What is Good Medicine?

Competency-Based Clinical including the whole person purposeful listening intently

Supervision
respect and compassion listening well supporting individual's unique
goals
building positive relationships exploring solutions
making positive informed
Developing a Competency-Based Approach to Clinical Supervision in Primary Care dedication to quality services treating both body and mind choices
Health-Service Psychology
collaboration being curious and individualizing plans
Presented at HealthPoint by: compassionate
listening closely being adaptable and humanistic
Chris Heffner
a partnership
Jessica Cowan
1 2

What is Good Supervision?

Welcome

1. Define clinical supervision and its core Part 1: Introduction to Competency-based Clinical
competencies. Supervision
2. Identify and discuss ethical, cultural, and
regulatory issues related to clinical Part 2: Ethical and Regulatory/Legal Issues in
Learning supervision. Agenda Clinical Supervision

Objectives 3. Describe psychotherapy-based,

developmental, process-based, and
Part 3: Supervision Models

integrated models of clinical supervision. Monday ---BREAK---

4. Identify and define the three components
of evidence-based clinical supervision April 30, 2018 Part 4: Evidence-Based Clinical Supervision (EBCS)
and discuss best practices related to
each. 1pm to 5pm Part 5: Structuring Supervision: (a) Initial Sessions,
5. Structure an initial, ongoing, and final (b) Ongoing Sessions, (c) Final Session
clinical supervision session.
Part 6: Common Factors Across Individual Models
6. Develop an individual competency-based
of Supervision
model for clinical supervision.
Final Discussion

3 4
 Please feel free to interrupt us if you
have questions, need clarification, or
just want to share an idea or some
insights. We encourage participation
It’s okay to and discussion throughout the
program.
Interrupt
Feel free to stand, walk around, or
take breaks as needed. We will take
a break about half way through the
program.

Please turn your cell phone ringers

off but leave your phones out. We
will be doing some interactive
exercises that will require your Question: Who was the first clinical supervisor?
phone.
5 6

Part 1: Introduction to Competency- Start with the Suppose a

End in Mind
Based Clinical Supervision miracle
● Overview of Clinical Supervision
● Introduction to Competency-Based Clinical Supervision
happens...

7 8
 Supervision is an intervention,
distinct from other professional
practice, provided by a more senior
member of a profession (or similar
What is Clinical Clinical Supervision profession) to a more junior
Supervision? in Health-Service colleague.
Psychology The relationship is evaluative and
hierarchical, it extends over time,
and has as its goals:
1. enhancing the professional
Definition and Goals competence and science-informed
practice (training) of the trainee,
2. monitoring the quality of services
American Psychological Association. (2014). Guidelines for Clinical provided
Supervision in Health Service Psychology. Retrieved from 3. protecting the public
[Link]
4. providing a gatekeeping function for
Bernard, J. M. & Goodyear, R. K. (2013). Fundamentals of clinical entry into the profession
supervision (5th ed.). Boston, MA: Pearson.
9 10

Clinical Supervision is Clinical Supervision is not

● An evidence-based practice ● Psychotherapy
distinct from other professional ● An extension of psychotherapy
Clinical Supervision activities.
Clinical Supervision (or assessment)
● The signature pedagogy of the ● A means to do psychotherapy
in Health-Service mental health professions. in Health-Service through a trainee
Psychology ● An action-oriented pedagogy. Psychology ● A single task with logical steps
● The third most frequent activity and a linear progression
of psychologists after ● Clinical or Case Consultation
What is it... psychotherapy and assessment. What it is not... ○ The consultancy relationship is
considered voluntary,
non-binding, and equal.
○ The supervisory relationship is
considered mandatory, binding,
and hierarchical.
11 12
 Like everything we do as psychologists,
supervision has as its foundation a relational
component that allows both parties to work
together toward common goals.

The Supervision The Importance of Despite its importance, the relationship is

Triad and Dyad Relationships often not discussed and it is rarely measured.

Three questions can increase client

commitment and goal achievement by about
26% according to Norcross (2011):

1. Are we making progress toward your

goals?
2. What would you like more of and less of?
3. How is our relationship?

Norcross, J. (2011). Psychotherapy Relationships that Work:

Evidence-based Responsiveness. New York: Oxford University Press.
13 14

APA Education Collaborative:

Be knowledgeable about theories, models, and

effective practices in supervision.

What does it mean What Makes a Apply this knowledge to the supervision of direct

to be competent? Supervisor service delivery by psychology trainees, trainees

from other health professions, and, as
Competent? appropriate, to the supervision of services
provided by other health care professionals.

Competence in supervision includes knowledge,

collaborative skills, and attitudes.

From APPIC:

Rather than a unitary concept, supervisor

competence is a construct of knowledge, skills,
The Association of State and Provincial Psychology Boards (2015). Supervision Guidelines for Education and Training
leading to Licensure as a Health Service Provider. Retrieved from attitudes, and values.
[Link]

15 Health Service Psychology Education Collaborative (2013, August 5). Professional Psychology in Health Care Services: A 16
Blueprint for Education and Training. American Psychologist.
 Tasks (somewhat flexible) include:

Competency-based supervision is a ● Observation

metatheoretical approach that explicitly ● Collaborative Self-Assessment and Feedback
identifies the knowledge, skills, and attitudes ● Experiential Learning and Skill Development
that comprise clinical competencies, and ● Instruction, Modeling, and Mutual Problem
Competency- meets criterion- referenced competence Competency- Solving
standards consistent with evidence-based ● Ongoing Assessment, Feedback and, Evaluation
Based Supervision practice. based Tasks and ● Role-Modeling
(according to Falender & Benchmarks
Because it is metatheoretical, it is very Benchmarks (not as flexible) are
Shafranske) criterion-referenced and determined by:
flexible and can include any model (including
developmental, process-based, and
● Accreditation standards (APA, APPIC)
psychotherapy based models) or approach to
● Regulations
clinical supervision.
● Ethical Standards
● Evidence-based (research, expertise, and client
Includes Tasks and Benchmarks across variables (or trainee variables).
Multiple Domains. ● Organizational Standards / Requirements /
Policies
● Best Practices across multiple domains
Falender, C. A., Shafranske, E. (2014). Competence in competency-based supervision practice. Construct and
Falender, C. A., Shafranske, E. (2014). Competence in competency-based supervision practice. Construct and
application. Professional Psychology: Research and Practice, 38(3), 232-240.
17 application. Professional Psychology: Research and Practice, 38(3), 232-240. 18

