Role of mentor in the context of clinical supervision.
Family psychotherapy (Management)
|Author:||Allanach, Robert C.|
|Publication:||Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Summer, 2009 Source Volume: 12 Source Issue: 2|
|Topic:||Event Code: 200 Management dynamics Computer Subject: Company business management|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
The role of mentor in supervision for marriage and family therapists is an elemental part of the clinical model. Though mentors take on varied roles in different professions, the development of mentoring systems within the scope of marriage and family therapy clinical supervision provides the necessary constructs through which therapists can develop their essential skills.
There have been healers of one sort or another throughout the history of humankind, and these "healers" were essential to their communities. They have been called witchdoctors, priests, shamans, medicine men, and brujos. Today we call them physicians, psychotherapists, psychologists, social workers, and counselors. These "healers" had some common characteristics: the candidate received his/her "call" from dreams, underwent a period of isolation under the close supervision of an experienced healer, and finally returned to the community (Edsman, 1967). Therefore, a historical foundation for both psychotherapy and supervision exists.
Supervision belief systems and rituals materialized early as clinicians decided to train others. The focus of this training was the efficacy of a particular theory, such as behavioral, psychodynamic, or client-centered therapies. Typically, norms were conveyed indirectly. Today clinical supervision is the construction of individualized learning plans for supervisees treating patients.
My philosophy of supervision flows from the adage that I share with my trainees frequently: "Never require of the patient what you have not required of yourself." This forms a core belief of the psychotherapeutic process, as well as the supervisory effort. One doesn't learn psychotherapy from a textbook, a professor, or a training program alone; one learns it by immersion into the process. Like the personal experience of psychotherapy, a student grasps the art of supervision through the immersion methodology. Through the psychotherapeutic process I learned about my personal demons, family of origin issues, core beliefs, and personal motives of action; I discovered how these impacted my interactions with others. It was here, in the consultation room, that I embraced the spirituality of imperfection and came to honor the girl of change. It was here I learned to trust the process and to value of the art of psychotherapy. The ground of my supervisory approach is years of supervision blended with personal psychotherapeutic experience. I bring "my story" into the supervisory session to share on both the conscious and unconscious levels. Clearly the supervisee also brings "a story." My personal experiences of psychotherapy and supervision, supported by academic training, form my image of the effective psychotherapist and supervisor: mentor.
For marriage and family therapy practitioners, the mentor's role in supervision is elementary to the clinical model. The development of mentoring systems provides the necessary constructs through which therapists develop essential skills. One may interpret the mentor's role in a variety of ways, with few specific definitions wholly applicable to supervision in the clinical setting. Todd and Storm (1997) recognize that mentors can improve the function of the individual within the clinical setting by acting as both educators and confidants. I go even further by asserting a strength-based approach is paramount. I attempt to assist the supervisee in identifying clinical and personal strengths. I want the supervisee to realize that the clinician is his/her best clinical resource. This comes about by the supervisee's recognition of the personal clinical ground of being. This ground of being gets its root in one's own appreciation of family history and its dynamics. The supervisee accepts that everyone carries personal family dynamics into other systems, including clinical (Minuchin, 1974; Haley, 1976).
The systematic manner in which supervision is applied is called a "model." Three types of models emerged as direction became more purposeful. These were (1) developmental models, (2) integrated models, and (3) orientation-specific models. This article addresses the integrated developmental model and the role of mentor within the context of clinical supervision. I base my supervisory philosophy on the integrated developmental model (IDM).
Liddle (1988) supports the benefits of a developmental model of supervision. The integrated developmental model's foundation is in the clinical observations made. The clinician must attend to "what's going on in the room," verbally and non-verbally ... the silent curriculum. As in the consultation room, where the therapist observes carefully "the folded arms," "the shift of voice tone or eye," "the seating patterns," and "the shift in a sitting position of the patient," the supervisor likewise sees these as important in the supervising arena. It is vital that the supervisor sees the relationship as multilayered and contextual. The supervisor and supervisee, as part of the clinical family, bring to the session the mythologies, prejudices, coalitions, triangles, rules, expectations, loyalties, and histories of the family of origin (Minuchin, 1974; Haley, 1976). Using this framework, the supervisor assists the supervisee in behavioral and thinking changes that bolster the supervisee's treatment of patients (Liddle, 1988). I believe that "live supervision" is the most helpful. The corresponding nature of training and therapy is the foundation of my personal philosophy.
