists HNEH Pol 10_02 Rogers, C (1957). The necessary and sufficient conditions of therapeutic change. Journal of Consulting Psychology. 21, Schindler, N J & Talen, M R (1996). Supervision 101: the basic elements of teaching beginning supervisors.The Clinical Supervisor14(2), Worthen, V & McNeill, B W (1996). A phenomenological Investigation of “Good Supervision Events”. Journal of Counselling Psychology 43(1).
89 Module 5: Supervising for the development of competencies in working with difference.
90 “ … do not neglect diversity issues and the “-isms”. Unfortunately, diversity and multicultural issues are all too often overlooked. Diversity and the –isms are often viewed as background instead of foreground as supervisors work with supervisees and those supervisees’ work with clients” (Ellis, 2010). “… all people are multicultural and thus all interactions are cross- cultural” Hage et al. (2006).
91 Group exercise Reflection No 1.
92 Reflection No. 1 Following opening quotes: “ … do not neglect diversity issues and the “- isms”. Unfortunately, diversity and multicultural issues are all too often overlooked. Diversity and the –isms are often viewed as background instead of foreground as supervisors work with supervisees and those supervisees’ work with clients.” “… all people are multicultural and thus all interactions are cross-cultural” How does this fit with your experience of having received and given Supervision? According to this quote, each one of is a multicultural being: have you ever been recognized as being so: was this a positive or a negative experience?
93 The practice of Clinical Psychology is fundamentally about working with and understanding difference. This entails coming to an understanding of the unique features of the client, their history, particular strengths, weaknesses and preoccupations, their presentation and how they construes the problems central to his/her arrival, or to the referral seeking the assistance that Clinical Psychology promises.
94 The Discipline of Psychology, from where we as clinicians come from, tries to establish, by using the rigor of scientific investigation, the communalities of human development and experience. People are its primary subject matter, a subject matter that it seeks to explore and investigate in order to equate, to establish norms and develop normal expectations, to describe what is usual and to reflect back these principles, relationships - even laws - to explain, and to assist prediction in human behaviour.
95 To learn about Psychology and psychological practice is to internalize some of this wisdom, at least in part. To practice as a Psychologist is to develop an ever-more reliable set of these values, as an internal gauge, used as a complex but actually quite personal and individual ‘psychometric tool’, active in the processes of assessment, evaluation and intervention with clients. Clinical Psychological practice relies on this wisdom, but its focus is on departures from the norm, on variance, on the unusual aspects of experience and on aberrations in cognition, emotion, behavior and experience. Often the differences we seek as clinicians to examine are subtle and not readily disclosed.
96 In the consideration of Individual and Cultural Diversity (ICD), attention is drawn to those more prominent, more evident differences: Race Gender Age Religion Disability Ethnicity Sexuality Socio-economic status All which create sharper and more “visible” divisions, which may be the source of the experience of marginalization, disempowerment and stereotyping, in our clients and in ourselves. Individual and Cultural Diversity – Micro- effects: Impact at the practitioner level.
97 Group reflection exercise: What are the differences that have shaped me and how has this influenced the way I view myself, other people and the world? Consider, race, culture, class, gender, sexuality, religion, and disability. How have these differences influenced the way others have seen me?
98 Cultural issues abound. Some differences are evident in the physical appearance, the dress and/or the language of the other. Supervisors, in the work of supervision, need to highlight the differences in culture that might be experienced less evidently, for example, within and between organizations within our society. Most of all, the Supervisor needs to attune the Supervisee to the cultural differences that apply to family life – his or hers is different from yours: yours is different from his: and the client’s experience is different to you both.
99 It can be challenging for the newly-trained Psychologist to confront his or her own biases. Self-evaluation may not have been much experienced in four or more years of studying Psychology, which emphasized objectivity and a dispassionate approach. Rather than the practitioner being the objective and detached product of science that the research-based teachings of Psychology might encourage us to be, the practitioner must recognize, be conscious of, and to some extent embrace, his or her uniqueness. The novice Supervisee will progressively be brought to recognize that we are, each of us, a product of diverse influences. Our individuality and functionality as clinicians are products of many of the same factors, including those embodied in the study and application of diversity and difference, that result in very different personal outcomes for our clients.
