Feedback During Clinical Supervision

Feedback during Clinical Supervision

Lecture Notes

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 superviseeand clinical supervisors should have an awareness of this personal and professional growth.

These are important assumptions that call clinical supervisors to become aware of a number of issues. They are:

That the personal issues of a counselor 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 happening 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 physical 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.

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.

The Integrated Developmental Model for Supervision (Stoltenberg, Mc Neill, & Delworth, 1998)

Level 1 / Level 2 / Level 3 / Level 3i (Integrated)
Motivation /

Skill acquisition is focus.
Very high motivation and high anxiety

.Motivation wavers.
Increased complexity results in shaken confidence

Stable motivation
Doubts are still present but not

disabling.

Professional identity becomes important.

Strives for stable motivation across all domains.

Autonomy /

Needs high structure with minimal challenge
Dependent on supervisor

Dependency-autonomy conflict.
Can be quite assertive and begins to follow his/her own agenda.
Functions more independently and may only want requested specific help. Other times can be evasive and dependent

Increased self-efficacy.
Is more clear about when to actively seek supervision and consultation.
Knows his or her limitations.
Retains responsibility.

Moves conceptually and behaviorally across all domains.
Solid coherent professional identity.

Awareness /

Limited self awareness
Very high self focus with high anxiety about grades and strengths.

Focus is now more on the client.
Greater understanding of client’s issues and worldview becomes evident.
May be enmeshed or confused and lose effectiveness
Balance is an issue

Accepts own strengths and weaknesses.
Has high empathy and understanding.
Focuses on client, processes and self.
Uses self as a therapeutic tool in sessions

Personal understanding across relevant domains.
Monitors impact of personal and professional life.
More accepting of own self.
Empathic with clients but also is able to pull back and look at own reactions to client issues and responses.

Level 1 / Level 2 / Level 3 / Level 3i (Integrated)
Other
Characteristics /

Limited to directly relevant experiences.
Limited knowledge regarding theories and techniques
Considerable confusion and anxiety

Resolution of Level 1 issues.
Develops more empathy regarding the client because of less anxiety about own performance.

Resolution of Level 2 issues.
Feels secure in own personal identity and in professional identity.
Strives for and establishes a balance between personal and professional lives

/ Same only more developed as Level 3
Focus /

The high focus on techniques and skill development leaves little capacity for seeing issues from the client’s perspective or of being in touch with one’s own issues or affective processes.

Begins to see and focus on the issues of transference and counter-transference and may get confused and overwhelmed.
Might need a referral for personal counseling at this point if not already engaged in such.

Focuses on his or her personal approach.
Notion of an independent practice is a realization.

The qualities of a Master Therapist may become evident.
Other professionals begin requesting consultation and supervision time.

Feedback /

More collegial supervision at this point..

More collegial supervision as needed at this point.
Clinical Supervision of supervision is most appropriate as well.

Transition to Level 2:

Motivation may decrease for new approaches/techniques and the counselor may desire more autonomy then is warranted. The counselor also begins to move toward increased awareness of the client and away from self awareness related to performance anxiety.

Transition to Level 3:

The counselor shows an increased desire to personalize his or her orientation and is more conditionally autonomous. He or she better understands limitations and the focus begins to include self-reactions to the client.

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 feelings or issues that the counselor currently has 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 supervisor of the counselor is important and the counselor should receive for review a blank summative evaluation form.

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 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.

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 facilitate the counselor’s awareness of his or her self and personal issues that appear to be triggered by clients’ 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.

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 they possess the ability to use the consultation/supervision process 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 or challenging 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.

IV. Understanding the difference between formative and summative feedback (evaluation) and making 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 / Summative Feedback or Evaluation
The process of facilitating skill acquisition and professional growth through direct feedback / The formal evaluation or the moment of truth when the supervisor steps back and takes stock and decides how the counselor measures up.
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. / 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.

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 decide the criteria they will use for summative evaluations but they also 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 asummative 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 and looking over Frame and Stevens-Smith’s work as well as others’ research, the PSU committee devised a peer feedback form that is supposed to be instated within the next year. Please see a copy of it in your packet. Usually our peers rather then our supervisors tend to know more about out interpersonal relationship skills. Thus I recommend that you consider making peer feedback a regular part of your overall yearly evaluation process. At Counseling Alternatives Group 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 counselor but we facilitate the retreat ourselves in the spring. This year unfortunately we got off track. Every time we attempted to set a retreat up, one of the five partners had a parent who either died or became terminally ill. Thus we got a little discombobulated. Hopefully we will get back on track this fall but we all acknowledge that we emotionally and psychologically 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.

V. Making the provision of feedback a more positive experience for the counselor

Trainee

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.
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.
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.
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.
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.
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.
Avoid premature evaluations.
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.

“Whenever a trainee is denied appropriate supervision and evaluation, the professional community is diminished.” (Bernard and Goodyear, 1998)