Clinical Supervision djpowell2@yahoo David J. Powell, Ph.D.

1. Clinical Supervisiondjpowell2@yahoo.comDavid J. Powell, Ph.D. Section 2

2. Principles It’s about the relationship!!! Stage of Readiness for Change Direct Observation Offer Hope Know your model of counseling Section 2 Section 2 2

3. 1. An essential part of our program. 2. Supervision enhances morale & staff retention. 3. Every clinician needs/has a right to supervision. Supervisors need supervision. 4. Get management support

4. 6. A skill by itself! 7. Supervisors are usually both administrative & clinical supervisors.

5. Evidence-based practices require ongoing supervision. • Supervisors are gatekeepers. • You need to observe counselors in action. Section 2

6. Top EBP Motivational Interviewing Matrix Model CBT 12 Step Facilitation Psychopharmacology Solution-Focused Therapy Contingency Management Section 2 6

7. Goal was to ensurecompetency.DOES IT WORK? Section 2

8. Session Rating Scale Relationship I wasn’t heard, I was heard understood & ---------------------------- understood & respected respected Goals & Topics We didn’t talk We talked about about what I ---------------------------- what I wanted wanted to to talk about talk about Section 2

9. Approach or Method The approach The approach is a isn’t a good fit ----------------------- good fit Overall: Something’s The session was missing in the ------------------------ right today session today Section 2

10. Models Competency: Discrimination Treatment-based: MI, CBT Developmental: Stoltenberg Discipline-specific: MSW, MFT Integrated: Blended

11. “A disciplinedtutorialprocess ….. on 4 dimensions: Administrative, Evaluative, Supportive, & Clinical.” Super-vision Section 2

12. Blended Model Insight Skill Contextual Factors Stage of Development Contextual Factors DescriptiveDimensions PHILOSOPHY SELF

13. Cognitive (Mental) Behavioral (Skills) Spiritual (Inward) How to counsel Why to counsel Affective (Emotional) Latent (Unconscious)

14. Coach Teacher Mentor The Relationship Consultant Visionary

15. Rationale for Supervision • What a way to learn! • It improves morale & care • We must supervise ethically & legally Section 2

16. University of Georgia, 2009 • Counselors & supervisors only moderately satisfied with supervisory relationships. • Both report negative experiences in supervision. • Supervisors think they are doing a better job than supervisees do. • Both are dissatisfied with pay & promote-ability. • Both intend to quit.

17. 6. Neither optimistic about finding other work. 7. As supervision improves, so does job satisfaction.

18. CASE MANAGEMENT & CLINICAL SUPERVISION Clinical Supervision Focus on therapist Skill Development 1 Case Presentation Case Management Focus on patient Continuum of Care Multiple Reviews Section 2 Section 2 18

19. Isomorphism • What exists in one environment is mirrored in another. Section 2

20. Selling Supervision to Supervisors Selling supervision Administrative: QA, risk management, HR issues, marketing Clinical: improves care, skill development, cultural competency

21. Professional: career ladder, credentialsWorkforce development: recruitment, retention, staff moraleEvaluation: data gathering

22. Self-Assessment 3 pressing issues for your agency? 3 things for you to improve on as a supervisor?

23. Organizational Readiness Context: culture/philosophy Clinical skills Motivation, morale Relationships: trust, staff health Environmental: context, patients

24. Your program is required by the state to implement an EBP, Motivational Interviewing. You’ve had 5 days MI training & are the supervisor. You’re presenting the EBP to staff who will be trained in MI soon. David, a licensed addictions counselor with 20 yrs. experience, feels his counseling approach (12-Step Facilitation & psychoeducation) works fine. He’s respected for his relationships with clients. He’s skeptical about “academically-based research” that offers “new-fangled approaches.” Jane is a CAC with 3 yrs. experience, with good training, but lacks experience. Her concern about MI is that she has to learn something new before “she integrates the old stuff.” She’s been influenced by David who she sees as having much wisdom.

25. Legal & Ethical Issues:Macro ethicsMicro ethics Section 2

26. Bibliography • Janet Falvey, Managing Clinical Supervision • Beauchamp & Childress, Fundamentals of Medical Ethics • Gutheil & Brodsky, Preventing Boundary Violations in Clinical Practice Section 2

27. Ray, a recovering counselor, has a 2 day relapse after his wife’s death. He goes to AA, sees his sponsor & a counselor. Your agency policy requires 2 yrs of continuous sobriety. No one knows of his relapse. He fears he will lose his job. He seeks your advice as a friend.

