Supervision Essentials for the Integrative Developmental Model [1 ed.] 1433821419, 9781433821417

Table of contents :
Contents
Foreword to the Clinical Supervision Essentials Series
Acknowledgments
Introduction
Chapter 1
Theory and Overriding Structures
Chapter 2
Goals, Tasks, and Functions
Chapter 3
Supervisory Methods and Techniques
Chapter 4 Structure and Process of Supervision—Supervising Nahal
Chapter 5
Common Supervisory Issues
Chapter 6
Research/Support for the Integrative Developmental Model and Future Directions
Appendix A: Case Conceptualization Format
Appendix B: Supervisee Information Form for Nahal
Suggested Readings
References
Index
About the Authors

Citation preview

Clinical Supervision Essentials HANNA LEVENSON and ARPANA G. INMAN, Series Editors

Supervision Essentials for

the Integrative Developmental Model Brian W. McNeill and Cal D. Stoltenberg

American Psychological Association • Washington, DC

Supervision Essentials for

the Integrative Developmental Model

Clinical Supervision Essentials Series Supervision Essentials for Psychodynamic Psychotherapies Joan E. Sarnat Supervision Essentials for the Integrative Developmental Model Brian W. McNeill and Cal D. Stoltenberg

Copyright © 2016 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 www.apa.org

To order APA Order Department P.O. Box 92984 Washington, DC 20090-2984 Tel: (800) 374-2721; Direct: (202) 336-5510 Fax: (202) 336-5502; TDD/TTY: (202) 336-6123 Online: www.apa.org/pubs/books E-mail: [email protected]

In the U.K., Europe, Africa, and the Middle East, copies may be ordered from American Psychological Association 3 Henrietta Street Covent Garden, London WC2E 8LU England Typeset in Minion by Circle Graphics, Inc., Columbia, MD Printer: Maple Press, York, PA Cover Designer: Mercury Publishing Services, Inc., Rockville, MD The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Library of Congress Cataloging-in-Publication Data McNeill, Brian, 1955- , author. Supervision essentials for the integrative developmental model / Brian W. McNeill and Cal D. Stoltenberg. — First edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4338-2141-7 — ISBN 1-4338-2141-9 I. Stoltenberg, Cal D., author. II. Title. [DNLM: 1.  Psychotherapy—education. 2.  Counseling—education. 3.  Internship and Residency.  WM 18] RC480 616.89'14007155—dc23 2015027502 British Library Cataloguing-in-Publication Data A CIP record is available from the British Library. Printed in the United States of America First Edition http://dx.doi.org/10.1037/14858-000

Contents

Foreword to the Clinical Supervision Essentials Series

vii

Acknowledgments

xiii

Introduction 3 Chapter 1.  Theory and Overriding Structures

11

Chapter 2.  Goals, Tasks, and Functions

31

Chapter 3.  Supervisory Methods and Techniques

53

Chapter 4. Structure and Process of Supervision— Supervising Nahal

79

Chapter 5.  Common Supervisory Issues

103

Chapter 6. Research/Support for the Integrative Developmental Model and Future Directions

115

Appendix A:  Case Conceptualization Format

121

Appendix B:  Supervisee Information Form for Nahal

127

Suggested Readings

131

References 133 Index 141 About the Authors

151 v

Foreword to the Clinical Supervision Essentials Series

W

e are both clinical supervisors. We teach courses on supervision of students who are in training to become therapists. We give workshops on supervision and consult with supervisors about their supervision practices. We write and do research on the topic. To say we eat and breathe supervision might be a little exaggerated, but only slightly. We are fully invested in the field and in helping supervisors provide the most informed and helpful guidance to those learning the profession. We also are committed to helping supervisees/consultees/trainees become better collaborators in the supervisory endeavor by understanding their responsibilities in the supervisory process. What is supervision? Supervision is critical to the practice of therapy. As stated by Edward Watkins1 in the Handbook of Psychotherapy Supervision, “Without the enterprise of psychotherapy supervision, . . . the practice of psychotherapy would become highly suspect and would or should cease to exist” (p. 603). Supervision has been defined as an intervention provided by a more senior member of a profession to a more junior colleague or colleagues who typically (but not always) are members of that same profession. This relationship 77 is evaluative and hierarchical, 77 extends over time, and 1

Watkins, C. E., Jr. (Ed.) (1997). Handbook of psychotherapy supervision. New York, NY: Wiley.

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FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

77 has the simultaneous purposes of enhancing the professional function-

ing of the more junior person(s); monitoring the quality of professional services offered to the clients that she, he, or they see; and serving as a gatekeeper for the particular profession the supervisee seeks to enter. (p. 9)2

It is now widely acknowledged in the literature that supervision is a “distinct activity” in its own right.3 One cannot assume that being an excellent therapist generalizes to being an outstanding supervisor. Nor can one imagine that good supervisors can just be “instructed” in how to supervise through purely academic, didactic means. So how does one become a good supervisor? Supervision is now recognized as a core competency domain for psychologists4,5 and other mental health professionals. Guidelines have been created to facilitate the provision of competent supervision across professional groups and internationally (e.g., American Psychological Association,6 American Association of Marriage and Family Therapy,7 British Psychological Society,8,9 Canadian Psychological Association10).

2

Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Boston, MA: Pearson.

3

Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Boston, MA: Pearson.

4

Fouad, N., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings, P. S., Madson, M. B., et al. (2009). Competency benchmarks: A model for understanding and measuring competence in professional psychology across training levels. Training and Education in Professional Psychology, 3 (4 Suppl.), S5–S26. http://dx.doi.org/10.1037/a0015832

5

Kaslow, N. J., Rubin, N. J., Bebeau, M. J., Leigh, I. W., Lichtenberg, J. W., Nelson, P. D., et al. (2007). Guiding principles and recommendations for the assessment of competence. Professional Psychology: Research and Practice, 38, 441–51. http://dx.doi.org/10.1037/0735-7028.38.5.441

6

American Psychological Association. (2014). Guidelines for clinical supervision in health service psychology. Retrieved from http://www.apa.org/about/policy/guidelines-supervision.pdf

7

American Association of Marriage and Family Therapy. (2007). AAMFT approved supervisor designation standards and responsibilities handbook. Retrieved from http://www.aamft.org/imis15/Documents/ Approved_Supervisor_handbook.pdf

8

British Psychological Society. (2003). Policy guidelines on supervision in the practice of clinical psychology. Retrieved from http://www.conatus.co.uk/assets/uploaded/downloads/policy_and_guidelines_on_ supervision.pdf

9

British Psychological Society. (2010). Professional supervision: Guidelines for practice for educational psychologists. Retrieved from http://www.ucl.ac.uk/educational-psychology/resources/DECP%20Supervision% 20report%20Nov%202010.pdf Canadian Psychological Association. (2009). Ethical guidelines for supervision in psychology: Teaching, research, practice and administration. Retrieved from http://www.cpa.ca/docs/File/Ethics/ EthicalGuidelinesSupervisionPsychologyMar2012.pdf

10

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FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

The Guidelines for Clinical Supervision in Health Service Psychology11 are built on several assumptions, specifically that supervision 77 77 77 77 77 77

77 77 77 77 77 77 77 77 77 77

requires formal education and training; prioritizes the care of the client/patient and the protection of the public; focuses on the acquisition of competence by and the professional development of the supervisee; requires supervisor competence in the foundational and functional competency domains being supervised; is anchored in the current evidence base related to supervision and the competencies being supervised; occurs within a respectful and collaborative supervisory relationship that includes facilitative and evaluative components and is established, maintained, and repaired as necessary; entails responsibilities on the part of the supervisor and supervisee; intentionally infuses and integrates the dimensions of diversity in all aspects of professional practice; is influenced by both professional and personal factors, including values, attitudes, beliefs, and interpersonal biases; is conducted in adherence to ethical and legal standards; uses a developmental and strength-based approach; requires reflective practice and self-assessment by the supervisor and supervisee; incorporates bidirectional feedback between the supervisor and supervisee; includes evaluation of the acquisition of expected competencies by the supervisee; serves a gatekeeping function for the profession; and is distinct from consultation, personal psychotherapy, and mentoring.

The importance of supervision can be attested to by the increase in state laws and regulations that certify supervisors and the required multiple super­v isory practica and internships that graduate students in all professional programs must complete. Furthermore, research has American Psychological Association. (2014). Guidelines for clinical supervision in health service psychology. Retrieved from http://www.apa.org/about/policy/guidelines-supervision.pdf

11

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FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

confirmed12 the high prevalence of supervisory responsibilities among practitioners—specifically that between 85% and 90% of all therapists eventually become clinical supervisors within the first 15 years of practice. So now we see the critical importance of good supervision and its high prevalence. We also have guidelines for its competent practice and an impressive list of objectives. But is this enough to become a good supervisor? Not quite. One of the best ways to learn is from highly regarded supervisors—the experts in the field—those who have the procedural knowledge13 to know what to do, when, and why. Which leads us to our motivation for creating this series. As we looked around for materials that would help us supervise, teach, and research clinical supervision, we were struck by the lack of a coordinated effort to pre­ sent the essential models of supervision in both a didactic and experiential form through the lens of expert supervisors. What seemed to be needed was a forum where the experts in the field—those with the knowledge and the practice—present the basics of their approaches in a readable, accessible, concise fashion and demonstrate what they do in a real supervisory session. The need, in essence, was for a showcase of best practices. This series, then, is an attempt to do just that. We considered the major approaches to supervisory practice—those that are based on theoretical orientation and those that are meta-theoretical. We surveyed psychologists, teachers, clinical supervisors, and researchers domestically and internationally working in the area of supervision. We asked them to identify specific models to include and who they would consider to be experts in this area. We also asked this community of colleagues to identify key issues that typically need to be addressed in supervision sessions. Through this consensus building, we came up with a dream team of 11 supervision experts who not only have developed a working model of supervision but also have been in the trenches as clinical supervisors for years. Rønnestad, M. H., Orlinsky, D. E., Parks, B. K., & Davis, J. D. (1997). Supervisors of psychotherapy: Mapping experience level and supervisory confidence. European Psychologist, 2, 191–201.

12

Schön, D.A. (1987). Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco, CA: Jossey-Bass.

13

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We asked each expert to write a concise book elucidating her or his approach to supervision. This included highlighting the essential dimensions/key principles, methods/techniques, and structure/process involved, the research evidence for the model, and how common supervisory issues are handled. Furthermore, we asked each author to elucidate the supervisory process by devoting a chapter describing a supervisory session in detail, including transcripts of real sessions, so that the readers could see how the model comes to life in the reality of the supervisory encounter. In addition to these books, each expert filmed an actual supervisory session with a supervisee so that her or his approach could be demonstrated in practice. APA Books has produced these videos as a series and they are available as DVDs (http://www.apa.org/pubs/videos). Each of these books and videos can be used together or independently, as part of the series or alone, for the reader aspiring to learn how to supervise, for supervisors wishing to deepen their knowledge, for trainees wanting to be better supervisees, for teachers of courses on supervision, and for researchers investigating this pedagogical process.

