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The Supervision Quarterly

Winter 2016

Welcome to the Winter Edition of
The Supervision Quarterly

In this edition:

Models and techniques for clinical supervision

This edition will look at a variety of methods and techniques which you can use to enhance the effectiveness of supervision. 

Regardless of whether you are engaged in peer, individual or group supervision, it is important to work out the best method/s to use to help each supervisee learn and grow. By far the most common form of supervision is a verbal case presentation. Whilst a vast array of information can be covered in this type of presentation, it limits supervisee learning as it does not provide an opportunity for the supervisor to accurately assess supervisee skills.  What is said is done in practice does not always equate with what the supervisee actually does in practice! This edition will provide a summary of the different methods and techniques you can apply in supervision to ensure greater variety, engagement and learning opportunities.
 
The following table provides a summary of the different methods and techniques that should be used to enhance the supervisory process, learning and review supervisee competencies:
Models and Techniques for Enhancing Clinical Supervision

1. Case Presentation
  • Provides a structured format with clear questions for assessment and formulation
 
2. Writing Activities
  • Journaling
  • Activity log
  • Simulated case reviews
  • Worksheets
 
3. Live Observation
  • Observing client interview (within room)
  • Behind one way screen
            
4. Audio/video recording
  • Review audio or video of an interview
 
5. Experiential methods
  • Role play
  • Role reversal
  • (using genograms, family sculpting, art therapy, whiteboard work, genograms)

1. Case Consultation/Presentation

Case presentation is the most common method used in supervision.  Generally a supervisee is provided a case presentation/case review form to complete prior to supervision. The advantages of the form is that it creates structure, identifies goals and purpose for the discussion and can be tied to the contract and learning objectives

-> Example of a form that provides a framework for discussion.

A simple case presentation form provides a good structure and has the advantage of being able to be completed relatively quickly before the supervision session. 

You can add any number of sub-headings that will open up further exploration of learning goals (e.g. ->  4 P’s of biopsychosocial formulation).
 
By encouraging your supervisee to fill out a case presentation form prior to the session, it means they have done some pre-thinking about:
  • the reason/s they are presenting the case for discussion;
  • what their question is for supervision; and  
  • possible hypotheses.
It also means that you can possibly cover more material in the one session!

Recommendation

  1. Teach your supervisee to complete the form in preparation for supervision – make it a habit
  2. Always ensure they come prepared with a question for supervision – ‘what do you want help with’?
  3. Decide if you want a quick overview of all or most cases or if one or two cases will be explored in depth.

Benefits of Case Consultation

  1. Clear and succinct goals can be easily articulated
  2. Structured in a way to reflect on theoretical framework, assessment and treatment
  3. Teaches supervisees to think about the questions they need answered or help with/teaches case conceptualisation.
Promotes self-awareness and organisational skills (be prepared for the supervision session).

Disadvantages

  1. Can cover up a myriad of practice issues (don’t actually get to see the supervisee in action) …it is only self-report (possible deception)
  2. Too much structure might restrict creativity
  3. Expectation that the supervisee knows what the important elements are to report
  4. Might miss potential problems and as such limits the supervisors effectiveness as a teacher and trainer

2. Writing Activities

Preparing the supervisee to use written formats in supervision is helpful as it provides an alternative medium for reviewing clinical practice both within and outside the supervision session. 

The different types of written techniques include:
  • Activity log book
  • Journal writing
  • Process recording

Activity log book

The log book ensures that the supervisee maintains an accurate record of the material presented in supervision.  It allows you to record material presented and compare what, when and how clinical competencies are discussed. Make it a habit that your supervisee brings their activity log book to supervision AND complete on the spot!
Doing it retrospectively leaves too much to error and possible deception.  Leave 5 minutes at the end of the session for your supervisee to enter material discussed and any evaluative comments (or signatures) that you need to add because if you leave it until the end of the month, or worse still, at the end of the contract period you simply won’t remember the intricacies of what was discussed and any evaluative comments you need to make.
 
Most interns or newly graduated practitioners need to keep a daily log of activities or process record so it is important to provide opportunities within the supervision session to reflect on the material that is entered in the log book. It is also important to encourage experienced clinicians to keep a record of their CPD throughout the year rather than just at the end of the reporting period! Model best practice yourself as the supervisor by demonstrating your adherence to this practice.

Journal Writing

Keeping a journal of important issues that might arise outside the supervision session encourages independent thinking and enhances self-awareness. 

How it is done
1. Introduce journal writing as a supervision technique when first meeting and establishing your working alliance
2. Find an opportunity in the supervision session where you might introduce the supervisee to reflect on the topic, theme, issue discussed and ask them to journal any thoughts/ideas about the issue outside the session AND then bring to the next session
3. Review the journal – questions like ‘what did you notice when you reviewed your journal?.....what do you see as the core theme or themes that stand out for you? …….how did writing and thinking about the issue help you work towards resolving or managing the issues/feelings etc., ‘ The journal is a tool that when used wisely in supervision acts as a self-supervision technique. 

