Clinical Supervision: The State of the Art Carol A. Falender and Edward P. Shafranske Pepperdine University Since the recognition of clinical supervision as a distinct professional competence and a core competence, attention has turned to ensuring supervisor competence and effective supervision practice. In this article, we highlight recent developments and the state of the art in supervision, with particular emphasis on the competency-based approach. We present effective clinical supervision strategies, providing an integrated snapshot of the current status. We close with consideration of current training C 2014 Wiley Periodicals, Inc. J. Clin. Psychol.: In Session practices in supervision and challenges.  70:1030–1041, 2014. Keywords: clinical supervision; competency-based supervision; supervision

The recognition of clinical supervision as a distinct professional competence and a core competency in psychology (Fouad et al., 2009; Kaslow et al., 2004), has been transformative, resulting in increased scholarship on supervision, development of guidelines and regulatory attention, and generally an increase in the identification of components of effective supervision (Falender & Shafranske, 2004, 2008, 2012; Ladany, Mori, & Mehr, 2013). More recently, greater attention has been placed on diversity factors, emphasizing multicultural supervision practice (Falender, Burnes, & Ellis, 2013; Falender, Shafranske, & Falicov, 2014). Competency-based supervision (Falender & Shafranske, 2004) is a metatheoretical approach that is compatible across psychotherapy-focused, feminist, multicultural, and other supervision models and offers enhanced accountability to ensure client welfare and development of clinical competencies (Farber & Kaslow, 2010). Competency-based supervision has the additional strength of organizing specific supervisor competencies for practice. In light of its intentional orientation to the articulation, assessment, and development of specific professional competencies, the approach is in sync with the competency movement in the United States and with professional psychology globally as international supervision regulations and training models are increasingly competency-based (e.g., Psychology Board of Australia, 2013). In this article, we highlight recent developments and the state of the art in clinical supervision with particular emphasis on the competency-based approach. We close with consideration of current training practices in supervision and challenges.

Definitions Multiple definitions of clinical supervision have been proposed (e.g., Bernard & Goodyear, 2014; Falender & Shafranske, 2004; Milne, 2009), reflecting differing viewpoints—recall the 1,000 blooming flowers of psychology (Fox & Barclay, 1989)—and increasing the complexity of studying, learning, and practicing clinical supervision. Definitions have emphasized different aspects of supervision, including the nature of the relationship (hierarchical vs. collaborative), critical factors involved in learning, the nature of the knowledge, skills and attitudes/values necessary for competence, approaches to assessment and feedback, and the necessity for a reflective approach for both supervisor and supervisee. Other definitions have emphasized the functions of supervision, including the need to ensure protection of the public, monitoring the quality of professional services, and gatekeeping, as References cited but not in the list are available from the author. Please address correspondence to: Carol A. Falender, 1158 26th Street, #189, Santa Monica, CA 90403; E-mail: [email protected]  C 2014 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(11), 1030–1041 (2014) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22124

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well as its role in enhancing life-long professional functioning. Milne (2009) pointed out that current definitions are problematic in that they lack specificity, do not account for interprofessional practice (i.e., practice across multiple mental health and medical disciplines), may not emphasize the critical nature of the supervisory relationship, and generally undermine efforts to systematically study supervision. As Kavanagh (2011) stated, “A competency emphasis requires clarification of the nature and theoretical grounding of competencies, and of the most effective methods to train and assess them, including an evaluation of problem based learning approaches and of optimal modes of supervision” (p. 65). An existing challenge is to facilitate a consensus about supervision (involving a precise, inclusive definition) while accommodating the different perspectives and varieties of supervision that are blooming. Falender and Shafranske (2004) defined clinical supervision as a distinct professional activity in which education and training aimed at developing science-informed practice are facilitated through a collaborative interpersonal process. It involves observation, evaluation, feedback, facilitation of supervisee selfassessment, and acquisition of knowledge and skills by instruction, modeling, and mutual problem-solving. Building on the recognition of the strengths and talents of the supervisee, supervision encourages self-efficacy. Supervision ensures that (it) is conducted in a competent manner in which ethical standards, legal prescriptions, and professional practices are used to promote and protect the welfare of the client, the profession, and society at large. (p. 3) In addition, they added metafactors or superordinate values: integrity-in-relationship, highlighting the major supervisory responsibility of modeling and embracing integrity in practice; ethical, values-based practice, attentive to values and beliefs across the supervision triad of client, supervisee/psychotherapist, and supervisor; appreciation of diversity and multiple cultural identities among the same triad; and science-informed, evidence-based practice, attentive to outcomes that have been identified as essential to supervision practice (Falender & Shafranske, 2004). More specifically, Falender and Shafranske (2007) defined competency-based supervision as “an approach that explicitly identifies the knowledge, skills and values that are assembled to form a clinical competency and develop learning strategies and evaluation procedures to meet criterion-referenced competence standards in keeping with evidence-based practices and the requirements of the local clinical setting” (p. 233). This definition provides a structure for establishing goals and the means to achieve the goals of supervision and to initiate a collaborative process of supervisee self-assessment, evaluation, planning, and monitoring. A foundational premise of this and other competency-based approaches is that through the incorporation of the competence model, clinicians will be encouraged and enabled throughout their professional careers to self-assess, directing attention to specific knowledge, skills, and attitudes/values required for contemporary practice (many of which build upon existing competencies). Such a model is based upon foundational and functional competencies identified by the profession (e.g., Benchmarks, Fouad et al., 2009; Hatcher et al., 2013) as the structure and vehicle for training, monitoring, and evaluation. There has been movement toward greater accountability and advocacy for advancing empirical support for supervision practice, leading to an international movement toward competencybased clinical supervision–for example, the American Psychological Association Board of Educational Affairs appointment of a Supervision Task Force to develop “Guidelines for Clinical Supervision in Health Service Psychology” (APA, 2014). In this article we address effective clinical supervision, providing an integrated snapshot of the current status.