About This Book In this book, Supervision Essentials for the Integrative Developmental Model, Brian McNeill and Cal Stoltenberg work from an integrative perspective that incorporates cognitive, affective, interpersonal, developmental, and social influences on supervisee development. The supervisor’s goal is to increase awareness, motivation, and autonomy across different clinical activities and levels of functioning, helping the supervisee progress along a continuum from neophyte to expert therapist. In this approach, the supervisor uses numerous specific tasks while assessing trainee readiness across multiple competency domains, all the while taking into account the context and/or setting in which supervisees work. To say the least, this developmental approach demands a lot from the supervisor! Fortunately, in this book, Drs. McNeill and Stoltenberg provide a clear framework for supervisors to follow. In addition, they provide many examples from

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FOREWORD TO THE CLINICAL SUPERVISION ESSENTIALS SERIES

supervision sessions to illustrate their concepts. All combined, this book elucidates an invaluable, pragmatic approach for supervisors and supervisees alike. No matter what your theoretical orientation, the integrative developmental model has much to offer. We thank you for your interest and hope the books in this series enhance your work in a stimulating and relevant way. Hanna Levenson and Arpana G. Inman

xii

Acknowledgments

W

e would like to acknowledge our many trainees over many years, who have taught us so much, and without whom this book would not have been possible. We also acknowledge the many clients who our students have worked with, and who put their confidence in therapists in training and their supervisors at critical times in their lives. Finally, thanks to the series editors, Hanna Levenson and Arpana G. Inman for their support, feedback, and input throughout the process of producing both this book and the DVD.

xiii

Supervision Essentials for

the Integrated Developmental Model

4

Introduction

A

s longtime professors and trainers of counselors and psychologists, we find that one of the most satisfying aspects of our work is observing and mentoring the professional growth of students in becoming competent providers of clinical services to their clientele. Therefore, we are pleased to share our model of the supervision and training process with readers involved in this important and enjoyable work. The integrative developmental model (IDM) as an approach to supervision has progressed for nearly 30 years, beginning with Stoltenberg’s (1981) straightforward model that posited counselor growth through four stages of professional development. The influence of this initial presentation on the practice of clinical supervision from a developmental perspective led to an explosion of developmental conceptualizations. Reflective of the heuristic value of such models, at one point, Worthington (1987) compared 16 developmental models, to which Watkins (1995) added six!

http://dx.doi.org/10.1037/14858-001 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

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Supervision Essentials for the Integrative Developmental Model

Subsequent books (Stoltenberg & Delworth, 1987; Stoltenberg, McNeill, & Delworth, 1998) significantly expanded this view with the integration of research and constructs with empirical investigations, as well as research from related areas of inquiry, leading to our most recent presentation of this IDM (Stoltenberg & McNeill, 2010). Consequently, the IDM has evolved from its initial beginnings as the counselor complexity model (Stoltenberg, 1981) to the subsequent integration of important clinical activity components (e.g., domains of practice) of the supervisory process first noted by Loganbill, Hardy, and Delworth (1982), resulting in the current conceptualization. In this brief introduction, we begin by defining supervision, offering a quick summary of the IDM, describing our personal journeys toward this conceptualization of supervision, and offering a road map for the rest of the book.

SUPERVISION DEFINITIONS AND GOALS Definitions of the process of supervision have evolved over time, emphasizing, for the most part, similar aspects with variations in perceived important components. For example, Falender and Shafranske (2004) defined supervision as a “distinct professional activity in which education and training aimed at developing science-informed practice are facilitated through a collaborative interpersonal process” (p. 3) that also involves observation, evaluation, supervisee self-assessment, and the acquisition of knowledge and skills in the form of trainee clinical competencies and outcomes. In their periodically revised comprehensive text on clinical supervision, Bernard and Goodyear (2014) defined supervision as “an intervention provided by a more senior member of a profession to a more junior colleague or colleagues who typically (but not always) are members of the same profession” (p. 9) and emphasized the evaluative and hierarchical nature of the supervisory relationship that extends over time to enhance the professional functioning of more junior persons, with the supervisor monitoring the quality of services and serving a gatekeeping function for the profession. Hill and Knox (2013) stressed the professional development of the supervisee, as well as client welfare in the supervisory relationship. 4

Introduction

We agree with the definition of supervision recently adopted by the Board of Educational Affairs Task Force on Supervision Guidelines (American Psychological Association [APA], 2014): Supervision is a distinct professional practice employing a collaborative relationship that has both facilitative and evaluative components, that extends over time, which has the goals of enhancing the professional competence and science-informed practice of the supervisee, monitoring the quality of services provided, protecting the public, and providing a gatekeeping function for entry into the profession. Henceforth, supervision refers to clinical supervision and subsumes supervision conducted by all health service psychologists across the specialties of clinical, counseling, and school psychology. (p. 5)

At the same time, however, we adhere to a more traditional “master– apprentice” definition of supervision that highlights the “intensive, interpersonally focused, one-to-one relationship in which one person is designated to facilitate the development of therapeutic competence in the other person” (Loganbill et al., 1982, p. 4). These definitions encompass the variety of skills training, interventions, and attention to professional and personal development that are evident in this volume. In examining the merging of skills, professional development, and personal development as an individual on the journey to therapeutic competence, it is also important to reflect on the goals or endpoint in this journey. These goals, we believe, are best expressed in the research on master therapists first reported by Jennings and Skovholt (1999) and later expanded upon by Skovholt and Jennings (2004). The characteristics of master therapists are listed here. 77 77 77 77 77

Master therapists are voracious learners. Accumulated experiences are a major resource for master therapists. Master therapists value cognitive complexity and the ambiguity of the human condition. Master therapists appear to have emotional receptivity, defined as being self-aware, reflective, nondefensive, and open to feedback. Master therapists seem to be mentally healthy and mature individuals who attend to their own emotional well-being. 5

Supervision Essentials for the Integrative Developmental Model

Master therapists are aware of how their emotional health affects the quality of their work. 77 Master therapists possess strong relationship skills. 77 Master therapists hold a number of beliefs about human nature that help to build strong working alliances. 77 Master therapists appear to be experts at utilizing their exceptional relationship skills in therapy. 77

We believe that these characteristics represent crucial therapeutic qualities related to the acquisition of skills or competencies that are often not addressed in approaches to training that conceptualize the process of becoming a therapist (e.g., Falender & Shafranske, 2004). Consequently, our model is designed to focus on the path to competence as a master therapist across domains, accounting for how therapeutic skills, knowledge, and attitudes are developed and suggesting best mechanisms for encouraging professional development.

THE IDM IN SUMMARY In the IDM, we view the growth of therapists as progressing through three developmental stages or levels: Level 1, beginning; Level 2, intermediate; and Level 3, advanced. There is also a fourth level, 3i, in which the supervisee has achieved an integrated level of skills across all domains and structures. The supervisor’s attention is focused at each level on the following overriding supervisory structures (see Chapter 1, this volume, for an in-depth look at each structure): motivation to become an effective psychotherapist, autonomous functioning in clinical practice, and 77 self- and other (i.e., client) awareness in both cognitive and affective realms. 77 77

We also attempt to measure the growth of therapists across the following eight specific domains of clinical practice (see Chapter 2 for an in-depth look at each specific domain): intervention skills competence, 77 assessment techniques, 77

6

Introduction

77 77 77 77 77 77

interpersonal assessment, client conceptualization/diagnosis, attention to individual differences in client work, theoretical orientation, treatment plans and goals, and professional ethics.

Thus, the core aim of the IDM is to provide differing and flexible facilitative supervisory environments and interventions to best enhance developmental progression through the levels. We note here that the “integrative” aspect of the IDM refers to an integration of recent research, as well as an examination of theory and research beyond the area of clinical supervision (and psychotherapy) to help illuminate processes held in common with other areas of psychology. For instance, in understanding the supervision process, Stoltenberg and McNeill (2010) noted the importance of cognitive models (cognitive and emotional processing; Anderson, 2005; Greenberg, 2002), schema development and refinement (McVee, Dunsmore, & Gavelek, 2005; Schön, 1987) and skill development; development from novice to expert (Anderson, 2005); interpersonal influence (Dixon & Claiborn, 1987; Stoltenberg, McNeill, & Crethar, 1995) and social intelligence (Goleman, 2006); motivation (Petty & Wegener, 1999; Ryan & Deci, 2000); and of course, models of human development (Lerner, 1986). In the chapters that follow, we investigate each of these interactive elements in more detail.

OUR PATHS AS SUPERVISORS In both the Counseling Psychology Program and the University Counseling Services (UCS) at the University of Iowa in the early 1980s, there was a hotbed of supervision activity. This activity included classes and other didactic and experiential training with such supervision scientist–practitioners as Ursula Delworth, Emily Hardy, Carol Loganbill, and Gerry Stone. At this time Cal Stoltenberg worked as a graduate assistant under the guidance of Ursula Delworth, which resulted in the publication of the initial developmental 7

Supervision Essentials for the Integrative Developmental Model

model of clinical supervision (Stoltenberg, 1981). Cal later accepted a position in the Psychology Department at Texas Tech University, where Brian McNeill was a graduate student in the Counseling Psychology Program. During this time, Cal presented a job talk/colloquium on his supervision model, which helped earn him notoriety as a young upstart who dared to tell his elders how to supervise. Brian later completed his degree, with Cal as his advisor, and went on to enroll in his predoctoral internship under UCS Director/Training Director Ursula Delworth, taking advantage of opportunities to coteach beginning practicum, engage in supervision of a less-experienced trainee, attend supervision training seminars, and receive supervision on supervisory activities. Ursula Delworth remained a valued mentor to both of us well into our postgraduate careers, as did Cal for Brian. This lineage has had a significant influence on both of our careers, as we have enjoyed numerous opportunities in the past 30 years to supervise students at various levels of development through our work as professors, including teaching practicum-type courses and developing and teaching courses in supervision. Cal has held academic positions at Texas Tech University and the University of Oklahoma, where he served as director of training for the APA-accredited program in counseling psychology for nearly 20 years. Brian has worked in both academic and practice settings and served as director of doctoral training for two APA-accredited programs in counseling psychology at The University of Kansas and Washington State University. It appears that both the IDM specifically and developmental conceptualizations of the supervision process in general have survived the test of time since Cal presented his initial model.