Often I find that supervisees do their own problem solving outside the session by writing down their ideas and reflecting on the themes and ideas that stand out.  It is also a great way to externalise negative emotions that might be brewing and act as a great self-care intervention.

Thompson (2010) provides a useful document that outlines some of the benefits of journal writing http://journaltherapy.com/wp-content/uploads/2011/01/TWI_ThompsonFINAL.pdf

Process recording of interview

 
Process record keeping of the client session is another great tool to vary the presentation of material in supervision. In this technique supervisees are asked to write up an account of the session immediately or soon after the session. 
 
Divide the page in half – on the left side the supervisee is asked to record the session, or part of the session, as accurately as possible.
 
On the right side the supervisee is asked to process their thoughts and feelings in relation to the material presented (and their Reponses).
Session Recount
 
Therapist: So what do you want to talk about today?
 
Client: I really don’t know where to start….. (silence for one minute)

Therapist: pause…….what’s on your mind?

Client: I have something really difficult to tell you and I don’t know where to begin

Therapist: ……hmmmm……..what would help you to start to tell me about it?
Clinical Reflections

I felt nervous as this is the first time that have seen a client myself in the clinic
 
 

I didn’t know where to start
 
 
 


I felt that they were holding back and I wanted to use a structured assessment tool rather than sit with the awkwardness and silence…….
The supervisor helps explore and unpack the supervisee’s hypotheses about the clinical presentation, review the theoretical framework to consider the different options and help unpack possible transference and countertransference.  From this analysis the supervisee is encouraged to deconstruct (make sense of the material presented in the session) and work towards reconstructing (developing improved understanding) and think about new ways of responding to the client based on their reflections and discussion in supervision.

3. Live Observation

Live supervision is a very helpful way of assisting the supervisee to develop new skills for developing clinicians.  Live supervision can be observation or interactive and can occur with the supervisor behind a one or two way screen, using video and telecommunication or sitting in the room, either nearby the clinician or unobtrusively in the corner of the room. 

Whichever way you choose to use live supervision it is important to ensure that the clinician and the client/family are agreeable to have someone watch in (or comment) on the session AND that there are clear  guidelines how the meeting will be conducted. 

For example, will the supervisor interrupt throughout the interview to correct or help the clinician, will there be a mid-point break (and discussion will take place outside the room), or will the supervisor simply observe and comment after the session? Will the supervisor provide feedback only to the clinician or also to the client/family (act like a reflective team)?

https://postmoderntherapies.wikispaces.com/file/view/MRI%20and%20Reflecting%20Teams.pdf/32851783/MRI%20and%20Reflecting%20Teams.pdf

Live supervision can cause anxiety for both the clinician and the client BUT it also provides support, corrective feedback and guidance. As the supervisor, talk about how the clinician might be feeling about the live supervision context and try and normalise feelings of anxiety and provide helpful strategies to manage the process.

Encourage the supervisee to reflect on their performance and consider what they did well and what they could do differently next session. 
If the supervisor is likely to engage as a co-therapist it is essential that turn-taking in the interview be clearly discussed. Unless the session is one where the supervisor is modelling and demonstrating a particular skill, the interview is best led by the supervisee in training and the supervisor limit the amount of corrective questioning in the session as this can undermine the clinician in the eyes of the client.

Smith provides a thorough overview here.
Some helpful ideas to make live supervision facilitative and effective
  1. Explain the purpose of observation
  2. Get permission from the client to observe the session
  3. Orient the observation process
  4. Be collaborative – work out best sitting placement within the room/or if outside the room when and how often to interrupt with feedback etc.,  stay within your contracted role (i.e. if you say you are only observing then don’t start asking questions or giving directions)
  5. Ensure you offer a debrief straight after the session – 5 – 10 minutes is fine and then you can review properly and discuss within your designated supervision time
  6. Perhaps use a structured feedback form or checklist to guide observation and feedback
Observe more than one session - if it is a great session you want to see that the skills are maintained with different presentations. If it is a poor session you want to ensure that your supervisee is  not left feeling disheartened by the process.

4. Audio and Video Recording

Using audio or video recording of the actual session provides direct and useful information about the supervisee’s work. Video recording provides extra information as you see the actual nuances of the interaction (eye contact, body language etc.) but both are helpful in that they provide actual material covered in the session.
It is recommended that at least one recording of a session be presented every few months in supervision….even more if possible.  Once the supervisee uses this medium once or twice you will find they want to continue bringing their work to the supervision session as depth of analysis offers considerable learning for the supervisee.
When reviewing the material in the session it is helpful to ask the supervisee to pick a spot where they would like to play the recording. Play small sections (up to a few minutes at the most) and first invite the supervisee to comment before adding a supervisory lens and critique. Leave time to listen to the recording - don’t rush the process for reflective learning.