APA has identified Seven Domains (and

29 Guidelines)

A. Supervision Competence
B. Diversity Competency-Based Supervision means
Supervision C. Supervisory Relationship Operational Definition demonstrating required Knowledge,
Domains D. Professionalism of Competency-based Skills, and Attitudes/Values (KSAs)
(According to APA Guidelines E. Assessment / Evaluation / Feedback
F. Professional Competence Problems
Supervision across the various domains of
for Clinical Supervision in supervision by comparing actual
Health Service Psychology) G. Ethical, Legal, and Regulatory supervision tasks and outcomes with
Considerations. accepted benchmarks within the
As a partner of Antioch University, a profession.
Free 2 Credit APA Approved CE
Course titled “Guidelines for Clinical
Supervision” is available at
American Psychological Association. (2014). Guidelines for Clinical Supervision in Health Service Psychology. Retrieved
[Link]. Coupon Code: antioch.
from [Link]
19 20
Exercise 1: Supervisor Strengths
and Goals

Handout

Question: What are your strengths as a clinical supervisor?

21 22

Part 1 Takeaways ● Competency-Based Supervision means demonstrating

required Knowledge, Skills, and Attitudes/Values (KSAs)
Part 2: Ethical and
across the various domains of supervision by comparing

Regulatory/Legal Factors in
actual supervision tasks and outcomes with accepted
● Clinical supervision is a unique activity that can be benchmarks within the profession.
differentiated from other similar activities and requires ● Both APPIC and the APA Education Collaborative break

Clinical Supervision
its own training and set of competencies. clinical supervision competence into three broad groups:
● Clinical supervision is the signature pedagogy for (1) knowledge, (2) skills, and (3) attitudes and values.
training psychologists. ● Competency-based supervision is a metatheoretical
● Supervision is an intervention provided by a senior approach that explicitly identifies the knowledge, skills, and
professional to a trainee that is evaluative, hierarchical attitudes that comprise clinical competencies, and meets
and extends over time. criterion- referenced competence standards consistent
● Along with training, supervision has three additional with evidence-based practice.
goals (in order of importance): (1) monitoring the ● APA outlines seven domains within supervision, including
quality of client care, (2) protecting the public, and (3) Supervision Competence; Diversity, Supervisory
professional gatekeeping. Relationship; Professionalism; Assessment / Evaluation /
● The supervisory relationship provides a foundation for Feedback, Professional Competence Problems; and Ethical,
supervision but is not often discussed and is rarely Legal, and Regulatory Considerations.
measured. 23 24
 #1 Priority: “...highest duty of the
Duty to Protect supervisor, protecting the Ethical Guidelines Overview
public.”
● Supervisor/Supervision is a Model for ● Responsibility to provide, and
● Supervisors are gatekeepers = Ethical Decision Making. The supervisor and document, timely, accurate and
supervision relationship/processes serve as a model relevant feedback/evaluation
evaluating trainee’s suitability to
for ethical and legal responsibility, both in
enter and remain in the field. client/clinical work (incorporating ethical discussion) &
supervision/supervisory relationship ● Informed Consent &
Documentation: supervisors provide
● primary ethical and legal ● Responsibility to Maintain Your clear information about the expectations for,
obligation to protect the welfare Competence as a Supervisor* + and parameters of, supervision to trainees
preferably in the form of a written supervisory
of the client/patient Monitor/Evaluate the Competence of contract.
Your Trainee(s).
American Psychological Association. (2014). Guidelines for Clinical Supervision in Health Service Psychology. Retrieved from
[Link]
Barnett, J. E., & Molzon, C. H. (2014). Clinical supervision of psychotherapy: Essential ethics issues for supervisors and American Psychological Association. (2014). Guidelines for Clinical Supervision in Health Service Psychology. Retrieved from [Link]
supervisees. Journal of Clinical Psychology, 70(11), 1051–1061. [Link] Barnett, J. E., & Molzon, C. H. (2014). Clinical supervision of psychotherapy: Essential ethics issues for supervisors and supervisees. Journal of clinical psychology, 70(11), 1051-1061.
The Association of State and Provincial Psychology Boards Supervision Guidelines for Education and Training leading to 25 American Psychological Association. (2014). Guidelines for Clinical Supervision in Health Service Psychology. Retrieved from [Link] 26
Licensure as a Health Service Provider August 2015 Ellis, M. V. (2010). Bridging the Science and Practice of Clinical Supervision: Some Discoveries, Some Misconceptions. [Link]

Minimum Elements of a Supervision Contract:

● Context, method, format of supervision Ethical Guidelines: Problems & Challenges

● Responsibility of supervisor to protect client

Informed Consent ● Roles and expectations, goals and tasks Harmful or inadequate supervision is the Why Problems in Supervision Occur