The integrated developmental model is a combination of different models. It blends the Longanbill, Hardy, and Delworth model with the Stoltenberg model (Pearson, 2001). This sets out a framework where there are four developmental stages spread across three developmental structures. These are autonomy, motivation, and self- and other awareness. Autonomy refers to the supervisee's own feeling and sense of independence. Motivation looks to the sense of identifying--in their professional duties--the sense of fit they achieve and see, as well as the sense of consistency that is achieved. The self- and other awareness is the sense by which the external environment is perceived and the complex interaction between the outside and the self. The psychotherapeutic investigation of one's own intra-psychic and interpersonal processes protect the patient from the clinician's conflicts and deploys oneself to the maximum benefit of the patient. My psychotherapeutic and supervisory experiences allow me to internalize "a voice of self-supervision." A good supervisor attempts to mold the supervisee into a clinician that is ever aware of the multilayered parallel processes and of the contextual aspects of the therapeutic relationship. Once integration and internalization of the supervision takes root, the supervisee carries the "voice of self-supervision" inside as a sort of supervisory superego.
Todd & Storm (1997) identify three important aspects to this focus: (1) a capacity for self-monitoring; (2) a comparison of one's role to some ideal model; and (3) intent to change one's therapeutic behavior towards continued growth and improvement.
At level one the supervisees will demonstrate low levels of confidence in their own abilities. They will be keen to learn and anxious about their own effectiveness in any relevant situation (Stoltenberg et al., 1998). This stage will show a higher level of dependency on the supervisor for direction and guidance as well as for instruction and support (Stoltenberg et al., 1998). This is normal for the supervisee at this point.
The supervisees' levels of confidence, motivation, and anxiety will fluctuate at stage two (Pearson, 2001). There will be some dichotomy in their performance between a desire for freedom and autonomy and a continued feeling of dependency. This also will be matched by an increase in the awareness of the patient's needs (Pearson, 2001, Stoltenberg et al., 1998). The supervisor's reaction should be to adjust the balance of control and direct supervision in the supervisory relationship.
Supervision is most difficult at level three, because it is the least structured and most idiosyncratic (Pearson, 2001; Stoltenberg et al., 1998). The need for supervision of a different style is overwhelming. The call for the supervisor to pose challenges shifts to the need for the supervisee to challenge himself/herself (Stoltenberg et al., 1998). Therefore, self-challenge requires that there will be a greater amount of learning and direction for the supervisee. The final stage also entails the highest level of emotional analysis of the supervisee's own feelings.
At the outset of this article, I noted the importance of the personal psychotherapeutic experience within a clinician's training. The balance is found when the supervisor is mindful of these questions. "How does this (issue/emotion/thought) impact your relationship with the patient? How does this (issue/emotion/thought) impact you in session?" Campbell (2000) notes that the background for effective supervision and mentoring is based on an individual's capacity to separate what he/she knows as a clinician from his/her role as a supervisor. An individual's talent as a therapist does not translate into an ability to delineate what another person must do in terms of their own development in the clinical setting. In fact, it is Campbell's contention that there is a training process for supervisors in which supervisors learn how to train others. The art of supervision is "learned" within the process of supervision.
Many state licensing bodies now call for specialized training for clinical supervisors. Today, clinical supervision is a sub-specialty with its own body of research/theory, models, and competencies. National certification bodies, such as the American Association of Marriage and Family Therapy, have their own requirements.
The situation of the supervision can demand employment of different models. Each setting will have unique needs and requirements for both the supervisor/mentor and for the learner's progress. Clinicians apply a particular theoretical approach to supervision and therapy in orientation-specific models (such as Adlerian, solution-focused, and behavioral). This can result in some innovative tactics. For example, rural clinics use telehealth technology that links several settings to a main training site. Supervisees present video and/or audio tapes and they examine each case under live supervision.