28. A critical care physician sees an unconscious Jehovah’s Witness, admitted with multiple organ dysfunction. A blood transfusion was indicated. His family refused for religious reasons. One night the on-call resident, unaware of the patient’s faith, ordered a transfusion. The next day staff saw the blood hanging & stopped the transfusion with no clinical consequences. Disclosure will cause the family significant distress. Must we tell them?

29. Assumptions Standards not a cookbook. Each situation is unique We make mistakes. Answers may be elusive. Section 2

30. The Puzzle • Legal: Minimal level of acceptable practice • Ethical: Highest ethical standards • Moral: Personal Values

31. Boundary = appropriate behavior • Boundary crossing = benign deviations from standards, harmless, non-exploitative, may advance therapy goals • Boundary violation = significant deviations from standards, harmful, exploitative Section 2

32. Principle: Boundary issues are 1st clinical issues Ethical issues – 2nd Legal issues – 3rd

33. Responsibility always belongs to counselor. • Patients shouldn’t be blamed for boundary violation. Section 2

34. You’re late for a flight to a family vacation. You receive an emergency call from a local hospital. Your clients tried to commit suicide & needs to be hospitalized. He’s desperate to talk with you in person immediately, refusing to talk on the phone, about a secret he just discovered. You have no idea what the “secret” is. Section 2

35. It’s been a hard week. You go to the movies with your partner. The theatre is packed. As the theatre lights dim you lean over & give your partner a passionate kiss, & while doing so, notice in the seat next to your partner is a active client of yours who you saw today when the client revealed intense sexual attraction to you. Section 2

36. You’re having hard financial times & may have to declare bankruptcy. You’re trying to sell your house for 12 months, but no buyers. The only person to come to an open house is a client who says, “I’d love to buy it.”

37. Congratulations! You’re being sued Top reasons for suits • Sexual impropriety (20%) • Incorrect treatment (14%) • Breach of confidentiality (7%) • Incorrect diagnosis (7%) Section 2

38. Claims to Ethics Boards Sexual/dual relationship– 35% Unprofessional, negligence-- 29% Conviction of crimes—9% Impairment—4% Improper record keeping—3% Fraud with credentials—2%

39. Key Cases Peck vs. Addison County Jaffee vs, Redmond Section 2

40. Hug a client Give client a gift Practice when tired, distressed Give indigent client bus fare home Give client a peck on cheek Go to the funeral of client’s mother Be sexual attracted to client Section 2

41. Respondeat Superior • Dual Relationships • Confidentiality Section 2

42. Respondeat Superior Section 2

43. VICARIOUS LIABILITY “The supervisor may be held liable for damages of a supervisee solely because you’re a supervisor.” Section 2

44. The Key Question Did you make a REASONABLE EFFORT TO SUPERVISE? Section 2

45. Dual Qualities vs. Dual Relationships • Abuse of power & choice • Intentional personal gain • Harm done Section 2

46. Dual Relationships Is this relationship necessary? Cui bono? Will it hurt the client? How will it affect therapeutic alliance? Is it documented? Have we discussed risks with the client?

47. A former client, 35 yrs old, saw a 40 yr old counselor at a class reunion. They were both from Vermont & discovered they were at the same campgrounds as teens. They laughed a lot about this & went to dinner together. After dating for a year they married. The wedding was attended by former clients & therapists. Section 2

48. A married couple seeks counseling, both partners believe that men are the natural, God-ordained leaders in a marriage & a woman’s place is to be obedient to her husband. But, they have “slips” when he looks to her for guidance or when she finds it hard to accept his decisions. They’re seeking help to eliminate these “slips” as they think it runs against God’s wishes & as taught in the Bible. Section 2

49. You’re a counselor where the policy is if a client misses 2 appts. without calling, counseling automatically terminates. A single mother client uses public transportation, has no phone, can’t find baby sitters, doesn’t show for her appointment for a 2nd time. Your supervisor insists you terminate counseling, sending client a letter so stating, given the waiting list of potential clients seeking help.

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