& Documentation ● Criteria for success and completion with sample

evaluation/feedback tools
seventh most reported reason for
disciplinary actions by licensing boards ● Lack of competence re supervision
content/roles
● Processes and policies for if performance (ASPPB, 2013c).
● Supervisor’s lack of skill
criteria is not met or if ethical issues arise (for
both trainee and/or supervisor) ● Inadequate = failure to meet minimum ● Motivational issues (disinterest, resentment,
standards. 49% report receiving inadequate abuse of power)
● Expectations for supervision preparation
supervision at some point. ● Poor boundaries/exploitive
● Limits of confidentiality (what information will ● Harmful = psychological, emotional or physical ● Transference-countertransference
be shared and with who, etc.) ● Individual/cultural differences
harm/trauma to the trainee. 51% of trainees
● Expectations related to personal disclosure experience harmful supervision at some point ● Administrative challenges (dual role, lack of
organizational support)
● Ethical areas including: Duty to warn/protect, American Psychological Association. (2014). Guidelines for Clinical Supervision in Health Service Psychology. Retrieved

multiple relationships, emergency procedures from [Link]

Gray, L.A., Ladany, N., Walker, J.A. & Ancic, J.R. (2001). Psychotherapy trainees’ experience of counterproductive events in
supervision. Journal of Counseling Psychology, 48, 371-383.
American Psychological Association. (2014). Guidelines for Clinical Supervision in Health Service Psychology.
Retrieved from [Link] 27 Nelson, M.L. & Friedlander, M.L. (2001). A close look at conflictual supervisory relationships: The trainee’s perspective. 28
Journal of Counseling Psychology, 48, 384-395
 ● Supervisors: “Assume professional and legal
responsibility for the work of the supervisee”
● Direct Liability
○ Supervisor is liable if actions of supervisor Duty to Protect: Clinician Wellbeing & Self-Care
caused harm to trainee or client
● Vicarious and Strict Liability
Regulatory/Legal ○ Supervisor may be liable if actions of the ● Self-Care is an Ethical Obligation to Maintain
trainee (even if not suggested/known to
Issues supervisor) cause harm to the client
Clinical Competence and Protect the Client
● WAC 246-809-334 Supervisor Standards
Highlights: ● Supervisors Can Facilitate Self-Care by
○ Two years post-licensure Encouraging/Assessing:
○ The approved supervisor must not be a ○ Solution-focused problem solving
blood or legal relative or cohabitant of the ○ Discussing issues/feelings in supervision
licensure candidate, licensure candidate's ○ Peer support
peer, or someone who has acted as the ○ Encouraging reflection on positive/transformative
licensure candidate's therapist within the events (clinical work, professional development etc.)
past two years ○ Cognitive reframing of errors
○ A minimum of 15 hours of training in clinical ○ Other self-care behaviors
supervision
Washington State [Link]
[Link] ○ Minimum 25 hours of supervision
Polychronis, P. D., & Brown, S. G. (2016). The strict liability standard and clinical supervision. Professional Psychology:
Research and Practice, 47(2), 139. experience Falender, C. A., & Shafranske, E. P. (2012). Getting the most out of clinical training and supervision: A guide for practicum
students and interns. American Psychological Association.
The Association of State and Provincial Psychology Boards Supervision Guidelines for Education and Training leading to
Licensure as a Health Service Provider August 2015
29 Santana, M. C., & Fouad, N. A. (2017). Development and validation of a self-care behavior inventory. Training and Education in 30
Professional Psychology, 11(3), 140–145. [Link]

Exercise 2: Self-Care in
Supervision
Indications that a Trainee is
Experiencing Burnout?

Ways to Address These Signs

in Supervision?

Question: How often was self-care discussed in supervision when you were a trainee?

31 32
Ethical & Legal/Regulatory Takeaways
Part 3: Supervision Models
As a supervisor, your primary ethical Modeling sound ethical practices and
●
responsibility is to protect the client
●
decision making in supervision includes
● Psychotherapy-based Models
transparency and informed consent related ● Developmental Models
● Your secondary responsibility is to protect the to supervision processes, roles etc. ● Process-based Models
public and serve as a gatekeeper for the
profession ● As a supervisor it is important to routinely
● Integrated/Hybrid Models
assess competence (yours and your ● Individual Supervision Models
● Know what ethical guidelines, policies/procedures trainee’s)
are in place in your organization and how to
integrate those policies into supervision ● Modeling and assessing self-care is an
(modeling, discussion, application in clinical important and often overlooked component
decision making etc.) of competence

33 34

Supervisors are therapists first so most naturally

bring their therapeutic approach to their work as
a supervisor.
Psychotherapy-based models approach
supervision from a specific theory of human
Models of Clinical nature, such as:
Supervision ● Psychodynamic
● Humanistic
● Cognitive-Behavioral
● Solution-focused
● Feminist
● Narrative
Psychotherapy-based Models
● Systems
Assumptions and techniques are typically
shared across both therapy and supervision.
Supervisor models the psychotherapy
Question: What is your primary therapeutic approach with clients? techniques and approaches in the course of
35 supervision. 36
 Example: Solution-Focused Supervision Like stage theories, developmental models of
supervision assume that trainees pass through
Assumptions of Solution-Focused Supervision (Lutz, 2014) stages as they develop as therapists.
1. Supervisor and trainee both want to do a good job APA uses a developmental model. Per accreditation
2. … want to be proud of their work
guidelines, training must be:
3. … want to make a difference
Models of Clinical 4.
5.
Trainee has reasonable problem-solving skills
Goal is to add and strengthen solution-building skills
Models of Clinical ● Sequential
● Cumulative
Supervision 6. Respect by supervisor toward trainee translates to
respect by trainee toward client (supervision is a
Supervision ● Graded in complexity
APA also uses a domain model for the training of
model for psychotherapy)
psychologists that includes nine competency areas
Supervisor Roles in SF Supervision (Lutz, 2014) or domains:
1. Guru (Subject Matter Expert, Teacher, Trainer) ● Research
2. Gatekeeper (Administrator, Evaluator) ● Ethical and legal standards
Psychotherapy-based Models 3. Guide (Coach, Cheerleader) Developmental Models ● Individual and cultural diversity
Example Three phases of supervision (Trenhaile, 2005)
● Professional values, attitudes, & behaviors
1. Trainee strengths and goals (identifying trainee ● Communication & interpersonal skills
strengths and determining goals for supervision) ● Assessment
2. Solution-Focused supervision (applying solution ● Intervention
Lutz, A.B. (2014). Learning solution-focused therapy: An illustrated guide. focused principles and techniques) ● Supervision
Washington D.C.: American Psychiatric Association. 3. Trainee feedback (providing ongoing trainee
Trenhaile, J.D. (2005). Solution-focused supervision: Returning the focus ● Consultation & interprofessional /
to client goals. Journal of Family Psychotherapy 16, 223-228.
feedback using a solution-focused model)
37 interdisciplinary skills 38

