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Feedback in Clinical Supervision

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1 Feedback in Clinical Supervision
Lois A. Ehrmann MA, LPC/ACS, CAC/CCS- Diplomate Counseling Alternatives Group 444 East College Avenue, Suite 460 State College, PA 16801 (814) Hello My name is Lois Ehrmann and I am very happy to be here to share this information with you. I am an outpatient counselor in State College and have been specializing in addiction treatment for over 16 years. During my career about 14 years ago the clinical supervisor at my agency asked me to provide supervision for some masters level students who were doing their practicum with us. I said “YES” and then realized “Oh No…actually I said something else then Oh No..I really don’t know what I’m doing here! So being the predominantly ethical counselor I tried to be I went looking for resources and found some but not a huge amount of information. I muddled along as well as I could. In the year 2000, I made a choice to engage in the sadomasochistic activity of returning to graduate school to attain a doctorate in Counselor Education/Rehabilitation Services. I am currently ABD, all but dissertation at this point in time but one of the best things that ever happened while I was involved in this program was that I took part in an excellent set of courses that focused on clinical supervision. Initially there was the dydactic lecture discussion course and then after that we experienced a practicum in clinical supervision. Each doctoral student was supervised in their supervision of Masters level counselor education students. This was an amazing experience and to say the least I was humbled and eternally grateful that I did not hurt any of my past supervisees prior to this formal training. My experiences prior to during and now after that phase in my program has enriched me greatly and empowered me to become credentialed as an Approved Clinical Supervisor through NBCC/NCE and thought the PA Chemical Abuse Board. Hopefully I can share with you a little bit of the Knowledge I gained from that experience. I keep after the faculty to offer a certificate program in clinical supervision but they’re busy right now maintaining the new CACREP accredidation and the CORE accredidation.

2 In TWO hours or less, we will discuss……
Assumptions about counselor development and clinical supervision IDM of Clinical Supervision Feedback Matching to Counselor Development Formative versus Summative Feedback Feedback within a Positive Supervisory Environment Formative Feedback Small Group Exercises and Closure

3 Assumptions Counselors are…. The self as a therapeutic tool
Personal and professional development Clinical Supervision should be life long I Assumptions about counselor development and clinical supervision Counselors are persons who use their training to help others. They often use the tool of themselves in some way to help a client understand him or herself better. Counselors continue to develop both personally and professional over time. Therefore clinical supervision should be a life long commitment on the part of the supervisee and clinical supervisors should have an awareness of this personal and professional growth.

4 Important Issues for Supervision
Personal issues When should they be discussed? Changing nature of supervision based on developmental stage Structure and methods of feedback may need to change over time too. These important assumptions call clinical supervisors to become aware of a number of issues, They are: That the personal issues a counselor have may transmit over into work with clients. That personal issues must be discussed in clinical supervision but only in reference to the effect such is having on present clients. In certain circumstances the counselor should be encouraged to at least temporarily leave the field. A referral to another professional for the individual’s personal issues should be formally made. That clinical supervision needs to change as the counselor grows into greater personal and physically maturity. Finally the structure and the methods of feedback given in supervision may need to change dependent of where the supervisee is in the developmental process.

5 The Integrated Developmental Model of Supervision (Stoltenberg, Mc Neill & Delworth, 1998
Three movements across development: motivation, autonomy and awareness Domains of counseling: assessment, diagnostics, conceptualization, treatment goals and implementation of interventions Review the chart II. The Integrated Developmental Model for supervising Counselors and Therapists Stoltenberg, Mc Neill, and Delworth (1998). Review the chart of stages or phases of the model. Point out the authors talk about the stages in process in relationship to the counselor’s motivation, autonomy, and awareness. The model also proposes that as counselors develop and mature their competence grows in the domains of assessment, diagnostics, conceptualization, treatment goals and implementation of interventions.