ROAD MAP OF THE BOOK In this volume, we present the basic principles related to the theory and practice of IDM, which is fully articulated in IDM Supervision: An Integrative Developmental Model for Supervising Counselors and Therapists (Stoltenberg & McNeill, 2010). Although much of the content of this book is derived from that more comprehensive volume, we hope that the current presentation will serve as a solid introduction to our model and spark interest in those who wish to gain more detailed information. 8

Introduction

In Chapter 1, we take a deeper look at the foundations of the IDM by examining relevant theory, with an in-depth examination (across all developmental levels) of the three overriding structures by which we view therapist development: self-awareness and awareness of others, motivation, and autonomy. In Chapter 2, we discuss the goals, tasks, and functions of supervision and the primacy of the supervisory relationship and the necessity of supervisee evaluation and feedback. We expand our focus to the eight domains of clinical practice by which trainees are assessed in the IDM. In Chapter 3, we examine various supervisory methods and techniques, including specific supervisory interventions across all developmental levels, always within the context of multicultural and ethical considerations. In Chapter 4, we demonstrate the direct clinical application of the IDM by analyzing a real-life supervisory session documented in the DVD The Integrative Developmental Model of Supervision. In Chapter 5, we discuss common challenges that arise at various levels of supervisee development and provide strategies for overcoming them. Finally, in Chapter 6, we briefly examine the empirical support for the IDM and point out directions for future research in the area of clinical supervision.

9

1

Theory and Overriding Structures

I

n this chapter, we investigate the three overriding structures that provide markers in assessing professional growth and by which we monitor trainee development in the integrative developmental model (IDM): self and other awareness, motivation, and autonomy. Within any given area of clinical practice, these structures reflect the level of development at which the trainee is currently functioning. Differences will also be apparent in the nature of the supervisee’s ability to reflect on his or her practice inside and outside of supervision. Consequently, it is important to begin by addressing how supervisee growth is promoted through the levels via self-reflection.

THEORETICAL UNDERPINNINGS Encouraging trainees to engage in processes such as reflection-in-action (in therapy sessions) and reflection-on-practice (in supervisory sessions) in some form characterizes most approaches to supervision (Bernard & http://dx.doi.org/10.1037/14858-002 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

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Supervision Essentials for the Integrative Developmental Model

Goodyear, 2014). Consequently, we have incorporated the ideas of refining schemata or knowledge evolution, as proposed by Schön (1987), as the process of reflective practice. Schön described knowing-in-action (KIA) as the process by which our actions indicate what we really know. This information about a particular action reflects solidified knowledge that we often overlook when we describe our own behavior. In essence, it has become automatic and doesn’t require conscious monitoring. When our actions fail to lead to anticipated outcomes, this “surprise” elicits a process Schön called reflection-in-action (RIA), in which we use reasoned and purposeful experimentation to improve our performance in the here and now. The KIA may reflect skills developed in other areas that do not readily transfer into new domains. When we reflect-in-action, we attend more carefully to the current context, notice aspects that may differ from what we typically encounter, and modify our thinking to enhance the likelihood of success at the new task. This process describes what can occur in a psychotherapy session when the therapist’s typical response to or intervention with a client does not produce the expected reaction or outcome. Of course, one needs to be attentive in the here and now to client reactions to be aware of unexpected responses (verbal or nonverbal). When we reflect on our actions, evaluating the process we used and the lessons learned, we are engaging in reflection-on-action (ROA). By doing this, we come to understand more completely how our KIA might have led to an unexpected outcome and how effectively (or not) our RIA might have addressed the new challenge. This, of course, describes the process by which a therapist reflects on clients and the therapy process between sessions (as time permits), as well as what typically occurs in supervision. However, it is important to realize that we cannot reflect on something that we don’t notice. Either through close attention to our work in sessions, carefully monitoring videos of sessions, or recognizing events through interaction in supervision, reflection (RIA or ROA) only works when we recognize the need for it. Of additional importance in supervision is encouraging RIA and ROA by supervisees as a process of ongoing evaluation and refinement of one’s skills. Appropriate supervision environments and experience can lead to the development of expertise, improving the ability to organize information and concepts into patterns that can be recognized quickly and 12

Theory and Overriding Structures

solutions to the problems activated. We now examine how these reflective, as well as other cognitive and affective, processes manifest themselves in relation to the overriding structures of the IDM. Overriding Supervisory Structures We view the growth of therapists as progressing through three developmental stages or levels, with attention focused at each level on the overriding supervisory structures of motivation to become an effective psychotherapist, autonomous functioning in clinical practice, and self-awareness and other (i.e., client) awareness in both cognitive and affective realms. Self- and Other Awareness: Cognitive and Affective This structure has both cognitive and affective components and indicates where the individual is in terms of self-preoccupation, awareness of the client’s world, and enlightened self-awareness (see Table 1.1). The cognitive component describes the content of the thought processes characteristic across levels, and the affective component accounts for changes in emotions, such as anxiety. Specifically, it reflects the development and refinement of schemata (declarative knowledge, or content we know, and procedural knowledge, understanding processes or how to perform a skill) by trainees in domains relevant to clinical practice. Conversely, the affective component accounts for changes in emotions. For instance, the trainee’s ability to engage in effective empathic understanding is an important aspect of the affective component of this structure. The content of what is in working memory during therapy and the nature of the KIA for a particular trainee and the degree to which RIA can positively affect the therapy process are characteristics of different levels for this structure. Essentially, this structure reflects the development of one’s knowledge base, cognitive and affective, and one’s ability to use this knowledge in the professional context. Motivation This structure reflects the supervisee’s interest, investment, and effort expended in clinical training and practice. Changes over time tend to go from early high levels through a vacillation from day to day and client to 13

Supervision Essentials for the Integrative Developmental Model

Table 1.1 Definition of Therapist Level in Terms of Overriding Supervisory Structures Therapist level

Motivation

Autonomy

Self/other awareness

1

Highly motivated

Dependent; need for structure

Cognitive: self-focus but limited self-awareness Affective: performance anxiety

2

Fluctuating between high and low; confident/lacking confidence

Dependency– autonomy conflict; assertive versus compliant

Cognitive: focus on client; understand perspective Affective: empathy possible, also overidentification

3

Stable; doubts not immobilizing; professional identity is primary focus

Conditional dependency; mostly auto­nomous

Cognitive: accepting and aware of strengths/ weakness of self and client Affective: aware of own reactions and empathy

3i

Stable across domains; professional identity established

Autonomous across domains

Personalized understanding crosses domains; adjusted with experience and age

Note. From IDM Supervision: An Integrative Developmental Model for Supervising Counselors and Therapists (3rd ed., p. 40), by C. D. Stoltenberg and B. W. McNeill, 2010, New York: Routledge. Reprinted with permission.

client, culminating in a stable degree of motivation over time. Implications for influence of the supervisor from various power bases and the ramifications for processing by the supervisee are important here. The roles of amotivation, extrinsic and intrinsic motivation, and various regulatory mechanisms directly affect the trainee’s willingness to engage in the learning process. These processes also play an important role in one’s willingness to recognize his or her responsibility for learning and subsequent effectiveness in practice. In short, this structure is affected by the trainee’s awareness of cognitive and affective components of the learning and practice environments, which can elicit a range of reactions from confusion to clarity, self-absorption to empathy, and anxiety to a sense of confidence 14

Theory and Overriding Structures

and efficacy. Clearly, these reactions affect one’s sense of control and motivation, which in turn affect the trainee’s willingness to engage in the often complex and challenging actions of learning and practice. Autonomy Changes in the degree of independence demonstrated by trainees over time accompany the other structural changes. Beginners tend to be rather dependent on supervisors or other authority figures and eventually grow into a dependency–autonomy conflict, or professional adolescence. Clinical experience and supervision allows therapists to become conditionally autonomously functioning professionals. This awareness of strengths and weaknesses allows the individual to accurately assess the need for additional supervision or consultation regarding professional issues. Changes in motivation from extrinsic to more intrinsic and confidence in one’s knowledge and competence have direct implications for the sense of autonomy experienced for different domains by trainees. A desire for independence and a sense of efficacy can have a motivating effect on learning (if one perceives that he or she can develop adequate skills and positively affect professional growth), or it can elicit a reticence to explore new understandings and approaches or even new domains of practice (for fear of incompetence or unwillingness to invest in the learning process). This response can also limit one’s investment in self-evaluation or evaluation by others and critical reflection (ROA) so the trainee does not have to confront evidence that is contrary to comfortable perceptions of competence. Structures Defined Across Levels 1 Through 3i Now that we have summarized our overriding structures, we examine how these structures vary across levels of therapist development. As noted, our model views development as occurring within eight specific domains of clinical practice (detailed in Chapter 2) and progressing through Levels 1, 2, and 3, with a final push toward integration across domains (Level 3i). Consequently, any given trainee (except for perhaps one at the entry level with no relevant prior experience) often is functioning at different levels across various domains at any point in time. 15

Supervision Essentials for the Integrative Developmental Model

Level 1 Supervisees who are functioning at the early Level 1 stage for a particular domain display some common characteristics. If they are new to the field in the initial phases of education and training in psychotherapy, they often have limited direct relevant experience, although they may have considerable related experience that may be indirectly related to clinical work (i.e., general interpersonal skills). Their background knowledge usually is limited to an introduction to theories and techniques at the graduate level and, perhaps, broad exposure to various areas of psychology or mental health through undergraduate education. The supervisor can choose from among various approaches, but typically a focus on relationship skills and simple intervention strategies is predominant. Supervisees who may have had considerable experience in other areas of clinical activity (e.g., other therapy orientations, other modalities, related mental health experience) nevertheless will be functioning at Level 1 if these experiences are significantly different from the primary training focus in supervision. For example, it is common to encounter supervisees with significant training and experience in individual counseling or psychotherapy, within one or two orientations, with particular populations, but with little or no knowledge or experience in another orientation, another therapeutic modality (e.g., marital, family, group therapy), or with clients coming from significantly different cultural backgrounds. Similarly, supervisees may have engaged in significant training in assessment but little in psychotherapy or vice versa. Level 1 trainees have limited background in the particular domain of focus in at least a portion of what is addressed in supervision. New trainees are Level 1 across most or all domains, whereas advanced supervisees, sometimes even more advanced therapists at the higher levels, have limited background in certain domains of the clinical experience under supervision. Self and Other Awareness.  Learning new skills, theories, and intervention strategies tends to result in considerable confusion and anxiety in Level 1 supervisees. At this level, their evaluation of self-performance often is guided by a perception of their proficiency in faithfully performing a given 16

