Mindful Happiness

Anthony Quintiliani, Ph.D, LADC

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Core Elements in Clinical Supervision

Core Elements in Clinical Supervision

In addition to what supervisors bring into group supervision and clinical training, the list below will be used for discussion about YOUR supervisory role. The order of content below is generally random. The content noted applies to clinical supervision; it could also apply to doing effective therapy. The skills and knowledges here make up a toolbox for effective clinical supervision. That said, it cannot include everything.

  1. DO NO HARM in all supervision modalities (individual, group, education/training)!
  2. Know your code of ethics, especially sections relating to clinical supervision, education/training, clinical relationship, and the role of technology.
  3. Understand how the past becomes the present – your own attachment and developmental history and experience. Your own “dragons.”
  4. Know how to use strong empathy and therapeutic alliance/relationship skills.
  5. Face the reality of co-occurring conditions in clinical practice. Even if your role is dealing with “the walking well,” there are most likely co-occurring conditions if not diagnoses.
  6. Know how to use and supervise 2-3 evidence-based therapies ( BT, CT, CBT, CBT-M, Process-Based CBT, DBT, DBT-S, MBSR, MBCT, MBRP, ACT, Narrative and Solutions-Oriented approaches, etc.
  7. Recognize that the EBTXs are the science behind the art of therapy. Client and supervisee  progress require both art and science.
  8. Experiment with creativity – but do no harm.
  9. Know how to use restructuring and reframing.
  10. Understand the science behind client-matching variables. Recognize the impact of anxiety, depression, trauma, addictions, etc.
  11. Do your best to use a bio-psycho-social-spiritual model. Pay attention to preferences of people you supervise. Never impose a narrow focus.
  12. Consider Quintiliani’s “neurotherapy” by using cognition, affect, behavior, sensory experiences (see, hear, feel,, etc.) as well as intuition, spirituality and relational variables and conditions.  Refer to the Attachment-CABS-VAKGO-IS-Rels model.
  13. Study more neuroscience and how it relates to cognitive and behavior change and the human mind-body system.
  14. Learn and use effective emotion regulation skills and practices.
  15. Focus on the impact of cognition (thoughts and deep structures), emotion, behavioral conditioning, social justice, marginalization, trauma (especially pre-verbal), addictions (include pesky cellphones), and mindfulness.
  16. Observe! Observe! Observe! (direct observation of the work) and Respect! Respect! Respect!
  17. Remain fully aware of possible transference and countertransference processes, especially projective identification.
  18. Know that context, personal aspiration, and personal values matter.
  19. Recognize parallel process from therapy to supervision and back again.
  20. Know that in most states the supervisor is 100% responsible for the actions of the people they supervise, even if those actions were not recommended or are unknown to you.
  21. Know how to use compassion in practical ways, especially with defensive ego-protective patterns in people.
  22. Never make identifications of the whole person as their clinical condition of diagnosis. In fact, add much more to the individualized interventions.
  23. As you observe and respect be a good mentor to motivate, but never forget client protection is the first priority. Their progress is a second priority.
  24. Know your roles: hire, fire, oversight, evaluate, train, support, organize, coordinate, and DOCUMENT. Know abut all HIPAA and 42 CFR Pt 2 requirements.
  25. Always use a written supervision contract/agreement, and recognize informed consent aspects as well as due process in it.
  26. In co-occurring work, seek a role for 12 Steps and/or peer recovery support.
  27. Keep strong BOUNDARIES in all aspect of this work.
  28. Pay attention to learning styles.
  29. Some of the work is a form of palliative care, in that counseling and therapy sometimes deal with life-or-death issues. It is a form of sacred work.
  30. Know about duty to warn and protect – and its various implications.
  31. Supervision (like therapy) needs to be structured but not rigid.
  32. Recognize that generic “talking” has very little empirical support for supporting change in serious co-occurring disorders.
  33. Be capable in dealing with conditions of potential suicide, self-harm, and harm to others.
  34. Supervision needs to be based on an agreement, a professional development plan, and change-oriented interventions, techniques, and processes. In the final analysis, the supervisor is in charge – final decision making re. competence of supervisees and protection of others.
  35. Look after your own self-development as lead clinicians and supervisors.
  36. All may fail if you do not attend to your own SELF-CARE and the self-care of the people you supervise.  Etc.!

Be well and reduce suffering!

 

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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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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New Edition of Mindful Happiness in Production…Coming soon!