Example: Logan, Hardy, & Delworth Model

Process-based Models:
As we grow as trainees in each of these areas we cycle
● Are concerned about the processes
through three-stages (developmental levels):
involved within supervision.
1. stagnation (lack of awareness)
Models of Clinical 2. confusion (awareness without answer) Models of Clinical ● Can provide a means to deepen the
supervision and can identify issues
3. integration (answer with integration).
Supervision Includes the following functional areas:
Supervision related to the process.
● Highlights the importance of roles within
1. Competence
the supervisory relationship.
2. Emotional awareness
3. Autonomy ○ Facilitative Roles
4. Professional identity ○ Authoritative Roles
5. Respect for individual differences ● Can be difficult to apply on their own
Developmental Models Process-based Models
6. Purpose and direction since they often lack theory and focus.
Example 7. Personal motivation
8. Professional ethics
With 8 developmental issues, each at any of 3 stages
(Total of 24 possible foci), supervisors tend to focus on
Bernard, J. M. & Goodyear, R. K. (2013). Fundamentals of clinical only a select few issues at any given time.
supervision (5th ed.). Boston, MA: Pearson.
39 40
 Bernard’s Discrimination Model Integrated or Hybrid models can include:
● Includes three foci or processes:
● Integration of various supervision
○ intervention
models and psychotherapy approaches.
Models of Clinical ○ conceptualization
○ personalization
Models of Clinical
Supervision ● Includes three supervisor role: Supervision ● Target Issues models aimed at a specific
issue (multiculturalism for example).
○ teacher
○ counselor
● Common Factors models combine the
○ consultant
common aspects across various
At any given time, the supervisor may be supervision models. Most integrated
Process-based Models tasked with assuming any of the three roles Integrated/Hybrid Models models do this now.
Example in addressing any of the three foci. In this
sense, there are nine possible interactions. ● Evidence-based Supervision with
Foci and role will typically change many times identifiable and measurable problems or
within every session. competencies.
Bernard, J. M. & Goodyear, R. K. (2013). Fundamentals of clinical
supervision (5th ed.). Boston, MA: Pearson.
41 42

Example: Integrated Developmental Model *

● Most widely used stage developmental model of supervision.
● Four Levels (Developmental):
○ Level 1: Entry. Trainees have limited experience, focus is on
skill development issues.
○ Level 2: Intermediate: Trainees become less dependent, focus

Models of Clinical ○
is on process issues.
Level 3: Advanced: Trainees begin developing a personalized Models of Clinical
Supervision Supervision
approach as they become independent practitioners.
○ Level 3i: Integrated. Personalized approach occurs across
domains (intervention, assessment, conceptualization, etc.).
● Three Overriding Structures (Processes):
○ Motivation (Drive, Interest, Focus, etc.)
○ Autonomy (Competence and Confidence)
○ Awareness (Self and Others)
● Eight Domains of Professional Functioning (Domains/Functions):
○ Intervention
Assessment
Integrated/Hybrid Models ○
○ Interpersonal Assessment
Integrated/Hybrid Models
Example ○ Client Conceptualization Example
○ Individual Differences
○ Theoretical Orientation
○ Treatment Planning
○ Professional Ethics
4x3x8=96
● Flexibility: Supervision interventions can be facilitative or authoritative
Bernard, J. M. & Goodyear, R. K. (2013). Fundamentals of clinical and can incorporate psychotherapy-based theory and techniques.
supervision (5th ed.). Boston, MA: Pearson. *IDM Cube Image Copyright © 2018, Chris Heffner, PhD, PsyD,
43 [Link]. Used with Permission. 44
 Psychotherapy Models focus on the approach. Foundation: Building a solid relationship is key to a successful outcome so
I try to use a humanistic foundation based on Carl Rogers’ three core
Developmental Models focus on the trainee level. conditions: Congruence or Genuineness, Unconditional Positive Regard, and
Empathy. I also consider the assumptions of Solution-Focused interventions
and try to be strengths-based when possible.
Process Models focus on the relationship and
processes within supervision Frame: I use a developmental approach similar to IDM, especially with new

Individual My Individual
therapists to make sure we focus on the core conditions for effective
Integrative and Hybrid Models combine aspects of psychotherapy before getting too focused on technique and specific
interventions. I also use a strengths-based frame.
Supervision Model all models and approaches.
Supervision Model I consider Vygotsky’s Zone of Proximal Development (can’t do, can do with
*Individual Supervision Models are designed by and
for an individual supervisor and often include: (in a perfect world) help, can do alone) when I think of the stages that my students progress
through.