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technique or following a particular strategy with a client. New declarative knowledge is necessary but not sufficient. Procedural knowledge, or how best to utilize and implement information, is necessary for effective practice. Thus, development and refinement of schemata are required. This cognitive self-focus, or attempting to tap this information for use in working memory, leaves little attentional capacity for considering the client’s perspective, empathy, or even processing the therapist’s own affective or cognitive reactions to the client. Considerable RIA (active “here and now” monitoring of behavior) on the adequacy of the KIA used by the trainee (behaviorally, how and why they do what they do), and reflection-on-practice (at a later time) is necessary for one to develop effective and efficient procedures for therapeutic skill implementation. Research has indicated that this self-focus tends to elicit significant anxiety in the supervisee, which can complicate effective performance (Hale & Stoltenberg, 1988). Concern for incompetence, a sense of lack of efficacy or control of one’s ability to be effective, or simply confusion regarding what to do can elicit an anxious response in trainees. This can stimulate or motivate a desire to learn or lead a trainee to fall back on familiar ways of interacting with people developed outside the therapy context (or from other earlier marginally relevant experiences). In considering the awareness structure, supervisors need to monitor both cognitive and affective components. Cognitive.  The confusion, lack of certainty, or loss of a sense of what to do is characteristic of the lack of knowledge or interference with therapist cognitions at this level. Because of the need to reflect constantly on the rules or procedures, skills, theories, and other didactic material being learned, it is difficult for trainees to carefully listen to and process information provided by the client in session. It is also difficult for them to recall relevant information (activation and retrieval) and utilize it in working memory immediately in the session, when they are struggling to understand the client’s perspective. The trainee’s schemata related to this aspect of practice within this clinical situation are not sufficiently developed and integrated (activation links) to allow for quick and easy access. As our review of learning theories and cognitive processing suggests (i.e., 17

Supervision Essentials for the Integrative Developmental Model

Stoltenberg & McNeill, 2010), adding facts and skills is not enough. Procedures for utilizing information from memory in a way that affects one’s implementation of effective therapeutic behaviors (pattern development and matching) also tend to be limited and improve only with relevant experience, reflection, and deliberate practice with accurate feedback on one’s performance. Add to this the trainee’s concern with evaluation by the client and the supervisor (fear of critical feedback or of making a mistake), and it is easy to see how confusion can reign. Affective.  This component of self-awareness accompanies the cognitive confusion. Developmentally, we know that the state of disequilibrium caused by a perception of insufficient understanding often elicits conflict or discomfort in a given situation. Add to this the fear and anxiety often associated with one’s perception that he or she is not meeting acceptable standards of understanding or behavior (objective selfawareness) or the anticipation of a negative evaluation by others (client and supervisor; evaluation apprehension), and it is easy to understand the range of negative emotions that Level 1 therapists may experience (Hale & Stoltenberg, 1988). Level 1 supervisees are characterized by a focus (one might say a preoccupation) on the self, and it is often a negative focus rather than insightful self-understanding. Although it is typical for trainees at this level to be excited about learning how to engage in professional practice, even the more mature and personally developed trainees tend to experience the confusion and anxiety associated with this stage. In addition to the negative emotional experiences associated with evaluations of one’s behavior, lack of knowledge, and confusion, to the extent that the Level 1 trainee is able to attend to the client, he or she may experience anxiety, fear, sadness, and a range of other emotions that emanate from the client. Thus, the trainee may experience this “low road” social processing of affect from the client, with little or no conscious awareness of the origins of these feelings, in addition to the emotions stimulated by the “high road” conscious cognitive processes that are not yielding adequate results. As Level 1 supervisees gain experience and are exposed to a facilitative supervision environment, their confidence and skills increase, and 18

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they begin to feel less of a need to focus so intently on their own performance. Their comfort level in engaging in practice increases as their KIA becomes more adequate, producing fewer “surprises” in sessions or situations of confusion and eliciting less-distracting RIA that is focused on their own behavior. In addition, subsequent self-evaluations of their behavior (ROA), which typically are focused on how well they engage in particular “fundamental” counseling skills or behaviors, become more positive as they see their performance in these circumscribed interactions as more similar to that of models (other students, supervisors, videos of counseling techniques). They then begin the transition to Level 2, switching their focus more toward their clients and away from monitoring their own skills, anxiety, and recall of clinical directives conveyed during the educational process. They are now more able to notice the impact of the therapeutic process on the client and attend more carefully to the client’s communications. Motivation.  Level 1 supervisees typically are highly motivated. Some of this motivation is a function of their desire to become fully functioning clinicians. Often some “end-state” model of a professional based on personal acquaintances or depictions of therapists in books or film serves as a developmental goal for the beginning trainee. The desire to move quickly from neophyte to expert can be a strong motivator. In addition, some of this early motivation is a function of wanting to grow beyond the uncertainty, confusion, and anxiety associated with this stage. This motivation to learn and grow often only reflected in a desire to learn the “best” or the “correct” approach to dealing with clinical problems. There also often is a desire to share this understanding and expertise with clients, and the perception of professional effectiveness can result in a measure of confidence and serve to reinforce the person’s selection of career path. Ryan and Deci’s (2000) self-determination theory provides some guidance in understanding how motivation may influence trainee behavior. With the demands for learning the work of the psychotherapist, Level 1 trainees are likely to function at various levels of extrinsic motivation, particularly with reference to behaviors to be learned to effectively perform counseling and psychotherapy (or assessment, and so on). One might 19

Supervision Essentials for the Integrative Developmental Model

expect that the “overall” motivation for entering training and pursuing a career in mental health work might well reflect intrinsic motivation, with some sense of internal locus of causality for (at least) being in a training program, and self-determined interest and inherent satisfaction with the “idea” or role of practitioner. However, with regard to specific intention to act or engage in behaviors required by training programs (e.g., skill development and demonstration, work with clients), motivation may be more extrinsic, with a perception of an external regulatory style in which the locus of causality for one’s behavioral intentions is perceived as largely external (dictated by professors or supervisors). One’s behavior can be seen as significantly controlled by externally provided rewards and punishments (from supervisors, professors, and even clients) and compliance with training demands. As experience and proficiency increase, the level of perceived internal causality and self-control, with more internal rewards and punishments, is expected to develop. Getting past the early perception of inadequacy and experiencing some measure of success begins the transition to Level 2. Here we may see a reduced desire for learning new approaches or techniques as the supervisee may prefer to enjoy a feeling of emerging self-efficacy as a clinician. The confidence that comes with positive evaluations from others (and positive self-evaluations) regarding one’s performance of skills and the ability to develop a sufficient therapeutic relationship to keep clients returning can result in considerable intrinsic motivation and less of a sense of the locus of causality residing externally. The risk of again experiencing feelings of incompetence can reduce trainees’ motivation to explore new approaches and expand their therapeutic repertoire. They may be comfortable, for the moment, in their perceptions of adequacy. Autonomy.  Novice clinicians, whether across the board or in a specific domain, tend to show considerable dependency on the supervisor, which is an appropriate response to their lack of knowledge and experience and their scant understanding of the processes involved. They typically rely on the supervisor to provide structure in supervision and guidance for their behavior in the focal domains. They are looking to the supervisor, other authority 20

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figures, or other sources to provide information they can elaborate on and integrate into an overall structure (schemata) from which to understand the clinical process and direct therapeutic behavior (productions; KIA). Similarly, good examples provided by supervisors and others can help in skill acquisition and refine early pattern development and matching for the trainee. Again, early successes tend to decrease the supervisee’s perception of the need to depend on the supervisor and lead to a desire for more autonomy in supervision and clinical practice. The developing, more intrinsic perceived locus of causality for therapeutic behavior results in more selfcontrol and desire for greater independence, less compliance with directives from supervisors or other authority figures, and less reliance on externally provided rewards (from the supervisor). Initially, clients returning for sessions and appearing committed to the therapeutic relationship may suffice for positive evaluation from the client. A rather simplistic understanding of a complex phenomenon may lead supervisees to desire more autonomy in practice than is warranted. The trainee’s motivation to learn and develop can be reduced by a sense of incompetence with new skills or approaches or demands from the supervisor for a more complex view of the process. Such supervisees will need to be encouraged to take risks beyond the point where skill deficiencies would be considered a hindrance. Level 2 The resolution of Level 1 issues allows the supervisee to move into Level 2. This transition can be facilitated or hindered by the supervision environment. However, we must not forget that this developmental sequence occurs within domains, so we may expect to find differential growth across domains. This differentiation may be a function of more of a focus on some domains rather than others during prior supervision, resulting in greater growth in these domains than others. Additional training opportunities may result in more development in certain domains, and the trainee’s personal characteristics may be better suited to particular domains of practice, so there may be more rapid growth in those domains. 21

Supervision Essentials for the Integrative Developmental Model

Self and Other Awareness.  The transition in switching away from a primary focus on the supervisee’s own thoughts and performance toward more of a focus on the client enables movement into Level 2. Cognitive.  With the freeing up of awareness from self-preoccupation, the trainee has more attention available to direct toward the client and can begin to understand the client’s world more fully, marking a structural shift in the area of cognition. However, this additional perspective may confuse the supervisee. A trainee in late Level 1 may have a fairly naive and simplistic view of the client and clinical processes (schemata, patterns); now these processes may seem complex, confusing, and overwhelming to the Level 2 supervisee. As one attends more to the reactions of the client in therapy, the inadequacy of “applying skills” to clients in certain contexts or a “one size fits all” approach will become more apparent to the trainee. The knowledge-in-action now includes sufficiently developed fundamental counseling skills to allow the trainee to provide a safer environment for the client, which can stimulate more exploration and disclosure. The trainee can now listen more carefully to the client and, with encouragement, strive to more fully understand the world of the client. The impact of trainee behaviors on the client will also become more salient if this is a focus of supervision, and the trainee will become more aware of how the client responds and whether or not the client views his or her situation as improving as a function of therapy. By attending more completely to the client, as opposed to the self, the trainee may become more aware of inadequacies in his or her knowledge-inaction and, once again, experience confusion and frustration when client behavior (verbal and nonverbal) suggests less-than-satisfying responses or lack of overall progress. At other times, the power of relationship-enhancing skills or learned structured interventions will prove to be sufficient, and the trainee will exhibit confidence in his or her competence. If we have much control over the difficulty of clients assigned to our supervisees, it is at this point that we encourage working with clients experiencing more challenging issues. The function of this type of challenge is to push trainees to accommodate to new understandings when they are experiencing difficulties in assimilating new experiences into existing schemata. This 22