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Using Creativity in Clinical Supervision

Using Creativity in Clinical Supervision

Effective clinical supervision is a combination of hearable direction about clinical practice, gentle-direct leadership, clinical “Know-How,” evidence-based skills, complex psychodynamics, and the willingness to work with others on their developmental processes. There are risks involved. I have provided clinical supervision and consultation to other clinicians for 43 years without a legal or ethical issue. I do not think you should allow your creative spirit to run wild; there are many very serious ethical and legal implications in supervision.  These are not benign; most states hold clinical supervisors 100% accountable for the actions of their supervisees, whether those actions were known and recommended by the supervisor or not.

Here we will look at the work of Leonardo DaVinci, the genius in art, science, engineering, and humanities. He saw art as science and science as art – most clinicians recognize these combinations in their own clinical work. I will simply note a list of documented attitudes, values and behaviors that DaVinci mastered. Here is the list. Courage may be needed to move off your comfort-path.

 

  1. Practice intense curiosity and deep awareness about the specific details of your work. As you do this apply a sense of wonder about your observations and  different possible perspectives you encounter. Multiple realities of perspectives do exist. There may not be one absolutely correct response.
  2. Observe! Observe! Observe! Notice how your supervisees do their work, and how their idiosyncratic personalities and attitudes influence that work and your supervision. Be certain to pay close attention to the facts of reality, but better to procrastinate a bit before making big decisions. Be sure you have all the correct facts. You may need to test your hypothesis.
  3. Use your personal imagination more, and visualize the situations that cause you the greatest concerns. Remember: Do No Harm! In some situations it may actually be ok to use day dreaming and helpful fantasy for new perspectives for problem solving.
  4. Be sure to keep written lists of all the things you need to do. Also, write in your own “supervision development journal” about new things you learn and lessons you wish you already knew. Review selected parts of that journal with your own supervisor.
  5. It pays to be a little obsessive when dealing with supervisees and the welfare of their clients. Your growth also depends upon being a bit obsessive with learning new clinical processes and evidence-based interventions. However, remain creative and highly responsible in your role. Document everything you do in your role.
  6. For more see Isaacson, W. (2017). Leonardo DaVinci…New York: Simon & Schuster.

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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New Edition of Mindful Happiness in Production…Coming soon!

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Supervision and Self-Care in Trauma Therapy

Supervision and Self-Care in Trauma Therapy

Today there  is an ever-increasing demand for effective trauma therapy.  Our American clinical history on this matter leaves much to be desired. John N. Briere and Cheryl B. Lanktree offer important suggestions on how to use clinical supervision and self-care in your clinical work with clients suffering from serious psychological trauma. Here in a nutshell is what they noted. For a more detailed review, please read the cited  material on your own.

Supervision and self-care include the following:rain-mindfulhappiness

  1. Supervisors work on emotional reactions common in trauma therapy;
  2. Guidance and working through unhelpful thoughts, feelings and behaviors;
  3. Use of clinical documentation as a metaphor for structure and true liability protection;
  4. Problematic boundary issues;
  5. Obtaining social-emotional support from others, especially a clinical team;
  6. Participating in personal psychotherapy as needed;
  7. Using mindfulness skills (especially T. Brach’s 2013 RAIN process) in trauma work – both with clients and as self-care;
  8. As a reminder RAIN includes Recognition, Acceptance, Investigation, and Non-Identification when dealing with highly stressful immediate experiences;
  9. Maintaining a personal practice of effective self-care in your work and in your life outside of work.

In addition, they note specific and repeated clinical interactions that help clients but may also deplete emotional and energetic resilience in therapists.  These include attention to:

mindful-happiness-r-a-i-n

  1. Caretaker issues – supports, emotions, energy;
  2. General environmental and relational safety;
  3. Specific risks regarding dangerous behaviors;
  4. Anxiety, depression, grief, anger and other emotionally dysregulating conditions;
  5. Poor sell-concept, low self-esteem, and various self-identity problems;
  6. Various acting out and acting in situations;
  7. Suicidal and self-harm risks and behaviors;
  8. Consequences of various attachment problems and deficits;
  9. Social, school, and family adjustment conditions;
  10. Various somatization complaints; and,
  11. Psychosexual preoccupation, stress, and behaviors.