6 Feedback for the Level 1 Counselor
Establishing structure Clear communication of expectations Encouragement and affirmation Specific recommendations of strategies Encouragement to link theory to strategies selected Late Level 1 challenges or confrontations In looking at this model of professional counselor development and in reviewing the characteristics the question now becomes “What types of feedback are best conveyed to a counselor in any particular phase of development during clinical supervision?” III. Feedback most appropriate for Level of Counselor (Delworth, Vespia and Stone, 1999) For Level 1 counselors: Structuring the supervision session is important. For example give counselors a format for presenting cases in supervision. An example would be the one used at our agency where the counselor writes out the presenting problem, the steps taken or proposed steps to take, any issues that the counselor currently feels about the client or the problem and the feedback presented by the supervisor or other peers during group clinical supervision. In addition communicating clearly the expectations of the counselor that the supervisor has is important and giving the counselor a blank summative evaluation form to review should be done. Counselors at this level need to be encouraged and affirmed for taking risks with the supervisor and supervisory interventions that are most helpful to these new counselors are praise, reinforcement of the appropriate demonstration of skills, careful and attentive listening, other indications of appreciation and care. A study by Daniels and Larson (2001) demonstrated that when new counselors experienced positive affirming feedback they interpreted the clinical encounter as a mastery experience and their sense of self efficacy (I can do this!!) increased while their performance anxiety decreased. Conversely when new counselors who did the same intervention as the other group was given negative feedback about the strategy they attempted, they interpreted this as a failure experience and their sense of self efficacy decreased while their performance anxiety increased. Prescriptive interventions that these counselors need are the specific recommendation about a specific intervention regarding a specific need of a client. Gradually offering alternative interventions so that the growing counselor can begin to develop autonomy is recommended. Stimulation of growth as a counselor can also occur by encouraging the new counselor to link an intervention to its theory. At times challenges or confrontations of the new counselor will need to occur but it is best to try to wait until his or her anxiety has been reduced and when he or she has begun to demonstrate an increased level of autonomy. Using confrontational feedback too early in the counselor developmental process can result in the freezing of the development of the counselor and he or she can become stuck. Once a counselor exhibits increased comfort and risk taking within the supervisory relationship then increased confrontation may be needed to move the counselor out of his or her safety zone into trying new techniques. Catalytic interventions or feedback are used to expand the awareness of the new counselor in aspects of clinical practice. (i.e. comments on the treatment process, exploring the counselor’s thoughts or feelings about a particular point in the counseling process with a client). This is usually more effective in the latter part of Level 1 and helps the counselor to grow in awareness of client issues. Fitch and Marshall (2002) found that use of cognitive interventions with new counselors during supervision about self defeating thoughts helped many of them to stop sabotaging their performance with clients. Observation via direct or videotaped means of the counselor’s interactions with clients is really important at this stage. Constructive feedback on these interactions really reinforces the skill development that is essential for effectiveness. Use of role playing and role reversal should be frequent and the supervisor should have ample resources such as client workbooks and technical guides available for use by the new counselor. Make sure feedback is balanced and try always to comment on the strengths in the counselor first and then move toward the growth areas that need to be addressed.

