CLINICAL SUPERVISION AND PROFESSIONAL DEVELOPMENT OF THE SUBSTANCE ABUSE COUNSELOR PDF

CLINICAL SUPERVISION AND PROFESSIONAL DEVELOPMENT OF THE SUBSTANCE ABUSE COUNSELOR About this learning material: This learning material is based on SAMHSA TIP 52 published in 2014. In 2019, Amanda Gilmore, PhD modified the original TIP for Ce4Less learners to include current information on the topics detailed in Clinical Supervision and Professional Development of the Substance Abuse Counselor. These modifications include some text changes and updated citations. Dr. Gilmore received her PhD in Clinical Psychology from the University of Washington, completed her clinical internship at the VA Puget Sound Health Care System, and received postdoctoral training in posttraumatic stress research at the Medical University of South Carolina (MUSC). She joined the faculty at MUSC in 2016 and currently holds a joint appointment in the College of Nursing and the Department of Psychiatry & Behavioral Sciences. Her research interests primarily focus on the development and testing of (1) integrated prevention programs for alcohol and drug use, sexual assault, and sexual risk behaviors among high-risk groups including adolescents, college students, and service members, (2) innovative technology-based interventions to improve the rate of treatment access and decrease treatment drop-out among underserved populations; and (3) secondary prevention programs for individuals who experienced recent sexual assault. She is also interested in the acute effects of alcohol on sexual decision making. Dr. Gilmore has served as a Principal Investigator or Co-Investigator on grants from NIDA, NIAAA, the Office for Victims of Crime and the Department of Homeland Security as well as several internal grant mechanisms. She is also a licensed clinical psychologist with particular expertise in the treatment of substance use disorders, posttraumatic stress disorder, and suicidal behaviors and she founded and led clinics that have provided treatment to recent sexual assault victims, victims of crime with posttraumatic stress and suicidal behaviors, and integrated behavioral health care within an OB/GYN clinic. What is a TIP? Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and 1 knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://store.samhsa.gov. Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. If research supports a particular approach, citations are provided. Learning Objectives Upon completion of this course the learner will be able to: Discuss the various models of supervision. Describe different counselor characteristics. Explain the continuum of cultural competence. Describe the purpose of an IDP. Recognize how supervisors balance clinical and administrative functions. Discuss the different methods of clinical supervision. 2 TABLE OF CONTENTS Part 1 - Chapter 1........................................................................................................................................ 6 Introduction..........................................................................................................................................................6 Definitions........................................................................................................................................................................................ 6 Rationale.......................................................................................................................................................................................... 7 Functions of a Clinical Supervisor..................................................................................................................................................... 8 Central Principles of Clinical Supervision.................................................................................................................9 Guidelines for New Supervisors............................................................................................................................ 12 Problems and Resources................................................................................................................................................................ 13 Working with Staff Who are Resistant to Supervision................................................................................................................... 14 Things a New Supervisor Should Know.......................................................................................................................................... 15 Models of Clinical Supervision.............................................................................................................................. 16 Clinical Supervision for Motivational Interviewing................................................................................................ 17 Developmental Stages of Counselors.................................................................................................................... 20 Developmental Stages of Supervisors................................................................................................................... 21 Cultural and Contextual Factors............................................................................................................................ 23 Ethical and Legal Issues........................................................................................................................................ 26 Direct Versus Vicarious Liability..................................................................................................................................................... 27 Dual Relationships and Boundary Issues........................................................................................................................................ 28 Informed Consent........................................................................................................................................................................... 29 Confidentiality................................................................................................................................................................................ 30 Supervisor Ethics............................................................................................................................................................................ 33 Monitoring Performance...................................................................................................................................... 33 Behavioral Contracting in Supervision........................................................................................................................................... 33 Individual Development Plan......................................................................................................................................................... 34 Evaluation of Counselors................................................................................................................................................................ 34 Addressing Burnout and Compassion Fatigue................................................................................................................................ 36 Gatekeeping Functions................................................................................................................................................................... 38 Methods of Observation...................................................................................................................................... 39 Recorded Observation.................................................................................................................................................................... 42 Live Observation............................................................................................................................................................................. 43 Practical Issues in Clinical Supervision................................................................................................................... 46 Distinguishing Between Supervision and Therapy......................................................................................................................... 46 Balancing Clinical and Administrative Functions............................................................................................................................ 49 Finding the Time to do Clinical Supervision................................................................................................................................... 50 Documenting Clinical Supervision.................................................................................................................................................. 53 Structuring the Initial Supervision Sessions................................................................................................................................... 55 Methods and Techniques of Clinical Supervision................................................................................................... 57 Administrative Supervision.................................................................................................................................. 58 Documentation for Administrative Purposes................................................................................................................................. 59 Time Management......................................................................................................................................................................... 60 3 Technology in Clinical Supervision........................................................................................................................ 61 Potential Benefits of Technology-Assisted Supervision................................................................................................................. 62 Resources............................................................................................................................................................ 64 Part 1 - Chapter 2...................................................................................................................................... 66 Introduction........................................................................................................................................................ 66 Vignette 1—Establishing a New Approach for Clinical Supervision......................................................................... 67 Overview........................................................................................................................................................................................ 67 Background..................................................................................................................................................................................... 67 Learning Goals................................................................................................................................................................................ 