Training package for Psychology Supervisors. A competency based initiative.

1. Training package for Psychology Supervisors. A competency based initiative. Yasmina Nasstasia, Wayne Clarke, Chris Wilcox & Katrina Delamothe

2. Hunter and Coast ICTN (Rowena Amin) • Colleagues from respective Universities including; Craig Gonsalves, Ros Knight, & Kathryn Nicholson Perry. Thank You Acknowledgements to:

3. Module 3: Understanding your development and role as a supervisor.

4. For some time now… in the practice of Psychology, Clinical Supervision has been referred to as a “core competency”. Yet, training of Psychologists in developing this core competency has been patchy in Australia, as it has across our profession internationally.

5. We have witnessed a strengthening of the profession. National Registration has brought with it: the development of standards, an increasing emphasis on fitness to practice, and an intense focus on equipping new graduates for professional practice. By ensuring increasing rigor, by way of close supervision, in the way new Psychologists are entering clinical practice, the practice of Supervision in this context has become a key focus - competency is essential.

6. With guidelines for the Supervision of new graduates well developed, the focus has shifted and broadened so that now the practice and delivery of Supervision generally is beginning to receive the attention it warrants.

7. Whilst across the Psychology profession, Supervision is now an essential element of practice monitoring generally and professional development specifically. There is still no consensus as to what constitutes effective training in Supervision.

8. The view in the past seemed to be that the skill of providing good Supervision was learned by some kind of osmosis… Supervisors knew how to supervise by having been themselves supervised. The majority of Psychologists who provide Supervision have had little training.

9. Consider: How did you learn to supervise? How helpful was this? What if anything was missing? What would you have liked to be different?

10. This set of supervision training modules will, it is anticipated, produce active, involved and committed Supervisors, in whatever context, and across a range of different demands, whose knowledge and awareness of their role will ensure that they avoid the pitfalls of the process.

11. Supervision in Psychology: Current status “Professional practice supervision is a key element in clinical governance. These processes seek to ensure that the individual practitioners are supported in the development of their: Practice knowledge, Skills, Service delivery, Accept responsibility for their professional practice and Are equipped to provide the highest possible levels of care consistent with evolving evidence relevant to that care. (NSW Government – Health Allied Health Professional Practice Supervision).

12. This Policy statement emphasizes that Supervision is aimed at enhancing consumer protection, the safety of care in complex clinical environments, and the Supervisee’s satisfaction in their role. It underscores the risk-averse themes within the public sector generally and the desire to retain staffing resources.

13. “Extensive literature andresearch indicates that Clinical Supervision brings a range of benefits to practice outcomes for Allied Health Professionals. These benefits are together considered so strong, that Health providers are now recognizing the risks of not supporting and promoting Clinical Supervision in their health professional workforce and many are mandating the practice” (HNELD Pol 13_01)  So, in terms of making Supervision a requisite for continuing professional practice, Psychologists are ahead of the game, and have been for some time.

14. The Psychology Board of Australia (PsyBA) regards the experience of Supervision as a component of Continuing Professional Development (CPD) indicating that it is ”… the means by which members of the profession maintain, improve and broaden their knowledge, expertise and competence, and develop personal qualities in their professional lives ... “ So that CPD encompasses all aspects of Supervision and ongoing education.

15. Yet, Supervision and mandatory training for Clinical Supervisors is not without its detractors, nor is it without some controversy. When this policy was first introduced by way of discussion paper, two Colleges of the Australian Psychological Society (APS) (Gonsalvez & Milne (2010) “were keen to see more evidence of the effectiveness of Supervisor training” Another “… wanted to see evidence of the effectiveness of Supervisor training programs implemented … in other states”.

16. What is the Supervisory process in Clinical Psychology and what is it meant to achieve? At its heart, Supervision is an interpersonal exchange. In this respect, whatever the aims of the relationship professionally and personally, for both the Supervisor and the Supervisee, the quality of that relationship stands out as being the single most important factor in considering effectiveness in Supervision.

17. Functions of Supervision. Across disciplines, Supervision is aimed at the provision of monitoring, guidance and feedback on matters of personal, professional and educational development in the context of the care of patients. (Kilminister & Jolly (2000) Three functions have been emphasized in the literature about Supervision: that, in essence, it has a: 1. Normative aspect (administrative), 2. Formative aspect (educational) and 3. Restorative function (supportive).

18. The process of Supervision may take many forms: Supervision as a 1:1 process where the Supervisor is the more experienced practitioner Within a group setting Between two clinicians as peer supervision

19. Supervision may also have different purposes Tutorial or Educational function Training Supervision Managerial Supervision Consultancy Supervision Peer Supervision It is important for the Supervisor to consider the nature of the supervisory contact between the Supervisor and the Supervisee, the parameters for the Supervisory experience, and the boundaries that obtain to these needs.

20. The most common problem occurs when two distinct roles merge: for example when a Supervisory experience becomes a management tool. Also, what aspects of the Supervisory relationship are confidential needs to be considered.