Effective Clinical Supervision Effective supervision is defined as practice that encourages supervisee development and autonomy, facilitates the supervisory relationship, protects the client, and enhances both client and

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supervisee outcomes. The following statements present a composite of components of effective supervisor practices:

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Demonstrate respect for the supervisee and client(s); Collaboratively assess supervisee competence (with supervisee self-assessment and supervisor feedback) and develop goals and tasks to achieve these. Form a supervisory alliance; Identify strains to the supervisory relationship and work to repair them; Clarify and ensure understanding of supervisee roles and supervisor expectations. Assess, reflect on, and enhance specific supervisee competences; Collaboratively construct a supervision contract providing informed consent regarding expectations and supervisor and supervisee roles and responsibilities; Monitor, protect the client, and be a gatekeeper with transparency, sharing assessment of competencies with the supervisee. Gatekeeping refers to the supervisor responsibility to ensure the suitability of individuals entering the profession; Infuse awareness of the role diversity plays in clinical and supervision practice, including consideration of the multicultural identities of client, supervisee, and supervisor; Reflect on worldviews, attitudes, and biases, and infuse these in conceptualization, assessment, and intervention; Encourage and support supervisee reflection on clinical practice and the process of supervision; Engage the supervisee in skill development using interactive and experiential methods (e.g., role play, modeling); Attend to personal factors, unusual emotional reactivity, and countertransference and engage in management of these to inform the clinical process; Provide ongoing accurate positive and corrective feedback anchored in competencies; Observe directly—live or video—and use observation regularly to provide behavioral, anchored feedback on competencies and identified supervisee goals (Falender & Shafranske, 2014).

Supervisory Alliance Alliance is acknowledged as a metatheoretical essential component of supervision. It is the central feature that influences and (we theorize) is influenced by specific supervisory practices (best and worst). The alliance is developed through a collaborative process in which goals and the tasks to achieve these are identified, based in part on the supervisee’s self-assessment of competence. The supervisory relationship is grounded in respectful process (CPA, 2009) and is critical to managing conflicting role demands that can strain the supervisory alliance. The supervisory relationship is complex, with tension between the duty to protect both the client (and by extension the public) and the integrity of the profession while ensuring, promoting, and monitoring the development of requisite competence of the supervisee. A collaborative relationship emerges around the goals and tasks to achieve them, and exists within the supervisory power differential. Feminist, cognitive, psychodynamic, and family systems-oriented psychologists have all described supervisory relationships that are collaborative, with shared communication regarding client work and supervisee progress, and with a commitment to transparency such that feedback and evaluation are normative and not a surprise. The supervisory relationship is strongly connected to outcomes of supervision, at least from the supervisee’s perspective (Inman & Ladany, 2008). Pearce, Beinart, Clohessy, and Cooper (2013) developed and validated the Supervisory Relationship Measure, with factors of safe base (created by supervisor), supervisor commitment, trainee contribution, external influences (e.g., stressors, evaluation concerns, past experience of supervision), and supervisor investment, reflecting the fuller view of the complexity of the supervisory alliance. Both supervisees and supervisors reported feeling the supervision was a safe base in strong alliances. In addition,