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increased understanding can occur as a function of dealing with clients who have more complex mental health issues, life circumstances, or who come from significantly different cultural backgrounds than the trainee. Approaches perceived by the trainee to have successfully worked in the past may now prove to be inadequate. More RIA is required, which can also prove confounding. The ROA that occurs between sessions and in supervision can help the trainee refine schemata, improve activation and retrieval of relevant information, and produce new pattern development and matching. Affective.  It is frequently difficult to feel someone else’s sadness, pain, or anger when you are preoccupied with your own anxiety or when you are pleased with how well you just “reflected” back to the client. However, in Level 2, the opportunity to develop empathy more fully with the client becomes possible. The supervisee’s newly developed ability to focus on the client can yield a sensing of the emotional experience of the client. Rather than guessing what emotions the client may be experiencing at any given time, the Level 2 therapist can develop the ability to pick up on verbal and nonverbal cues that communicate the inner emotional experience of the client. This can add considerable depth to the supervisee’s understanding of the client. It can also increase the likelihood of enmeshment, countertransference, or an “intervention paralysis” for the supervisee, who may now be nearly as emotionally overwhelmed as the client. Goleman (2006) noted that both pleasant and unpleasant emotions are contagious if we are attuned to others. The amygdala, via low road processing, extracts meaning from others’ nonverbal behavior before we are consciously aware of it. Because this process is not directly connected to speech centers in the brain, we can actually “feel” others’ emotions in a preconscious manner. Early attempts by trainees to “empathize” with clients by reflecting feelings during sessions often take the form of looking at the client’s nonverbals or assessing the situation described by the client and guessing at the surface or underlying feeling. Other times, the trainee will relies on pulling feeling words from the client’s statements for reflections. However, now that the trainee doesn’t need to focus on his or 23

Supervision Essentials for the Integrative Developmental Model

her own behavior as closely because many counseling skills have become more natural, careful attention to the client can allow the trainee to access emotions more directly. As Goleman noted, closely attending to another with intensive eye contact allows “mirror” neurons in our brains to be activated, resulting in experiencing the same emotions as the other person. Observers can note well-coordinated nonverbal behavior in which we tend to match postures, tone, and so forth with another. For this to occur, an intense focus on the other person is required, essentially shutting off, or reducing attention to, high road cognitive processes. Interestingly, this enables another mechanism for having an impact on the client because the possibility of attuned mutual attention goes both directions. The conscious high road processing comes into play later, when we examine our emotions and label the feelings we are experiencing. For the Level 2 supervisee, the lifting of the veil of anxious self-awareness can result in a deeper and more accurate understanding of the client. Taken to the extreme, it can also lead to an inability to get beyond the confusion or intense emotion stimulated by a singular focus on the client. The transition beyond Level 2 to Level 3 consists of altering the focus to include more high road processing by the therapist regarding interactions with the client and RIA on what is known by the supervisee regarding the clinical processes at work. Tapping into relevant schemata while engaged in clinical activity allows the trainee to “adjust on the fly” to events in therapy. Careful ROA between sessions and during supervision enables more schema refinement and better pattern development and matching by the trainee. Motivation.  The confidence that accompanies perceptions of selfefficacy in clinical practice has been shaken by an increased awareness of the complexity of the enterprise. The effects on motivation can be significant. Some supervisees react to this confusion by seeking additional support and guidance and displaying high levels of motivation to learn, returning to a more extrinsic motivation with an externally perceived locus of causality, relying on guidance and praise from the supervisor (and others) and focusing on compliance with behavioral 24

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recommendations. For others, reacknowledging confusion and frustration can reduce motivation to learn and engage in clinical activities. A state approaching “amotivation” in self-determination theory can exist, in which a sense of incompetence and lack of control can inhibit growth in the trainee. For some trainees, there ensues a questioning of their suitability for the profession, particularly if peers are perceived to be progressing further and more quickly. The confusion and, at times, fear of incompetence contrasting with feelings of confidence and effectiveness can be reflected in vacillating motivation in these supervisees. For some, the realization that a good relationship with the client or using techniques in therapy isn’t always sufficient to bring about change results in disequilibrium and the uncomfortable feeling that one isn’t sufficiently accomplished as a therapist. The transition issues for this level of trainee revolve around the goal of broadening and deepening one’s understanding of the therapeutic process, utilizing oneself as a therapeutic tool, and personalizing an orientation to professional practice. A self-understanding that can develop from learning how one’s personal characteristics interact with clinical practice issues forms the basis for the work of Level 3. In addition, effectively combining the ability to intensively focus on understanding the client’s perspective and empathize, balanced by in-session reflection calling into working memory the emotional experiences and relevant information, signifies movement to Level 3. Autonomy.  The dependency of the early Level 1 trainee has given way to a sense of efficacy and a desire for some autonomy in the Level 2 supervisee. This often takes the shape of a dependency–autonomy conflict, not unlike that experienced in adolescence. At times, confidence is high, and the supervisee wants to assertively develop his or her own ideas. The locus of causality for one’s behavior moves toward more internality, and the trainee feels more control over the therapy process. Here, a level of independent functioning is possible with rather specific requests for help when confusion arises or choices among options need to be made. At other times, when things are not going so well and the trainee experiences a lack of control or a sense of incompetence, the supervisee may become dependent or, 25

Supervision Essentials for the Integrative Developmental Model

on occasion, evasive. This person will show lowered confidence in clinical work and sometimes behavior similar to that of early Level 1 trainees. As the Level 2 therapist transitions to Level 3, a more consistent conditional autonomy appears as motivation becomes more intrinsic, with fewer bouts of feelings of incompetence or lack of control. This supervisee is now better able to understand the parameters of his or her competence, and the dependency–autonomy conflict fades. Level 3 The turbulence and uncertainty associated with Level 2 give way to a more stable, autonomous, and reflective Level 3 therapist. The trainee has successfully developed and refined declarative and production schemata that more adequately reflect a broader perspective on the therapeutic process. In addition, the increased experience, reflection on this experience, deliberate practice, and facilitative feedback have enabled the therapist to move toward greater expertise with more functional awareness of patterns and the ability to match current patterns perceived in practice with others encountered in prior experiences. Thus, one’s work becomes more efficient and effective. In addition, “surprise” situations or unexpected events in practice that previously would have required extensive ROA at a later time (often in supervision) can now more readily be handled by RIA as events unfold. The transitional phase to Level 3 brings about more of a focus on a personalized approach to clinical practice and a greater use and understanding of the self as psychotherapist. Self and Other Awareness: Cognitive and Affective.  Some of the focus on the self that we saw in Level 1 returns in Level 3, although the quality of the self-focus is remarkably different now. Rather than a self-preoccupation, this therapist exhibits more insightful self-awareness. From the cognitive perspective, the therapist is able to alternate an intensive focus on the client and working to understand the client’s world with the ability to activate and move into working memory relevant schemata regarding client processes and characteristics and knowledge of relevant information and productions related to the process of therapy. The KIA is more adequate to handle a broader array of practice events; the therapist’s abilities 26

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in RIA allow for more effective changes in strategies to occur “on the fly” in the therapeutic context. More challenging events, alternatives for action, and integration of knowledge across contexts is the focus of ROA both individually and in supervision. The supervisee is more accepting of himself or herself, with a better understanding of current professional strengths and weaknesses. Affectively, the focus on empathy, an important developmental milestone in Level 2, remains. However, the therapist now is able to intensively focus on the client using low road processing and tapping into the emotional experience of the client, and then “pull back” and engage in high road processing, being able to more effectively label the emotions he or she is experiencing and conveying that back to the client. Thus, the intensive cognitive and affective client focus that developed in Level 2 is combined with and augmented by better skills in RIA and pattern matching, enabling the therapist to be more effective. The competence and confidence that has developed enables the therapist to be better able to use himself or herself (personal characteristics, genuine responses) in sessions. Motivation.  The fluctuating motivation we observed in Level 2 has been replaced with a more stable high level of motivation for professional development and practice. Motivation has moved from extrinsic (sometimes amotivational) to more intrinsic as the perceived locus of causality for one’s behavior and effectiveness in practice becomes increasingly internal. As described by Ryan and Deci (2000) in general terms, one’s behavior becomes more self-determined, moving to greater congruence, awareness, and synthesis with self. Periodic ups and downs will continue but within a narrower range of motivation and tending toward more internality. Remaining doubts about one’s clinical effectiveness are not disabling, and there is considerably more concern for the total professional identity and how the therapist role fits into it. Autonomy.  A commitment to retaining responsibility for one’s clinical work is characteristic of this stage. Although there is a solid sense of when consultation is necessary, the firm belief in one’s autonomy and professional judgment is not easily shaken. The supervisee is less easily influenced by others (e.g., supervisors, designated experts) as the breadth of knowledge 27

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and ability elicits more internal processing. The notion of independent practice is now less of a goal and more of a realization. Supervision is useful in solidifying gains and broadening one’s perspectives, but it tends to become more collegial at this point, with less of a difference in levels of expertise between supervisor and supervisee. Level 3i (Integrated) Once the therapist has reached Level 3 in several domains, the primary goal becomes integration across the domains, or generalizing knowledge and skills from one domain to others and increasing the fluidity of moving among various aspects of professional practice. The therapist now learns to move smoothly from, for example, assessment through conceptualization, developing treatment goals, and implementation of interventions. Self and Other Awareness.  The transition to Level 3i is characterized by a personalized understanding of clinical practice that spans domains, as the therapist is able to monitor the impact of personal life changes on professional identity and performance. This self-understanding is apparent from the therapist’s awareness of how his or her personal characteristics affect various clinical roles, as well as an integration and consistency of identity across these roles. Motivation.  Relatively high and stable intrinsic motivation is evident across a number of domains. The therapist is likely to be aware of domains in which this motivation is lacking and understand the reasons for it. Decisions concerning professional and personal goals dictate which domains and professional roles emerge as most important. A refocusing of one’s practice to new areas may occur, necessitating a revisiting of Level 1 or Level 2 issues, depending on the similarity of the new domains to those in which professional development is high as well and the ease of generalization of knowledge and skills across these domains. Autonomy.  The therapist is able to move conceptually and behaviorally from one domain to another with a high degree of fluidity. The possibility of refocusing one’s practice to new domains brings about changes in 28

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autonomy consistent with the level of professional development of related domains. However, professional identity is solid across most domains relevant to the person’s practice.

CONCLUSION In this chapter, we reviewed the three overriding supervisory structures across development levels. In the next chapter, we examine supervisee assessment in more detail across various domains of practice and discuss how the IDM is enacted via the supervisory relationship.