21. In time PsyBA may require more accountability around Supervision by means of recording contacts, and thought will need to be given then to the recording process and what aspects of Supervision can be transparent, as well as those aspects that cannot. Sensitivity is required by the Supervisor, who may have multiple roles with the Supervisee with respect to the risk that Supervision can be overly directive when there are management imperatives that need to be conveyed to the Supervisee.

22. Supervision that has more to do with bureaucratic process, rather than aims such as developing practice knowledge, enhancing skills, and ensuring that service delivery is profession-directed, is management. BUT, there needs to be recognition that, inherent in the Supervision contract, the Supervisor will be seen as having authority. In some instances – with 4+2 candidates, or Post-graduate students on placement – this authority will have a strong, structured evaluative aspect to it.

23. As a general rule, some evaluation always needs to be built into Supervision, simply to reflect upon, at each session, whether the goals of the Supervisee and the Supervisor, have been achieved, before Supervision moves on prematurely to the next issue. (Davys & Beddoe (2010) (p103-104).

24. Boundaries All relationships have their boundaries. All relationships require boundaries to some degree. In considering the aims of Supervision, following is a useful list of general conditions that provide a sense of how the relationship is constructed and contained:

25. Specification is required with respect to: • Aims of Supervision • Frequency • Duration • Cost (if any) • Confidentiality (and its limitations) • Accountability to professional or registration bodies and organizational policy • Interruptions • Issues of safety • Limits to clinical accountability (particularly if the Supervisor is not from the same profession) • Record keeping • Preparation • Agenda setting • Feedback and review • Processes for dealing with conflict and complaint • Relationship of Supervision to performance management, appraisal and counselling • Degree of access the Supervisee has to the Supervisor • Missed appointments

26. Contracting in Supervision – Vignette Looking at being open to how the Supervision will work best for the Supervisee, but also how it will meet the goals of the Supervisor: When discussing the Supervision contract, you and James discussed how he would like to receive feedback. He was keen to have his work looked at, but also felt that this would potentially create some difficulty for him. Past experience with Supervision, meant that James could see that feedback about his work, constructive criticism and the like, had created discomfort for him, and contributed to some avoidance. He thought that it might make him defensive to the point of not really listening to your feedback. In discussing this, James felt that the opportunity to be his own critic first might work best for him, so it was agreed that the format would be that you would seek James’ own assessment of the material presented to you before you offered any critique, and that this would be clearly prefaced by a cue for James, such as “now I will give you my thoughts on what you have presented” , to ensure that James was open to input. The decision was to review this structure after six months to see if it was meeting James’ goals ,and your goals in terms of the management of the Supervisory relationship.

27. Boundaries in context The context may set up other boundaries, for example, there may be different constraints around Supervision for Psychologists employed within Education, than those in Health. Particular parameters may also apply to Post-graduate students on placement. 4+2 Candidates have quite explicit and rigorous standards which apply to the Supervision they receive.

28. Supervision and Psychotherapy –Vignette Aimed to draw distinctions between the two, but also to see that the decision by Supervisor about what is the material for the Supervision, and what is not, is a difficult one at times: Your Supervisee reports feeling inadequate in his work with clients lately. At the same time, he reports that his life is “falling apart” but implies that this is a ‘no go ‘ area. You notice that, indeed, the Supervisee seems to be coasting with the clients presented, allowing some clients to set the running, and at other times moving clients away from exploring their insights into more general themes. Upon reflection, you feel that you too are coasting with the Supervisee, not addressing the difficulties that he is having, not drawing his attention the possible impact of his personal issues on his psychotherapeutic work, perhaps fearing that he might “fall apart” on you.

29. The nature of the relationship in Supervision. Clinical supervision is now recognized to be: “ … a designated interaction between two or more practitioners, within a safe and supportive environment, which enables a process of reflective, critical analysis of care, to ensure quality consumer services” (Clinical Supervision Guidelines for Mental Health Services – Queensland: available on the AHPRA website).

30. Supervision, What’s in it for you? 1. Supervisee 2. Supervisor

31. What’s in it for the Supervisee: Professional support An opportunity to off-load and reduce stress An opportunity to enhance knowledge and increase competence An opportunity to experience well-being and enhance professionalism

32. What’s in it for the Supervisor: • An opportunity to give back to the profession • An opportunity to learn about a fellow professional; the characteristics, insights and style of working of the supervisee; the particular work context of the supervisee; the characteristics of a different client group - that of the supervisee; the assessment skills highlighted with this client group; therapeutic goals for that client group; interventions that apply to this client group; the organizational principles and constraints the supervisee works within. • The opportunity to provide knowledge and foster competence • The opportunity to promote relevant policies and encourage practice that is evidence-based – through one’s own practice-based evidence • The opportunity to promote ethical practice

33. What is the supervisor/supervisee relationship essentially not about: • Management • Disciplinary process • Reportable process … yet • Individual Psychotherapy

34. Supervision is NOT psychotherapy, but some very similar conditions apply to the quality of the relationship that is set up between Supervisor and Supervisee when that relationship is going well. Consider the following, with respect to your own experience of good Supervision: What seems to apply and what does not?