7 Feedback for the Level 2 Counselor
Supervisors must be very flexible Balance between direct guidance and counselor autonomy Expressions of care and support Disclosure of past failures or difficult times Rationales and conceptualizations Increase catalytic interventions Level 2 Counselors: Supervisors need to be really flexible with counselors in this level. The task is to provide a balance between guidance and support and autonomy and challenge. In order to foster independence and confidence in the counselor the supervisory environment must be different then for the level 1 counselor. Supervisors need to decrease the structure and increase the autonomy. Facilitative interventions that express care and support are important. Sharing or disclosing one’s own past difficulties in similar situations with clients is very helpful to the counselor in the second level. Prescriptive interventions are also periodically needed but at times the level 2 counselor may get defensive or resistant. Supervisors can and should challenge the counselor in this stage to state rationales and conceptualizations for choosing the strategies with clients that they wish to implement. Conceptual interventions are important but only with a high level of support and empathy. There should also be an increase in catalytic interventions which are meant to further increase the counselor’s awareness of his or her self and personal issues that appear to be triggered by client’s problems or the dynamics between the client and counselor. Pointing out transference and counter-transference issues as well as delivering process comments about the relationship between the counselor and supervisor can help stir up the level 2 counselor just a bit in order to increase his or her awareness of self and others. Challenge within a supervisory relationship that is supportive is really important to assist the level 2 counselor to stretch into the next level of development and to increase levels of competence. Counselors in this level begin to demonstrate more openness in discussing and processing personal issues of self awareness , defensiveness and transference and counter transference and thus the supervisory relationship may reflect some of these issues as well. Try not to panic but use the dynamic to assist your supervisee to grow and gain experience in resolving these conflictual processes in a healthy manner. Monitoring with videotapes and direct observation should be regularly done even at this level. By the end of level 2 counselors come to understand that fluctuations in motivations within themselves are a normal part of their professional development and reflect greater understanding about the complexities of the issues clients bring into the counseling room. They become more secure and less defensive and more open as they move into the level 3.

8 Feedback for the Level 3 Counselor
Affirmation and support are needed but are less crucial Challenges to the counselors thinking and affective responses to clients Catalytic responses if counselor gets stuck in a client counselor situation Level 3 Counselors: These are professionals who have substantial experience and are well aware of what works for them within the supervisory relationship. They are able to effectively communicate their needs and use the consultation/supervision to their benefit. You will recognize the level 3 counselor because these people are less likely to bring into your session with them the good work they are doing with clients. They speak right away about the glitches they are experiencing in their work and use words such as, “I think I’m somehow being triggered by……” When she says this my skin begins to crawl because I feel…..” Facilitative interventions of support and affirmation continue to be important but are less crucial at this stage. The counselor has developed considerable confidence in his or her ability and the ego is less fragile then in the other levels. Prescriptive interventions are used rarely but may be appropriate when the counselor is less skilled in certain domains. Confrontational interventions are still occasionally needed but the response of a counselor in this stage is very different then the prior stages because the challenge is usually met with acceptance and a commitment to self analysis on the issue. The counselor may not agree in the final conversation but the analysis of the issue is definitely done. Catalytic interventions are used in response to the counselor being blocked or stagnated and occasional viewing of videotapes may still be done.

9 Different types of Feedback
Formative Feedback Summative Feedback or Evaluation Skill acquisition Professional growth Direct feedback Formal evaluation How does the person measure up Stresses progress and process Concerned with the final outcome Is the candidate qualified IV. Understand the difference between formative and summative feedback or evaluation and make sure your supervisee knows the difference too! When supervisors tell their supervisees that an intervention was a success they are most definitely evaluating the counselor. When a supervisor says nothing to a supervisee about an intervention, the supervisee is left ascribing a meaning to that “statement of nothing.” What are the possible interpretations that the counselor supervisee can make: The intervention was a huge success ! No need to discuss. The intervention was too too awful to even discuss. Remember that there is an evaluative message in all supervision. Formative Feedback versus Summative Feedback or Evaluation Formative=The process of facilitating skill acquisition and professional growth through direct feedback. Summative=The formal evaluation or the moment of truth when the supervisor steps back and takes stock and decides how the counselor measures up. Formative= This type of feedback causes little discomfort for supervisors. This type is the bulk of interactions with the counselor and this type stresses progress and process rather then outcome. Summative=This type causes great discomfort for supervisors because it is the final outcome picture and if counselors do not measure up they may be affected in their goal of reaching certification or licensure.