The individual supervision genre was the norm when I began my professional training, and group supervision was crucial to the learning process as well. This intense group training had four 12-week segments and a dyadic supervision group model. The chief supervisor led a process in which students presented case materials to a peer group. Here the focus was counter transference issues against theory. A conference to examine group dynamics and a conjoint evaluation of the process itself sometimes followed live observation. Large group meetings (topics determined via needs assessment) enriched the group process. Later in my training I encountered another model in which peers presented case studies and reviewed tapes of sessions. They emphasized learning theory and exploration of group dynamics as well as counter transference issues.
Proctor (1986) contends that, regardless of the model used and its interpretation, there are three main functions of clinical supervision. These are the formative function, the restorative function, and the normative function. The formative function begins the supervision relationship. There is a transfer of knowledge and skill from the supervisor to the individual being supervised. The mentor is a leader in the process here, and this is the education stage where the supervisee develops required skills. A working alliance forms with the supervisor passing knowledge and experience to the learner who seeks a similar path.
The second function is support. Individuals who already have many of the required clinical skills and knowledge may still need some type of help. Even a highly skilled therapist can weary under stress and pressure, and he/she needs the reassurance that comes from the backing of a supervisor. This fulfills the need for external contact. It provides affirmation of the correct courses of action and gives emotional support. It is here that the supervisor introduces the supervisee to the need for ongoing consultation with peers and for relationships with state and national marriage and family associations. A good mentor steers the supervisee into an ongoing involvement and active participation into the strong and supportive network these organizations offer.
The normative function is the final function described by Proctor (1986). This fulfills the legal obligation of supervision in many sectors where supervision needs to not only be present, yet also be recorded for reference and protection of the organization, profession, or the individuals concerned, such as in marriage and family therapy practice. Therefore, this can be seen as the more traditionally accepted role of the supervisor, that quality control and the protection of those involved become central to the role of the mentor as supervisor.
While I argue that supervision is a form of mentoring, clinical supervision is clearly moreso. There are specific competencies that must be addressed through the supervisory role. These include intervention competencies, conceptual competencies, therapeutic relationship competencies, perceptual competencies, management competencies, structural competencies, and overall competencies (Storm & Todd, 1997). The supervisor as mentor takes into account the importance of these elements as they relate to the capacity to provide support for individuals in the marriage and family therapy environment. A conscientious and exceptional mentor adheres to some basic principles, which are listed below.
* Supervise only in areas of expertise. The supervisor ensures that the supervisee is not entering into unchartered waters with patients. Supervisors direct supervisees to specific training programs that provide solid theoretical foundations and demonstrated procedures to treat patients in a clinically accepted fashion. Likewise, supervisors follow suit and teach supervisees what they themselves know.
* Choose a specific supervisory model. We use a sort of toolbox of theories in clinical work in order to address the clinical moment and to reach patients. In supervision we use various models to address certain needs of the supervisory situation and to deal with the supervisee's issues. Supervisors still need a solid model as foundation for the total supervision experience. This provides consistency and prevents confusion.
* Avoid dual relationships. Supervisors, like clinicians, are in very influential positions of power. Great care must constantly be exercised to avoid exploiting trust and dependency. Supervision is not therapy, and supervisors never treat supervisees. Supervisors are not friends, and supervision is professional by identification. Social contact and interaction impairs objectivity and professional judgment. Supervisors often have multiple roles, e.g., teacher or clinical and administrative supervisor. Invest time to clarify the expectations assigned to each role and be mindful of the power differential existing between the supervisor and the supervisee. Be vigilant against the abuse of power. Sexual contact and romantic involvement are unethical, even potentially criminal. If boundaries are not clearly defined at the outset, the supervisee can unconsciously interpret this as clear permission to cross boundaries in the clinical work.
* Regularly evaluate the supervisee's competence. A supervisor's central purpose is to increase the competence of the supervisee. Therefore, supervisors accept only those clinician-patient relationships wherein they themselves maintain a solid level of proficiency. The supervisor helps the learner appreciate personal limitations and levels of abilities.
* Be available for supervision and establish a consistent and regular schedule. When supervisors lend themselves to a large volume of supervisees they may not be as available as needed. This gives a supervisee the dangerous impression that overextension is normative. Balance is the root of good mental health. It is also the foundation of successful supervision and of quality mental health treatments.
* Formulate a sound supervisory contract and conduct screening interviews. Ascertain the supervisee's academic level and competencies (I recommend the Postgraduate Competency Document), and then finalize a solid learning contract.