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the scale was associated with and predicted supervisee clinical competence and supervisor satisfaction with supervision. In contrast, Rousmaniere and Ellis (2013) proposed a distinction between collaborative clinical supervision and the supervisory alliance and noted that in their sample supervisees reporting a high level of collaboration was rare. The Rousmaniere and Ellis scale deals explicitly with behavior and what is discussed in supervision as distinguished from attitudes and values including respect, fostering autonomy, or empowerment—a reflection of the essential tension of the relationship. The results of the study support the need for supervisor training to ensure a respectful, competent process. The alliance itself is a function of multiple factors, including the attachment histories and status of supervisor and supervisee (Gunn & Pistole, 2012), cultural identities of the participants (Son & Ellis, 2013), theoretical orientation of supervisor and supervisee (Watkins, 2011, 2013), diversity factors including gender (Hindes & Andrews, 2011) and race (Schroeder, Andrews, & Hindes, 2009), and supervisor style (Ladany, Walker, & Melincoff, 2001). Identification of strains and ruptures in the supervisory alliance and their repair are central supervisor competencies with direct effect on the clinical process (Falender & Shafranske, 2013; Safran, Muran, Stevens, & Rothman, 2008). When the supervisor notices a change in the supervisory alliance (e.g., a previously active and forthcoming supervisee suddenly becomes avoidant and withdrawn), the supervisor needs to reflect on the process of supervision that has occurred recently, weigh approaches to address the behavioral change, and discuss incident(s) that are indicative of a strain or rupture in the supervisory relationship. Strains or ruptures may be precipitated by misunderstandings, differing worldviews affecting client care, boundary conflicts, or even setting characteristics beyond the control of the supervisor (e.g., limited space, computers, clients). Results of a weaker or strained alliance between supervisor and supervisee include decreased supervisee disclosure (Mehr, Ladany, & Caskie, 2010), and even a perception of multicultural incompetence (Singh & Chun, 2010). In an analysis of the best and worst supervisory experiences, Ladany et al. (2013) concluded that the best supervisors were associated with supervisees who had a stronger emotional bond and greater agreement on tasks and goals of supervision, concluding that identified effective supervisor skills, techniques, and behaviors could be a framework for competence of supervisors. They also supported the highly interactive constellation of variables between supervisor and supervisee—that empowerment and encouraging autonomy in supervisees was well-received. They emphasized that supervisors should also be challenging, presenting feedback within the positive supervisory relationship. The supervisor who simply affirms supervisee behavior, sits remotely and offers little input, or is hesitant to reflect or challenge the supervisee is not demonstrating an essential component of effective supervision: providing ongoing corrective and positive feedback. Many supervisors harbor concern that feedback will damage the supervisory relationship and is to be avoided—a major misconception addressed later. Exploring supervisee process and behavior during a video review of a session, the supervisor may reflect upon the client’s response to an intervention and link the feedback to an ongoing supervisee goal (e.g., integrating consideration of the client’s worldview). We turn now to consideration of diversity and personal factors, which play a significant role in both clinical and supervisory relationships.

Diversity An ethical imperative underlying all clinical practice and supervision is diversity competence. We have defined supervision diversity competence as

incorporation of self-awareness by both supervisor and supervisee . . . an interactive encompassing process of the client or family, supervisee-psychotherapist, and supervisor, using all of their (multiple) diversity factors. It entails awareness, knowledge, and appreciation of the interaction among the client’s, supervisee/psychotherapist’s, and supervisor’s assumptions values, biases, expectations, and worldviews; integration and practice of appropriate, relevant and sensitive assessment and intervention

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strategies and skills; and consideration of the larger milieu of history, society, and socio-political variables. (Falender & Shafranske, 2004, p. 125) Although greater attention is being directed to diversity, still data are emerging that supervisors often are not initiating consideration of multiple diversity factors in supervision, nor are factors of privilege, historical trauma, and oppression being addressed (Falender, Shafranske, & Falicov, 2014; Hernandez & McDowell, 2010). Specific competence is needed to address the multiple identities (e.g., race, socioeconomic status, sexual orientation, gender identity, ethnicity, religion, disability, age) among client, supervisee/psychotherapist, and supervisor to consider the multiple worldviews and the effects of these upon the assessment and treatment of the client. Addressing these diversity competence factors and providing feedback and training when supervisees do not demonstrate adequate competence are important supervisor responsibilities. In the collaborative supervisory relationship, the supervisee is empowered to address diversity issues such as generation (age) and culture to reflect on different perspectives. For example, a supervisee may note that the presentation or communication style of the adolescent client is actually not dissimilar to the youth’s peer group. Several recent legal decisions provide supervisors guidance when a supervisee challenges remediation plans—resulting in one specific case from refusal to work with a client whose life style was in conflict with the religious beliefs and values of the supervisee–as a violation of his or her Constitutional rights to freedom of speech and religion (Behnke, 2012; Hutchens, Block, & Young, 2013). Consensus exists that graduate programs may impose ethical mandates on students and require them to provide services respectfully and affirmatively to clients regardless of their sexual orientation and diversity status. Supervisors should ensure clarity of rules and policies regarding gatekeeping and referrals of cases assigned to supervisees; provide clear, direct written and verbal feedback about supervisees’ ethics and professionalism; identify performance issues; develop a remediation plan with specified behaviors and timelines; carefully document each step; and continuously assess suitability to enter the profession of psychology including the supervisee’s professionalism and ethical compliance (Falender & Shafranske, 2013a; Johnson et al., 2008). Standards of professionalism and ethical practice, including in the context of working with clients who vary in diversity identity from the supervisee, need to be engrained in graduate training programs. Trainees should be expressly advised that the expectation is not to give up their personal and/or religious values, but that they are expected “to attain both demographic competency [in regard to all forms of diversity, e.g., age, gender, ethnicity, religion/spirituality, and sexual orientation] and demonstrate the competence of dynamic worldview inclusivity” (Bieschke & Mintz, 2012, p. 202).