68 Vignette 2—Defining and Building the Supervisory Alliance.................................................................................. 81 Overview........................................................................................................................................................................................ 81 Background..................................................................................................................................................................................... 81 Learning Goals................................................................................................................................................................................ 82 Vignette 3—Addressing Ethical Standards............................................................................................................. 93 Overview........................................................................................................................................................................................ 93 Background..................................................................................................................................................................................... 93 Learning Goals................................................................................................................................................................................ 93 Vignette 4—Implementing an Evidence-Based Practice....................................................................................... 104 Overview...................................................................................................................................................................................... 104 Background................................................................................................................................................................................... 105 Learning Goals.............................................................................................................................................................................. 105 Vignette 5—Maintaining Focus on Job Performance........................................................................................... 115 Overview...................................................................................................................................................................................... 115 Background................................................................................................................................................................................... 116 Learning Goals.............................................................................................................................................................................. 117 Vignette 6 — Promoting a Counselor from Within............................................................................................... 123 Overview...................................................................................................................................................................................... 123 Background................................................................................................................................................................................... 123 Learning goals............................................................................................................................................................................... 124 Vignette 7—Mentoring a Successor.................................................................................................................... 129 Overview...................................................................................................................................................................................... 129 Background................................................................................................................................................................................... 129 Learning Goals.............................................................................................................................................................................. 130 Vignette 8—Making the Case for Clinical Supervision to Administrators.............................................................. 137 Overview...................................................................................................................................................................................... 137 Background................................................................................................................................................................................... 137 Learning Goals.............................................................................................................................................................................. 138 Part 2 - Chapter 1.....................................................................................................................................147 A Guide for Administrators................................................................................................................................. 147 Benefits and Rationale....................................................................................................................................... 147 Administrative Benefits................................................................................................................................................................ 148 Clinical Services Benefits.............................................................................................................................................................. 148 Professional Development Benefits............................................................................................................................................. 149 Workforce Development Benefits................................................................................................................................................ 149 4 Program Evaluation and Research Benefits......................................................................................................... 149 Key Issues for Administrators in Clinical Supervision........................................................................................... 149 Administrative and Clinical Tasks of Supervisors......................................................................................................................... 150 Assessing Organizational Structure and Readiness for Clinical Supervision................................................................................ 150 Administrative and Clinical Supervision.............................................................................................................. 152 Legal and Ethical Issues for Administrators......................................................................................................... 153 Diversity and Cultural Competence..................................................................................................................... 155 Developing a Model for Clinical Supervision....................................................................................................... 156 Implementing a Clinical Supervision Program..................................................................................................... 157 Phasing in a Clinical Supervision System...................................................................................................................................... 161 Documentation and Record Keeping........................................................................................................................................... 164 Evaluation..................................................................................................................................................................................... 166 Supporting Clinical Supervisors in Their Jobs............................................................................................................................... 168 Professional Development of Supervisors........................................................................................................... 171 Part 2 - Chapter 2.....................................................................................................................................172 Introduction...................................................................................................................................................... 172 Assessing Organizational Readiness.................................................................................................................... 173 Legal and Ethical Issues of Supervision................................................................................................................ 178 Selection and Competencies of Supervisors................................................................................................................................ 179 Substance Abuse Policy................................................................................................................................................................ 182 Supervision Guidelines....................................................................................................................................... 185 The Supervision Contract................................................................................................................................... 187 The Initial Supervision Sessions.......................................................................................................................... 189 Documentation and Recordkeeping............................................................................................................................................. 189 Evaluation of Counselors and Supervisors........................................................................................................... 196 Individual Development Plan.............................................................................................................................. 200 Audio and Videotaping....................................................................................................................................... 