* Be aware of financial considerations. Supervisors model for the supervisee several important aspects of a professional relationship. Treatment has financial considerations and so does supervision. Charge and collect fees for services rendered.
* Maintain professional liability coverage. Legal actions against mental health professionals are increasing nationally. Possible litigation against clinicians and supervisors requires that both maintain professional liability coverage with the proper endorsements. Supervisors need the proof of the learner's coverage before he/she allows that person to treat patients.
* Supervise honestly with integrity, transparency, and vulnerability. In the final analysis, the supervisor helps the supervisee in the integration of theory with the clinical process. At a minimum, this assistance includes (1) initial and ongoing patient assessment; (2) empathic discernment and constancy; (3) strategies of intervention; (4) interfacing individual/familial/cultural systems; and (5) overall case management. Honesty, integrity, transparency, and vulnerability are gifts necessary for good clinicians and must be qualities of a good supervisor.
This article is approved by the following for continuing education credit:
The American Psychotherapy Association provides this continuing education credit for Diplomates.
After studying this article, participants should be better able to do the following:
1. Learn the vital connection between the clinician's personal psychotherapeutic journey and an integrated developmental model of clinical supervision as a pathway to effective clinical practice.
2. Learn the foundation of integrated developmental model of clinical supervision.
3. Learn the key responsibilities, expectations, and protocols of effective clinical supervision.
KEY WORDS: clinical supervision, isomorphism, marrage and family therapy mentor, parallel processes
TARGET AUDIENCE: mental health professionls
PROGRAM LEVEL: Basic
DISCLOSURE: The author has nothing to disclose.
TO RECEIVE CE CREDIT FOR THIS ARTICLE
In order to receive one CE credit, each participant is required to
1. Read the continuing education article.
2. Complete the exam by circling the chosen answer for each question. Complete the evaluation form.
3. Mail the completed form, along with the $15 payment for each CE exam taken to:
2750 East Sunshine, Springfield, MO 65804. Or Fax to: (417) 823-9959. Or go online to www.americanpsychotherapy.com and take the test for FREE.
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POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages 40-43)
1. Within the scope of clinical supervision, mentors have mandated roles. Specifically, these responsibilities are:
a) The protection of the patient's welfare
b) The support for professional development
c) Maintaining and protecting the interests of the public at large
d) All of the above
2. Clinical supervision should never take into account a supervisee's personal family dynamics, mythologies, prejudices, or family of origin history.
3. The IDM (Integrated Developmental Model) espouses different and separate developmental stages. These are spread across different developmental structures. They are:
c) Self-other awareness
d) All of the above
4. The personal therapeutic experience of a clinician is equally as important as clinical supervision.
5. Highly competent clinicians always make highly competent clinical supervisors.
6. The main function(s) of clinical supervision are:
d) All of the above
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Proctor, B. (1986) A co-operative exercise in accountability. In Marken M., & Payne M. (Eds.). Washington, DC: National Youth Bureau and Council for Education and Training in Youth and Community Work.
Stoltenberg, C. D., McNeil, B., & Delworth, U. (1998). IDM supervision. San Francisco: Jossey-Bass.
Storm, C. L.. & Todd, T. C. (Eds.). (1997). The reasonably complete systemic supervisor resource guide. Boston: Allyn & Bacon.
Todd, T. C., & Storm, C. L. (1997). The complete systemic supervisor: Context, philosophy, and pragmatics. Boston: Allyn & Bacon.
Williams, A. (1994). Visual and active supervision. New York: Norton.
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By Robert C. Allanach, PhD, LMFT, DAPA, CGP
Dr. Robert C. Allanach, LMFT, DAPA, CGP has over 20 years of post-doctorate experience in treating child, adolescent, and adult patients. Currently, Dr. Allanach maintains a private practice. He also serves as a consultant to Medical Management Options, providing direct clinical services to adults in community mental health centers in Louisiana and Mississippi, as well as at an inpatient unit for juvenile sex offenders. He has been a member of the American Psychotherapy Association since 1999. Dr. Allanach received his training in clinical supervision at Our Lady of Holy Cross College in New Orleans. For more information, visit his Web Site: www.doctorallanach.com.
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