Clinical supervision in healthcare practice

Supervision

What is clinical supervision? The answer to that question would seem fairly obvious to a layperson; however, there are many differing professional and theoretical notions of just what clinical supervision is and how it should be implemented. In order to understand the complexities of the concept of "clinical supervision" and to come to some practical understandings regarding how clinical supervision should be used in counseling a discussion of its potential conceptualizations is important.

After reviewing the conceptualizations of the term "supervision" and applying them in a definitional context Milne (2007) came to the conclusion that clinical supervision is a relationship -- based educational training situation that is work -- focused and manages, supports, and evaluates the work of the supervisee(s). The supervisor relies on several main interventions that are comprised of corrective feedback, teaching, and corroborative goal setting. Supervision's objectives are: 1) normative (quality control), restorative (encourage emotional processing), and formative (facilitating the competence of the supervisee). It would be nice if the notion of clinical supervision for counseling students was that straightforward and easy to conceptualize; however, it is not quite that straightforward. Nonetheless, adding some ideas from some earlier conceptualizations of counseling supervision can help expand this definition.

Goodyear and Bernard (1998) described clinical supervision in counseling as an intervention provided by a senior member of the profession to a junior member (or junior members). This intervention is a relationship that extends over a period of time, is evaluative, enhances the professional functioning of the junior member or members, monitors the quality of the supervisee's professional services, and at the same time the supervisor serves as a sort of gatekeeper for new members entering a particular profession. Haynes, Cory, and Moulton (2003) stated that the primary goal of clinical supervision is to create an environment in which the supervisee is able to gain the needed experience and knowledge to become an independent practicing professional. An interesting observation by Haynes et al. is that clinical supervision is "artful" (p. 3) indicating that the specific expectations and rules of the supervisor are left open to interpretation depending on the context, the paradigm, etc. This is an interesting conceptualization because it leaves the interpretation of just what clinical supervision should be open to the supervisor and the particular context and supervisee(s) one is working with. However, in the same way that counseling and psychotherapy do subscribe to general principles we should expect the process of clinical supervision to also have general principles that can be successfully "tweaked" for specific contexts. With that in mind consider the notion of Powell and Brodsky (2004) who conceptualized clinical supervision as a disciplined tutorial process that takes general principles and transforms them into practical applications. According to this view there are four overlapping areas of focus in clinical supervision that consist of an administration aspect, and evaluative aspect, a clinical aspect, and a supportive aspect. Following up on this conceptualization there are several important distinctions to be made:

1. Clinical supervision emphasizes the improvement of counseling skills in the supervisee, whereas administrative supervision focuses on the performance and procedural aspects of the agency (e.g., complying with procedures and using correct documentation).

2. Clinical supervision develops the effectiveness of the supervisee through positive changes in the supervisee's skills, knowledge, and attitudes.

3. The supervisor/supervisee relationship is not a counseling or treatment relationship and the supervisor only intervenes to improve the supervisor's performance.

4. Given the above the supervisor takes on the role as a mentor and representative of the agency in which the relationship takes place.

5. Quality supervision is based on a relationship that emphasizes this type of authority, involves clear expectations for everyone, and is based on the notion of accountability.

Because clinical supervision is based on theoretical principles and not invariant factual criteria there are a number of different models of clinical supervision in existence. For instance, there are a number of psychotherapy -- based supervision models that conform to the specific psychotherapy paradigm of the supervisor such as psychodynamic supervision models, client centered supervision models, etc.; however, perhaps these models could be viewed as being limited by the restrictions of their own particular paradigm (Stoltenberg, 2008). Dow, Hart, and Nance, (2009) conceptualized the development of the style of the supervisor as an internal model that starts with the assumptions and theoretical orientations of the supervisor, moves on to the style and focus regarding counseling/psychotherapy that the supervisor uses or believes important, and then moves into specific supervisory techniques. Moreover, we could also surmise that different supervisees are in different stages of development and will need different approaches to their supervision depending on their stage of professional development. Given that notion, it is the opinion of this writer that the developmental models of counseling supervision offer a more complete guideline for clinical supervisors than the psychotherapy -- based supervision models offer.