Addressing Personal Factors and Countertransference in Supervision Personal factors consist of beliefs, attitudes, life experiences, personality and interpersonal styles that emanate from sources outside of graduate education, clinical training, and professional practice. Clinical supervision provides the context for novice clinicians to develop appreciation for the role that personal factors play in their conduct of psychotherapy (Falender & Shafranske, 2004, 2012). Consistent with efforts to gain awareness of the influence and interactions of multicultural identities in clinical and supervisory relationships, supervision aims to enhance awareness of the psychotherapist’s own contributions to the treatment process. Supervisors play a pivotal role in modeling the importance of personal factors, including the role of diversity, by drawing attention to the (often subtle) influences affecting both the supervisory and clinical relationship. Developing awareness of personal factors should be not only included in the supervision contract but also actively demonstrated by the supervisor in his or her conduct of supervision. Countertransference stands out among the potential effects of personal factors on the clinical process. Originally conceptualized within the psychoanalytic tradition, countertransference is recognized more broadly as a class of clinical phenomena in which “distinctly different, unusual,

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or idiosyncratic acts or patterns of therapist experience or behavior” appear (Kiesler, 2001, pp. 1061–1062). Gaining awareness of and managing countertransference reactions is an important clinical responsibility (Gelso, Hayes, & Hummel, 2011) and a competency to be developed in clinical supervision (Shafranske & Falender, 2008). Exploration of countertransference is a significant informer of treatment, providing insight into the effect the supervisee’s personal factors have in guiding or limiting therapeutic exploration. Supervisees normatively experience varying intensity of emotional reaction to a client but may feel uncomfortable bringing this to supervision, instead redirecting the client away from intense material, or simply terminating the therapy. Given its personal nature, supervisors must be particularly mindful (no matter their theoretical orientation) to delimit exploration of personal factors and countertransference to their effect on the supervisee’s understanding and therapeutic engagement with his or her client and the supervisory relationship. If the distinction between supervision and psychotherapy is not upheld, then high risk exists that the dyad slides down the slippery slope of engaging in treatment (Frawley-O’Dea & Sarnat, 2001; Shafranske & Falender, 2008). The quality of the supervisory working alliance appears to affect the likelihood of countertransference disclosure (Shafranske & Falender, 2013). In addition to fostering an effective alliance, it is recommended that supervisors include management of countertransference as a competency to be developed in the supervision contract; regard countertransference as an informer of the therapeutic process; model and give examples of their use of countertransference; and reinforce supervisee efforts to bring countertransference into awareness. Videotape review, self-directed journaling, and Interpersonal Process Recall (IPR; Kagan, 1980) facilitate identification of markers of countertransference. IPR is a supervision technique that entails a collaborative supervisor–supervisee video review of the client session attending to emotional and cognitive responsivity of minute sequences of the interaction.

Competences, Self-Assessment, Feedback, and Evaluation Self-assessment is a significant aspect of competency-based clinical supervision as is ongoing self-monitoring of performance (Epstein et al., 2008). Self-assessment is based on the supervisee’s reflective capability to determine competency areas of strength and those in development. Skill in self-assessment is key to ensuring continuing competence (Eva & Regehr, 2013). Regehr and Eva (2006) concluded that self-assessment entails the interaction of cognitive and metacognitive theory, social cognitions, and reflective practice, and thus has been difficult. Neither psychologists nor physicians have excelled in self-assessment of competence (Dunning, Heath, & Sills, 2004; Williams, Dunning, & Kruger, 2013), with poor performers reporting highest (and most inflated) views of their performance. However, regular and routine feedback is highly effective in enhancing accuracy of self-assessment, especially if anchored in behavioral ratings. An evolving standard of practice is supervisee ongoing self-assessment combined with faculty appraisals of supervisee development of competencies, anchored in competencies agreed upon by the profession (Kamen, Veilleux, Bangen, VanderVeen, & Klonoff, 2010), a technique that is being adopted in multiple training settings using a frame such as Competencies Benchmarks (Fouad et al., 2009; Hatcher et al., 2013). The collaborative assessments set the baseline for development of the supervisory alliance and the supervision contract from which monitoring and evaluation follow (Falender & Shafranske, 2012). The supervisee first self-assesses on the competency document (e.g., Fouad et al., 2009) after being informed that it is more desirable to identify areas to work on because assessment of areas of relative weakness is a competency. Then the supervisor provides ongoing feedback on the supervisee’s ratings, ideally from video or live review of the supervisee’s clinical work. Standardized narratives are being used as assessment and feedback devices with some success (Regehr et al., 2012). An example is the formalized summative evaluations of competency using Objective Structured Clinical Examination (OSCE), similar to those conducted formatively and summatively in social work (Bogo et al., 2011) and medicine (Khan, Ramachandran, Gaunt, & Pushcar, 2013). In these assessments, the supervisee is assigned a standardized pa-

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tient to diagnose and develop a treatment plan. The assessment is observed with the supervisee self-assessing prowess and supervisors rating and providing competence feedback and evaluation useful in the supervision process. The competency-based frame is a significant tool to enhance goal setting, assessment feedback, and evaluation of targeted competencies.