203 Bibliography.............................................................................................................................................206 5 PART 1 Chapter 1 Introduction Clinical supervision is emerging as the crucible in which counselors acquire knowledge and skills for the substance abuse treatment profession, providing a bridge between the classroom and the clinic. Supervision is necessary in the substance abuse treatment field to improve client care, ensure evidence-based practice delivery, develop the professionalism of clinical personnel, and impart and maintain ethical standards in the field. In recent years, especially in the substance abuse field, clinical supervision has become the cornerstone of quality improvement and assurance. Your role and skill set as a clinical supervisor are distinct from those of counselor and administrator. Quality clinical supervision is founded on a positive supervisor–supervisee relationship that promotes client welfare and the professional development of the supervisee. You are a teacher, coach, consultant, mentor, evaluator, and administrator; you provide support, encouragement, and education to staff while addressing an array of psychological, interpersonal, physical, and spiritual issues of clients. Ultimately, effective clinical supervision ensures that clients are competently served. Supervision ensures that counselors continue to increase their skills, which in turn increases treatment effectiveness, client retention, and staff satisfaction. The clinical supervisor also serves as liaison between administrative and clinical staff. This TIP focuses primarily on the teaching, coaching, consulting, and mentoring functions of clinical supervisors. Supervision, like substance abuse counseling, is a profession in its own right, with its own theories, practices, and standards. The profession requires knowledgeable, competent, and skillful individuals who are appropriately credentialed both as counselors and supervisors. Definitions This document builds on and makes frequent reference to CSAT’s Technical Assistance Publication (TAP), Competencies for Substance Abuse Treatment Clinical Supervisors (TAP 21-A; CSAT, 2007). The clinical supervision competencies identify those responsibilities and activities that define the work of the clinical supervisor. This TIP provides guidelines and 6 tools for the effective delivery of clinical supervision in substance abuse treatment settings. TAP 21-A is a companion volume to TAP 21, Addiction Counseling Competencies (CSAT, 2006), which is another useful tool in supervision. The perspective of this TIP is informed by the following definitions of supervision: Broadly speaking, supervision is integral clinical practice, wherein the main goal is for a more senior clinician to improve the knowledge and skills of a novice clinical through supervisory feedback (Davidson, 2017). “Supervision is a disciplined, tutorial process wherein principles are transformed into practical skills, with four overlapping foci: administrative, evaluative, clinical, and supportive” (Powell & Brodsky, 2004, p. 11). Furthermore, supervision is critical to the training of new therapists, wherein an experienced therapist (i.e. supervisor) directly contributes to the ongoing training of the therapist-in- training (i.e. supervisee). In an effort to accomplish this, supervisors strive to establish an educational environment where the supervisees professional learning goals can be achieved (Bernard & Goodyear, 2019). Supervision is “a social influence process that occurs over time, in which the supervisor participates with supervisees to ensure quality of clinical care. Effective supervisors observe, mentor, coach, evaluate, inspire, and create an atmosphere that promotes self-motivation, learning, and professional development. They build teams, create cohesion, resolve conflict, and shape agency culture, while attending to ethical and diversity issues in all aspects of the process. Such supervision is key to both quality improvement and the successful implementation of consensus and evidencebased practices” (CSAT, 2007, p. 3). Rationale For hundreds of years, many professions have relied on more senior colleagues to guide less experienced professionals in their crafts. This is a new development in the substance abuse field, as clinical supervision was only recently acknowledged as a discrete process with its own concepts and approaches. As a supervisor to the client, counselor, and organization, the significance of your position is apparent in the following statements: Organizations have an obligation to ensure quality care and quality improvement of all personnel. The first aim of clinical supervision is to ensure quality services and to protect the welfare of clients. Supervision is the right of all employees and has a direct impact on workforce development and staff and client retention. 7 You oversee the clinical functions of staff and have a legal and ethical responsibility to ensure quality care to clients, the professional development of counselors, and maintenance of program policies and procedures. Clinical supervision is how counselors in the field learn. In concert with classroom education, clinical skills are acquired through practice, observation, feedback, and implementation of the recommendations derived from clinical supervision. Functions of a Clinical Supervisor You, the clinical supervisor, wear several important “hats.” As defined by Milne and Watkins (2014), the supervisor is responsible for establishing ‘‘relationship-based education and training that is work-focused and which manages, supports, develops and evaluates the work of colleagues.’’ You facilitate the integration of counselor self-awareness, theoretical grounding, and development of clinical knowledge and skills; and you improve functional skills and professional practices. These roles often overlap and are fluid within the context of the supervisory relationship. Hence, the supervisor is in a unique position as an advocate for the agency, the counselor, and the client. You are the primary link between administration and front-line staff, interpreting and monitoring compliance with agency goals, policies, and procedures and communicating staff and client needs to administrators. At its fundamental core, one of the key functions of the supervisor is to construct an environment where effective supervision can take place (Lambie & Blount, 2016). Figure 1. Roles of the Clinical Supervisor 8 As shown in Figure 1, your roles as a clinical supervisor in the context of the supervisory relationship include: Teacher: Assist in the development of counseling knowledge and skills by identifying learning needs, determining counselor strengths, promoting self-awareness, and transmitting knowledge for practical use and professional growth. Supervisors are teachers, trainers, and professional role models. Consultant: As established by Bernard and Goodyear (2019), the supervisor’s functions extend to incorporate the consulting role of case consultation and review, monitoring performance, counseling the counselor regarding job performance, and assessing counselors. As a consultant, supervisors provide alternative case conceptualizations, oversight of counselor work to achieve mutually agreed upon goals, and professional gatekeeping for the organization and discipline (e.g., recognizing and addressing counselor impairment). Coach: In this supportive role, supervisors provide morale building, assess strengths and needs, suggest varying clinical approaches, model, cheerlead, and prevent burnout. For entry-level counselors, the supportive function is critical. Mentor/Role Model: The experienced supervisor mentors and teaches the supervisee through role modeling, facilitates the counselor’s overall professional development and sense of professional identity, and trains the next generation of supervisors. Central Principles of Clinical Supervision The Consensus Panel for this TIP has identified central principles of clinical supervision. Although the Panel recognizes that clinical supervision can initially be a costly undertaking for many financially strapped programs, the Panel believes that ultimately clinical supervision is a cost saving process. Clinical supervision enhances the quality of client care; improves efficiency of counselors in direct and indirect services; increases workforce satisfaction, professionalization, and retention (see vignette 8 in chapter 2); and ensures that services provided to the public uphold legal mandates and ethical standards of the profession. The central principles identified by the Consensus Panel are: 1. Clinical supervision is an essential part of all clinical programs. Clinical supervision is a central organizing activity that 9 integrates the program mission, goals, and treatment philosophy with clinical theory and evidence-based practices (EBPs). The primary reasons for clinical supervision are to ensure (1) quality client care, and (2) clinical staff continue professional development in a systematic and planned manner. In substance abuse treatment, clinical supervision is the primary means of determining the quality of care provided. 2. Clinical supervision enhances staff retention, improves morale, and prevents burnout. Staff turnover and workforce development are major concerns in the substance abuse treatment field. Given the multifaceted and supportive nature of clinical supervision, effective supervision can serve as a potential buffer against negative aspects related to this line of work and prevent therapist burnout (Knudsen, Roman, & Abraham, 2013). 3. Every clinician, regardless of level of skill and experience, needs and has a right to clinical supervision. In addition, supervisors need and have a right to supervision of their supervision. Supervision needs to be tailored to the knowledge base, skills, experience, and assignment of each counselor. All staff need supervision, but the frequency and intensity of the oversight and training will depend on the development of good supervisors. The benefits that come with years of experience are enhanced by quality clinical supervision. 4. Clinical supervision needs the full support of agency administrators. Just as treatment programs want clients to be in an atmosphere of growth and openness to new ideas, counselors should be in an environment where learning and professional development and opportunities are valued and provided for all staff. 5. The supervisory relationship is the crucible in which ethical practice is developed and reinforced. The supervisor needs to model sound ethical and legal practice in the supervisory relationship. This is where issues of ethical practice arise and can be addressed. This is where ethical practice is translated from a concept to a set of behaviors. Through supervision, clinicians can develop a process of ethical decision making and use this process as they encounter new situations. 6. Clinical supervision is a skill in and of itself that has to be developed. Good counselors tend to be promoted into supervisory positions with the assumption that they have the requisite skills to provide professional clinical supervision. However, clinical 10 supervisors need a different role orientation toward both program and client goals and a knowledge base to complement a new set of skills. Programs need to increase their capacity to role, skill level, and competence of the individual. 7. Clinical supervision in substance abuse treatment most often requires balancing administrative and clinical supervision tasks. Sometimes these roles are complementary and sometimes they conflict. Often the supervisor feels caught between the two roles. Administrators need to support the integration and differentiation of the roles to promote the efficacy of the clinical supervisor. (See Part 2.) 