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2

Goals, Tasks, and Functions

A

s noted in Chapter 1, the basic goal of the integrative developmental model (IDM) is straightforward: to encourage and foster trainee development as a therapist from the lower to higher levels in terms of clinical functioning. In this chapter, we discuss the variety of supervisor tasks related to this goal, including setting expectations for supervision, attending to the supervisory relationship, assessing trainee developmental level across the eight domains of practice, providing feedback and evaluation, and considering the context/setting in which training takes place.

SETTING EXPECTATIONS FOR SUPERVISION The initial meetings between the supervisor and supervisee set the stage for a positive working relationship. It is important for both participants to gain an early understanding of the professional experience and background

http://dx.doi.org/10.1037/14858-003 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

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Supervision Essentials for the Integrative Developmental Model

of the other. Although the primary focus is on the training needs of the therapist, the supervisor should provide information on theoretical orientation(s), professional experience across domains, and approach to supervision. This information allows the supervisee to develop an initial sense for the expertise and credibility of the supervisor and an impression about the domains for which the supervisor will be able to provide effective supervision. The supervisor should collect, either formally or informally, information from the therapist concerning the extent of prior therapy, assessment, consultation experience, and any other experiences relevant to the domains to be addressed in supervision. It is also important to assess the supervisee’s expectations regarding supervisor availability, how the sessions will be conducted, who is responsible for what level of structure, and so forth. These expectations are generally subject to change as the supervision relationship develops, but clarifying them early on can help avoid disappointment or resentment should the experience differ from expectations. Ethical guidelines note the importance of establishing an appropriate process for providing feedback to students and supervisees. They should be informed about the expectations for performance, how their work will be evaluated, how feedback will be provided, and the responsibilities associated with the clinical practice experience. It is important to attend carefully to the mechanisms for evaluation and feedback in supervision. Therapists should be evaluated on the basis of actual performance or established training requirements, not on subjective perceptions of personal characteristics or unsubstantiated negative impressions of the theoretical orientation implemented. We have found it useful to share with supervisees the specific criteria for evaluation. This usually takes the form of an evaluation instrument that is reviewed in supervision every couple of months and completed at the end of the supervision relationship or periodically during extended supervisory relationships. The instrument, or series of criteria, should reflect expectations and standards relevant to the goals and objectives of the training experience or job description. No one form suffices across all settings, so it is important to take some time and develop criteria targeted for a particular supervisory experience. If possible, it can be useful to have 32

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the supervisee participate in the articulation of goals and objectives and the related performance criteria. Supervision is not a one-way street. It should also be made clear that ongoing evaluation and feedback concerning the utility of the supervision provided will be collected, and of course, this type of evaluation will vary across training sites. We recognize that there is an obvious power differential present in most supervisory relationships that can inhibit honest evaluation of the supervision or result in retribution by the supervisor. Still, it is difficult for supervisors to improve or effectively evaluate their own performance without detailed feedback from their supervisees. It is most helpful if an organizational climate can be established within a mental health facility that values candid and regular feedback across roles. Finally, a review of current cases and clinical responsibilities of the supervisee should be conducted. This review usually needs to be quite brief, given the other issues to be addressed in the initial session. More extensive information on clients and activities can be acquired by an examination of relevant case notes, reports, and so forth by the supervisor outside the supervision session. However, the stage should be set for the continuation of monitored treatment by the supervisee with informed input by the supervisor. In addition, the schedule for subsequent supervision sessions, expectations for channeling paperwork, and so forth should be established by the end of the session.

THE SUPERVISORY RELATIONSHIP Central to the master–apprentice approach to the training and supervision of psychotherapists is the supervisory relationship that develops and evolves over time between the participants. This relationship involves personal and professional aspects that encompass the roles of teaching, mentoring, consultation, and evaluation. The moment-to-moment interactions of the participants also have a meaningful, intimate inter­ personal relationship that contributes to the increased self-awareness of the supervisee and serves to encourage further learning of psycho­ therapeutic skills. In our review of the recent theory and research related to the supervisory relationship (Stoltenberg & McNeill, 2010), we concluded 33

Supervision Essentials for the Integrative Developmental Model

that the supervisory relationship serves as the base of all effective teaching and training. Indeed, as Loganbill, Hardy, and Delworth (1982) suggested in the early theorizing of developmental approaches, the supervisory relationship is essential in supervision, as is the counseling relationship in psychotherapy, although the two are quite different. Supervisees of varying developmental levels bring differing expectations to the supervisory relationship; thus, there are various ways to strengthen the supervisory relationship. Beginning Level 1 supervisees are experiencing supervision for the first time; thus, their previous experiences with faculty members within the educational environment may be limited to the formal student–professor relationship. As a result, the more informal and unstructured aspects of the supervisory relationship are novel to them and may need to be clarified. In addition to the anxiety reflective of the typical Level 1 therapist, beginning trainees may experience anxiety related to engaging in a more interpersonally focused relationship with a supervisor. In addition, their evaluation anxiety is high and may be manifested in a trepidation to reveal too much of themselves as individuals beyond the role of a supervisee’s willingness to learn. In essence, the beginning Level 1 supervisee is not sure what to expect in the supervisory relationship. It is important for the supervisor of the beginning supervisee to communicate empathy and understanding of the journey toward becoming a therapist. Recalling and sharing one’s own experiences at this stage may help reduce the supervisee’s anxiety and provide needed affirmation and validation. Clarifying expectations and slowly establishing trust are the primary initial relationship-building skills. Creating an atmosphere of support, acceptance, and acknowledgment of the inevitability of making mistakes helps to build trust. Recall that the Level 1 therapist demonstrates limited self- and other awareness. Thus, interpersonal processing of relationship dynamics between the supervisor and supervisee, as well as commenting on personality characteristics of the therapist, is best limited to those with obvious implications through concrete interventions. A more intense focus on these dynamics is best left for supervisees who are making the transition into Level 2, with attention paid to ethical supervisor behavior and the need to address these 34

Goals, Tasks, and Functions

issues in terms of competencies rather than from a therapeutic perspective (Kaslow et al., 2007). Because of the trial and tribulation associated with the Level 2 supervisee, the therapist–supervisor relationship at this stage is perhaps the most likely to undergo significant conflict and stress. At this point, the supervisee has also experienced other supervisory relationships and thus brings a set of expectations to the current relationship. Prior expectations may also have evolved by previous contact with a supervisor in another capacity (e.g., in a classroom setting). In clarifying expectations for supervisory sessions at this level, the supervisor may find it helpful to assess the therapist’s perception of the nature of previous supervisory relationships. The supervisee who has experienced an unsatisfying relationship may express a desire for a qualitatively different experience. In contrast, the therapist who has experienced a satisfying, facilitative relationship with a previous supervisor may have similar or high expectations for the current one. Because of the high dependence on the supervisor at Level 1, the supervisee may have come to idolize a previous supervisor. That is, the positive or negative interpersonal dynamics that characterized the previous relationship influence the present relationship, as the earlier supervisor may come to set the standard for reference to or comparison with the current developing supervisory relationship. In assessing the nature of a previous supervisory relationship, the supervisor should understand and show respect for the expectations the supervisee brings to the new relationship. This type of intervention also sets the stage for clarification of expectations, discussion of differing supervisory styles, and anticipation of the potential impact of possible stylistic and procedural differences. One of the primary tasks of the supervisor of the Level 2 therapist is to foster a sense of independence that, coupled with the supervisee’s developing sense of competence but lack of experience, results in a dependency–autonomy conflict. As a result, Level 2 therapists may resist or resent supervisors’ lack of direction in fostering the supervisee’s autonomy or directives concerning client welfare. These may be viewed as “overmonitoring” by confident supervisees. Such resistance or resentment 35

Supervision Essentials for the Integrative Developmental Model

places a strain on the supervisory relationship that all too often is left unaddressed by both supervisors and therapists. This covert conflict and struggle seethes below the surface, resulting in passive–aggressive behaviors on the part of supervisees, who may selectively present successful cases or actively avoid discussion of cases for which they suspect the supervisor will challenge their skills or choice of intervention. The supervisee may passively agree with supervisor directives but not carry them out. As a result, the supervisor becomes increasingly frustrated by the perceived lack of respect for his or her clinical skills or power differential. As Worthen and McNeill (1996) found, supervisors may first need to “normalize the struggle” in the form of a personal self-disclosure or acknowledge the supervisee’s strengths and weaknesses in terms of multiple levels of development across various domains to defuse the situation and reduce supervisee defensiveness. Despite the conflicts that supervisees at Level 2 experience, research indicates that at this level they begin to demonstrate an increased readiness and openness to processing of personal issues of self-awareness, defensiveness, transference and countertransference, and the supervisory relationship (Worthen & McNeill, 1996). Thus, at this point it may be necessary for the supervisor to confront and process the dysfunctional aspects of the supervisory relationship in the here and now. In addition, the parallel process between the supervisory and counseling relationships may become evident as a function of the development of the Level 2 supervisee’s selfand other awareness. Thus, confronting and processing the immediate aspects of the supervisory relationship can resolve impasses in the relationship, and it has the added benefit of modeling the interpersonal process aspects of the therapeutic relationship. Because the Level 2 therapist is fluctuating in terms of developing a consistent sense of self- and other awareness, process-type interventions may not always break through and resolve relationship issues. At this time, however, the supervisor may be planting the seed or setting the stage for later processing of the supervisory relationship as the supervisee moves to Level 3. Level 3 or Level 3i therapists have experienced numerous supervisory relationships by the time they have progressed through various training and employment settings. It remains important for supervisors of Level 3 36

Goals, Tasks, and Functions

therapists to assess the impact of previous positive and negative super­ visory relationships and the potential impact on the current relationship. Higher-level therapists may experience aversion to overt evaluation and have a stronger desire for more rewarding supervision because of previously unrewarding supervision experiences. For instance, these supervisees also view good supervision as characterized by an empathic, nonjudgmental relationship, with encouragement to experiment and explore, and they are satisfied when their struggles are normalized (Worthen & McNeill, 1996). Therapists who are entering Level 3 in initial domains often are making a transition to a new and unfamiliar setting (e.g., predoctoral internship), perhaps encountering unfamiliar personnel and policies. Although it is common for these therapists to experience temporary regression, their highly developed skills and sense of self-awareness usually allow for the transition to the new setting to occur quickly. This transition is aided by a supportive and safe environment in which the supervisee is able to establish an effective supervisory alliance. It is at this stage that the supervisee is most willing to explore personal dynamics and issues as related to the impact on client work. Now the supervisor may use the therapeutic relationship to increase the supervisee’s insight into the impact personal characteristics and reactions toward clients have on the therapeutic process. The use of parallel process interventions, or process checks, will attend to the therapist’s needs and willingness to examine these issues. The mutual respect and collegial exploration of these issues that now characterize the supervisory relationship lead to new insights by the therapist and take on a special significance, depth, and satisfaction associated with mentoring and observing the progress of a competent supervisee. It is not unusual for these relationships to continue long past the supervisory experience. Additional time may be spent attending to the supervisee’s professional development needs at this point, including job search and future goals. Damage to the supervisory alliance at this point occurs primarily through misassessment of the supervisee’s developmental level or rigidity by supervisors who apply similar techniques to all levels of therapists by not attending to the Level 3 supervisee’s needs. Although processing of relationship dynamics can be extremely valuable at this stage, a constant 37

Supervision Essentials for the Integrative Developmental Model

or overly intrusive focus on process or relationship dynamics to the exclusion of other tasks important to the development of the supervisee can result in high levels of anxiety and dissatisfaction for therapists.