100 Supervision offers an opportunity to assist the Supervisee to raise awareness around some of these issues around differences, not only with the clients that he or she sees, but also with differences as they play out in his or her development as a clinician.
101 How might you start a conversation with your Supervisee about the differences that have shaped them? Example: asking your Supervisee to talk about some of the differences that have shaped his or her development as a clinician: talk about the differences between us, as Supervisor and Supervisee.
102 It is indeed challenging to realize that we are all biased. We all view the world through our own particular lens that has been shaped, rightly or wrongly, by the social milieu and socialization experiences that we have been raised within. As clinicians, Psychologists take account of race and ethnicity in our interactions with our clients, but we would recoil to having that described as being, at any level, racist. But this being the case, we might also be regarded as being sexist, homophobic, ageist, and that we hold views around social class and status, simply because these factors are embroidered into our formulations, our diagnoses, and are reflected in the interventions we enact with our clients.
103 Self-awareness and self-monitoring are essential components in the delivery of psychological services. In this respect we cannot effectively provide supervision to others, which facilitates and develops skills around dealing with diversity in our Supervisees in their work, unless we have an unself-conscious awareness of those differences that go to describing our own selves as people and as clinicians. We might be happy to be described as being a ‘Behavioural Psychologist’, but less happy to be described as being ‘old’.
104 For the Clinician, self-awareness, some degree of self-acceptance are components in the vital equipment we take with us to our interactions with our clients. Some degree of comfort and skill in dealing with difference and diversity, as well as sensitivity to, and awareness of, our own vulnerabilities - our blind-spots and ‘buttons’ which may be pressed - is a necessary skill, requisite in providing therapy: it is just as much a factor in the provision of Supervision.
105 As the more experienced, even worldly, Psychologist providing Supervision to a professional colleague, whether that colleague is a novice or a peer, we must not display complacency. Because of the differences in experience between the two participants, there is a power imbalance, at least early in the Supervisory relationship, and that must be acknowledged. This imbalance may make it difficult for both parties to explore other aspects of difference and diversity that characterize the relationship.
106 Hawkins and Shohert (2007) examine the power imbalance in the context of dealing with diversity within Supervision, and describe role power, cultural power and personal power. Role power is inherent in the Supervisor, and depending on context, may bring with it legitimate power, reward or coercive power. Cultural power derives from the dominant social and ethnic group, in Australia that is white, Anglo-Saxon, heterosexual and able-bodied. Personal power is particular to the individual, and may derive from authority of their expertise, their presence and/ or their personality.
107 This will become more difficult if the more apparent differences cannot be discussed, and their impact on the Supervision acknowledged, explored and effectively minimized. Supervisor-Supervisee alliance is essential towards facilitating this open discussion. Being open about difference as it exists between the participants in the Supervision will make it easier to acknowledge and discuss diversity, cultural difference and the like as it exists within the Supervisee-client dynamic.
108 How do we facilitate that awareness within ourselves? What experiences have you had with people from a different cultural background? Were you aware of any prejudices? What if any were directed towards you?
109 It is essential that the Supervisor, perhaps through the processes of his or her own Supervision, is equipped with a clear understanding of his or her own status within these broad considerations of individual and cultural diversity. This refers not just to having an awareness and an acceptance of his or her own differences, and those factors within his or her own development that have created those differences, but also that the Supervisor is attuned to his or her own reactions to divergence or difference in others.
110 In terms of appreciating and understanding the value systems of clients who are culturally different, it is important to learn about our client’s values and to not impose our values. We also need to be willing to learn about socio-political forces that have affected our clients and to consider applicability of psychology treatments for different groups. As members of organizations, Psychologists need to think about how diversity-friendly their organisation are, and how they can instil the celebration of difference in our psychology community.