8. Culture and other contextual variables influence the supervision process; supervisors need to continually strive for cultural competence. Supervisors require cultural competence at several levels. Cultural competence involves the counselor’s response to clients, the supervisor’s response to counselors, and the program’s response to the cultural needs of the diverse community it serves. Since supervisors are in a position to serve as catalysts for change, they need to develop proficiency in addressing the needs of diverse clients and personnel. 9. Successful implementation of EBPs requires ongoing supervision. Although a substantial number of EBPs for substance use exist, they are not always successfully integrated into clinical practice. To bridge this gap and implement EBPs, the supervisor’s responsibilities extend to understand, evaluate, and implement relevant practices in clinical settings (Dorsey et al., 2017). To ensure that these practices are successfully integrated, supervisors can oversee programmatic activities by training, encouraging, and monitoring therapists-in-training. Adhering to this guideline, excellence in clinical supervision can be achieved, and may provide greater utilization to the EBP model. Because State funding agencies now often require substance abuse treatment organizations to provide EBPs, supervision becomes even more important. 10. Supervisors have the responsibility to be gatekeepers for the profession. Supervisors are responsible for maintaining professional standards, recognizing and addressing impairment, and safeguarding the welfare of clients. More than anyone else in an agency, supervisors can observe counselor behavior and respond promptly to potential problems, including counseling some individuals out of the field because they are ill-suited to the 11 profession. This “gatekeeping” function is especially important for supervisors who act as field evaluators for practicum students prior to their entering the profession. Finally, supervisors also fulfill a gatekeeper role in performance evaluation and in providing formal recommendations to training institutions and credentialing bodies. 11. Clinical supervision should involve direct observation methods. Direct observation should be the standard in the field because it is one of the most effective ways of building skills, monitoring counselor performance, and ensuring quality care. Supervisors require training in methods of direct observation, and administrators need to provide resources for implementing direct observation. Although small substance abuse agencies might not have the resources for one-way mirrors or videotaping equipment, other direct observation methods can be employed (see the section on methods of observation, pp. 20–24). Guidelines for New Supervisors Congratulations on your appointment as a supervisor! By now you might be asking yourself a few questions: What have I done? Was this a good career decision? There are many changes ahead. If you have been promoted from within, you’ll encounter even more hurdles and issues. First, it is important to face that your life has changed. You might experience the loss of friendship of peers due to your shift in role to a supervisor. You might feel that you knew what to do as a counselor, but feel totally lost with your new responsibilities (see vignette 6 in chapter 2). You might feel less effective in your new role. Supervision can be an emotionally draining experience, especially at first, as you now have to work with more staff-related interpersonal and human resources issues. Before your promotion to clinical supervisor, you might have felt confidence in your clinical skills. Now you might feel unprepared and wonder if you need a training course for your new role. If you feel this way, you’re right. Although you are a good counselor, you do not necessarily possess all the skills needed to be a good supervisor. Your new role requires a new body of knowledge and different skills, along with the ability to use your clinical skills in a different way. Be confident that you will acquire these skills over time (see the Resources section, p. 34) and that you made the right decision to accept your new position. 12 Suggestions for new supervisors: Quickly learn the organization’s policies and procedures and human resources procedures (e.g., hiring and firing, affirmative action requirements, format for conducting meetings, giving feedback, and making evaluations). Seek out this information as soon as possible through the human resources department or other resources within the organization. Ask for a period of 3 months to allow you to learn about your new role. During this period, do not make any changes in policies and procedures but use this time to find your managerial voice and decision-making style. Take time to learn about your supervisees, their career goals, interests, developmental objectives, and perceived strengths. Work to establish a contractual relationship with supervisees, with clear goals and methods of supervision. Learn methods to help staff reduce stress, address competing priorities, resolve staff conflict, and other interpersonal issues in the workplace. Obtain training in supervisory procedures and methods. Find a mentor, either internal or external to the organization. Shadow a supervisor you respect who can help you learn the ropes of your new job. Ask often and as many people as possible, “How am I doing?” and “How can I improve my performance as a clinical supervisor?” Ask for regular, weekly meetings with your administrator for training and instruction. Seek supervision of your supervision. Problems and Resources As a supervisor, you may encounter a broad array of issues and concerns, ranging from working within a system that does not fully support 13 clinical supervision to working with resistant staff. A comment often heard in supervision training sessions is “My boss should be here to learn what is expected in supervision,” or “This will never work in my agency’s bureaucracy. They only support billable activities.” The work setting is where you apply the principles and practices of supervision and where organizations are driven by demands, such as financial solvency, profit, census, accreditation, and concerns over litigation. Therefore, you will need to be practical when beginning your new role as a supervisor: determine how you can make this work within your unique work environment. Working with Staff Who are Resistant to Supervision Some of your supervisees may have been in the field longer than you have and see no need for supervision. Other counselors, having completed their graduate training, do not believe they need further supervision, especially not from a supervisor who might have less formal academic education than they have. Other resistance might come from ageism, sexism, racism, or classism. Particular to the field of substance abuse treatment may be the tension between those who believe that recovery from substance abuse is necessary for this counseling work and those who do not believe this to be true. Another tension in the field may be the between those who believe in abstinence only treatments and those who believe in harm reduction treatments. In addressing resistance, you must be clear regarding what your supervision program entails and must consistently communicate your goals and expectations to staff. To resolve defensiveness and engage your supervisees, you must also honor the resistance and acknowledge their concerns. Motivational interviewing skills, the very skills that are used within substance abuse treatment, may prove to be useful within supervisor- supervisee relationships as well. Abandon trying to push the supervisee too far, too fast. Resistance is an expression of ambivalence about change and not a personality defect of the counselor. Instead of arguing with or exhorting staff, sympathize with their concerns, saying, “I understand this is difficult. How are we going to resolve these issues?” When counselors respond defensively or reject directions from you, try to understand the origins of their defensiveness and to address their resistance. Self-disclosure by the supervisor about experiences as a supervisee, when appropriately used, may be helpful in dealing with defensive, anxious, fearful, or resistant staff. Work to establish a healthy, positive supervisory alliance with staff. Because many substance abuse counselors have not been exposed to clinical supervision, you may need to train and orient the staff to the concept and why it is important for your 14 agency. You may also disclose that you also have a supervisor, and they have a supervisor, to normalize the situation. Things a New Supervisor Should Know Eight truths a beginning supervisor should commit to memory are listed below: 1. The reason for supervision is to ensure quality client care. As stated throughout this TIP, the primary goal of clinical supervision is to protect the welfare of the client and ensure the integrity of clinical services. 2. Supervision is all about the relationship. As in counseling, developing the alliance between the counselor and the supervisor is the key to good supervision. 3. As culture and ethics influence all supervisory interactions, particular emphasis must be given to diversity, power, and relatedness in supervision. Contextual factors, culture, gender, age, race, and ethnicity all affect the nature of the supervisory relationship. Different supervisory models have been developed to increase sensitivity towards diversity issues and promote cultural competency throughout (Tsui & O’Donoghue, 2014). 4. Be human and have a sense of humor. As role models, you need to show that everyone makes mistakes and can admit to and learn from these mistakes. 5. Rely first on direct observation of your counselors and give specific feedback. The best way to determine a counselor’s skills is to observe him or her and to receive input from the clients about their perceptions of the counseling relationship. This can be done through direct live observation or taping a session via video or audio and providing feedback during supervision. 6. Have and practice a model of counseling and of supervision; have a sense of purpose. Before you can teach a supervisee knowledge and skills, you must first know the philosophical and theoretical foundations on which you, as a supervisor, stand. Counselors need to know what they are going to learn from you, based on your model of counseling and supervision. Prior to teaching new knowledge or skills, provide the supervisee with a rationale for the 15 new knowledge and skills so they understand why you are teaching it and how it will benefit their clients. 7. Make time to take care of yourself emotionally, mentally, and physically. Again, as role models, counselors are watching your behavior. Do you “walk the talk” of selfcare? 