Clinical Supervision: An essential ingredient to enhancing treatment outcome with forensic populations

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

2. http://www.youtube.com/watch?v=9ZaLipDgFZQ

3. So you want to be a clinical therapist?

4. Introduction Overview • Goals of supervision • Styles of effective (and ineffective) supervision • Enhancing positive therapeutic outcomes • Obstacles to supervision • Transference and counter-transference issues • Managing the “impact” of working with difficult populations • Monitoring Supervision

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

6. What is clinical supervision? “Supervision is an intervention that is provided by a senior member of a profession to a junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the junior member(s), monitoring the quality of professional services offered to the clients she, he, or they see(s), and serving as a gatekeeper of those who are to enter the particular profession.” Bernard and Goodyear (1998)

7. Who supervises forensic therapists? • A licensed professional with experience providing direct services in the field of forensic psychology • A licensed professional with experience providing direct services to the population with which the intern works -Board of Psychology (on supervision)

8. APA Laws, Regulations, and Standards 1.04 Boundaries of Competence b) Psychologists provide services, teach, or conduct research in new areas or involving new techniques only after first undertaking appropriate study, training, supervision, and/or consultation from persons who are competent in those areas or techniques. Maintaining Expertise Psychologists who engage in assessment, therapy, teaching, research, organizational consulting, or other professional activities maintain a reasonable level of awareness of current scientific and professional information in their fields of activity, and undertake ongoing efforts to maintain competence in the skills they use. APA GUIDELINES

9. Sexual Offender Therapist Qualifications • Has received specialized training regarding sexually abusive individuals. • Currently licensed in a mental health profession/medical field. • Unlicensed clinicians such as interns and pre-licensed practitioners must be supervised by a qualified, licensed clinician. • CCOSO Adult Guidelines and Best Practices

10. Experience A qualified therapist: • 2000 hours of face-to-face clinical experience in the assessment and/or treatment of sexual offenders. • Therapists with less than the above-delineated education and experience should not have primary responsibility for an offender in therapy but may provide psychotherapy and other services to sexual offenders under supervision of a therapist who has such education and experience. • CCOSO Treatment Guidelines

11. Training Sexual offender therapists should obtain 30 hours of bi-annual sexual offender continuing education that is specific to their work with sexual offenders. • CCOSO Treatment Guidelines

12. California Sex Offender Management Board (CASOMB) “Registered interns or psychological assistants may provide sex offender specific evaluation or treatment services when functioning under the supervision of a licensed practitioner who meets the established criteria. Such interns or psychological assistants may apply to the regulatory body for approval and listing.” -CASOMB Recommendations Report January 2010

13. CASOMB continued “A one-year provisional approval status level should be offered to those licensed therapists who are pursuing sufficient education, training, and experience and provide a sufficient plan to correct any deficiencies. A provider with provisional approval should not be permitted to supervise interns or psychological assistants in the area of sex offender treatment until becoming qualified as an approved provider. No licensed clinical supervisor should supervise more than four unlicensed interns or licensed therapists with only provisional approval.” -CASOMB Recommendations Report January 2010

14. CASOMB continued 2 “Interns or psychological assistants should co-facilitate one hundred hours of direct services with an approved licensee before being eligible for approved provider status. Treatment providers who do not meet the hours of service requirement may apply to be listed as approved providers if there are reasonable limitations on experience hours such as working in rural counties with fewer referrals.” -CASOMB Recommendations Report January 2010

15. § 2913 (d) Board of Psychology Laws and Regs. No licensed psychologist may register, employ, or supervise more than three psychological assistants at any given time unless specifically authorized to do so by the board. No board certified psychiatrist may register, employ, or supervise more than one psychological assistant at any given time. No contract clinic, psychological corporation, or medical corporation may employ more than 10 assistants at any one time. No contract clinic may register, employ, or provide supervision for more than one psychological assistant for each designated full-time staff psychiatrist who is qualified and supervises the psychological assistants. No psychological assistant may provide psychological services to the public for a fee, monetary or otherwise, except as an employee of a licensed psychologist, licensed physician, contract clinic, psychological corporation, or medical corporation.

16. §4980.45. EMPLOYMENT OR SUPERVISION OF REGISTRANTS; MAXIMUM NUMBER OF REGISTRANTS • A licensed professional in private practice who has satisfied the requirements of subdivision (g) of Section 4980.03 may supervise or employ, at any one time, no more than a total of two individuals registered as either a marriage and family therapist intern or associate clinical social worker in that private practice. • An individual supervised after being granted a qualifying degree shall receive at least one additional hour of direct supervisor contact for every week in which more than 10 hours of client contact is gained in each setting. No more than five hours of supervision, whether individual or group, shall be credited during any single week. • Direct supervisor contact provided in a group shall be provided in a group of not more than eight (8) supervisees and in segments lasting no less than one continuous hour.