111 Consider racism, sexism or homophobia among your colleagues: What do you do when there is racism, sexism or homophobia among your colleagues? Would you be likely to confront the colleague? What would you want to ask or tell them? What about if this was your Supervisee? Group discussion:
112 The American Psychological Association (APA) (2000) has set out a range of standards relating to the consideration and inclusion of factors, encompassed within the ICD descriptors, for education and training of Psychologists, the provision of clinical services by Psychologists, and the research undertaken by Psychologists. Individual and Cultural Diversity - Macro- effects: impact within Psychology as a profession.
113 Such Guidelines are needed to take account of “… the different needs for particular individuals and groups historically marginalized or disempowered within and by Psychology (my emphasis) based on their ethnic heritage and social group identity or membership”. This is a very important issue, reflecting on how Psychology has been practiced, at least in the USA, in that it recognizes that the past failure to consider cultural diversity has effectively further marginalized the very people that our profession has sought to assist. Within the profession, this failure has even unwittingly marginalized some of our colleagues. (Vignette)
114 Diversity – Vignette Looking at how non-acknowledgement can unwittingly affect us professionally: An indigenous Psychologist working in the generalist agency in which you are both employed, where you are her senior but not her manager, raises in Supervision some concerns about how she feels she is being pigeon-holed. She indicates that, although she is employed as a Generalist, the way the agency has been allocating cases, has resulted in her having an exclusively indigenous caseload. She has become a Specialist of sorts, although this is not her role, or her skill. She is in a bind because she feels strongly about the lot of her people, but she feels that her culture is being over-emphasised without this ever being openly discussed in a way that she can take issue with it. She does not want to be disloyal on one hand, but she wants the opportunity to work with the same range of problems that the agency covers. All of her clients tend to be among the poorest and most dysfunctional, but she feels that if she makes a complaint about her professional development, it will be taken that she wants to avoid these clients and to be given an easier role in the agency
115 APA further asserts that, in the work that Psychologists undertake, they are in a position to provide leadership as agents of pro-social change, advocacy, and social justice. As a profession, Psychology is in a position to promote societal understanding, affirmation and appreciation of multiculturalism and draw attention to the damaging effects of individual, institutional and societal racism, prejudice, and all forms of oppression based on stereotyping and discrimination.
116 The six founding principles for the development of these Guidelines are worth considering, in a summary form, as they seem also to apply to the sensitivity to, and focus on, dealing with difference and diversity in the Supervisory process.
117 The ethical conduct of Psychologists is enhanced by knowledge of differences in beliefs and practices that emerge from socialization Understanding and recognizing the interface between individuals’ socialization experiences can enhance the quality of education, training, practice and research Recognition of the intersection of racial and ethnic group membership with other dimensions of identity enhances the understanding and treatment of all people. Knowledge of historically derived approaches that have viewed cultural differences as deficits, helps Psychologists to understand the under- representation of ethnic minorities in the profession. Psychologists are uniquely able to promote racial equity and social justice. Psychologists recognize that organizations can be gatekeepers or agents of the status quo rather than leaders in a changing society with respect to multiculturalism.
118 Culture: is defined as the belief systems and value orientations that influence customs, norms, practices and social institutions, including psychological processes (language, care taking practices, media, and educational systems) and organizations. Inherent in this definition is the recognition that all individuals have a cultural, ethnic and racial heritage. Culture is also described as an embodiment of a worldview, through learned and transmitted beliefs, values and practices. It encompasses a way of living informed by the historical, economic, ecological, and political forces on a group.