8. You have a unique position as an advocate for the agency, the counselor, and the client. As a supervisor, you have a wonderful opportunity to assist in the skill and professional development of your staff, advocating for the best interests of the supervisee, the client, and your organization. Models of Clinical Supervision You may never have thought about your model of supervision. However, it is a fundamental premise of this TIP that you need to work from a defined model of supervision and have a sense of purpose in your oversight role. Four supervisory orientations seem particularly relevant. They include: Competency-based models. Treatment-based models. Developmental approaches. Integrated models. Competency-based models (e.g., microtraining, the Discrimination Model [Bernard & Goodyear, 2019; Dunlap, 2017], and the Task-Oriented Model [Mead, 1990; Simpson-Southward, Waller, & Hardy, 2017], focus primarily on the skills and learning needs of the supervisee and on setting goals that are specific, measurable, attainable, realistic, and timely (SMART). They construct and implement strategies to accomplish these goals. The key strategies of competency-based models include applying social learning principles (e.g., modeling role reversal, role playing, and practice), using demonstrations, and using various supervisory functions (teaching, consulting, and counseling). Treatment-based supervision models train to a particular theoretical approach to counseling, incorporating EBPs into supervision and seeking fidelity and adaptation to the theoretical model. Motivational interviewing, cognitive–behavioral therapy, and psychodynamic psychotherapy are three examples. These models emphasize the counselor’s strengths, seek the supervisee’s understanding of the theory and model taught, and incorporate the approaches and techniques of the model. The 16 majority of these models begin with articulating their treatment approach and describing their supervision model, based upon that approach. Clinical Supervision for Motivational Interviewing Of particular importance to those supervising within the field of substance abuse, specifically, is the role of motivational interviewing. Motivational Interviewing (MI) is an evidence-based program that has demonstrated its effectiveness to treat substance use disorders (Miller & Rollnick, 2013). As indicated in the previous sections, competency-based clinical supervision works by identifying both the knowledge and skills that clinicians need to deliver treatment appropriately, both within a given setting and to their clientele. Elements of competency-based supervision include: direct observation, providing performance-based feedback, and individualized coaching to increase supervisee knowledge and skills (American Psychological Association, 2015). Martino et al. (2016) determined that the competency-based approach of supervision for MI, called Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) was an effective supervisory approach. Most interestingly, it was found that the clinicians who were supervised with MIA-STEP significantly increased their MI knowledge, skills, and competency, compared to those who received supervision as usual (Martino et al., 2016). In other words, clinicians that were supervised using this competency-based model were better at using the skills necessary to effectively deliver MI than were their peers. This raises interesting questions about the future development of supervisory models, and how their effectiveness can impact clinicians and the populations treated. Developmental models, such as McNeill & Stoltenberg (2016) understand that each counselor goes through different stages of development and recognize that movement through these stages is not always linear and can be affected by changes in assignment, setting, and population served. (The developmental stages of counselors and supervisors are described in detail below). Integrated models, including the Blended Model, begin with the style of leadership and articulate a model of treatment, incorporate descriptive dimensions of supervision (see below), and address contextual and developmental dimensions into supervision. They address both skill and competency development and affective issues, based on the unique needs of 17 the supervisee and supervisor. Finally, integrated models seek to incorporate EBPs into counseling and supervision. In all models of supervision, it is helpful to identify culturally or contextually centered models or approaches and find ways of tailoring the models to specific cultural and diversity factors. Issues to consider are: Explicitly addressing diversity of supervisees (e.g., race, ethnicity, gender, age, sexual orientation) and the specific factors associated with these types of diversity; Explicitly involving supervisees’ concerns related to particular client diversity (e.g., those whose culture, gender, sexual orientation, and other attributes differ from those of the supervisee) and addressing specific factors associated with these types of diversity; and Explicitly addressing supervisees’ issues related to effectively navigating services in intercultural communities and effectively networking with agencies and institutions. It is important to identify your model of counseling and your beliefs about change, and to articulate a workable approach to supervision that fits the model of counseling you use. Theories are conceptual frameworks that enable you to make sense of and organize your counseling and supervision and to focus on the most salient aspects of a counselor’s practice. You may find some of the questions below to be relevant to both supervision and counseling. The answers to these questions influence both how you supervise and how the counselors you supervise work: What are your beliefs about how people change in both treatment and clinical supervision? What factors are important in treatment and clinical supervision? What universal principles apply in supervision and counseling and which are unique to clinical supervision? What conceptual frameworks of counseling do you use (for instance, cognitive–behavioral therapy, 12-Step facilitation, psychodynamic, behavioral)? What are the key variables that affect outcomes? (Kohrt et al., 2015; Knaup, Koesters, Schoefer, Becker, & Puschner, 2009) 18 According to Watkins & Milne (2014), qualities of an effective supervision model can be broken into 4 competencies: Generic supervision competencies: where there is an ability to help supervisee reflect on their own work and on the usefulness of supervision. i.e., underpinning generic skills common to all approaches Specific supervision competencies: focusing on helping the supervisee practice their learned clinical skills. i.e., acquisition of the skills necessary to employ any therapy or approach Application of supervision to specific models/contexts: where the focus shifts to the supervision and oversight of clinical case management. i.e., focus on delivering treatments that are evidenced based or show initial efficacy Metacompetencies: where the focus shifts to oversee the acquisition and development of supervisor and supervisee metacompetencies. i.e., Development of supervisee/supervisor metacompentencies Finally, it is imperative to recognize that, whatever model you adopt, it needs to be rooted in the learning and developmental needs of the supervisee, the specific needs of the clients they serve, the goals of the agency in which you work, and in the ethical and legal boundaries of practice. Pilling and Roth (2014) expand upon these four general competencies, and recommend overall guidelines that clinical supervisors, in whatever model of supervision they may choose. These include: ability to utilize educational principles that enhance and promote supervisee learning foster ethical practice work across a spectrum of diverse clientele 19 ability to adapt supervision to organization context ability to form and maintain adequate supervisee/supervisor alliance. Developmental Stages of Counselors Counselors are at different stages of professional development. Thus, regardless of the model of supervision you choose, you must take into account the supervisee’s level of training, experience, and proficiency. Different supervisory approaches are appropriate for counselors at different stages of development. An understanding of the supervisee’s (and supervisor’s) developmental needs is an essential ingredient for any model of supervision. Various paradigms or classifications of developmental stages of clinicians have been developed (Barrio Minton, Myers, & Paredes, 2016; Ivey & Digilio, 2016; Skovholt 2017; Allan, McLuckie, & Hoffecker, 2016). This TIP has adopted the Integrated Developmental Model (IDM) of (McNeill & Stoltenberg, 2016) (see figure 2, p. 10). This schema uses a three-stage approach, which occur across the development of new clinicians. These structures include, awareness (self and other), motivation, and dependency- autonomy. The three stages of development have different characteristics and appropriate supervisory methods. Further application of the IDM to the substance abuse field is needed. (For additional information, see McNeill & Stoltenberg, 2016.) It is important to keep in mind several general cautions and principles about counselor development, including: There is a beginning but not an end point for learning clinical skills; be careful of counselors who think they “know it all.” Take into account the individual learning styles and personalities of your supervisees and fit the supervisory approach to the developmental stage of each counselor. There is a logical sequence to development, although it is not always predictable or rigid; some counselors may have been in the field for years but remain at an early stage of professional development, whereas others may progress quickly through the stages. 20 Counselors at an advanced developmental level have different learning needs and require different supervisory approaches from those at Level 1; and The developmental level can be applied for different aspects of a counselor’s overall competence (e.g., Level 2 mastery for individual counseling and Level 1 for couples counseling). Developmental Stages of Supervisors Just as counselors go through stages of development, so do supervisors. The developmental model presented in figure 3 provides a framework to explain why supervisors act as they do, depending on their developmental stage. It would be expected that someone new to supervision would be at a Level 1 as a supervisor. However, supervisors should be at least at the second or third stage of counselor development. If a newly appointed supervisor is 21 still at Level 1 as a counselor, he or she will have little to offer to more seasoned supervisees. Pilling and Roth (2014) also provide a summary of key aspects to building supervisor competencies. These competencies can be extended to any supervisory model, and include: The ability to structure supervision sessions Ability to help the supervisee synthesize, present, and understand clinical information and findings Foster the ability for supervisees to reflect on their work The ability to use a range of methods to provide supervisory feedback Ability to assess a supervisee’s competence level and use objective measurements of competence Ability to help supervisee practice acquired clinical skills Ability to incorporate direct observation findings into supervision Ability to supervise and provide feedback in group-sessions Ability to provide supervision standards 22 Cultural and Contextual Factors