17. Forensic Psychotherapy as a Specialty Sex Offender Management “Best Practices” Collaboration, specialization, education, judicial leadership, and buy-in … all for victim and community safety

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

19. Types of Sexual Offender Populations? • High –Moderate – Low Risk Sexual Offenders • Inpatient • Outpatient • Group/Individual Therapy • Pretrial • Presentencing • Treatment/Assessment • Mandated/Voluntary • Children, Juvenile, Adult, Male, Female, DD etc

20. Supervision is NOT Counseling Counseling: Purpose- personal growth, understanding, decision-making Goal- determined by client need Timeframe-self-paced Agenda- based on client needs Process- anaffective process which includes, listening, exploring, teaching, supporting

21. Types of Forensic Psychology Supervision • Clinical • Administrative

22. Clinical Supervision Purpose- improves clinical skills, professional performance and knowledge Goal – increases knowledge and skills Timeframe- issupervisee and task defined Agenda- is based on task and skills needed Process- includesassessing performance, teaching specific skills (e.g., testing, theoretical orientation)

23. Administrative Supervision Purpose – assure compliance with agency and professional procedures and policies Goal- consistent use of approved formats (e.g., documentation, etc) Timeframe- ongoing Agenda – based on agency policy and professional guidelines Process – clarify expectations, policy, procedures, and monitoring compliance

24. APA Ethics Code 7.02 Descriptions of Education and Training Programs Psychologists responsible for education and training programs take reasonable steps to ensure that there is a current and accurate description of the program content (including participation in required course- or program-related counseling, psychotherapy, experiential groups, consulting projects, or community service), training goals and objectives, stipends and benefits, and requirements that must be met for satisfactory completion of the program. This information must be made readily available to all interested parties.

25. Program/Supervisor Goals (competencies expected from the program) (SFFI example) 1.To provide an environment that facilitates knowledge of forensic psychology 2. To provide an environment that promotes collegiality 3.To re-enforce empirically supported interventions 4. To provide the education and support for supervisees to gain practical understanding of risk assessment and integrate that understanding into therapeutic interventions (These should be in writing and provided to the intern)

26. Goals of Supervision(competencies expected of the supervisor) 1. The ability to identify a supervisee’s strengths and growing edges professionally and personally. 2. The ability to formulate interventions that integrate the supervisee’s abilities and strengths with empirically guided interventions. (e.g., assist the supervisee in developing a personal paradigm for working with forensic populations that is also grounded in current/best practice). 3. The ability to form an appropriate and effective helping relationship. 4. The ability to identify and address ethical issues as they arise. 5. The ability and intent to instill amenability to growth. (e.g., Give and receive constructive feedback without getting defensive.) 6. Impart wisdom: The ability to pass on lessons learned through experience.

27. Supervisee Goals(competencies expected of the supervisee) These are goals developed collaboratively between supervisee and supervisor. Ideal goals are: Specific - the goal is clearly understood by both the supervisor and the trainee Realistic - the goal is within the abilities of the trainee and the trainee believes that he/she can attain the goal Challenging - the goal engages the trainee in a way that motivates effort Measurable/Observable– the goal is concrete enough that both the supervision and the trainee can monitor progress and achieve a sense of accomplishment upon attainment

28. Establishing Goals • Goal Relevance • refers to goals that are pertinent to a particular supervisee’s needs. • Goal Importance • works toward identifying goals that are personally significant to the supervisee. • Goal Attainability • refers to goals that the supervisee believes could be achieved. • Emotional Salience • refers to setting goals in which the natural rewards are obvious to the supervisee. -Cullari ,1996

29. Formalizing the Goals for Supervision “Goals of supervised experience should be written and signed by both the supervisor and the trainee” • Best practices and accepted standards that have been developed by the American Psychological Association, the Association of Psychology Postdoctoral and Internship Centers (APPIC), and the California Psychology Internship Council (CAPIC).

30. Intern goal and evaluation form –hand out

31. Goals for Supervision Examples

32. Goal Objectives

33. RECAPThree Goals of SupervisionPerformance, Knowledge, Safety • To provide a safe, supportive, reliable, enriching environment within which the supervisee will develop practical knowledge of the specialty of forensic psychotherapy and integrate that understanding into applying interventions that are supported empirically and effectively prevent reoffense Easy, right?!

34. Exercise

35. Enhancing Positive Therapeutic Outcomes The Supervisor as Guardian of Public Safety Supervision within the sub-niche of psychotherapy involving treatment of offenders is unique in several ways. Foremost, the over-arching goal of the supervisor supervisee relationship is to prevent client sexual re-offense. Good supervisors attempt to balance liability for community safety with the growth of the clinician.