1. Foundation or set of assumptions about Focus: I have been using more Solution-Focused techniques to focus on
strengths and professional growth. I use CBT techniques and Socratic
supervision Questions to challenge faulty trainee thinking, bring awareness to trainee
2. Framework or model (developmental An Example behaviors, and draw out ideas and insights. Reviewing notes, watching
videos, and roleplay are part of both prep and in-session work.
component, processes, supervision structure) By Chris Heffner
3. Focus or approach (tasks, interventions, I can be consultant and mentor (more facilitative) but also teacher and
administrator (more authoritative).
techniques, roles, goals)
4. Flexibility to to adapt to any situation. Flexibility: These roles are very fluid, with more authoritative roles in the
beginning and more facilitative roles as the therapist gains competence. The
*Four-F Model of Individual Supervision Copyright © 2018, Chris *Four-F Model of Individual Supervision Copyright © 2018, Chris strengths-based approach works well in shorter sessions and is focused on
Heffner, PhD, PsyD, [Link]. Used with Permission. Heffner, PhD, PsyD, [Link]. Used with Permission. the needs at the moment, allowing for adaptability.
45 46

Exercise 3: Individual (Competency- Part 3 Takeaways

Based) Supervision Model ● Four primary models of clinical supervision ● The Integrated Developmental Model (IDM) of
include psychotherapy-based, developmental, Supervision is a commonly used integrated model
process-based, and integrated/hybrid. of supervision that incorporates three processes,
● Psychotherapy-based models often pull from four developmental levels, and eight domains.

Handout Psychodynamic, Humanistic,

Cognitive-Behavioral, Solution-focused, and
● Psychotherapy approaches and their underlying
theories and assumptions can be easily added to
Feminist approaches, among others. the IDM to create a more individualized model.
● Developmental models focus on the ● Individual supervision models are unique to
developmental stage of the trainee. every supervisor, should have a solid foundation,
● Process-based models focus on the processes frame, and focus, and should be flexible enough
and roles within clinical supervision and are to adjust to each situation.
often combined with other models.
47 48
 Part 4: Evidence-Based Clinical Components
of Evidence
Supervision (EBCS) Based Clinical
● Best Available Research
● Clinical Expertise
Supervision
● Trainee Factors (EBCS)
● Assessment

Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A
guide for practicum students and interns. Washington D.C.: American Psychological Association.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015).
Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision
49 to bring science to integrative practice. Psychotherapy, 52(2), 185. 50

● Trainee Outcomes:
○ enhanced self- awareness
○ enhanced treatment knowledge
○ skill acquisition and utilization

EBCS Component 1: Supervision

○ enhanced self-efficacy
○ strengthening of the trainee–patient relationship

What Does the

Best Available
Matters ● Client Outcomes
○ Outcomes of patients in supervised vs
unsupervised settings:

Research
■ rated their symptoms lower
■ their satisfaction with treatment and the
working alliance higher
Tell Us About ■ more likely to stay in treatment
○ Supervisors account for as much as 16% of
Supervision? variance in outcome when symptom/condition
severity and therapist factors are controlled for

Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A guide for practicum
students and interns. Washington D.C.: American Psychological Association.
Rousmaniere, T. G., Swift, J. K., Babins-Wagner, R., Whipple, J. L., & Berzins, S. (2016). Supervisor variance in
psychotherapy outcome in routine practice. Psychotherapy Research, 26(2), 196–205.
51 Wrape, E. R., Callahan, J. L., Ruggero, C. J., & Edward Watkins, C. (2015). An exploration of faculty supervisor variables and 52
their impact on client outcomes. Training and Education in Professional Psychology, 9(1), 35–43.
 ●

Supervision is Most ●
Factors That Impair
Effective When the the Working Alliance
Working Alliance is…
●
● ●
Working ○
●

●
●
○
○ ●
Ellis, M. V. (2010). Bridging the Science and Practice of Clinical Supervision: Some Discoveries, Some Misconceptions.
●
[Link]
Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A guide for practicum ○ ●
students and interns. Washington D.C.: American Psychological Association.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015). Evidence-based supervision: ○
Tracking outcome and teaching principles of change in clinical supervision to bring science to integrative practice.
Psychotherapy, 52(2), 185. ○ Ellis, M. V. (2010). Bridging the Science and Practice of Clinical Supervision: Some Discoveries, Some Misconceptions.
[Link] C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and
Horrocks, S., & Smaby, M. H. (2006). The supervisory relationship: Its impact on trainee personal and skills development.
supervision: A guide for practicum students and interns. Washington D.C.: American Psychological Association.
Compelling perspectives on counselling: VISTAS, 173-176.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015). Evidence-based supervision: Tracking
outcome and teaching principles of change in clinical supervision to bring science to integrative practice. Psychotherapy, 52(2), 185.
53 Horrocks, S., & Smaby, M. H. (2006). The supervisory relationship: Its impact on trainee personal and skills development. Compelling 54
perspectives on counselling: VISTAS, 173-176.

● Knowledge
○ Supervisors who are more recent graduates are
correlated to better client outcomes (Wrape,
2015).
● Skills
○ Supervising in multiple modalities (group,

EBCS Component 2: Clinical Expertise: ○

individual)
Forming working alliance

Clinical Expertise Your Knowledge, ○

○
Providing feedback
Promoting growth and self-assessment

Skills, Attitudes & ○

○
Assessing trainee needs and developmental level
Discussing relevant multicultural factors

Values ○
○
Eliciting/integrating trainee feedback
Teaching/training/demonstrating
○ Boundary setting
○ Consultation
○ Scientific thinking, translating theory into practice
● Attitudes & Values
○ Appreciate/respect responsibilities to client and
trainee
Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A ○ Commitment to learning/growth
guide for practicum students and interns. Washington D.C.: American Psychological Association.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015). ○ Commitment to evidence based practices
Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision
to bring science to integrative practice. Psychotherapy, 52(2), 185. ○ What values do you bring to the supervision
Wrape, E. R., Callahan, J. L., Ruggero, C. J., & Edward Watkins, C. (2015). An exploration of faculty
supervisor variables and their impact on client outcomes. Training and Education in Professional process?
55 Psychology, 9(1), 35–43. 56
 ● Developmental - Stage of Training
○ Where is the trainee now? Where do they want
to be? Where “should” they be?