Ethical and Legal Competencies The Supervision Contract The supervision contract integrates all the components of supervision and addresses the ethical standard of informed consent (Thomas, 2010). This informed consent document combines the expected competencies of the setting and supervisor with the supervisee self-assessment to ensure an integrated plan for supervision. The contract lays out the expectations for supervisor and supervisee roles and responsibilities, the goals and tasks to achieve them specific to the supervisee (making this a “living document” that is modified with the supervisee’s progress to achieve goals and formulate new ones). The contract lays out the duties of the supervisor, including protection of the client as the highest priority, clarification of the supervisor’s multiple and potentially conflicting roles of client protection and gatekeeper for the profession, and balanced with the role of enhancing and facilitating the growth and development of competence of the supervisee. The contract clarifies the potential role conflicts the supervisor and supervisee may encounter as the supervisor performs these multiple roles. The contract contains general and setting-specific information as follows:

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Scope of practice under supervision Length of contract period Specific roles and expectations of the supervisor and supervisee (e.g., self-assessment, productivity, frequency of supervision, policies regarding cancellations and emergencies) Expected processes (e.g., modeling, role play) Expected preparation (e.g., case conceptualizations, timing to provide video recordings to allow supervisor review, summary of evidence-based practices for individual cases) Expectations regarding ongoing and timely supervisor feedback anchored in competencies and linked to a stated number of live or audio reviews of clinical work and of two-way feedback (supervisee to supervisor) regarding process as well as progress Expected identification of areas of competence not developing normatively, and expectations for successful completion of the contract and process if expectations are not being met Specification of evaluation measures and timing of those Specification of limits of confidentiality (e.g., supervisory responsibility to report to training teams, graduate program, licensing board, and highest duty to maintain of protection of the client), with reference to ethics standards and code of ethics (APA 2010), relevant state laws (e.g., duty to warn and protect and child abuse mandatory reporting), and state licensure regulations and site personnel practices Expectation that personal factors and experience will be a part of clinical supervision (previously stated in recruitment materials as per APA, 2010, 7.04) Explication of the possibility that the supervisee will need to seek psychotherapy or other supportive work should personal issues be beyond the purview of supervision Expectations relevant to the needs of specific settings (e.g., boundary expectations, multiple sites with different responsibilities) and expectations associated with the responsibility for required documentation of supervision sessions.

The supervision contract is not a static document, nor are its components. The evolving nature of professional practice, clinical training and supervision, and societal changes necessitate ongoing reflection on establishing clear and reasonable standards and expectations. One example of the need for ethical responsiveness to cultural changes is found in the use of the Internet– including social networks and search engines—and the boundary issues that ensue from such use. These issues are discussed in the following section.

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Internet The Internet has brought new challenges to clinical supervision, often reflected in the competence and worldview perspective differences between supervisees and their supervisors. Supervisees may be highly fluent in all aspects of social networking and search engines and consider them intrinsic in all interactions (Myers, Endres, Ruddy, & Zelikovsky, 2012). For example, supervisees may use search engines to obtain information about clients or supervisees, they may connect (or “friend”) clients on social networks, and/or they may text or e-mail clients. Although most supervisees believe it is unethical and inappropriate to use search engines or social networks to find client information, the vast majority of supervisees have nevertheless reported that they did access such information–although most reported the search or contact was planful and the client was aware of the search (DeLillo & Gale, 2011). The supervisor is responsible for ensuring that attention to standards of professionalism and ethical problem solving are brought to bear on emerging Internet issues. Some proposed areas to discuss or incorporate into the supervision contract (derived from DeJong et al., 2012) include acknowledging different generational attitudes (e. g., among supervisor, supervisee, and client[s]) toward digital media; modeling and discussing Internet professionalism explicitly, enlisting active learning including role play and vignettes derived from the supervisees to ensure understanding and ethical compliance in Internet practice (e.g., netiquette, boundaries, safety issues); discussing and providing readings and guidelines on professionalism and ethics; and ensuring a professional online footprint with the understanding that the boundaries between professional and personal are vastly diminished with Internet search engine access. As with all supervision practice, Internet practices should be guided by the ethical principles and code of conduct and emerging standards that are articulated in supervision contracts.

Clinical Supervision Illustration The following illustration is drawn from a supervision session that focused on the management of countertransference. The supervisee (CB) was a third-year female doctoral student in a secondary practicum rotation in a university-based outpatient community clinic. Consistent with the competency-based approach, specific training goals and competence objectives were discussed and mutually agreed upon at the beginning of the rotation. One of her goals was to enhance her comfort and skill at integrating principles and techniques from psychodynamic psychotherapy, particularly in respect to addressing client affect and her own awareness and use of emotion, to complement her developing strengths in cognitive-behavioral therapy. She began supervision commenting that she observed in a recent session that she shifted focus away from the client’s immediate emotional experience in asking a series of questions. The supervisor (ES) nodded approval and asked her to describe a particular moment when these dynamics began to emerge. CB described the events around the time the client “burst into tears.” CB: I noticed from reviewing the videotape [essential to the competency-based model], that when she [the client] started to cry, I tended to just jump in and ask her a number of questions... I wasn’t clear about the connection she was talking about, so I asked her a lot of questions. I worry that my quick interventions might’ve led her away from her affect in that moment. ES: Is that what, in fact, happened? How emotionally engaged was she, when you were asking the questions? CB: [Described the interaction in depth and concluded]: Well, she stayed in the affect for maybe, like three or four minutes, but I wish it could’ve been longer. CB was aware that she had become uncomfortable and thought it would be useful to learn about how she might have better addressed and “harnessed” the affect in the session. ES then asked CB to share her thoughts about the role of affect in therapy in general and in this case