119 Five levels at which aspects of culture can be seen are set out in Hawkins and Shohert (2007) (P106) with each influenced by the levels beneath it: Artefacts: the rituals, symbols, art, building, policies etc. Behaviour : the patterns of relating and behaving; the cultural norms Mind-sets: the ways of seeing the world and framing experience Emotional ground: the patterns of feeling that shape making of meaning Motivational roots: the fundamental aspirations that drive choices
120 Race: has no consensual definition, with the biological basis of race having been, at different times, the source of heated debate in Psychology. The definition of race therefore, is considered to be socially constructed rather than biologically determined, so that it is a category to which others assign individuals based on perceived physical characteristics, such as skin colour or hair type, and the generalizations and stereotypes made as a result. In the American literature concerning race, one sees this frequent references to People of Color (POC).
121 Ethnicity: in a like fashion to the concepts of race and culture, APA indicates that “ethnicity” does not have a commonly agreed upon definition. APA Guidelines refer to ethnicity as the acceptance of the group mores and practices of one’s culture of origin and the concomitant sense of belonging. APA notes that individuals may have multiple ethnic identities that operate,with different salience, at different times.
122 Multiculturalism and Diversity: these are terms that have been used interchangeably to include aspects of identity stemming from gender, sexual orientation, disability, socio-economic status and age (my emphasis). Mulitculturalism is the term used in American culture, whereas in Australia, the term “diversity” would more commonly be used to encompass these factors. Indeed, APA indicate that “multiculturalism in an absolute sense, recognizes the broad scope of dimensions of race, ethnicity, language, sexual orientation, gender, age, disability, class status, education, religious/spiritual orientation and other cultural dimensions” (P2). It stresses that all of these are critical aspects of an individual’s ethnic/racial and personal identity, and urges that Psychologists be cognizant of issues related to all of these dimensions of culture.
123 Guideline 1: Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves. Guideline 2: Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness, knowledge, and understanding about ethnically and racially different individuals. Guideline 3: As educators, Psychologists are encouraged to employ the constructs of multiculturalism and diversity in psychological education. Guideline 4: Culturally sensitive psychological researchers are encouraged to recognize the importance of conducting culture-centred and ethical psychological research among persons from ethnic, linguistic and racial minority backgrounds. Guideline 5: Psychologists strive to apply culturally-appropriate skills in clinical and other applied psychological practices. Guideline 6: Psychologists are encouraged to use organizational change processes to support culturally informed organizational (policy) development and practices. The Guidelines:
124 Addressing Diversity in Clinical Practice and Supervision Hawkins and Shohert (2007) provide a model intercultural sensitivity (P108), and suggest that clinicians may progress through these stages on the way to becoming more culturally effective in their work with clients: Denial: where one sees one’s own culture as the only real one Defence: against cultural differences, where one sees one own culture as the only good one Minimization: in which elements of one’s own cultural world view are experienced as universal Acceptance: in which there is recognition that one’s own culture is just one of a number for equally complex world views Cognitive adaptation: where one can look at the world ‘through different eyes’ Behavioural adaptation: where the individual can adapt their behaviour to different cultural situations and relationships
125 Fouad et al (2009) list as one of the key Foundational Competency Domains, working with individual and cultural diversity, often noted in the literature as ICD. The model distinguishes between the aims and expectations in the teaching and supervision, when the Supervisee is in the learning phase of his or her career, in the phase where practice takes place by way of internship, and when the Supervisee is in independent practice.
126 The focus is the development of self, as a Psychologist, and recommends that the Supervisor’s attention be drawn to establishing with the Supervisee a sense of how he or she has been shaped by individual and cultural diversity. Attention is drawn to knowledge, awareness and understanding of one’s own dimensions of diversity and the attitude of the experience of diversity in the other. It recommends that the Supervisor look for indicators that the Supervisee monitors and applies knowledge of self, as a cultural being, in the processes of assessment, treatment and consultation.
127. For example, white, Western people tend to regard their own culture as a kind of international norm. For Psychologists the risk in this is either that they regard themselves as being culturally neutral or, when working with someone from a different ethnic background, they may assume that their work with the client is correct any perceived cultural divergence.