10 Summative Feedback or Evaluation Clear Criteria are Important
Bernard and Goodyear (1998) Frame and Stevens-Smith (1995) Factual knowledge Generic clinical skills Orientation specific skills Clinical judgment skills Interpersonal attributes Multicultural competencies Openness Flexibility Positive attitude Level of cooperation Willingness to accept and use feedback Awareness of one’s impact on others The ability to deal with conflict Acceptance of personal responsibility Expression of feelings effectively and appropriately In order to do a responsible and ethical job of providing evaluation for a developing counselor the criteria from which the counselor will be judged must be established ahead of time and the counselor must be informed of this at the very beginning of the supervision relationship. There are various proposals (Hensley, Smith, & Waller-Thompson, 2003) in the literature regarding the areas that a summative evaluation should include. Bernard and Goodyear (1998) suggest that each individual program or facility must decide the criteria they will use for summative evaluations but they suggest broad areas such as factual knowledge, generic clinical skills, orientation specific skills, clinical judgment, interpersonal attributes and multicultural competencies. The issue of interpersonal attributes or relationship skills gets a little tricky but the argument for including these areas in the evaluation is that much of what works in the counseling situation has to do with the personhood and interpersonal health of the counselor. A number of authors have tried to identify what these interpersonal attributes should be but I especially like the areas proposed by Frame and Stevens-Smith (1995). I assisted PSU’s Department of Counselor Education and Rehabilitation Services in developing an summative evaluation as well as an impaired student policy and these were the criteria that were recommended by these authors: openness flexibility positive attitude level of cooperation willingness to accept and use feedback awareness of one’s impact on others the ability to deal with conflict acceptance of personal responsibility expression of feelings effectively and appropriately From researching this area the committee devised a peer feedback form that is being instituted this current year. Please see the copy in your packet. Usually our peers rather then our supervisors tend to know more about our interpersonal relationship skills on a core level. Thus I recommend that you consider making peer reviews a regular part of the whole feedback and evaluation process on at least a yearly basis. At Counseling Alternatives up until this current year our staff made it a habit to go on two retreats a year, one in the fall and one in the spring. At each retreat we engage in a peer feedback process. The Fall retreat process is usually facilitated by an outside facilitator and we facilitate the Spring one ourselves. This year we got off track because three of the five partners lost their parents to death and the year was sort of discombobulated. Hopefully we will get back on track this year as we all acknowledged we missed the retreats. The importance of maintaining an honest and caring favorable supervisory environment cannot be emphasized enough. “When the context of supervision is favorable the trainee stops asking, “How can I avoid criticism?” and starts asking “How can I make the most of this supervision time?” Identify Counseling Alternatives Group Summative Evaluation Form.

11 Make Feedback a Positive Experience- Some Tips
Acknowledge that supervision is unequal Be clear about administrative versus clinical supervision Address supervisee defensiveness Individual differences Make feedback mutual and continuous Flexibility Strong administrative structure Avoid premature evaluations V. Making the provision of feedback a more positive experience for the counselor Trainee 1. Acknowledge that supervision is an unequal relationship right from the beginning despite the high level of empathy that most supervisors try to provide. Show sensitivity to the position of the supervisee and this has the results of making the supervisor a more compassionate evaluator. 2. Be clear. Explain administrative supervision versus clinical supervision and the various roles you might play. Discuss early on about the whole feedback process both in week to week sessions and in the summative evaluation process. Give a copy of the forms used right away. 3. Address supervisee defensiveness openly. Remember that clinical supervision especially makes counselors feel naked at least initially. Defenses are natural so don’t hold the supervisee’s vulnerability against him. 4. Address individual differences openly. Make feedback a mutual and continuous process where the counselor supervisee is actively involved in identifying his or her own growth objectives and in evaluating your effectiveness as a supervisor. Show the form used for this as well. 6. Remain as flexible as possible. Realize that short term intrusions (a new baby, a new partner, elderly parents, death of a love one etc.) should not jeopardize the summative evaluation of the counselor. 7. Make sure your agency has a strong administrative structure. It is extremely damaging and destructive to have an effective and fair supervisor’s negative evaluation overturned by a higher up administrator. 8. Avoid premature evaluations.