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specifically. This intervention aimed at assessing and exploring her knowledge before turning to an exploration of skills. She briefly described the importance of emotion and obtaining a balance between thinking and feeling. ES summarized that one of the clinical goals was helping the client to develop greater competence in being able to “feel her affects, to modulate them appropriately, and to express them.” Here the supervisor shifted emphasis from exploring the supervisee’s beliefs and reactions to teaching. The supervisor–supervisee dyad then returned to a discussion of the clinical interaction and CB described the client’s obvious discomfort, wiping her tears and looking up at the ceiling in an effort to stop crying. ES: What was that like for you? CB: I think she was wanting to escape it; I could tell, you know, that she was really wanting this not to happen. And she was confused by it, made me kind of feel like I needed to fix that for her and take away the painful affect, while also trying to find out why, and help her, like, un-muddle her confusion at the time. [She described the questions she asked and posited that she might have colluded with her client by taking her away from her feelings, as if they were unacceptable]. [ES then framed the discussion by exploring whether she believed her interventions reflected responsive or reactivity, drawing upon a transtheoretical model of countertransference (Shafranske & Falender, 2012), which had been introduced earlier in supervision. CB reflected that her responses seemed to reflect both and commented]: CB: .Though I might say that my rationale and reasoning was based on the CBT model, I think a lot of it was my own kind of wanting to save her from her from her feeling uncomfortable, which made me feel uncomfortable that I couldn’t help her right then. ES: I really appreciate you talking about this [intended to compliment and reinforce her self reflectivity, willingness to talk about her reactions, and professional values– the ability to reflect and to use supervision effectively involves a supervisee’s values and professionalism], and you know most of our clinical decisions are probably going to be a confluence of personal reactivity plus a reactive responsiveness plus our training... I’d imagine it’s not one or the other, it’s usually a combination of both [A form of self-disclosure and teaching aimed at normalizing her experience and encouraging further exploration.] CB reflected further and noted that her reactions might have been caused in part by her similarity to the client in age, gender, and shared developmental issues. ES then introduced a psychoanalytic notion about intersubjective conjunctions and disjunctions and the challenges involved therein [teaching function aimed at enhancing knowledge regarding personal factors and the mutual influence of multicultural identities.] Later in the session, ES asked if there was something else he could do that would be helpful and CB suggested that he give an example of how he would have dealt with such a situation [explicitly focusing on skills]. ES: Well there were probably moments I reacted like you did [intending to further normalize and to model openness]. . . . Things get stimulated and so we may notice ourselves doing things like asking a lot of questions, or shifting focus, maybe intellectualizing, so I think that’s certainly something I can recognize in myself [and] doing that sometimes. It might be very subtle [rather than in dramatic moments]. . . . [ES then described a clinical interaction with a client who had been terribly abused] I found myself welling up with feeling, and what I found was helpful was actually to move more into her experience, rather than to worry about my eyes filling up with tears. . . . I relaxed for a moment, took a deep breath and tried to enter more

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into her world. And if I wanted to ask a question, it wouldn’t be like a series of questions, it might be like, “tell me more” in order to bring in the processing of the experience in the moment.

This led to further consideration of possible actions the therapist might have taken and the session ended with a summary of the major points, including discussion of countertransference management as a competence (knowledge) and further reinforcement of the supervisee’s excellent use of supervision (skills and values). The supervisor was mindful to consider each of the components of competence–knowledge, skills and attitudes/values–and to situate the discussion as congruent both to her training goals and with the Competencies Benchmarks (knowledge; Fouad et al., 2009).