It is quite obvious that while working with these serious conditions and symptoms, trauma therapists would remain at considerably high risk for vicarious traumatization.  Thus, the need to maintain regular effective clinical supervision and good self-care practices are of utmost importance to psychological survival of the therapist.

For more information refer to Lanktree, C. B. and Briere, J. N. (2017). Treating Complex Trauma in Children and Their Families: An Integrative Approach. Los Angeles,CA: SAGE Publications, pp. 220-246.

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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New Edition of Mindful Happiness in Production…Coming soon!

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Effective Clinical Supervision

Effective Clinical Supervision

Perhaps other than the mental health status of the therapist and her/his ethical clinical skills, there is no more important variable in successful clinical work than effective CLINICAL supervision.  I emphasize “clinical’ because in today’s bureaucratic systems, so much supervision tends to be about required procedures like utilization level, reporting requirements, and documentation for services rendered. There is nothing wrong with including these areas – as well as ethics and liability reduction – but this is NOT pure clinical supervision. In my over 35-year career as a clinical supervisor I have tried to maintain a few guidelines to clinical supervision-mindful happinesskeep my clinical oversight on target: good clinical supervision and at least adequacy in other areas bureaucratic practices. I have emphasized three areas of supervisory practice: the relationship, the balance between task-maintenance activities, and the “Triadic Model” of supervision. The ultimate importance of the supervisory relationship is obvious; it parallels a good clinical alliance between therapists and their clients.  Balancing task activities (bureaucracy) and maintenance activities (psychosocial support for the helper’s emotional health) is an ever-present challenge for clinical supervisors. The Triadic Model of clinical supervision, above all other approaches I have used, has in my opinion resulted in the best outcomes for me, my supervisees, and their clients.  This model integrates three areas of supervision: teaching evidence-based therapy skills (so you need know them), ethically matching such clinical skills to the supervisee’s abilities and their individual client’s conditions, and the emotional functioning of the supervisee (perhaps the single most important variable of all). With this as a foundation, I will now review what current research has to say about effective clinical supervision.

Effective Clinical Supervision includes:

  1. Advancing the personal and clinical growth of the supervisee;
  2. A positive working alliance in the supervisory relationship;
  3. Establishing effective empathy with reflection as a way to develop a “secure base” for the supervisee;
  4. Mutually-derived supervisory goals and processes;
  5. Encouraging supervisee autonomy and self-direction within limits;
  6. Attuned attention to the supervisee’s needs;
  7. Open, non-defensive clinical discussion about clients, their clinical conditions, skills, ethics, etc.
  8. Clarity in the supervisor’s clinical and interpersonal competence;
  9. A reality that the supervisor is skilled in several evidence-based therapy practices;
  10. Mutual respect and comfort in the process;
  11. Careful exploration of personal issues that may impede client and supervisee progress;
  12. Very selective self-disclosure related to client and supervisee outcomes;
  13. Ethical practice with clients’ interests and liability reduction in mind;
  14. Multicultural competence;
  15. Good clinical case formulations;
  16. Understanding and being able to deal with transference and countertransference processes;
  17. Clinical demonstration and role play of effective clinical skills, including the alliance;
  18. Practical and useful scientific viewpoints about therapy – knowing the clinical literature;
  19. Direct meaningful feedback to the supervisee regarding their progress or lack thereof;
  20. Formal evaluation based on goals of the supervision; and,
  21. Periodic supervisory supervision of the clinical supervisor.

Ineffective Clinical Supervision Includes:

  1. Any number of deficits related to the effectiveness characteristics noted above;
  2. Weak supervisory competence (clinical and supervisory);
  3. Devaluing and depreciating supervisory practices;
  4. Poor supervisory relationship;
  5. Weak clinical case formulations;
  6. Over-dependence on task/administrative activities in supervision;
  7. Poor skill as a trainer and therapist – not knowing what works best and why; and,
  8. Supervisor’s mental and emotional issues (especially personality, traumatic, mood, and addiction problems) that impede clinical development of the supervisee.

Note: By listing the ideal conditions of effective clinical supervision, I in no way imply that I utilized ALL of the positive characteristics in my own clinical supervision. That said, however, I know I utilized many of them as a conscious and mindful supervisory practice.

This post is based on many supervision practice and research sources. For a comprehensive review of research on clinical supervision refer to Ladany, N., Mori, Y. and Mehr, K. E. (January, 2013). Effective and ineffective supervision. The Counseling Psychologist, 41(1), 28-47

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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