ASSESSMENT AND EVALUATION Assessment and evaluation of therapists play ongoing and fundamental roles in the supervisory process. It is imperative to alter the approach to supervision to meet the changing needs of supervisees across developmental levels and contexts and to provide the appropriate supervision environment to encourage and facilitate growth. By exposing supervisees to an environment that is too advanced, we run the risk of inducing confusion and anxiety, as well as negatively affecting client welfare. But if we expose therapists to an overly structured environment, their growth is frustrated, and they may become bored, inattentive, and resistant. By identifying the eight domains of development across the three structures, we have stressed the need to examine several areas within a particular level of development to assess supervisees accurately. Inherent in the IDM is the assumption that assessment is an ongoing process and intimately related to the process of evaluation. Consistent with this assumption is the provision of timely feedback to developing therapists in which their strengths and areas of weakness or improvement are clearly articulated and discussed in the context of the supervisory relationship. Across supervisory settings and developmental levels, therapists are understandably sensitive to evaluation. Evaluation has substantial implications for grades; recommendations for internship, professional advancement, and compensation; and licensure or certification information required by regulatory bodies. Consequently, the power differential that exists between supervisor and supervisee, as well as the threat to a therapist’s personal and professional development, adds to the anxiety associated with the evaluative process. Unfortunately, because of concurrent trepidation, negative connotations, and anxiety associated with evaluative procedures, supervisors all too often avoid what they perceive as negative feedback or instead give only vague and 38

Goals, Tasks, and Functions

overly general feedback to developing therapists. This sort of evaluation does little to strengthen supervisee skills. Indeed, it is often the failure in identifying areas of weakness during the evaluative process that inhibits the development of therapists, resulting in a pseudo-Level 3 therapist, or a trainee who superficially presents with advanced skills. From our perspective, the process of assessment and evaluation need not be characterized by these difficulties. The IDM provides a conceptualization in which identification of domains for which therapists demonstrate areas of strength and need for improvement is normalized. Referencing performance across levels according to supervisees’ previous training and experience in various domains reduces the negative aspects of evaluation. The overriding structures (awareness of self and others, motivation, and autonomy) also provide a context for normalizing the issues and struggles that supervisees can expect to encounter along the road toward development as a therapist.

Assessment Across Domains The IDM specifies eight domains of therapist clinical activity and performance that provide additional guidance in assessing developmental level. These domains are purposefully broad and inclusive yet specific enough to enable supervisors to highlight particular areas of practice in considering a trainee’s development. Intervention Skills Competence.  This domain addresses the therapist’s confidence in and ability to carry out therapeutic interventions. The developmental level in this domain will differ depending on the therapist’s familiarity with a given modality (e.g., individual, group, marital, or family therapy) and his or her theoretical orientation. It may also be affected by working with different types of clients whose constellation of identities (e.g., cultural, diagnosis) varies significantly from clients with whom the trainee has worked previously. Assessment Techniques.  This domain addresses the therapist’s confidence in and ability to conduct psychological assessments. Of course, numerous assessment devices and protocols exist, and the developmental 39

Supervision Essentials for the Integrative Developmental Model

level of the therapist will vary depending on experience and training across approaches (e.g., personality, vocational, neuropsychological). Interpersonal Assessment.  This domain reflects the use of self in conceptualizing a client’s interpersonal dynamics, which is crucial across a number of areas of practice. Interpersonal assessment occurs when a therapist uses his or her affective and cognitive reactions to elicit responses from the client that aid the assessment process or uses his or her reactions to the client as an indication of interpersonal and/or personality characteristics of the client. Again, the nature of this domain differs depending on the theoretical orientation of the therapist and the practice activity in which one is engaged. Client Conceptualization.  This domain includes, but is not limited to, diagnosis but goes beyond an axis or V code diagnosis and includes the therapist’s understanding of how the client’s characteristics, history, and life circumstances blend to affect adjustment. The nature of this conceptualization varies depending on the therapist’s worldview and theoretical orientation(s). Individual Differences.  This domain includes an understanding of gender, racial/ethnic, socioeconomic status, and cultural influences on individuals, as well as the idiosyncrasies that form the person’s personality. Various elements of this domain will surface or submerge across time depending on the themes addressed in therapy, assessment, or other enterprises, such as outreach and consultation. Theoretical Orientation.  This domain includes formal theories of psychology and psychotherapy, as well as integrative approaches and personal perspectives. The adequacy, complexity, and accessibility of a therapist’s understanding of processes may vary dramatically across orientations he or she uses in clinical practice. Treatment Plans and Goals.  This domain addresses how the therapist plans or organizes his or her efforts in working with clients in the psychotherapeutic context. The sequencing of issues and interventions leading to achievement of therapeutic goals and objectives will vary depending on the therapeutic orientation, the therapist’s skill level, and situational resources and constraints. How consciously or intentionally one focuses 40

Goals, Tasks, and Functions

on mediating or moderating factors in laying out a framework for achieving particular objectives that lead to specific outcomes will vary. Professional Ethics.  Different mental health professions are guided by their own professional ethics, which in turn are affected by their professional practice. This domain addresses how professional ethics and standards of practice intertwine with personal ethics in the development of the therapist.

General Markers of Supervisee Development Once again, it is important to keep in mind that supervisees are typically functioning at different levels of development for various domains at any given point in time. The range of levels, of course, tends to be less for very inexperienced therapists versus professionals with more experience. The novice therapist will be functioning largely at Level 1, whereas the therapist with considerable relevant and supervised experience is be expected to be functioning primarily at Level 3. However, it would be an error to assume that all experienced clinicians function at Level 3 across domains. We know therapists who seem to be unable to progress beyond Level 2 or, at times, Level 1 structures for particular domains. The Level 1 Therapist Across Domains Across domains, the Level 1 therapist has skills to learn and needs opportunities to practice them. In the domain of intervention skills competence, the Level 1 therapist tends to focus on how the skills should be performed and when to use them. The therapist’s evaluation of his or her effectiveness will be based primarily on self-perceptions of the adequacy of performing the techniques. Little awareness exists as to the effects of these interventions on the client. Consequently, our expectations are low in regard to interpersonal assessment. The high motivation of the Level 1 therapist across relevant domains is at least partially a function of the fear and anxiety present. There is a strong desire to emulate experienced therapists, often the supervisor, as a means of developing skill and confidence and moving beyond the anxious neophyte role. The theoretical orientation beginners adopt often 41

Supervision Essentials for the Integrative Developmental Model

is directly tied into the perceived orientation of a role model. Often the more easily understood or unambiguous models are those to which these therapists are drawn initially. At other times, rather complex theories are “abstracted” by the Level 1 therapist into some fairly simple and understandable constructs to make the information more digestible. Another common approach is to be attracted to a theory that fits most closely one’s own personal (often informal) theory of human behavior. This has the advantage of allowing the beginners to fill in the blanks in their knowledge of the theory with common sense, as they perceive it. Within the domain of individual differences, Level 1 therapists typically demonstrate little awareness of the complex intersections of individual differences on the therapeutic process but are highly motivated to learn more in this domain. Typically, the Level 1 trainee is quite dependent on the supervisor or others in authority. This is, of course, quite acceptable and usually imperative: The supervisor is the source of answers to the many puzzling questions with which beginner struggles. For example, producing a comprehensive, or even marginally inclusive, conceptualization or diagnosis of a client is often quite difficult for beginning therapists. Paging through a copy of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and trying to fit the client into appropriate categories can be at best a hit-or-miss enterprise. The supervisor can provide or guide the trainee toward the necessary insights, mechanisms for data collection, and integration of information. As the trainee develops these skills, the supervisor is still needed to validate or improve on the initial versions. Because Level 1 trainees lack experience, supervisors need to closely monitor potential ethical issues and be prepared to step in accordingly, providing guidance and structure. In summary, across domains, the Level 1 therapist is characterized by a predominant self-preoccupation, a strong motivation for learning how to become as proficient as other professionals, and a desire to be instructed and nurtured by a more experienced clinician. The Level 2 Therapist Across Domains The change in focus from the self to the client that occurs with Level 2 has many implications for practice across domains. In this stage, we 42

Goals, Tasks, and Functions

can expect to see a considerable increase in the therapist’s sensitivity to individual differences across clients. The increased empathic focus on the client allows the therapist to experience greater depth of emotional and cognitive understanding of the client, which increases the therapist’s appreciation for the client’s personality, experiences, and life circumstances. This greater depth and breadth of understanding of the client’s world can be quite useful to the trainee in developing more adequate case conceptualizations. On the other hand, this wealth of information, with all of its idiosyncratic nuances, can present real problems for the therapist in wading through the data and reducing the information to a concise conceptualization or diagnosis. At times, we may find a negative reaction to diagnosing or “labeling” a client because of the impersonal evaluation such processes can convey. This flood of information may also cause the therapist to freeze up in terms of making clinical decisions in treatment. By experiencing the client’s emotions and thoughts, solutions that may have appeared quite workable at Level 1 may now appear overly simplistic, naive, or too impersonal. Indeed, in terms of specific therapist behaviors and client progress, our Level 2 therapist may sometimes be less effective in terms of client outcomes than our naively confident late Level 1 therapist. In addition, this strong identification with the client may result in supervisees placing more emphasis on client welfare in situations in which others’ welfare may be equally as important (e.g., vulnerable individuals). This increase in perceived complexity of clinical practice and confusion concerning one’s ability to function as a professional can produce day-to-day (and sometimes hour-to-hour) fluctuations in motivation. Although early Level 1 therapists may lack sufficient clinical knowledge to make decisions, the Level 2 therapist may perceive too many or no adequate options and become immobilized. The domain of individual differences often remains quite relevant and has implications across the other domains. The desire to know and understand the client’s situation and view of the world is typically high, except when the confusion or emotions get too strong, and the Level 2 therapist retreats to the relative safety of inactivity. Regular reminders of professional ethics are important for Level 2 therapists. The dependency–autonomy conflict can create tension in the 43