Supervisor Training: Status and Challenges Generally, consensus exists that supervision practice requires specific dedicated training (Bernard & Goodyear, 2014). Training should begin with enhancing the competence of supervisees to be effective in that critical role (Falender & Shafranske, 2013a). Even though an accreditation requirement, individuals in the training pipeline are not consistently receiving adequate or, in some cases, any supervision training (e.g., in Canada: Hadjistavropoulos, Kehler, & Hadjistavropoulos, 2010; in United States: Crook-Lyon, Presnell, Silva, Suyama, & Stickney, 2011; Lyon, Heppler, Leavitt, & Fisher, 2008). When training in supervision is given, there is great variability in its nature and quality. For example, in Canada accredited training programs reported that although approximately 50% of programs required some coursework in clinical supervision, the amount and content were highly variable, with, for example, only 46% addressing liability issues (Hadjistavropoulos et al., 2010). About a quarter reported peer supervision and an additional 40% an elective with opportunity for supervision experience. In the United States, Lyon et al. (2008) reported that among interns, 39% completed a course in clinical supervision (26% clinical; 73% counseling) and 61% reported no coursework in this area. Over half of internships offered no supervision training. Generally, the major influence on supervision practice was judged by trainees to be the personal experience of having been supervised (Crook-Lyon et al., 2011) so that requisite supervisor competencies (Kaslow, Falender, & Grus, 2012) are not being transmitted. Enhancing both graduate education and training in clinical supervision, including supervision of supervision, appears necessary given its importance in assuring client welfare, performing gatekeeping responsibilities, and providing the quality of supervision required for effectiveness. This requires a commitment of resources within educational and clinical training institutions at a time when available resources (time, staff, budget) are often stretched to the limit. While taking into consideration the practical, day-to-day economics in mental health service delivery and training, it is necessary, given the enormity of responsibility, to ensure that those providing clinical supervision possess the needed competencies and the time to provide it effectively. A central concern is that ineffective or insufficient supervision occurs and is not monitored in current conditions in which a lack of supervisor accountability may exist.

Transforming to Competency-Based Supervision Discussion of competency-based supervision may be confusing. In reality, a competent approach to any clinical supervision is competency-based as it entails assessing the supervisee’s competencies, adjusting supervision to where the supervisee is currently functioning, monitoring the supervisee’s development and ensuring accurate and timely feedback so the supervisee is fully cognizant of areas needing improvement, and generally attending to client outcomes as an important aspect. The transformation to competency-based supervision, occurring across specialties (e.g., Grus, 2013; Stucky, Bush, & Donders, 2012), is broad-based, with impetus to change viewpoints of training in supervision, assessment of supervisor competence, and competency-based licensure, accreditation.

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The movement toward evidence-based clinical supervision (Milne, Sheikh, Pattison, & Wilkinson, 2011), another aspect of transformation, provides normative inclusion of outcome assessment in clinical supervision—determining and studying input to the supervision process, requisite training, and outcomes of supervisee competence and client symptom reduction. We would add ongoing consideration of client self-report of outcomes in the supervision session (Reese et al., 2009). That is, evidence-based clinical supervision refers to specific practices (skills) that are supported by evidence as well as to systematic analysis of efficacy. In their review of dissemination and implementation of evidence-based practices in child and adolescent mental health, supervision and fidelity were the factors with most empirical support (Novins, Green Legha, & Aarons, 2013). Kaslow et al. (2012) proposed that psychologists need to enlist transformational leadership skills to change the nature of training and to encourage the implementation of competencybased clinical supervision. Such a strategy would assist in changing the conception that clinical supervision is adequately conducted based on personal experience or through osmosis. Instead it would reinforce the concept that supervision is a distinct professional competency requiring specific training and comprising specific and systematic supervision including all the component knowledge, skills, and attitudes associated with effective supervision practice. A result will be increased accountability, attention to supervisee competence development, and support to address or to remediate competencies that are not developing sufficiently. Substantial evidence exists that such transformation is overdue. Failure to orient focus on competence jeopardizes client welfare as well as professional development. The transformation will require, in addition to a commitment to the model, significant efforts to ensure that human resources (i.e., allocation of sufficient professional time) are made available for training and supervision. Although the trajectory of such transformational change is complex, implementation of explicit competency-based approaches to clinical supervision is essential to meet the responsibilities of clinical training.

Selected References and Recommended Reading American Psychological Association (2014). Guidelines for clinical supervision in health service psychology. Retrieved from: http://apa.org/ed/resources/index.aspx Behnke, S. H. (2012). Constitutional claims in the context of mental health training: Religion, sexual orientation, and tensions between the first amendment and professional ethics. Training and Education in Professional Psychology, 6, 189–195. doi:10.1037/a0030809 Bieschke, K. J., & Mintz, L. B. (2012). Counseling psychology, model training values statement addressing diversity: History, current use, and future directions. Training and Education in Professional Psychology, 6, 196–203. doi:10.1037/a0030810 Canadian Psychological Association Committee on Ethics Supervision Guidelines Sub-Committee. (2009). Ethical guidelines for supervision in psychology: Teaching, research, practice, and administration. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/COESupGuide RevApproved7Feb09revisedfinal.pdf Crook-Lyon, R. E., Presnell, J., Silva, L., Suyama, M., & Stickney, J. (2011). Emergent supervisors: Comparing counseling center and non-counseling center interns’ supervisory training experiences. Journal of College Counseling, 14, 34–49. Retrieved from http://www.counseling.org/Publications/Journals.aspx DeJong, S. M., Benjamin, S., Anzia, J. M., John, N., Boland, R. J., Lomax, J., & Rostain, A. L. (2012). Professionalism and the Internet in psychiatry: What to teach and how to teach it. Academic Psychiatry, 36(5), 356–362. doi:10.1176/appi.ap.11050097. DiLillo, D., & Gale, E. B. (2011). To Google or not to Google: Graduate students’ use of the Internet to access personal information about clients. Training and Education in Professional Psychology, 5, 160–166. doi:10.1037/a0024441 Dunning, D., Heath, C., & Suls, J. M. (2004). Flawed self-assessment: Implications for health, education, and the workplace. Psychological Science in the Public Interest, 5(3), 69–106. doi:10.1111/j.15291006.2004.00018.x Falender, C. A., Cornish, J. A. E., Goodyear, R., Hatcher, R., Kaslow, N. J., Leventhal, G., . . . Sigmon, S. T. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60(7), 771–785. doi:10.1002/jclp.20013