● Values/Beliefs
EBCS Component 3.1: Trainee Factors ○ Desire to learn/grow

Trainee Factors
○ Open to feedback
○ Preparation/responsibility
○ Willingness to take initiative/risk
○ Multicultural factors
■ What differences/similarities exist,
power dynamics etc.

Development, Values,
Expectations, and Preferences. ● Expectations & Preferences
○ What does the trainee know about
supervision?
○ What have their experiences been in
supervision in the past?
Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A
guide for practicum students and interns. Washington D.C.: American Psychological Association.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015).
○ How do they learn best?
57
Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision
to bring science to integrative practice. Psychotherapy, 52(2), 185. ○ What are their personal preferences? 58

● Diversity and multicultural competence in ADDRESSING Component Supervisor Trainee

supervision should mirror multicultural sensitivity
in clinical work; recognizing the impact of culture Age/Generation
and identity on presentation, behavior, strengths,

Multicultural
and resilience.
Multicultural Disability Status - Developmental

Competence Disability Status - Acquired

Competence ● Multiculturally Competent Supervision Includes:

○ Facilitating awareness of individual in Supervision Religion/Spiritual Orientation

in Supervision multicultural beliefs/attitudes (trainee,

supervisor and client)
Ethnicity
● Additional tools for increasing Socioeconomic Status
○ Initiating discussions of diversity and culture
multicultural awareness and
○ Addressing potential areas of conflict: competence in supervision Sexual Orientation
○ ADDRESSING Model (Hays,
■ “my spiritual beliefs are similar to this 2016) Indigenous Heritage
client’s beliefs, maybe that’s playing a
role in why our perceptions of this
National Origin
Falender, C. A., Shafranske, E. P., & Falicov, C. J. (2014). Diversity and multiculturalism in supervision. In C. A. Falender, E. P.
client’s progress are different?”
Shafranske, C. J. Falicov, C. A. Falender, E. P. Shafranske, C. J. Falicov (Eds.) , Multiculturalism and diversity in clinical supervision:
A competency-based approach (pp. 3-28). Washington, DC, US: American Psychological Association. doi:10.1037/14370-001
Pettifor, J., Sinclair, C., & Falender, C. A. (2014). Ethical supervision: Harmonizing rules and ideals in a globalizing world. Training and
Gender
Education in Professional Psychology, 8(4), 201–210. Hays, P. A. (2016). Addressing cultural complexities in practice: Assessment, diagnosis, and
Tsong, Y., & Goodyear, R. K. (n.d.). Assessing Supervision’s Clinical and Multicultural Impacts: The Supervision 59 therapy. APA Books. 60
Outcome Scale’s Psychometric Properties. [Link]
 Evaluation Best Practices:
EBCS Component
Collaborative & Ongoing
3.2:
Evaluation ● Self-evaluation (of trainee and/or supervisor)
alone is associated with poor outcomes for
supervision and the client
● One-sided evaluation processes can be limiting
and/or harmful to the relationship and outcomes
● Best Practice: Self-Evaluation + Collaborative
Evaluation + Feedback + Expectations
(Competencies, Benchmarks) +
Resources/Means to Meet Expectations

Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A guide for practicum students and interns.
Washington D.C.: American Psychological Association.
61 Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015). Evidence-based supervision: Tracking outcome and teaching
principles of change in clinical supervision to bring science to integrative practice. Psychotherapy, 52(2), 185.
62

● Evaluation of the Trainee Example: APA Competencies for

○ Profession competencies (APA) Psychologists
○ Setting competencies (PCBH) 1. Professionalism:
a. Professional Values and Attitudes
○ Client outcomes b. Individual and Cultural Diversity
What Are We ○ Evaluation Setting and/or What are the c. Ethical, Legal Standards and Policy
d. Reflective

Evaluating in
program requirements
■ Formal feedback (formative,
Professional Practice/Self-Assessment/Self-Care
2. Relational:

Supervision? summative) Competencies for a. Relationships

3. Science:
Trainees a. Scientific Knowledge and Methods
● Evaluation of Supervision b. Research/Evaluation
Processes/Outcomes 4. Application:
a. Evidence-based Practice
○ Working alliance b. Assessment
○ Contract / expectations c. Intervention
d. Consultation
○ Supervisor competence
○ Program/setting ● Each setting may also have its own unique
Ammirati, R. J., & Kaslow, N. J. (2017). All supervisors have the potential to be harmful. Clinical Supervisor, 36(1), 116–123. Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A
Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A guide for practicum
students and interns. Washington D.C.: American Psychological Association.
requirements/expectations guide for practicum students and interns. Washington D.C.: American Psychological Association.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015).
competencies...
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015). Evidence-based supervision: Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision
Tracking outcome and teaching principles of change in clinical supervision to bring science to integrative practice. 63 to bring science to integrative practice. Psychotherapy, 52(2), 185. 64
Psychotherapy, 52(2), 185.
 Discussion: What competencies are we How to Evaluate
looking for in PCBH?
➔ Ongoing, Transparent, Collaborative & ➔ Supervisor Self Evaluation
What would we look for when evaluating a
Mix of Formal/Informal ◆ What did you like about what you did? Was the

Setting trainee on these competencies? outcome what you intended? What would you do
differently next time?
➔ Trainee Self Evaluation
Competencies How do these competencies apply to a
◆ Ask: What did you like about what you did? Was
◆ APPIC Clinical Supervision in Psychology:
Competency Based Supervisor Assessment
supervisor and the supervision process?
/Training the outcome what you intended? What would you
do differently next time?
➔ Supervision Relationship/Process/Outcome
Benchmarks - GATHER Model of PCBH ◆ Have trainee complete a copy of their
competency eval form - where do they think they ◆ Norcross’s 3 Questions: Are we making progress
towards your goals? What would you like
- Generalist are developmentally?
more/less of? How is our relationship?
- Accessibility ◆ Working alliance/relationship questionnaires
- Team Based ➔ Trainee Competency/Training Benchmarks
● Short Supervisory Relationship
◆ Formative and Summative Program Evaluations
- High Productivity Questionnaire (S-SRQ); Supervisory
◆ APA competency rating form Working Alliance Inventory (SWAI)
- Educator supervisor and trainee forms