128 Guidelines are listed as a means by which the Supervisor might gauge the extent to which the development of skills, within interactions where ICD factors are at play, are being fostered by means of the Supervisory process. For example, in terms of being able to relate effectively and meaningfully as a professional Psychologist to individuals, groups or communities, Fouad et al (2009) list, as a behavioural indicator, that the Psychologist needs to demonstrate the ability to: “… effectively negotiate conflictual, difficult or complex relationships … with individuals and groups that differ significantly from (himself or herself)”.
129 Hawkins and Shohert (2007) suggest that there are three ways of responding to culture: the Universalist, denies the importance of culture and emphasises the role of individual pathology; the Particularist takes the opposite view and sees all difference as cultural; the Transcendentalist, takes the view that “both the client and the therapist have vast cultural experiences that deeply influence their worldviews and behaviour” (P105). Which are you?
130 Group exercise 1 Culture: consider how questions around differences might be included: Your Supervisee presents a case of a CALD (culturally and linguistically diverse) client comes in for treatment of depression. He speaks excellent English. Should culture be included in the case formulation and case assessment and how? What questions can we as Supervisors ask our Supervisees to consider? ooOOoo For these and other like skills to be encouraged and developed within the Supervisee, they must be present in the Supervisor.
131 Group exercise 2 For Sexuality: Your Supervisee presents the case of a gay male who has presented for treatment of depression. Should sexuality be included in the case formulation and case assessment: how ? What questions can we as supervisors ask our supervisees to consider? How would you guard against racial and sexual stereotyping in counselling relationship with clients? How would you do this with Supervisees? For these and other like skills to be encouraged and developed within the Supervisee, they must be present in the Supervisor.
132 If we are to recognize rather than deny cultural difference, of any kind, we need to create a language across that difference. Within the Supervisory process, as with the therapeutic relationship presented by the Supervisee, understanding difference is not enough: if we do not complete the circle by including our own difference, we risk being absent from the process. Hawkins and Shohert (2007) indicate that his involves not just exploring and understanding the cultural factors, experiences and assumptions that we bring to the relationship – therapy or Supervision – but also being aware that some aspects of culture bring with them power. Thus dealing with difference involves both understanding culture as it applies to all three participants – Supervisor, Supervisee and client – and recognizing the inherent power imbalance that will exist a as these factors are explored and exposed.
133 An example of how standards might be achieved in that part of the Supervisory relationship directed at ensuring cultural competence in the Supervisee. This is a developmental model, focused around the stages of growth of overall competence within the Supervisee. It is essential that Supervisors explore racial, gender-related, ethnic and cultural dynamics within the Supervision. Spiritual beliefs and socio-economic issues, even political allegiances, should be added to this mix. General models for Supervision for Competency with Difference
134 There is in fact a supervisory triad of the client, the Supervisee, and the Supervisor that always needs to be considered, although it is the dyadic relationship between Supervisor and Supervisee. It is necessary for the Supervisor to build a strong working alliance with the Supervisee so that multicultural issues, which are often contentious or sensitive in nature, can be discussed frankly. Adopting a developmental approach simply takes account of the fact that the needs of the inexperienced Supervisee are quite different from the needs of the advanced trainee, or the experienced Supervisee, and require, of the Supervisor, different and changing strategies.
135 Building cultural awareness in the Supervisee is emphasized as a necessary first step to facilitating the development of skill in implementing sensitively directed, multicultural interventions in the Supervisee. The inclusion of discussion about the likely impact of the Supervisee’s own culture, whatever that might mean, on the perceptions and reactions of their clients generally is part of this process. How was it for you to sit with a client (… of a different culture, specified)? Did the (… identified cultural differences …) between the client and yourself affect your connectedness with him/her? Can you identify any multicultural issues that may affect you working with this client?
