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October 2, 2019 By Admin

Essential Knowledge for Clinical Supervisors

Essential Knowledge for Clinical Supervisors

This post will include information and skills dealing with research on role induction practices, quality of clinical supervision, psychodynamics of alliance, and progress measurement.  Since the information and skills for all these topics is complex, I will do my best to keep it as clear as possible. This information aims to improve existing clinical supervision practices.

Reducing anxiety of less experienced supervisees by role induction strategies

  1. First of all clarify both supervisee and supervisor roles, expectations, behaviors, skills, rights, responsibilities, and clinical development.
  2. Support supervises via clear information on process and skills training about cognitive, behavioral and emotional processes, skills, and clinical expectations.
  3. Include lowering anxiety and improving competence as ongoing clinical supervision activities. Measure them!
  4. Work directly on supervisees self-awareness capacities.
  5. Clinical and psychological development issues may exist; adjust clinical supervision to fit these parameters.
  6. Improvement in supervisees clinical competence and psychological health are ongoing goals.
  7. Important variables that impact success or failure are supervisor competence and supervisee openness to growth and emotional regulation patterns.
  8. Keep the quality of supervision in mind, and participate in mutual evaluation and openness to feedback. For best results keep supervisee input about the supervisor as anonymous as possible. Otherwise, supervisee anxiety will increase.
  9. Recall that ethics requires that there be a reasonably detailed supervision contract.
  10. Effective clinical supervision often translates into effective psychotherapy, which leads to improved client progress, better job satisfaction and self-esteem.

The Importance of clinical, evidence-based and psychodynamic training

  1. Perhaps the single most important aspect of effective clinical supervision is the quality of the alliance. This is a parallel process with the therapy itself.
  2. With improved training in psychodynamic alliance-building skills comes client self-reports of experiencing a stronger therapeutic alliance in therapy. Keep in mind the training is cognitive, behavioral, and affective in nature. It is experienced!
  3. Research is mixed about the differences in alliance quality regarding psychodynamic training vs other training (CT, CBT, humanistic, interpersonal, etc.). The study noted suggests that improved emphasis on psychodynamics skills and processes ends with a better therapy alliance, which is consistent with better outcomes for clients. Although other studies refute this finding, it does appear to be logical that a training program specializing in psychodynamic therapy would produce better outcomes for psychodynamics, thus perhaps a better clinical alliance.
  4. Manualized psychodynamic therapy training also showed substantial improvement in the clinical alliance and the amount of psychodynamic skills being used in therapy.

Comparative quality of clinical supervision and its implications

  1. Research including over 300 clinicians concluded that 69-79% received inadequate clinical supervision.
  2. What is more concerning is that the same research noted that 25-40% of clinicians received harmful clinical supervision.
  3. At other measurement times 51-55% of clinicians noted that they received exceptionally helpful clinical supervision. Last I heard a 50% range is a grade of F. We need to work on improving this reality!
  4. Research also supports that there are great differences between supervisee perceptions vs objective criteria used effectively to measure comparative quality of clinical supervision. So the indication is to use both – supervisee anonymous evaluation and direct observation and measurement of clinical performance.
  5. 86-92% of clinicians did receive some form of clinical supervision but both the regularity and quality varied.

The reality of using progress monitoring measures for clinician development

  1. The use of clinical progress monitoring measures regarding client clinical change improves outcomes. However they are used rarely.
  2. Clinicians noted that the use of such measures in therapy required technical expertise, additional costs, time in the session,  some
  3. increased anxiety, and was sometimes accompanied by negative responses from clients, other clinicians, and managers.
  4. There were few differences in use and barriers between agency clinicians and private practice clinicians.
  5. Since the benefits of progress monitoring in clinical practice is well established and is often part of evidence-based endorsements for therapies, it is important to increase the use of progress monitoring.
  6. Furthermore, the lack of progress monitoring may have negative impacts on clients and third-party payments for therapy.

For more information refer to Ellis, M. V., Hutman, H., Chapin, J. (2015). Reducing supervisee anxiety…Journal of Counseling Psychology, 62, No. 4, 608-620. Hilsenroth, M. J., Kivlighan, D. M., Slavin-Mulford, J. (2015). Structured supervision of graduate clinicians in psychodynamic psychotherapy…Journal of Counseling Psychology, 62, No. 2, 173-183. Ellis, M. V., Creaner, M., Hutman, H., Timulak, L. A comparative study of clinical supervision… Journal of Counseling Psychology, 62,  No. 4, 621-631. Ionita, G., Fitzpatrick, M., Tomaro, J., Chen, V. V., Ovington, L. (2015). Challenges in using progress monitoring measures…Journal of Counseling Psychology, 63,  No. 2, 173-182.