Reiter, J. T., Dobmeyer, A. C., & Hunter, C. L. (2017). The primary care behavioral health (PCBH) model:
An overview and operational definition. Journal of Clinical Psychology in Medical Settings, 1-18.
- Routine
Observation! Amerikaner, M., & Rose, T. (2012). Direct Observation of Psychology Supervisees’ Clinical Work: A Snapshot of Current Practice.
Clinical Supervisor, 31(1), 61–80
oper, M. (2016). Development and validation of a short version of the Supervisory Relationship Questionnaire. Clinical psychology &
psychotherapy, 23(1), 77-86.
65 66
Efstation, J. F., Patton, M. J., & Kardash, C. M. (1990). Measuring the working alliance in counselor supervision. Journal of Counseling
Psychology, 37(3), 322.

Collaborative Evaluation & Feedback Exercise

1. What are the issues presented?

2. What competencies (supervisor and/or trainee) are

Exercise 4: Evaluation and 3.

impacted?
How would you provide feedback in supervision? What

Feedback Exercise
would you say?
4. What kind of activities might you add, or how would you
shift the focus, in future supervision sessions to remediate
these issues? What resources would you need to
accomplish this?
5. How would you know when this issue was resolved? What
expectations might need to be set in order to accomplish
this?
6. How competent or confident did you feel to evaluate
and/or provide feedback in these areas?

67 68
Evidence-Based Clinical Supervision (EBCS)
Takeaways
Part 5: Structuring Supervision
● EBCS = Best Available Evidence + Clinical ● What to Evaluate in Supervision:
● The Initial Supervision Session and Negotiating Goals
Expertise + Trainee Factors + Evaluation ○ Trainee (competencies, individual factors) ● Ongoing Supervision Sessions and Tracking Progress
○
○
Supervisor (competencies, working alliance)
Supervision Process (setting, resources,
● The Final Supervision Session and Trainee Evaluation
● Relationship, relationship, relationship...the
expectations)
most important factor in determining
supervision outcomes ● How to Evaluate in Supervision
○ Formal: Program - formative and summative
● Your clinical expertise plays a crucial role (clinical evaluations, competency benchmarks
skill, knowledge, attitudes/beliefs)
○ Informal: Norcross’s three questions, working
alliance measures, SRS, observation, client
outcomes

69 70

The Initial
Supervision Session

Question: How often do you ask your trainees how you are doing as their supervisor?

71 72
 Foundation or set of assumptions about
supervision. Big picture philosophy of clinical Professional Relationships
supervision. How do you discuss this with your
trainee? ● Supervision Relationship
Expectations and Goals
Communicating the APA Recommends
●
Framework or model (developmental
● Trainee Progress
component, processes, supervision structure).
Foundation and Framework to determine tasks. How do you some Specific Tasks Professionalism
Defining the Frame of discuss this with your trainee?
during the course of
● Model Professionalism
Focus or approach (tasks, interventions,
Clinical Supervision techniques, roles, goals). What activities will you
supervision ● Formative and Summative Feedback
focus on? How do you discuss this with your
Assessment / Evaluation / Feedback
trainee?

Flexibility. Individual models should have a ● Quality of Feedback

solid foundation and framework and be flexible
● Trainee Self-Assessment
enough to adapt to any situation. How do you ● Seek Feedback
discuss this with your trainee? American Psychological Association. (2014). Guidelines for Clinical
*Four-F Model of Individual Supervision Copyright © 2018,
Chris Heffner, PhD, PsyD, [Link]. Used with Supervision in Health Service Psychology. Retrieved from
Permission. 73 [Link] 74

1. How will you begin establishing a

relationship?
● Determining individual model 2. How will you discuss Best Hopes (both
(foundation, framework, focus, and trainee and supervisor)?
flexibility) 3. How will you communicate your individual
Preparing for the ● Review administrative requirements Conducting the supervision model (what the trainee
should expect from you)?
Initial Clinical ● Review competency requirements,
benchmarks, and other clinical
Initial Clinical 4. How do you make sure to maintain the
supervision frame (how to avoid getting
Supervision Session requirements. How will you know Supervision Session sidetracked)?
what to expect from trainees? 5. How will you collaborate on goals?
● Review student information 6. How will you discuss expectations?
7. What are your expectations?
● Review client information
8. How will you understand the trainee’s
experience, strengths, and needs?
What else?
9. How will you verify agreement on goals
and other specifics (supervision contract)?

Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A Falender, C. A. & Shafranske, E. P. (2014). Getting the most out of clinical training and supervision: A What else?
guide for practicum students and interns. Washington D.C.: American Psychological Association. guide for practicum students and interns. Washington D.C.: American Psychological Association.
Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015). Holt, H., Beutler, L. E., Kimpara, S., Macias, S., Haug, N. A., Shiloff, N., ... & Stein, M. (2015).
Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision
to bring science to integrative practice. Psychotherapy, 52(2), 185. 75 to bring science to integrative practice. Psychotherapy, 52(2), 185. 76
 1. What are your best hopes for an ongoing
supervision session?
2. How will your trainee know your best hopes?
3. How will you structure the session?
4. How will you discuss and set goals for the session?
5. How will you prioritize activities?
Ongoing Supervision Conducting and 6. How will you maintain flexibility?

Sessions & Tracking Prioritizing Ongoing 7.

8.
How will you provide feedback?
How will the trainee demonstrate motivation?
Progress Supervision Sessions 9. How will the trainee demonstrate autonomy or
competence as a therapist?
10. How will the trainee isee demonstrate
self-awareness?
11. How will you track progress?
12. What kind of notes will you keep?
13. Will you assign homework?
14. What should occur between sessions and how will
you communicate this?
15. How will you end the session?