136 A four stage model is outlined: At the first level in the model, where Supervisees are described as having high motivation for client work, but anxiety and limited insight, they are described as being likely to have little knowledge of multicultural factors At the second developmental stage within the model Supervisees are described as striving more autonomy in their work with clients. At the third level of this model focused on building competency around multicultural issues, the Supervisee is likely to have reached an awareness that the interactions with clients can be limited by his/her own biases, and by the experience of conflicting values within the therapeutic conversation. In the fourth and final stage of the model there is a sense that an awareness of self-other has been achieved, it is acknowledged, and it is incorporated by the Supervisee in client work.
137 Hawkins and Shohert (2007) provide a general model for the provision of Supervision in which seven differing focal activities are described, with the authors recommending that Supervision move between the suggested modes over the course of the supervisory experience (Chapter 7). They have adapted their model to consider how this might apply to the Supervisor’s focus on working with the Supervisee where attending to cultural difference, of any kind, needs to be addressed.
138 Mode 1: Focus on the client and what and how they present. The client’s world is understood by way of the experiences he brings to and expresses in therapy. Cultural material may be brought explicitly or implicitly, with the task of the Supervisee to understand the extent to which the client’s experience is strongly derived from his culture, as opposed to what is more characterised by personality variables. The Supervisee will need to be attentive to the client’s non-verbal signs, and it is an opportunity for the Supervisor to increase the Supervisee’s awareness of his or her own tendency to give meaning to these signs through the medium of his or her own culture.
139 Mode 2: Exploration of the strategies and interventions used by the Supervisee. This mode provides the Supervisor with the opportunity to examine interactions and interventions that are born of the Supervisee’s own cultural experience. It acknowledges that this unconscious bias can be sharply evident in interventions that do not take full account of the cultural experiences and expectations of the client. The Supervisor, detecting this kind of error, might suggest that the Supervisee become more fully acquainted with the messages of the client’s cultural background in order to make more culturally sensitive interventions.
140 Mode 3: Focusing on the relationship between the client and the Supervisee. In this mode, the focus is on neither the Supervisee nor the client, but rather on the system that their meeting together has created. Questioning by the Supervisor is aimed at encouraging the Supervisee to see the relationship as a whole, rather than from his or her own perspective. It is an opportunity to examine transference and counter-transference, but to so with culture in focus. Unconscious prompts by the client about a desire to explore unspoken issues of culture may emerge. Some aspects of the power differential created by cultural differences, as it exists between the Supervisee and the client, might also become more evident.
141 Mode 4: Focusing on the Supervisee. In this mode, the Supervisor addresses the Supervisee’s own issues, and the extent to which these impact on client-based activities. It is founded on the Supervisee’s emerging awareness of his or her own prejudiced attitudes and feelings. Supervision in this mode is not psychotherapy directed at the eradication these biases. In the process, the Supervisee is encouraged to see that these are part of his or her growth and development. Consciously appreciated and taken into account by the Supervisee, they may be more a strength to framing interventions, than a vulnerability or a liability with clients from a different cultural background.
142 Mode 5: Focusing of the Supervisory relationship. Exploration of the way the relationship with the client is mirrored within the Supervisory relationship is possible in this mode of Supervision practice. In respect of the power differential that exists between the Supervisee and his or her Supervisor, this may provide a useful experience for the Supervisee as he or she experiences what it might be like in therapy for a client from a non-dominant culture.
143 Mode 6: The Supervisor focusing on their own process. The Supervisor needs to be attuned to the changes and reactions he or she experiences within the Supervision: this can be lost when the focus on role, and the processes associated with that role, are at the forefront of awareness. Reactions to the material being presented in a Supervision session may be related to the interaction of the Supervisor and the Supervisee as described in Mode 5, but it may also be that the Supervisor is picking up the unspoken reactions that the Supervisee has to the client, some of which may contain an element of tension or discord around cultural issues.