Culture is one of the major contextual factors that influence supervisory interactions. Other contextual variables include race, ethnicity, age, gender, discipline, academic background, religious and spiritual practices, sexual orientation, disability, and recovery versus non-recovery status. The relevant variables in the supervisory relationship occur in the context of the supervisor, supervisee, client, and the setting in which supervision occurs. More care should be taken to: Identify the competencies necessary for substance abuse counselors to work with diverse individuals and navigate intercultural communities. Identify methods for supervisors to assist counselors in developing these competencies. Provide evaluation criteria for supervisors to determine whether their supervisees have met minimal competency standards for effective and relevant practice 23 Models of supervision have been strongly influenced by contextual variables and their influence on the supervisory relationship and process, such as Holloway’s Systems Model (Meier & Davis, 2019) and Constantine’s Multicultural Model (Drinane, Owen, Adelson, & Rodolfa, 2016; Constantine, 2003). The competencies listed in TAP 21-A reflect the importance of culture in supervision (CSAT, 2007). The Counselor Development domain encourages self examination of attitudes toward culture and other contextual variables. The Supervisory Alliance domain promotes attention to these variables in the supervisory relationship. (See also the planned TIP, Improving Cultural Competence in Substance Abuse Counseling [CSAT, in development b].) Cultural competence in clinical supervision extends to include that both supervisees and supervisors maintain and foster the ability to each other in an effort to achieve the goals of supervision, despite potential differences, which include diversity and/or contextual issues (Tsui, O’Donoghue, & Ng, 2014). Culture shapes belief systems, particularly concerning issues related to mental health and substance abuse, as well as the manifestation of symptoms, relational styles, and coping patterns. Martin & Vaughn (2007) explain that cultural competency consists of four elements. These include: 1. Awareness of one’s own cultural background 2. Attitudes and behaviors towards differences in culture 3. Knowledge of different cultures, diversity issues, and worldviews 4. Skills and ability to interact and work with people within different cultures and contextual backgrounds Becoming culturally competent and able to integrate other contextual variables into supervision is a complex, long-term process. Jernigan et al. (2016) have identified several stages on a continuum of becoming culturally competent (see figure 4). Although you may never have had specialized training in multicultural counseling, some of your supervisees may have (Drinane, Owen, Adelson, & Rodolfa, 2016). Regardless, it is your responsibility to help supervisees build on the cultural competence skills they possess as well as to focus on their cultural competence deficits. It is important to initiate discussion of issues of culture, race, gender, sexual orientation, and the like in supervision to model 24 the kinds of discussion you would like counselors to have with their clients. If these issues are not addressed in supervision, counselors may come to believe that it is inappropriate to discuss them with clients and have no idea how such dialog might proceed. These discussions prevent misunderstandings with supervisees based on cultural or other factors. Another benefit from these discussions is that counselors will eventually achieve some level of comfort in talking about culture, race, ethnicity, and diversity issues. If you haven’t done it as a counselor, early in your tenure as a supervisor you will want to examine your culturally influenced values, attitudes, experiences, and practices and to consider what effects they have on your dealings with supervisees and clients. Counselors should undergo a similar review as preparation for when they have clients of a culture different from their own. Some questions to keep in mind are: What did you think when you saw the supervisee’s last name? What did you think when the supervisee said his or her culture is X, when yours is Y? How did you feel about this difference? What did you do in response to this difference? 25 Lee (2018) suggests that supervisors can ask questions about the potential ways in which a supervisee’s cultural background might inform their counseling work to help better understand how this might inform their clinical and theoretical orientations. Beyond self examination, supervisors will want continuing education classes, workshops, and conferences that address cultural competence and other contextual factors. Community resources, such as community leaders, elders, and healers can contribute to your understanding of the culture your organization serves. Finally, supervisors (and counselors) should participate in multicultural activities, such as community events, discussion groups, religious festivals, and other ceremonies. The supervisory relationship includes an inherent power differential, and it is important to pay attention to this disparity, particularly when the supervisee and the supervisor are from different cultural groups. A potential for the misuse of that power exists at all times but especially when working with supervisees and clients within multicultural contexts. When the supervisee is from a minority population and the supervisor is from a majority population, the differential can be exaggerated. You will want to prevent institutional discrimination from affecting the quality of supervision. The same is true when the supervisee is gay and the supervisor is heterosexual, or the counselor is non-degreed and the supervisor has an advanced degree, or a female supervisee with a male supervisor, and so on. In the reverse situations, where the supervisor is from the minority group and the supervisee from the majority group, the difference should be discussed as well. Ethical and Legal Issues You are the organization’s gatekeeper for ethical and legal issues. First, you are responsible for upholding the highest standards of ethical, legal, and moral practices and for serving as a model of practice to staff. Further, you should be aware of and respond to ethical concerns. Part of your job is to help integrate solutions to everyday legal and ethical issues into clinical practice. Some of the underlying assumptions of incorporating ethical issues into clinical supervision include: Ethical decision-making is a continuous, active process. Ethical standards are not a cookbook. They tell you what to do, not always how. 26 Each situation is unique. Therefore, it is imperative that all personnel learn how to “think ethically” and how to make sound legal and ethical decisions. The most complex ethical issues arise in the context of two ethical behaviors that conflict; for instance, when a counselor wants to respect the privacy and confidentiality of a client, but it is in the client’s best interest for the counselor to contact someone else about his or her care. Therapy is conducted by fallible beings; people make mistakes— hopefully, minor ones. Sometimes the answers to ethical and legal questions are elusive. Ask a dozen people, and you’ll likely get twelve different points of view. Helpful resources on legal and ethical issues for supervisors include: Sarnat (2016); Jacob, Decker, & Lugg, 2016, O’Donoghue & O’Donoghue, 2019; Egan, Maidment, & Connolly, 2018l American Psychological Association, 2018. Legal and ethical issues that are critical to clinical supervisors include (1) vicarious liability (or respondeat superior), (2) dual relationships and boundary concerns, (4) informed consent, (5) confidentiality, and (6) supervisor ethics. Direct Versus Vicarious Liability An important distinction needs to be made between direct and vicarious liability. Direct liability of the supervisor might include dereliction of supervisory responsibility, such as “not making a reasonable effort to supervise” (defined below). In vicarious liability, a supervisor can be held liable for damages incurred as a result of negligence in the supervision process. Examples of negligence include providing inappropriate advice to a counselor about a client (for instance, discouraging a counselor from conducting a suicide screen on a depressed client), failure to listen carefully to a supervisee’s comments about a client, and the assignment of clinical tasks to inadequately trained counselors. The key legal question is: “Did the supervisor conduct him- or herself in a way that would be reasonable for someone in his position?” or “Did the supervisor make a reasonable effort to supervise?” A generally accepted 27 time standard for a “reasonable effort to supervise” in the behavioral health field is 1 hour of supervision for every 20–40 hours of clinical services. Of course, other variables (such as the quality and content of clinical supervision sessions) also play a role in a reasonable effort to supervise. Supervisory vulnerability increases when the counselor has been assigned too many clients, when there is no direct observation of a counselor’s clinical work, when staff are inexperienced or poorly trained for assigned tasks, and when a supervisor is not involved or not available to aid the clinical staff. In legal texts, vicarious liability is referred to as “respondeat superior.” Dual Relationships and Boundary Issues Dual relationships can occur at two levels: between supervisors and supervisees and between counselors and clients. You have a mandate to help your supervisees recognize and manage boundary issues. A dual relationship occurs in supervision when a supervisor has a primary professional role with a supervisee and, at an earlier time, simultaneously or later, engages in another relationship with the supervisee that transcends the professional relationship. Examples of dual relationships in supervision include providing therapy for a current or former supervisee, developing an emotional relationship with a supervisee or former supervisee, and becoming an Alcoholics Anonymous sponsor for a former supervisee. Obviously, there are varying degrees of harm or potential harm that might occur as a result of dual relationships, and some negative effects of dual relationships might not be apparent until later. Therefore, firm, alwaysornever rules aren’t applicable. You have the responsibility of weighing with the counselor the anticipated and unanticipated effects of dual relationships, helping the supervisee’s self-reflective awareness when boundaries become blurred, when he or she is getting close to a dual relationship, or when he or she is crossing the line in the clinical relationship. Exploring dual relationship issues with counselors in clinical supervision can raise its own professional dilemmas. For instance, clinical supervision involves unequal status, power, and expertise between a supervisor and supervisee. Being the evaluator of a counselor’s performance and gatekeeper for training programs or credentialing bodies also might involve a dual relationship. Further, supervision can have therapy-like qualities as you explore countertransferential