77 What else? 78

Schedules never get changed

1. What would you like to accomplish in supervision There is always enough time
today?
2. How do you typically cope with the pressures of Unexpected problems never arise
clinical and academic work etc.?
Questions to Ask 3.
4.
Are there self-care practices that work for you?
How will you know afterwards that today’s
A Perfect (but likely No one gets sick or has a bad day

Your Trainee in 5.
meeting was useful?
What do we each need to do to go on improving
boring) World Everyone is open minded

Ongoing Sessions our clinical supervision sessions?

Everyone is self-aware
6. What happened in this session that made you feel
(From Cowan, 2017) rattled, nervous, happy, or surprised?
Everyone is highly motivated
7. What do you find easiest about your work with
clients so far?
Everyone is very respectful
8. What do you find hardest about your work with
clients so far?
Clients are always improving
9. How do you think you’ll look back on this
experience in five years?
Trainees are always learning and growing

Supervisors are always perfect

79 80
 ● Set expectations that are relevant for the
setting (IE that you may get paged during
supervision)
● Make a plan for how to handle
Supervision on the interruptions/delays
○ Schedule another time to meet
The Final
Fly: How to adjust ○ Write down the topic/goal that was
interrupted to reaffirm your
Supervision Session
to interruptions ○
commitment/interest
Use it as an opportunity for learning

and preserve the ■

■
How did it feel when X happened
How can we handle interruptions

working alliance like X when we’re with a client

81 82

● How will you structure the final

1. How long prior to the last session
session?
should it be discussed?
Preparing for the Conducting the
● How will you prioritize the final
2. How will you help your trainee
session?
prepare for the final session?
Final Supervision 3. How might preparations for the final Final Supervision ● How will you conduct and discuss the
trainee’s formative evaluation?
Session session be a mirror for the trainee’s
preparations for a final client session? Session ● How will you help your trainee
develop best hopes moving forward?
4. How will you prepare and conduct
● How will you motivate your trainee?
summative evaluations?
● What do you want your trainee to
5. How will you prepare any other
leave with?
administrative paperwork or tasks?
What else?
What else?

83 84
 How will you include relationship building?
Until that miracle happens...
Exercise 5: How will goals be developed and incorporated?
Start with the ● How will you use your strengths to improve

End in Mind ●
your work as a supervisor?

How will you build on your strengths as a

Supervision How will you measure ongoing progress?

●
supervisor?

What knowledge, skills, and attitudes/values

Structure How will you model professionalism?
would you like your trainee to leave each
session with?
How will you provide trainee feedback?
● What knowledge, skills, and attitudes/values
would you like your trainee to leave the final Handout How will the trainee self-assess?
session with?

How will you seek and use feedback?

85 86

Part 5 Takeaways Part 6: Common Factors Across

● First impressions are very important in both
psychotherapy and supervision and the first
● Starting with the end in mind will help you
determine the tasks needed to bring about
Individual Models of Supervision
session will serve as the foundation for the your desired outcome.
supervision relationship. ● Consider the knowledge, skills, and
● Supervision is often interrupted or impacted by values/attitudes that you want your trainees
outside events, especially in primary care, so to have at the end of their supervision
setting priorities for supervision is important. experience.
● Of the 29 Guidelines for Supervision, according to ● Be purposeful about how you will meet
the APA, 8 of them identify specific tasks related competencies in each domain.
to professional relationships, professionalism, and
Assessment/Evaluation/Feedback.

87 88
 Common Factors models in clinical supervision,
much like those in psychotherapy, are becoming
more common.
A Common Factors
The Competency-Based Model is flexible enough
Approach To Clinical to incorporate common factors across

Supervision:
psychotherapy models, developmental models,
process models, roles, and tasks.

Developing an
Organizational Model
What are some common factors
across your individual supervision
models?

Question: What would you name your Individual Supervision Model?

89 90

Discussion Questions (Moving Forward)

1. What are your plans to move forward toward
your target-self as a clinical supervisor? How
Final Discussion would you rate yourself now?
2. What ethical, cultural, or regulatory issues
might prevent you from moving forward and
Presentation Objectives / Topics
how might you flag the minefield?
1. Clinical supervision and its core 3. What models of supervision most appeal to
competencies you? Why?
2. Ethical, cultural, and regulatory issues 4. What are some best practices you learned
3. Models of clinical supervision from others? How will you implement them?
4. Components of evidence-based 5. How will structure be used to improve your
clinical supervision and best practices supervision sessions and measure supervision
5. Initial, ongoing, and final clinical goals?
supervision session 6. What are some key components of your
6. Individualized competency-based individualized supervision model? How could Question: How did we do? (Did we achieve our goals? What aspects of the program did you like? What would
model for clinical supervision you work together to create an organizational you add to or change about the program?)
model of clinical supervision? 91 92
 ● Cliffe, T., Beinart, H., & Cooper, M. (2016). Development and validation of a short version of the Supervisory
Relationship Questionnaire. Clinical psychology & psychotherapy, 23(1), 77-86.
● Cowan, J. (2017). Navigating supervision: Ten tips for psychology graduate students. Retrieved from

References
[Link]
● Crunk, A. E. & Barden, S. M. (2017). The common factors discrimination model: An integrated approach to counselor
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[Link] ● Efstation, J. F., Patton, M. J., & Kardash, C. M. (1990). Measuring the working alliance in counselor supervision. Journal
● American Psychological Association (2006). Evidence-based practice of psychology. Retrieved from of Counseling Psychology, 37(3), [Link], M. V. (2010). Bridging the Science and Practice of Clinical Supervision:
[Link] Some Discoveries, Some Misconceptions. [Link]
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95 96