Developmental models of supervision began to gain in popularity with Littrell, Lee-Borden, and Lorenz's (1979) description. These models focus on the change or development that supervisees undergo from their initial experiences and as they begin to get experience and to gain more confidence in their skills to advanced counseling students. Because this process occurs over a period of time, the developmental models of supervision assume that supervisees go through various stages of development in the same way that children mature or even clients in psychotherapy or counseling go through a developmental progression. According to Bernard and Goodyear (2009) the developmental models of supervision typically view the development of supervisees in one of three types of stages: 1) models that emphasize linear developmental stages, in much the same way as human physical growth develops in a linear fashion; 2) models that emphasize a conflict resolution approach to development in a rather stepwise manner, and; 3) lifespan developmental models. Integrated developmental models of supervision attempt to tie in these three developmental concepts into a more holistic model of clinical supervision (e.g., Stoltenberg, 1981; Haynes et al., 2003). The particular state of development that the supervisee is in helps to guide the supervisor regarding what types of skills/techniques should be focused on and the methodology and interaction style that the supervisor should use to assist the supervisee to develop. The integrated developmental models of supervision generally describe three levels of development in counseling students (these levels are often described as either levels, stages, or by similar designations; for purposes of simplicity this paper will simply describe them as Stage I, Stage II, and Stage III):

1. An initial stage of development (Stage I) where the supervisee is inexperienced and at the entry -- level position. Stoltenberg, McNeill, and Delworth (1998) describe the young supervisees as being high in anxiety, high in their motivation to perform, and yet at the same time very apprehensive about being evaluated. At this stage of development the supervisor will typically concentrate on such things as basic skills training, engaging in role -- playing exercises with the supervisee, trying to directly interpret the dynamics of the counseling relationship, and will focus on instructional readings that are general in nature to help the supervisee. At this point in the development of the supervisee the supervisor will also have to very closely monitor both the budding counselor and the clients that the counselor is working with.

2. In the mid- -- level of supervision (Stage II) supervisees may start to fluctuate in their levels of confidence and motivation and may attribute their own personal characteristics to the outcome of counseling sessions. In this phase supervisors continue to emphasize role-playing (but to a lesser extent than at Stage I) and concentrate on the dynamics and conflicts that occur as a result of the counseling sessions. Supervisees also begin to get a broader range of clients to work with in order to enhance their overall skill.

3. At Stage III the supervisees are much more stable and developed in terms of their motivation, empathy, and in the development of the therapeutic self and the everyday self. Here the supervisor helps them to continue to strive for this integration and to provide objective feedback/opinion as opposed to direct intervention.

As supervisees progress the supervisor is challenged to utilize approaches that are in line with the development of the supervisees. Since there are no standardized criteria to decide whether supervisee is in Stage I or Stage II it becomes the property of the supervisor to ascertain where the supervisee is and how to best help them progress. Certainly one would think that it is quite easy to ascertain the developmental level of beginning counselors; however, this may not always be the case. Even some beginning counselors will probably have higher levels of developmental maturity than others. The use of the wrong strategy on a particular level could result in complications for the development of the supervisee. Offering Stage I supervisees complete autonomy concerning how they handle their clients might lead to the intensification of the anxiety level in that particular supervisee or even worse could result in some potentially disastrous mishaps in the counseling sessions. Likewise, engaging in too much control over a Stage III supervisee could lead to quite a bit of tension in the supervisor/supervisee relationship and result in negative transference to clients in counseling sessions. Nonetheless, this notion that counseling supervisees develop in relatively predictable stages and that an effective supervisor can best help them progress by approaching them at the level of supervision that corresponds to their own development is very helpful in performing efficient and rewarding supervision for counseling trainees.