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Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Falender, C. A., & Shafranske, E. P. (2012). Getting the most out of clinical training and supervision: A guide for practicum students and interns. Washington, DC: American Psychological Association. Falender, C. A., & Shafranske, E. P. (2014). Clinical supervision in the era of competence. In W. B. Johnson & N. Kaslow (Eds.), Oxford Handbook of Education and Training in Professional Psychology. (pp. 291–313). New York: Oxford University Press. Falender, C. A., Shafranske, E. P., & Falicov, C. (Eds.). (2014). Multiculturalism and diversity in clinical supervision: A Competency-based approach. Washington, DC: American Psychological Association. Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. S., Madson, M. B., . . . Crossman, R. E. (2009). Competency benchmarks: A model for understanding and measuring competence in professional psychology across training levels. Training and Education in Professional Psychology, 3(4 Suppl), S5-S26. doi:10.1037/a0015832 Hatcher, R. L., Fouad, N. A., Grus, C. L., Campbell, L. F., McCutcheon, S. R., & Leahy, K. L. (2013). Competency benchmarks: Practical steps toward a culture of competence. Training and Education in Professional Psychology, 7(2), 84–91. doi:10.1037/a0029401 Hernandez, P., & McDowell, T. (2010). Intersectionality, power, and relational safety in context: Key concepts in clinical supervision. Training and Education in Professional Psychology, 4, 29–35. doi:10.1037/a0017064 Hutchens, N., Block, J., & Young, M. (2013). Counselor educators’ gatekeeping responsibilities and students’ first amendment rights. Counselor Education and Supervision, 52, 82–95. doi:10.1002/j.1556– 6978.2013.00030.x Johnson, W. B., Elman, N. S., Forrest, L., Robiner, W. N., Rodolfa, E., & Schaffer, J. B. (2008). Addressing professional competence problems in trainees: Some ethical considerations. Professional Psychology: Research and Practice, 39, 589–599. doi:10.1037/a0014264 Kaslow, N. J., Borden, K. A., Collins, F. L., Forrest, L., Illfelder-Kaye, J., Nelson, P. D., . . . Willmuth, M. E. (2004). Competencies conference: Future directions in education and credentialing in professional psychology. Journal of Clinical Psychology, 60, 699–712. doi:10.1002/jclp.20016 Kaslow, N. J., Falender, C. A., & Grus, C. (2012). Valuing and practicing competency-based supervision: A transformational leadership perspective. Training and Education in Professional Psychology, 6, 47–54. doi:10.1037/a0026704 Kiesler, D. J. (2001). Therapist countertransference: In search of common themes and empirical referents. Journal of Clinical Psychology, 57(8), 1053–1063. doi:10.1002/jclp.1073 Ladany, N., Mori, Y., & Mehr, K. W. (2013). Effective and ineffective supervision. The Counseling Psychologist, 41, 28–47. doi:10.1177/0011000012442648 Milne, D. L. (2009). Evidence-based clinical supervision: Principles and practice. Malden Leicester England: Blackwell Publishing. Milne, D. L., Sheikh, A. I., Pattison, S., & Wilkinson, A. (2011). Evidence-based training for clinical supervisors: A systematic review of 11 controlled studies. The Clinical Supervisor, 30(1), 53–71. doi:10.1080/07325223.2011.564955 Myers, S. B., Endres, M. A., Ruddy, M. E., & Zelikovsky, N. (2012). Psychology graduate training in the era of online social networking. Training and Education in Professional Psychology, 6(1), 28–36. doi:10.1037/a0026388 Pearce, N., Beinart, H., Clohessy, S., & Cooper, M. (2013). Development and validation of the supervisory relationship measure: A self-report questionnaire for use with supervisors. British Journal of Clinical Psychology, 52, 249–268. doi: 10.1111/bjc.12012 Reese, R. J., Usher, E. L., Bowman, D. C., Norsworthy, L. A., Halstead, J. L., Rowlands, S. R., & Chisolm, R. R. (2009). Using client feedback in psychotherapy training: An analysis of its influence on supervision and counselor self-efficacy. Training and Education in Professional Psychology, 3, 157–168. doi:10.1037/a0015673 Thomas, J. T. (2010). The ethics of supervision and consultation: Practical guidance for mental health professionals. Washington, DC: American Psychological Association.

Clinical supervision: the state of the art.

Since the recognition of clinical supervision as a distinct professional competence and a core competence, attention has turned to ensuring supervisor...
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