144 Mode 7: Focusing on the wider contexts in which work happens. Finally, to progress the Supervision, the aim of the Supervisor is to integrate the above-mentioned aspects of Supervision around culture. This process of integration also needs to take account of where the client work takes place and the context of Supervision – they may not be the same. Where cultural difference is involved in the Supervision, it needs to be acknowledged that the world of the client may be seen and interpreted differently by the Supervisee and the Supervisor. Similarly, the Supervisee needs to become attuned to the texture of his or her cultural learning, some of which may have been reinforced as part of professional development. Consideration of the formation of culturally based attitudes and values, and how they may impact on intervention, needs to be factored into Supervision. Aspects of the client – Supervisee relationship may be mirrored in the Supervisor – Supervisee relationship, and this may be brought into sharper focus when the issue of difference, between the Supervisee and his or her client, is in focus.
145 An example: Spirituality and Religion Group Exercise – Reflection No. 2
146 I want to now put a deeply personal question to you: I want you to think about how you answer this with respect to the public nature of your disclosure and who is with you to-day in the audience. Think about what you are prepared to say about yourself; you may need to self-censor; you may feel some caution about how others might construe your disclosure. In a few words, what can you say about your own spiritual beliefs, your religious practices, or your religious or spiritual affiliations? (Note down the answers with the intention of getting some idea of the diversity represented in this group) For those who had to self-censor, who had some caution about what they might say openly, please reflect upon this as we embark on the next part of this presentation Consider the reasons for this for you Consider as we talk about spirituality and religion as a multicultural concern, how similar disclosures might be difficult for our clients in therapy, or our colleagues in Supervision. Consider also how, if this is a difficulty with respect to religion and spirituality, how similar disclosures – about ethnicity, social class, sexuality – might prove to be just as difficult for our clients, for our colleagues in Supervision
147 There has been a tendency, in Psychology, to represent religious beliefs and behaviours negatively. It seems that this is largely because of the contradictions and confusions between the way in which the spiritual dimensions of the human condition are expressed and considerations of behaviours and ascriptions that relate to mental illness. Yet “… behavioural research … has linked clients’ spirituality and religiosity with improved mental health outcomes” Multiculturalism is often used as code for differences in the community where religion, and to a lesser extent, spirituality, are concerned. Immigration in particular, has introduced a great deal of diversity of religious traditions into the cultural life of Australia. Where once Christianity was the dominant religious culture, orchestrating most of the behaviours related to religious traditions, a plurality now best describes religious life in Australia. For this reason, Psychologists working with clients, and Psychologists paired in Supervision
148 Religion and spirituality are not interchangeable terms. For the purposes of this discussion: Spirituality refers to the meaning and purpose of one’s life, a search for wholeness and a relationship with a transcendent being. Religion, or religious involvement, is a means of expressing one’s spirituality, and generally refers to participation in an organized system of beliefs, rituals and collective traditions. Focus on spirituality and religion, for the Supervisor and the Supervisee, encapsulates basic considerations that obtain to any other aspect of diversity and difference as it relates to working with clients, and to the work of two professionals who come together to examine that work in Supervision.
149 A model for working in Supervision with Spirituality and Religion Discrimination Model: Intervention skills – the Supervisee’s skill in delivering an intervention conceptualization skills – the Supervisee’s ability to understand and synthesize information about the client, distinguishing between the essential and the non-essential Personalization skills – the personal traits of the Supervisee which contribute to the therapeutic relationship, including personality, cultural background, personal values and aspects of self. Three key Supervisory roles: As teacher, the Supervisor may instruct, model, provide feedback and evaluate. As counsellor, the Supervisor encourages reflection, assists the Supervisee in examining their own thoughts and their own internal schema of reality. As consultant, the Supervisor provides an objective resource to the Supervisee, always encouraging the Supervisee to trust their own perceptions, thoughts and insight s.
150 The implementation of the model involves the Supervisor identifying the focus area and what needs to be discussed at that point of Supervision, depending on what, and how, the Supervisee is presenting, and then determining which of the Supervisory skills is indicated for properly addressing that focus. The Discrimination Model might work in Supervision in the following way: if the Supervisee seems to be struggling with a client’s repeated reference to biblical material, the Supervisor must determine whether the Supervisee is unsure who to integrate the religious themes with the other themes that the client is presenting (conceptualization), or if the Supervisee is struggling to do what is needed (intervention), or if the Supervisee feels discomfort to the point of being unable to act (personalization).