Using IPR questions are often helpful in reviewing recordings. 
This link provides some guidelines.
Some examples of questions you can ask when reviewing include:
 
1. What were your thoughts/ feelings and reactions at this spot of the interview?
2. What would you like to have said at this point?  What got in the way?
3. What do you think the client was thinking? What do you think they wanted to ask/do at this point?
4. How do you think the client perceived you as the therapist at this time?
5. What did you want the client to do?
6. What message did you want to convey?
When recording make sure you have client consent and your management (i.e. team leader) are aware of the recording taking place and for what purpose. Explain also to the client that he/she can pause or stop the recording at any time and if they refuse to have the session recorded it will not impact on the therapeutic alliance.
 
Always ensure that you have a signed agreement to record the session and use with clients that you feel would benefit from the process. You can provide feedback to the client once discussed in supervision explaining that the extra feedback is like getting a ‘second opinion’. 
 
Ensure safe destruction of the recording once used in supervision. Erase – just don’t tape over. If using the recording for teleconferencing or the internet, additional safeguards are needed such as encoding and using a secure site. 
Confidentiality must be ensured.

5. Experiential Methods

Experiential methods are very useful and can be used as a learning technique for new clinicians or teaching a new skill for experienced clinicians. Some advantages to experiential methods are:

1. Can increase knowledge and skills about a particular intervention/skill
2. Bring to the surface underlying issues
3. Facilitates supervisee awareness
4. Enlivens case discussion
5. Provides alternative ways of thinking and wording in supervision making it more interactive and engaging
6. Can be easily inserted into a case presentation/discussion format
7. Provides a focus for kinaesthetic learning – learning by doing rather than just talking and reading

-> Using Experiential Learning in Supervision and Training Systemic Supervisors

Role Play Is a useful technique as it switches from talking about an issue to experiencing and acting out what has happened or might happen in a therapeutic session. You can set up the scene formally with providing background information to the case, or simply segue into the role play. 
’Let’s do a demonstration on how you would introduce a ‘values exercise’ in the therapy session?  What would say to the client?’
By acting out ‘how to’ apply certain skills the supervisee can practice how to deliver an intervention and get feedback on their performance and ways to improve their questioning skills.  The supervisor can also demonstrate how it is done.

Role reversal
In role reversal the supervisee changes roles with the client.  This provides ‘insight’ into how the client might be feeling and the supervisee can try out different questioning techniques to test out how to work with the client once they return to the therapy room.

Genograms
Using genograms to map out the client’s background is a very helpful experiential technique that not only gives information to the client but unpacks systemic understanding of influencing and transgenerational patterns for the client/family.  Using this experiential technique helps the supervisee to tell the client story/narrative highlighting repeating patterns/gaps/themes that can be further explored in the therapy session.  This YouTube video shows how using genograms can open up new understanding for the client and the clinician
https://www.youtube.com/watch?v=tRx7J1q6FE4

Whiteboard/visual work (art therapy/drawings)
Using the whiteboard in supervision to map out the clinical picture and all information known about the client is a useful tool to expand the lens ‘the map is not the territory’ (Korzybski/Bateson).
I find that starting with the genogram it is helpful for the supervisee to add relevant background information known about the client on the board. You can also then use the board to map out other pictures about the client (closeness and distance/hierarchy/wider systems issues – who else is involved/timeline etc., )

Sculpting
Sculpting provides a visual means of viewing relationship dynamics and is particularly helpful to use in a group supervision context.  It is interactive and employs kinaesthetic learning and reflection. The supervisee is asked to pick people from the group who can represent each family member and place them in a physical relationship to each other and in postures that represent their relationship (close, fused, distant, caring, angry etc.). A discussion about what comes from this sculptor then takes place providing new insight to the relationship.
https://www.psychotherapy.net/data/uploads/511942daefe54.pdf

Try out some of these ideas in your next supervision session to provide variety for new learning and reflection.  You will find they will provide new opportunities and enliven the discussion both in individual and group contexts.

What's On July 2016-December 2016

We have a number of workshops coming up in the second half of the year. CSS offers early bird and group booking fees for 3 or more who book and pay at the same time.


July


PsyBA Master Class
16 July 2016 - DARWIN

MANAGING DIFFICULTIES AND ETHICAL ISSUES IN SUPERVISION



August


2 day Skills Based Workshop for New Supervisors
12-13 August 2016 - SYDNEY

BOARD APPROVED SUPERVISOR TRAINING

 

September


PsyBA Master Class
16 September 2016 - SYDNEY

APPLYING SYSTEMIC PRACTICE IN SUPERVISION



October


PsyBA Master Class
21 October 2016 - SYDNEY

CLINICAL SUPERVISION FOR SCHOOL COUNSELLORS

2 day Skills Based Workshop
27-28 October 2016 - HOBART

WORKING WITH FAMILIES: FUNDAMENTALS OF SYSTEMIC FAMILY THERAPY
 


November

I hope that you have found this newsletter useful and you can apply some innovative ways of observing and providing feedback in supervision. Pass on this newsletter to your colleagues if you think they would like to read some of these ideas…..

Until next time,

Regards,
Christine 
Copyright © 2016 Clinical Supervision Services, All rights reserved.


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