35. PSYCHOTHERAPY: • Goals: • Relief of personal symptoms • Self-shifts in attitude • Fundamental changes in personality •  Fundamentals: • A working relationship between a trained MH professional and the person needing help to deal with emotional distress and/or poor functioning (relationship, work, social relationships) • The professional uses planned interventions according to psychological principles; therapy is aimed at improving self-awareness; therapists give long term emotional and practical support; therapy deals with a crisis or crises; therapies are aimed at improvement, by abolishing specific symptoms

36. What is it? • An emotionally charged, confiding relationship: • Unlike friendship • Expectation that therapist will be dependable and trustworthy • Issues raised may be deeply personal, distressing, or embarrassing • Therapist will be empathic, but sufficiently detached as to not be overwhelmed by what is raised

37. What is it? • It has a shared rationale: • Therapist provides an explanation of the problems and the intended methods for dealing with them. • This makes sense and is acceptable to the client.

38. What is it? • New knowledge is provided: • Arises from the relationship and emerges as part of the interchange. • Client obtains new information about himself, his situation, his problems and learns of new ways to change or challenge these things.

39. What is it? • Emotional arousal is facilitated: • The process of learning is not a cold, intellectual pursuit. • It encourages emotional expression • The client gets in touch with his feelings and this enriches the process

40. What is it? • It aims to instill hope: • Engagement with the professional raises the client’s hope for a positive outcome. • Therapist conveys optimism. • A therapeutic alliance is formed around hope and optimism.

41. What is it? • Success is experienced: • Course of treatment shifts concern • Mastery increases and the client no longer feels powerless and/or a victim.

42. What about counselling? Supervision is not a Counselling relationship either, but there are elements that are similar. Consider the following summary of what might constitute a relationship aimed at providing counsel, and consider whether Supervision encompasses some of these elements as well.

43. What is counselling? The aim is to help people make informed decisions about important matters and to assist in dealing with the impact of the decisions taken. Counselling and psychotherapy share many features, but counselling is distinct in that it is directed at assisting people of make critical decisions about their lives. These decisions might be about relationships, marriage, parenting and child management. In the work place, counselling might relate to educational and/or vocational choices, or it might arise from workplace issues and be about work practices. It might have a disciplinary aspect to it, where it is about job performance or training. It might be directed at conflict resolution or it it might deal with the effects of changes in employment or unemployment.

44. As with Psychotherapy, in Supervision, it is the relationship which matters most. For example, those attending workshops some years ago, conducted by Scott Miller, a visiting US psychotherapist and researcher, learned that there is no model or proven technique that guarantees successful outcome in Psychotherapy. Success hinges on the relationship established between therapist and client. The same may said of Supervision.

45. Let us consider further the nature of relationships as they occur in therapy and what we know of them. At the same time, consider that the same elements may apply equally to the relationship that is called Supervision.

46. There are often aspects to the therapeutic relationship which transcend, or perhaps underpin, the processes of history taking, symptom consideration and the formation of strategies These transactional elements relate to: TRANSFERENCE & COUNTERTRANSFERENCE

47. These concepts are drawn from the Psychoanalytic tradition. They provide a way of thinking about relationship formation and development generally, but also specifically, within Supervision. This is of particular relevance to the Supervisory relationship because of the power imbalance, and the traditional nature of Supervision which is hierarchical.

48. What is TRANSFERENCE? A Freudian concept relating to the phenomenon where an adult patient will re-enact or re-experience their childhood experiences of their parents and other authority figures, including siblings, within the therapeutic conversation. Freud noted that some of his patients attributed all kinds of things to him that had no foundation in objective fact. They expressed love or admiration or gratitude which was strangely out of place, or they expressed resentment, ridicule or hostility which was not justified by the therapeutic situation.

49. What is COUNTER-TRANSFERENCE? Respects the reality of transference as a matter of course in most human relationships and acknowledges that the therapist may experience similar feelings, or make similar ascriptions to his patients. So not only it is possible that the patient influences the therapeutic process with attitudes and behaviour’s irrationally based on earlier experiences, so might the therapist with his own. Unless, he is alerted to the problem and able to face his own previously unconscious biases.

50. Working with countertransference in supervision: Supervision provides a great opportunity to sensitize the Supervisee to these components of therapeutic interactions – of all interactions. Hearing the presentation of a case, the objective and detached ears of the Supervisor will pick up instances where the transference is occurring. Processing the case with the Supervisee enables the Supervisor to point out the reactions to the client that come from the Supervisee’s own unconscious. This will alert him to recurrent themes or to “spines” that will be brushed sometimes by some clients in some situations.