Empirical research has validated the approach of the integrated developmental models to some extent. In order to determine the supervisee's developmental McNeill, Stoltenberg, and Romans (1992) developed the Supervisee Levels Questionnaire -- Revised (SLQ -- R). Lovell (1999) found that the SLQ -- R results from trainees indicated that the level of education and prior supervised experience was related to the level of the supervisee opposed to such concepts as cognitive complexity. Thus, consistent with developmental theory the developmental level of supervisee sophistication was dependent on the amount formal training and supervision received. Anderson and Bang (2004) performed an extensive review of the literature regarding the training of substance abuse counselors and found that the Integrated Developmental Model of Supervision fit eight stringent criteria needed to effectively train substance abuse counselors. Paladino, Minton, and Kern (2011) found that Master -- level counseling students made greater gains when trained using the Integrated Developmental Model of Supervision compared to traditional models of training. Thus, an integrated developmental model of supervision appears to have a solid empirical basis for its use and can be adjusted to fit the needs of counseling supervisees/trainees.

Nonetheless, the model does have some potential weaknesses that have been identified. The first weakness is that the model focuses primarily on the development of counseling graduate students (Haynes et al., 2003). This makes the model difficult to apply to counseling students that need supervision in post graduate programs. For instance, a post doctoral level counselor getting training on a specific rotation could hardly be described as a Stage I entry-level counselor. Haynes et al. (2003) also report that the model presents limited methods of supervision that are applicable at over all supervisee levels, but especially at the more advanced levels such as Stage III.

This writer disagrees with these particular assumptions. The notion of an integrated developmental model assumes that there is a progression in a counseling student's development that can be used as a guideline to choosing appropriate supervision and supervisory techniques. The key here is the notion of a guideline to supervision and not the notion of conveyor belt or assembly line supervision techniques. For those budding counselors who are at Stage I and in the early parts of Stage II supervisees will need to offer more structure, more support, more direction, and more direct instruction. As trainees develop they will need less structure, less direction, more focus on theory and countertransference issues, and more feedback or suggestions as to what things to try. The supervisor can begin to allow the trainee to make suggestions and describe or predict the course of the counseling sessions once the supervisee has demonstrated growing levels of competence. Again, Haynes et al. (2003) described the supervision as a type of art form and this is where that particular aspect of supervision comes in. Supervisors are allowed some discretion in what appropriate measures they use with particular trainees. Moreover, there will be a number of differences that are based on cultural or interpersonal issues that affect the direct supervision of any particular counseling trainee. It is only a developmental model that seeks to integrate many different sources of theoretical models of supervision and counselor development that can allow for the flexibility needed to deal with these issues. These models can offer much more flexibility that can help guide the supervisor to help the counseling trainee develop to their maximum potential. Integrated developmental theories offer the potential for modification based on these issues and the modified theory initially developed by Skovholt and Ronnestad (1993) and then refined in 2003 is especially useful.

Using a longitudinal qualitative approach Skovholt and Ronnestad (1992) followed 100 therapists and counselors at different levels of experience from first-year graduate students to doctoral level counselors/therapists in order to improve on existing models of supervision. They were able to interview 60 of them in a pre and post intervention (counseling supervision) design. This led to an interesting integrated developmental model which began as an eight stage model but eventually ended up being composed of six developmental phases (Ronnestad & Skovholt, 2003). The use of the term phase in this model was believed to be more indicative of the gradual changes that counselors experience when compared to the more restrictive description "stage." Nonetheless the first three phases in this model are very similar to the three stages mentioned earlier (the Lay Helper; the Beginning Student; the Advanced Student). The last three phases address some of the criticisms of the Integrated Developmental Model discussed by Haynes et al. (2003). These phases include the Novice Professional, Experienced Professional, and Senior Professional phases.

The phases described by Ronnestad and Stovholt (2003) have excellent face validity in describing exactly where the trainee stands in their level of experience. Probably the greatest contribution of this particular theoretical orientation is that Ronnestad and Stovholt (2003) were able to identify 14 themes of development that occurs in counselors over these particular six phases. These 14 themes indicate that the development of a counselor (or therapist) is a very complex process that involves quite a bit of reflection on the part of the developing counselor. These themes can be very important in helping a supervisor to understand how counseling students develop and view themselves over the course of their development. For instance, one theme had to do with the development and integration of the counselor's professional and personal self. As counselors develop they also begin a process of integrating their own self-image into a more holistic viewpoint that resembles the Rogerian notion of self -- congruence.