151 Intervention Skills: On the basis of what has emerged from the assessment, the Supervisor and the Supervisee can determine interventions, techniques or other questions that may need to be answered, derived from, or related to, the religious and spiritual traditions that have been unearthed. Polanski (2003) gives examples of what these might be: loving-kindness meditations from Buddhist traditions; contemplative prayer from Christian traditions, suggesting that these might be used as adjuncts to other interventions initiated by the Supervisee, or emerging from the Supervisory conversation. The aim of Supervision within the focus on intervention is to teach the Supervisee new skills or to enhance existing skills, imparting information about the assessment process, and formulating with the Supervisee questions or techniques that are derived from the information gleaned with respect to religious or spiritual beliefs and affiliations. Supervision might be the moment when such interventions are rehearsed.
152 Conceptualization Skills: When religion and spirituality are being considered, the basic conceptualization skill needed by the Supervisee – and the Supervisor – is that spirituality actually exists, and that spiritual experiences make a difference to the individual’s behavior. The task of the Supervisee, in concert with the Supervisor, is to sort out what is essential in the exploration of spiritual and religious themes with the client. Guilt may be central theme: religion may be the source of this guilt just as it may be a source of strength for the client. In the Judeo-Christian traditions, the image of God as a parent prevails, so that clients raised in this tradition may have a construct of God based on their experiences with their parents.
153 Personalization Skills: This set of skills relates to the Supervisee’s ability to effectively and ethically address the client’s spiritual and religious beliefs out of an awareness of his or her own. The spiritually competent Supervisee (and Supervisor) engages in self-exploration of his or her beliefs in order to increase sensitivity, acceptance and understanding of the impact of his or her own belief system within therapy. Personalization skills of this kind may be challenging for the Supervisor to address: his or her experience as a result may range from the highly satisfying to the deeply uncomfortable, and some awareness and anticipation of this is advised.
154 Polanski (2003) concludes: “ The Supervisor’s position of power suggests that his or her attitudes toward spirituality and counselling will set the tone for how these issues are addressed in Supervision and may, consequently, influence the way the Supervisee addresses these issues with clients. Demonstrating a readiness to address these issues with Supervisees is essential for the Supervisors to ensure appropriate client care and to enhance the professional development of the counsellors ”. (p139)
155 References Davys, A & Beddoe, L (2010). Best Practice in Professional Supervision. LondonJessica Knight Falender, C A & Shipanske, E P., (2007). Competence in Competency-Based Supervision Practice: construct and application Professional Psychology: Research and Practice 38(3), Gonsalvez, C J & Milne, D. L (2010). Clinical supervisor training in Australia: a review of current problems and possible solutions Australian Psychologist45(4), Hawkins, P & Shohert, R (2000). Supervision in the Helping Professions Philadelphia Open University Press Kilminster, S M & Jolly, B C (2000). Effective supervision in clinical practice: a literature review. Medical Education34, Milne, D E; Sheikh, A I; Pattinson, S & Wilkinson, A.,(2011). Evidence-based Theory for Clinical Supervisors: a systematic review of 11 controlled studies The Clinical Supervisor 30(1), NSW Government Health (2013). Allied Health Professional Practice Supervision Doc HNELHD Pol13_01 NSW Government Health (2010). Continuing Professional Development for Psychologists HNEH Pol 10_02 Rogers, C (1957). The necessary and sufficient conditions of therapeutic change. Journal of Consulting Psychology 21, Schindler, N. J. & Talen, M. R. (1996). Supervision 101: the basic elements of teaching beginning supervisors. The Clinical Supervisor 14(2), Worthen, V & McNeill, B. W. (1996). A phenomenological Investigation of “Good Supervision Events” J ournal of Counselling Psychology 43(1), 25-34
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