12 Tips Continued 9. Practice what you preach
10. Attend to the health of the supervisory relationship 11. Balance ‘seriousness’ with ‘play’ 12. Only do it if you enjoy it Practice what you preach and let your supervisees see your own professional development such as taking time for trainings and keeping balance in your life. Pay attention to the health of the supervisor/supervisee relationship. Even though it is an unequal relationship it should still be positive and supportive. Keep “seriousness” in check. Try to make supervision sessions have an atmosphere of creative curiosity, freedom of imagination and openness to surprise as well as safe to make mistakes and to try on new roles. Only supervise others if you truly enjoy doing so because if you don’t you know these counselor types will see right through any attempts to hide this and it will interfere with the process of supervision.

13 Always Remember “Whenever a trainee (or counseling professional) is denied appropriate supervision and evaluation, the professional community is diminished.” (Bernard and Goodyear, 1998) Self-explanatory

14 Formative Feedback It’s an ongoing interactional process
You cannot NOT communicate because even when you say nothing you are communicating something! Any communication to another person contains both (A) a message about the relationship and (B) a message about some particular content. VI. Formative Feedback When providing feedback to counselor supervisees on an ongoing day to day basis I find it helpful to remember that the dialogue in really an interactional process. I am communicating with my supervisee and I am responding to both verbal and nonverbal cues as my supervisee is also communicating to me and responding to my nonverbal and verbal cues. Remember two important things about this interactional process: You cannot NOT communicate even when you say nothing you are communicating something! Any communication to another person contains both (A) a message about the relationship and (B) a message about some particular content

15 Interactional Process Example
Cn: “I had a difficult silent moment with this client we have been talking about. He was really angry at me and I had trouble figuring out what to do. I thought….” Sp: (interrupting the CN): Excuse me for interrupting but I need to get some clarity here first. The client was angry at you or someone else or…. What are the possible relationship messages of the Cn to the SP and the SP to the CN? What are the content messages? For example: A counselor had a difficult silent moment with a client who shared great anger with him. He began talking about the session with his supervisor. The supervisor interrupted the counselor’s verbal disclosure about the session and said, “Excuse me for interrupting but I need to get some clarity. The client was angry at you or someone else or ….” What are possible relationship messages: -I enjoy working with you and I want to clearly understand what happened and why you are in such distress about this…. This relationship between you and I is very tenuous and I need to find out what you did in the session to trigger this client into getting angry… What is the content message? Tell me who she was angry with. Each message either affirms challenges, discourages, confuses or angers a supervisee. If the meta-message is different from the stated message the result will be an unclear communication.

16 Tips for Formative Feedback
Focus on changeable behaviors Offer criticism as an opinion Separate personal feelings out Steer away from accusatory comments or ultimatums Some tips for more easily communicating formative feedback: focus only on the behaviors that can be changed offer criticism as an opinion separate personal feelings regarding the supervisee from the need to criticize steer away as much as possible form accusatory comments or ultimatums.

17 Good Formative Feedback is CORBS
C= Clear O= Owned R= Regular B= Balance S= Specific Good feedback follows the CORBS mnemonic devise. C=Clear: Be clear about any feedback you deliver. Being vague and faltering will increase anxiety in your supervisee and may not be understood. O=Owned: The feedback you give is your own perception and not the ultimate truth so phrase it as your own perception or opinion. R=Regular: When feedback is given regularly it is more often useful to supervisees. Try to give feedback as close to the event as possible and early enough for the person to do something about it. B=Balance: It is good to balance the negative with the positive feedback and if you find that the feedback you give to any one person is either always positive or always negative then this is a clue that your view is distorted in some way. S=Specific: Generalized feedback is hard to learn from. Phrases such as “You are irritating” can only lead to hurt and anger. “I feel irritated when you don’t use the pink phone message slips for phone messages because when you use plain white paper I do not register that I have to return a call back somewhere.” During every supervision evaluation, encourage the supervisee to do a little mini evaluation about how he or she feels he or she is performing with the current clients in the caseload. Encourage the counselor to identify what he or she thinks is going well and what he or she would like to go better. This helps the counselor to develop a better ability to self analyze and evaluate in the summative feedback process as well. Hand out a blank copy of Counseling Alternatives Formal Evaluation/Feedback form as well as the Case Consultation form for formative feedback.