36. Does Sex Offender Treatment Work? Hanson et. al, 2009. the Principles of Effective Correctional Treatment Also Apply to Sexual Offenders: A Meta-Analysis. Criminal Justice and Behavior, 36, 865-891.

37. Yes! Sex Offender Treatment Does Work…But it has room to improve 1. A meta-analysis examining 129 studies of treatment of sex offenders ultimately included only 22 studies that met basic study quality criteria. Quality was defined per the Collaborative Outcome Data Committee guidelines. 2. Results 22 studies. N=3,121 treated sex offenders. N=3,625 non-treated sex offenders 10.9% sexual recidivism for treated group v. 19.2% for no-treatment = 43% reduction in sexual recidivism. 3. Conclusion Risk Need Responsivity principles should be a primary consideration in the design and implementation of treatment programs for sexual offenders.

38. The Guiding Principles of Effective Interventions: Risk, Need, Responsivity(Bonta & Andrews, 2007; Hanson et. al, 2009)

39. Effective Treatment Targets Criminogenic Needs

40. The Purpose of Treatment Need & Responsivity • The objective of treatment is to help the client ameliorate ‘Needs’. • This requires creating an environment that facilitates treatment engagement so that the offender will maximally Respond to treatment. • ‘Responsivity’ refers to the environment for change. • The therapeutic landscape must be safe, supportive, continual, reliable. • The supervisory landscape must be safe, supportive, continual, reliable.

42. The ‘Real’ Purpose of Treatment • Change the Structure & Function of the Brain • ‘Good therapy’: a meaningful experience in a safe context that alters the neuronal processing template, directly shaping the circuits responsible for memory, emotion and self-awareness.

43. The Neurobiology of Change • Patterns of energy and information flow within the brain…and between brains. • Experience shapes the genetically programmed maturation of the nervous system. • All new input is filtered through this neuronal processing template. Changes are use-dependent, occurring only in novel or extreme situations. • Attributing meaning to experience (emotion) causes new patterns of connections among nerve cells in the brain, at a sub-cortical level. This is how memory “works”. • Memory is the way past events effect future responses. • Concepts evoke change only when meaning is ascribed to experience. • Good therapists attend to the neurobiology of interpersonal experience: Human connections shape neural connections. • If it evokes meaning, ‘information’ from this workshop…from your supervision sessions…from your supervisee’s therapy sessions will be encoded, stored & retrieved by the brain in implicit and explicit memory systems.

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

45. RECAP Enhancing Positive Outcomes • Effective sexual offender therapy, and effective sexual offender therapist supervision, can and does happen • It is guided by the goal of preventing victim harm • It includes thorough assessment and targets specified and empirically based needs • Conducted in a relational landscape that maximizes brain based change • Involves making new implicit and explicit memory patterns through experience and emotion

46. The Therapeutic ProcessEssential to Outcome • The “How” is as Important as the “What” of Treatment • SOT Programs that highlight the therapeutic relationship are successful at enhancing positive behavior change and reducing recidivism (Marshall et al, 2003; 2010) • A convenient overshadowing: Strongly manualized programs and purely didactic (psychoeducational) are inadequate at evoking the kind of change needed by offender clients • Experiential methods are essential for brain integration • Effective therapy, and effective supervision, employs positive approaches that motivate change and identify strengths, using them to build skills while still targeting relevant needs • Approach goals facilitate treatment engagement, disclosure, and prosocial identification

47. Supervisors are mindful of what works, and doesn’t work, in therapy with sexual offenders • Authoritarian and aggressive techniques do not work with abusive individuals (i.e. confrontation, shock, anger, revenge on behalf of victims, demand for change). They elicit resistance, argumentativeness, manipulative placation, eroded self-esteem, drop-out. • Effective process facilitates emotion processing and regulation. It helps clients regulate the affective precursors to offending. Interpersonal schemas are changes through emotional expression. • Many sexual offender clients are particularly responsive to therapy process variables because they were betrayed by someone in a position of trust and they are poised toward suspiciousness.

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

49. Follow the Responsivity Principle Offender Recovery Begins with Empathy for the Offender “To sense the client’s private world as if it were your own, but without ever losing the "as if” quality—this is empathy, and this seems essential to therapy. To sense the client’s anger, fear, or confusion as if it were your own, yet without your own anger, fear, or confusion getting bound up in it, (is empathy). When the client’s world is this clear to the therapist, and he moves about in it freely, then he can both communicate his understanding of what is clearly known to the client and can also voice meanings in the client’s experience of which the client is scarcely aware.” (Carl Rogers, 1957, p.99)

50. Obstacles to Effective Supervision Strains in supervision can be brought about by the challenges inherent in clinical practice, conflicts in the goals and/or tasks, inadequate attention to the values modeled by the supervisor and/or the essential therapist characteristics, inadequacies in technical competence, boundary crossings, problematic supervisee behavior, and negative transference, countertransference, and parallel process phenomena.