issues with supervisees, and there is an expectation of professional growth and self-exploration. What makes a dual relationship unethical in supervision is the abusive use of power by either party, the likelihood that the relationship will impair or injure the supervisor’s 28 or supervisee’s judgment, and the risk of exploitation (see vignette 3 in chapter 2). Boundary violations and sexual impropriety represent some of the most legalistically vulnerable issues among psychotherapists (Andreopoulous, 2017). (See the discussion of transference and countertransference on pp. 25–26). In particular, Herlihy & Corey (2014) describe the complexities of cultural and diversity issues related to boundary violations. What makes these relationships most challenging are the complexities embedded within and that there is a requirement for counselors to make judgment calls and apply the learned code of ethics to these situations. Codes of ethics for most professions clearly advise that dual relationships between counselors and clients should be avoided. Dual relationships between counselors and supervisors are also a concern and are addressed in the substance abuse counselor codes and those of other professions as well. Problematic dual relationships between supervisees and supervisors might include intimate relationships (sexual and non-sexual) and therapeutic relationships, wherein the supervisor becomes the counselor’s therapist. Sexual involvement between the supervisor and supervisee can include sexual attraction, harassment, consensual (but hidden) sexual relationships, or intimate romantic relationships. Other common boundary issues include asking the supervisee to do favors, providing preferential treatment, socializing outside the work setting, and using emotional abuse to enforce power. It is imperative that all parties understand what constitutes a dual relationship between supervisor and supervisee and avoid these dual relationships. Sexual relationships between supervisors and supervisees and counselors and clients occur far more frequently than one might realize (Wilkinson, Smith, & Wimberly, 2019). In many States, they constitute a legal transgression as well as an ethical violation. The decision tree presented in figure 5 indicates how a supervisor might manage a situation where he or she is concerned about a possible ethical or legal violation by a counselor. Informed Consent Informed consent is key to protecting the counselor and/or supervisor from legal concerns, requiring the recipient of any service or intervention to be sufficiently aware of what is to happen, and of the potential risks and alternative approaches, so that the person can make an informed and intelligent decision about participating in that service. The supervisor must inform the supervisee about the process of supervision, the feedback and 29 evaluation criteria, and other expectations of supervision. The supervision contract should clearly spell out these issues. Supervisors must ensure that the supervisee has informed the client about the parameters of counseling and supervision (such as the use of live observation, video- or audiotaping). A sample template for informed consent is provided in Part 2, chapter 2. Confidentiality In supervision, regardless of whether there is a written or verbal contract between the supervisor and supervisee, there is an implied contract and duty of care because of the supervisor’s vicarious liability. Informed consent and concerns for confidentiality should occur at three levels: client consent to treatment, client consent to supervision of the case, and supervisee consent to supervision (Bernard & Goodyear, 2019). In addition, there is an implied consent and commitment to confidentiality by supervisors to assume their supervisory responsibilities and institutional consent to comply with legal and ethical parameters of supervision. (See also the Code of Ethics of the Supervision [ACES], available online at http://www.acesonline.net/members/supervision/. With informed consent and confidentiality comes a duty not to disclose certain relational communication. Limits of confidentiality of supervision session content should be stated in all organizational contracts with training institutions and credentialing bodies. Criteria for waiving client and supervisee privilege should be stated in institutional policies and discipline-specific codes of ethics and clarified by advice of legal counsel and the courts. Because standards of confidentiality are determined by State legal and legislative systems, it is prudent for supervisors to consult with an attorney to determine the State codes of confidentiality and clinical privileging. In the substance abuse treatment field, confidentiality for clients is clearly defined by Federal law: 42 CFR, Part 2 and the Health Insurance Portability and Accountability Act (HIPAA). Key information is available at http://www.hhs.gov/ocr/privacy/. Supervisors need to train counselors in confidentiality regulations and to adequately document their supervision, including discussions and directives, especially relating to duty-to-warn situations. Supervisors need to ensure that counselors provide clients with appropriate duty-to-warn information early in the counseling process and inform clients of the limits of confidentiality as part of the agency’s informed consent procedures. 30 Under duty-to-warn requirements (e.g., child abuse, suicidal or homicidal ideation), supervisors need to be aware of and take action as soon as possible in situations in which confidentiality may need to be waived. This requires both supervisors and supervisees to have adequate knowledge of specific practices within an organization, and how to properly handle these issues as they arise (Webber & DeRoche, 2016). What mechanisms are in place for responding to crises? In what timeframe will a supervisor be notified of a crisis situation? Supervisors must document all discussions with counselors concerning duty-to-warn and crises. At the onset of supervision, supervisors should ask counselors if there are any duty-to-warn issues of which the supervisor should be informed. New technology brings new confidentiality concerns. Websites now dispense information about substance abuse treatment and provide counseling services. With the growth in online counseling and supervision, the following concerns emerge: (a) how to maintain confidentiality of information, (b) how to ensure the competence and qualifications of counselors providing online services, and (c) how to establish reporting requirements and duty to warn when services are conducted across State and international boundaries. New standards will need to be written to address these issues. (The National Board for Certified Counselors has guidelines for counseling by Internet at http://www.nbcc.org/Assets/Ethics/NBCCPolicy RegardingPracticeofDistanceCounselingBoard.pdf) 31 32 Supervisor Ethics In general, supervisors adhere to the same standards and ethics as substance abuse counselors with regard to dual relationship and other boundary violations. Supervisors will: ▪ Uphold the highest professional standards of the field. ▪ Seek professional help (outside the work setting) when personal issues interfere with their clinical and/or supervisory functioning. ▪ Conduct themselves in a manner that models and sets an example for agency mission, vision, philosophy, wellness, recovery, and consumer satisfaction. ▪ Reinforce zero tolerance for interactions that are not professional, courteous, and compassionate. ▪ Treat supervisees, colleagues, peers, and clients with dignity, respect, and honesty. ▪ Adhere to the standards and regulations of confidentiality as dictated by the field. This applies to the supervisory as well as the counseling relationship. Monitoring Performance The goal of supervision is to ensure quality care for the client, which entails monitoring the clinical performance of staff. Your first step is to educate supervisees in what to expect from clinical supervision. Once the functions of supervision are clear, you should regularly evaluate the counselor’s progress in meeting organizational and clinical goals as set forth in an Individual Development Plan (IDP) (see the section on IDPs below). As clients have an individual treatment plan, counselors also need a plan to promote skill development. Behavioral Contracting in Supervision Among the first tasks in supervision is to establish a contract for supervision that outlines realistic accountability for both yourself and your supervisee. The contract should be in writing and should include the purpose, goals, and objectives of supervision; the context in which supervision is provided; ethical and institutional policies that guide supervision and clinical practices; the criteria and methods of evaluation and outcome measures; the duties and responsibilities of the supervisor and supervisee; procedural considerations (including the format for taping and opportunities for live observation); and the supervisee’s scope of practice and competence. The contract for supervision should state the rewards for fulfillment of the contract (such as clinical privileges or increased compensation), the length of 33 supervision sessions, and sanctions for noncompliance by either the supervisee or supervisor. The agreement should be compatible with the developmental needs of the supervisee and address the obstacles to progress (lack of time, performance anxiety, resource limitations). Once a behavioral contract has been established, the next step is to develop an IDP. Individual Development Plan The IDP is a detailed plan for supervision that includes the goals that you and the counselor wish to address over a certain time period (perhaps 3 months). Each of you should sign and keep a copy of the IDP for your records. The goals are normally stated in terms of skills the counselor wishes to build or professional resources the counselor wishes to develop. These skills and resources are generally oriented to the counselor’s job in the program or activities that would help the counselor develop professionally. The IDP should specify the timelines for change, the observation methods that will be employed, expectations for the supervisee and the supervisor, the evaluation procedures that will be employed, and the activities that will be expected to improve knowledge and skills. An example of an IDP is provided in Part 2, chapter 2(p. 122). As a supervisor, you should have your own IDP, based on the supervisory competencies listed in TAP 21A (CSAT, 2007), that addresses your training goals. This IDP can be developed in cooperation with your supervisor, or in external supervision, peer input, academic advisement, or mentorship. Evaluation of Counselors Supervision inherently involves evaluation, building on a collaborative relationship between you and the counselor. Evaluation may not be easy for some supervisors. Although everyone wants to know how they are doing, counselors are not always comfortable asking for feedback. And, as most supervisors prefer to be liked, you may have difficulty giving clear, concise, and accurate evaluations to staff. The two types of evaluation are formative and summative. A formative evaluation