18 Small Group Work Use the time to share with your colleagues a difficult encounter you experienced with a supervisee where you felt you needed to give some appropriate direction or feedback. Then do the following: Try to figure out the stage of development the counselor fits into and Discuss the type of feedback appropriate to the situation. Use COMBS to devise a feedback statement. VII. Small Group Work doing Role Plays and Practicing Formative Evaluation Each small group will be asked to do the exercises listed in the slide.

19 Closure How did it go? Anything new learned that could help in future supervision sessions? References Thanks for joining me today for this workshop! No special notes

20 References Bernard, J., & Goodyear, R. (1998). Fundamentals of Clinical Supervision (2nd Edition). Boston, MA: Allyn and Bacon. Daniels, J., & Larson, L. (2001). The impact of performance feedback on counseling self- efficacy and counselor anxiety. Counselor Education and Supervision, 41, 120- 130. Delworth, U., Vespia, K, Stone, C. (1999). Counselor supervision: A model for on-site supervisors. Counseling and Human Development, 32, 1-12. Frame, M., & Stevens-Smith, P. (1995). Out of harm’s way: Enhancing monitoring and dismissal processes in counselor education programs. Counselor Education and Supervision, 35, Fitch, T, & Marshall, J. (2002). Using cognitive interventions with counseling practicum students during group supervision. Counselor Education and Supervision, 41, IX. References Benard, J., & Goodyear, R. (1998). Fundamentals of Clinical Supervision (2nd Edition). Boston, MA: Allyn and Bacon. Daniels, J., & Larson, L. (2001). The impact of performance feedback on counseling self- efficacy and counselor anxiety. Counselor Education and Supervision, 41, 120- 130. Delworth, U., Vespia, K, Stone, C. (1999). Counselor supervision: A model for on-site supervisors. Counseling and Human Development, 32, 1-12. Frame, M., & Stevens-Smith, P. (1995). Out of harm’s way: Enhancing monitoring and dismissal processes in counselor education programs. Counselor Education and Supervision, 35, Fitch, T, & Marshall, J. (2002). Using cognitive interventions with counseling practicum students during group supervision. Counselor Education and Supervision, 41, Hensley, L., Smith, S., & Waller-Thompson, R. (2003). Assessing competencies of counselors in training: Complexities in evaluating personal and professional development. Counselor Education and Supervision, 42, Pearson, Q. (2000). Opportunities and challenges in the supervisory relationship: Implications for counselor supervision. Journal of Mental Health Counseling, 22(4), Stoltenberg, C., Mc Neil, B., & Delworth, U. (1998). IDM Supervision: An integrated developmental model for supervising counselors and therapists. San Francisco: Jossey-Bass Publishers.

21 References continued Hensley, L., Smith, S., & Waller-Thompson, R. (2003). Assessing competencies of counselors in training: Complexities in evaluating personal and professional development. Counselor Education and Supervision, 42, Pearson, Q. (2000). Opportunities and challenges in the supervisory relationship: Implications for counselor supervision. Journal of Mental Health Counseling, 22(4), Stoltenberg, C., Mc Neil, B., & Delworth, U. (1998). IDM Supervision: An integrated developmental model for supervising counselors and therapists. San Francisco: Jossey-Bass Publishers.

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