Anthony R. Quintiliani, PhD., LADC  

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont and the Home of The Monkton SanghaChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

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Filed Under: Clinical Alliance, Clinical Practice, Clinical Supervison, Featured, Training Tagged With: CLINICAL DEVELOPMENT, CLINICAL SUPERVISION, EVIDENCED BASED

March 17, 2016 By Admin

Best Possible Clinical Alliance

Winnicott’s Ideas – Best Possible Clinical Alliance

To develop and maintain a strong clinical alliance it is best to follow some of the well-known clinical advice on this topic.  Rogers, Kohut, Winnicott and many others have suggested just how to do so.  Here are some general clinical recommendations for mindfulhappiness-winnicottenhancing the clinical alliance.

  1. Develop authentic respect for the client.
  2. Share power and responsibility for the outcomes – all the outcomes.
  3. Maintain a cooperative and supportive demeanor. Smile!
  4. As much as is possible maintain “unconditional positive regard.”
  5. Utilize deep, contemplative listening with clear mindfulness.
  6. Be reasonably flexible regarding real-world client situations.
  7. Directly reinforce HOPE as you push gently for increased self-efficacy.
  8. Be very patient!
  9. Be in authentic compassion for the client’s pain and suffering, and allow your own reactions.
  10. Use evidence-based approaches in your psychotherapy, while also being creative.
  11. Always apologize when you have made errors, harmed the frame of psychotherapy, or unintentionally harmed the client – DO NO HARM is the rule.
  12. Support the client’s belief and relief from his/her spiritual understandings and practices.
  13. Be nice! Treat the client as you would like to be treated.

Now let’s examine some more complex ideas and practices as recommended by W. D. Winnicott.  In this brief article I will only note the suggestion without much detail.  If you have questions, please feel free to email them to me at anthony@mindfulhappiness.org  Here is his list.

  1. Work hard to assist the client in improving their “sense of self” in “going-on-being” as a “good enough” person.
  2. Stabilize the client’s “secure base” (Bowlby) in a “secure holding environment” within the therapy dyad.
  3. Allow the defenses of the “false self” to exist as you enhance “object constancy” in the clinical relationship.
  4. Support the client’s true self development “as a potentiality” in the therapy.
  5. Pay mindful attention to the client’s mind-body presentations, realizing that both cognitive/verbal/executive parts of self are as important as emotional(sensation)/experiential parts of the self. People communicate consciously and unconsciously via multiple areas of human functioning.
  6. Learn about and respond appropriately to the client’s interoceptive world as false and true selves activate in object related transferences. Here sensations, emotions, inner feelings may be very important.
  7. Use stronger empathy and conscious projection within the empathic relationships as to allow safety in regression into the client’s past object related/attachment failures.
  8. Experiment actively by being a good “transitional object” in “potential space” so the client can utilize you as an outside object in a real relationship. Hope for strong internalization by the client.
  9. Foster the client’s security, safety, trust and courage in your clinical interactions.
  10. Maintain a tight therapy frame regarding time, space, expectations, payment (within reason), roles, boundaries, etc.
  11. Use the process of projective identification consciously in therapy (not clearly noted by Winnicott but suggested indirectly).
  12. As Winnicott noted “stay alive, stay awake.”

Its will not be easy to implement all of these alliance-holding strategies.  However, the more mindful and skilled psychotherapists are about them, the better the strength and resilience of the clinical alliance will be.  Work hard; accept the rewards; be happy!

For more details refer to Fromm, M. G. and Smith, B. L. (Eds.). (1989). The Facilitating Environment: Clinical Applications of Winnicott’s Theory. Madison, CN: International Universities Press, pp. 6-8, 25-26, 55-87, 77-78, 145-171, 489-515.

By Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, VermontChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

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Filed Under: ANTHONY QUINTILIANI, Clinical Alliance, Counselor Activites, Featured, Ideas & Practices, Training Tagged With: CLINICAL ALLIANCE, DONALD WINNNICOTT

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