is an ongoing status report of the counselor’s skill development, exploring the questions “Are we addressing the skills or competencies you want to focus on?” and “How do we assess your current knowledge and skills and areas for growth and development?” Summative evaluation is a more formal rating of the counselor’s overall job performance, fitness for the job, and job rating. It answers the question, “How does the counselor measure up?” Typically, summative evaluations are 34 done annually and focus on the counselor’s overall strengths, limitations, and areas for future improvement. It should be acknowledged that supervision is inherently an unequal relationship. In most cases, the supervisor has positional power over the counselor. Therefore, it is important to establish clarity of purpose and a positive context for evaluation. Procedures should be spelled out in advance, and the evaluation process should be mutual, flexible, and continuous. The evaluation process inevitably brings up supervisee anxiety and defensiveness that need to be addressed openly. It is also important to note that each individual counselor will react differently to feedback; some will be more open to the process than others. There has been considerable research on supervisory evaluation, with these findings: The supervisee’s confidence and efficacy are correlated with the quality and quantity of feedback the supervisor gives to the supervisee (Bernard & Goodyear, 2019). Ratings of skills are highly variable between supervisors, and often the supervisor’s and supervisee’s ratings differ or conflict (Fulton et al., 2016). Good feedback is provided frequently, clearly, and consistently and is SMART (specific, measurable, attainable, realistic, and timely) – and accessible to supervisees (McComb et al., 2018). Direct observation of the counselor’s work is the desired form of input for the supervisor. Although direct observation has historically been the exception in substance abuse counseling, ethical and legal considerations and evidence support that direct observation as preferable. The least desirable feedback is unannounced observation by supervisors followed by vague, perfunctory, indirect, or hurtful delivery (Hauer et al., 2015). Clients are often the best assessors of the skills of the counselor. Supervisors should routinely seek input from the clients as to the outcome of treatment. The method of seeking input should be discussed in the initial supervisory sessions and be part of the supervision contract. In a residential substance abuse treatment program, you might regularly meet with clients after sessions to discuss how they are doing, how effective the counseling is, and the quality of the therapeutic alliance with the counselor. (For examples of client satisfaction or input forms, search for Client-Directed Outcome-Informed Treatment and Training Materials at 35 http://www.goodtherapy.org/ client-directed-outcome-informed-therapy.html) Before formative evaluations begin, methods of evaluating performance should be discussed, clarified in the initial sessions, and included in the initial contract so that there will be no surprises. Formative evaluations should focus on changeable behavior and, whenever possible, be separate from the overall annual performance appraisal process. To determine the counselor’s skill development, you should use written competency tools, direct observation, counselor self-assessments, client evaluations, work samples (files and charts), and peer assessments. Examples of work samples and peer assessments can be found in Bernard and Goodyear (2019), Alfonsson et al., 2018, and Davys, May, Burns, & O’Connell,2017). It is important to acknowledge that counselor evaluation is essentially a subjective process involving supervisors’ opinions of the counselors’ competence. Addressing Burnout and Compassion Fatigue Did you ever hear a counselor say, “I came into counseling for the right reasons? At first, I loved seeing clients. But the longer I stay in the field, the harder it is to care. The joy seems to have gone out of my job. Should I get out of counseling as many of my colleagues are doing?” Most substance abuse counselors come into the field with a strong sense of calling and the desire to be of service to others, with a strong pull to use their gifts and make themselves instruments of service and healing. The substance abuse treatment field risks losing many skilled and compassionate healers when the life goes out of their work. Some counselors simply withdraw, care less, or get out of the field entirely. Most just complain or suffer in silence. Given the caring and dedication that brings counselors into the field, it is important for you to help them address their questions and doubts. (See Maslach, 2017, and Wagaman, Geiger, Shockley, & Seigel, 2015.) You can help counselors with self-care; help them look within; become resilient again; and rediscover what gives them joy, meaning, and hope in their work. Counselors need time for reflection, to listen again deeply and authentically. You can help them redevelop their innate capacity for compassion, to be an openhearted presence for others. You can help counselors develop a life that does not revolve around work. This has to be supported by the organization’s culture and policies that allow for appropriate use of time off and self-care without punishment. Aid them by encouraging them to take earned leave and to take “mental health” days when they are feeling tired and burned out. Remind staff to spend time 36 with family and friends, exercise, relax, read, or pursue other life-giving interests. It is essential that clinical supervisors provide the necessary support by establishing and maintaining working relationships with supervisees – in that they are able to address stress reactions and compassion fatigue in the workplace as a natural part of their experience, rather than an individual failing or pathology (See Carruth & Field, 2016). Rest is good; self-care is important. Everyone needs times of relaxation and recreation. Often, a month after a refreshing vacation you lose whatever gain you made. Instead, longer term gain comes from finding what brings you peace and joy. It is not enough for you to help counselors understand “how” to counsel, you can also help them with the “why.” Why are they in this field? What gives them meaning and purpose at work? When all is said and done, when counselors have seen their last client, how do they want to be remembered? What do they want said about them as counselors? Usually, counselors’ responses to this question are fairly simple: “I want to be thought of as a caring, compassionate person, a skilled helper.” These are important spiritual questions that you can discuss with your supervisees. Other suggestions include: Help staff identify what is happening within the organization that might be contributing to their stress and learn how to address the situation in a way that is productive to the client, the counselor, and the organization. Get training in identifying the signs of primary stress reactions, secondary trauma, compassion fatigue, vicarious traumatization, and burnout. Help staff match up self-care tools to specifically address each of these experiences. Support staff in advocating for organizational change when appropriate and feasible as part of your role as liaison between administration and clinical staff. Assist staff in adopting lifestyle changes to increase their emotional resilience by reconnecting to their world (family, friends, sponsors, mentors), spending time alone for self-reflection, and forming habits that re-energize them. Help them eliminate the “what ifs” and negative selftalk. Help them let go of their idealism that they can save the world. 37 If possible, in the current work environment, set parameters on their work by helping them adhere to scheduled time off, keep lunch time personal, set reasonable deadlines for work completion, and keep work away from personal time. Teach and support generally positive work habits. Some counselors lack basic organizational, team-work, phone, and time management skills (ending sessions on time and scheduling to allow for documentation). The development of these skills helps to reduce the daily wear that erodes well-being and contributes to burnout. Ask them “When was the last time you had fun?” “When was the last time you felt fully alive?” Suggest they write a list of things about their job about which they are grateful. List five people they care about and love. List five accomplishments in their professional life. Ask “Where do you want to be in your professional life in 5 years?” You have a fiduciary responsibility given you by clients to ensure counselors are healthy and whole. It is your responsibility to aid counselors in addressing their fatigue and burnout. Gatekeeping Functions In monitoring counselor performance, an important and often difficult supervisory task is managing problem staff or those individuals who should not be counselors. This is the gatekeeping function. Part of the dilemma is that most likely you were first trained as a counselor, and your values lie within that domain. You were taught to acknowledge and work with individual limitations, always respecting the individual’s goals and needs. However, you also carry a responsibility to maintain the quality of the profession and to protect the welfare of clients. Thus, you are charged with the task of assessing the counselor for fitness for duty and have an obligation to uphold the standards of the profession. Experience, credentials, and academic performance are not the same as clinical competence. In addition to technical counseling skills, many important therapeutic qualities affect the outcome of counseling, including insight, respect, genuineness, concreteness, and empathy. Research consistently demonstrates that personal characteristics of counselors are highly predictive of client outcome (McCaughin & Hill, 2015). The essential questions are: Who should or should not be a counselor? What behaviors or attitudes are unacceptable? How would a clinical supervisor address these issues in supervision? 38 Unacceptable behavior might include actions hurtful to the client, boundary violations with clients or program standards, illegal behavior, significant psychiatric impairment, consistent lack of self-awareness, inability to adhere to professional codes of ethics, or consistent demonstration of attitudes that are not conducive to work with clients in substance abuse treatment. You will want to have a model and policies and procedures in place when disciplinary action is undertaken with an impaired counselor. For example, progressive disciplinary policies clearly state the procedures to follow when impairment is identified. Consultation with the organization’s attorney and familiarity with State case law are important. It is advisable for the agency to be familiar with and have contact with your State impaired counselor organization, if it exists. How impaired must a counselor be before disciplinary action is needed? Clear job descriptions and statements of scope of practice and competence are important when facing an i

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