Supervision Essentials for the Integrative Developmental Model

supervisory relationship that may limit the willingness of the therapist to share feelings and thoughts with the supervisor. Becoming too enmeshed with a client or assuming too much responsibility for the client’s wellbeing can result in unfortunate consequences. The Level 3 Therapist Across Domains The Level 3 therapist is more able to use insightful self-awareness in addition to the awareness of the client’s experience developed during Level 2, resulting in useful interpersonal assessment. Both come into play in practice, giving a depth and breadth of perspective to the therapist. His or her treatment goals and plans may reflect this integration of sources of information, including individual differences. Knowledge of one or more guiding theories, conceptualization of the client’s difficulties, and confidence in one’s own abilities result in more adequate treatment plans. The Level 3 therapist is able to integrate information acquired through empathic listening to and skillful assessment of the client, monitor his or her own responses in the clinical situation, and separate from the process to make more objective third-person observations. This results in an improved ability to plan and carry out effective treatments. In addition, we find little variation in how this individual functions across different professional roles in domains in which development has reached Level 3. In other words, the integration of personal characteristics with professional behavior is high. Motivation is stable and relatively high as the therapist makes great strides toward developing a personalized therapeutic style. This personalization of clinical practice allows for considerable autonomy for the Level 3 therapist. The therapist’s developed schemata and integration of prior experiences reflects an understanding of theory and implementation of interventions that makes supervision consultative rather than didactic. Recommendations for changes or observations of other effective therapists are sifted through the Level 3 therapist’s understanding of self and how this translates into his or her therapeutic behavior. This will not appear as defensiveness in supervision but rather as a thoughtful translation of one person’s strengths and understandings into another’s repertoire. 44

Goals, Tasks, and Functions

The Level 3i Therapist This therapist is fully functioning across domains relevant to her or his practice. Level 3 structures are in play, and a fluidity of movement among them is apparent. In our experience, Level 3i is not often fully achieved, but clinicians who reach this point are considered experts by their colleagues. The growth experienced as movement into Level 3i is less vertical (moving up the levels) and more horizontal in spreading understanding across domains and linking relevant schemata. Development within each domain is utilized to generate new awareness through integration and linking of schemata, as well as learning in response to input from others. The Level 3i therapist is creative, able to integrate previously retained knowledge across areas, learn from others, and evolve strong and appropriate accommodations and assimilations throughout the life cycle. The ongoing work of this therapist is to reestablish networks of knowledge with self-understandings that change as the individual continues to mature. At this point, we have outlined the characteristic thoughts, feelings, and behaviors associated with each of the developmental levels in terms of the overriding structures across selected domains of therapist experience. Thus, the complexity of the IDM is such that evaluation of therapists encompasses accurate assessment across domains. Although this type of qualitative assessment involves the clinical judgment of the supervisor, it is necessary to move beyond global clinical impressions related to general developmental level. Using the IDM as a guide, Figure 2.1 provides a method of organizing supervisor impressions according to developmental level and overriding structures across the eight domains of counselor development. Simply adding check marks in the appropriate boxes across supervisee levels, overriding structures, and domains provides an overall assessment of trainee development. Additional Sources for Supervisee Assessment Bernard and Goodyear (2014) reviewed and provided examples of the numerous scales used to quantify a wide range of supervisee behaviors, perceptions, and so forth. Although these scales provide useful information related to the characteristics of therapists, most are used primarily 45

In te Co rve m nti pe on te S nc k e ills A ss Te ess ch me ni nt qu es In te A rpe ss rs es o sm na en l t Cl i Co ent nc ep tu al iz at io n In di v D id iff u er al en ce s Th e O ore rie ti nt cal at io n Tr e G atm oa e ls nt an d Pl an s Pr of Et es hi sio cs n al

Two

46 One

M

A DA M

A DA M

A DA M

A DA M

A DA M

A DA M

A DA M

A DA

Note: M = Motivation, A = Awareness, DA = Dependency/Autonomy

Figure 2.1 Counselor development profile. From IDM Supervision: An Integrative Developmental Model for Supervising Counselors and Therapists (3rd ed., p. 178), by C. D. Stoltenberg and B. W. McNeill, 2010, New York, NY: Routledge. Reprinted with permission.

Supervision Essentials for the Integrative Developmental Model

Three

Goals, Tasks, and Functions

to gather information and quantify certain specific supervisee behaviors for the purpose of research investigations. Thus, they typically are limited to a single perspective or a range of characteristics associated with a particular research topic and tend to be less practical in conducting the ongoing comprehensive assessment process of developmental supervision associated with the IDM. Consequently, our focus is on the procedures that are most practical and available to working super­ visors across settings in assessment and evaluation from a developmental standpoint. Work Samples Recorded Therapy Sessions.  Direct access to therapists’ working skills and behaviors by means of live observation or videotapes or audiotapes of sessions is crucial to an accurate assessment of current supervisee functioning. Similarly, in the provision of feedback, behaviorally grounded impressions and observations provide the specificity that supervisees most often desire. Replayed recorded excerpts provide concrete examples of therapists’ interventions and immediate client reactions, again promoting ROA that leads to more effective RIA. This record enables the supervisor to point out the impact or lack of effectiveness of certain strategies or interventions. A discussion of alternative strategies may then ensue that can be rehearsed or role-played within the supervision session. There is no substitute for direct access to sessions for providing examples of supervisee behavior across all the eight domains. As the eminent philosopher and Hall of Fame baseball manager and player Yogi Berra once said, “You can observe a lot by just watching” (Berra, 2015). This is important for an accurate developmental qualitative assessment. Written Performance Samples.  In addition, we find the modified Case Conceptualization Format (see Appendix A) a useful work sample directly indicative of therapist development within the domains of client conceptualization, assessment, and treatment goals. Psychological reports and case notes also provide examples of therapist performance in various domains. It is very important, however, to assess a variety of work samples 47

Supervision Essentials for the Integrative Developmental Model

from supervisees. Certain samples may be selected based on perceived effectiveness, or they may be reflective of only limited skills. In addition, work samples for one client may not be indicative of a trainee’s work with another client. For example, it is not unusual for supervisees to demonstrate skills in written activities (e.g., diagnosis) but have trouble implementing other skills in therapy sessions. Work samples should not be limited to one modality or another if the goal is an accurate picture of a therapist across domains. Both of us have been affiliated with training programs that require competency evaluations in the form of psychological assessments with written reports, recorded demonstrations of empathic/attending skills, and demonstrations of therapeutic competence with written statements of therapeutic orientation with a recorded demonstration. Typically, such evaluations are required for assessment of advancement to candidacy and/or readiness for a postdoctoral internship. Therapist Feedback To set the context for ongoing assessment and feedback, supervisors need to conceptualize for supervisees the overall process of development, including expectations for developing skills within certain levels. For example, new supervisees typically are expected to begin developing basic facilitative listening and attending skills in the first semester of an organized practicum. The purposes of assessment should be presented at the beginning of the supervisory relationship so that the issue of evaluation is open and discussed before problems or misperceptions are formed. Supervisees need to understand that it is in their best interests for assessment and evaluation to occur on an ongoing basis. Feedback to trainees concerning their performance should be provided in continually during the supervisory process. The qualitative assessment process requires collecting information from a variety of sources. Once completed, it is extremely important to provide direct concrete feedback to the supervisee in the form of a written or oral evaluation of skills at least once or twice during the supervisory relationship. Across training settings, such formal evaluations all too often lack a systematic format and may be limited to global impressions or lack coverage of the various 48

Goals, Tasks, and Functions

domains. In addition, the anxiety or discomfort that some supervisors feel in providing an evaluation of a supervisee and, in some cases, a grade or employment evaluation of therapeutic skills causes them to avoid this activity. We believe that the use of the IDM provides a system of assessment and evaluation that helps to normalize the process of therapist development in a nonthreatening manner. By conceptualizing supervisee strengths and weaknesses in terms of levels of performance within various domains, the emphasis is on the growth of the developing therapist. Although there are skills associated with various approaches to therapy that must be learned to provide effective service to clients, the IDM places skills and techniques in a context of progressive movement toward a desired end state. Thus, being at a particular level of development need not be viewed as negative but rather can be seen as the culmination of training to this point in time. Consequently, there is nothing wrong with being a Level 1 or 2 therapist. Rather, it is a reflection of the individual’s development to date given the growth-inducing experiences provided during the course of training and how they have been integrated. Supervisees will experience different rates of growth. Even with those who develop more slowly than others, the rate of development need not be considered a limiting factor in the degree of potential development. Thus, conceptualizing and communicating the process of evaluation and assessment to supervisees in this manner and remaining open to discussion of feedback and areas of clarification or disagreement from supervisees reduces the anxiety associated with evaluation. Feedback is presented within the context of the normal developmental process of becoming a therapist. We can never entirely eliminate the anxiety associated with evaluation from the supervisee’s perspective. However, normalizing the process through developmental assessment and placing strengths and weaknesses in the context of the normal progression provides less tension for the examination of therapist strengths and weaknesses. Supervisors have the opportunity to model acceptance of and openness to the evaluative process by seeking ongoing feedback and evaluation regarding their own supervisory style. Evaluation of supervisors can also 49

Supervision Essentials for the Integrative Developmental Model

be performed on a formal basis and communicated to supervisors at the termination of a supervisory relationship.

CONTEXT AND SETTING Our mentor and colleague Ursula Delworth first described a model of supervision across settings (Stoltenberg & Delworth, 1987), which was further articulated in detail by Stoltenberg and McNeill (2010). Briefly, the supervision-in-context model (SIC) describes a way to conceptualize the differential influences of the training agency, the clinical supervisor, and (if the therapist is a student) the training program on the supervisee. This model has proved particularly helpful for participants when they discuss influences, responsibilities, and interactions across these contexts, and examining the role of supervision across contexts requires us to expand our view of supervision beyond the dyad of supervisor and supervisee or the triad of supervisor, supervisee, and client to an examination of the setting in which supervision occurs. There are specific characteristics of settings that affect supervisees. Among the most important are disciplinary mix, staff roles, ease of entrance and exit for clients, and amount of structure. Most often, in selecting a setting for field experience, supervisees focus on the types of clients served. This is certainly an important variable but is by no means a total indicator of fit. Some supervisees at some phases of training find a good match in settings that are relatively open and unstructured. Others, because of their individual characteristics or developmental level, are consistently frustrated and overwhelmed in such settings. Given our developmental approach, we choose to place Level 1 supervisees in settings that are relatively structured, have a method to assign appropriate clients to the supervisee, and probably have a limited number of professional disciplines represented on the staff (e.g., mostly psychologists, counselors, social workers, or psychiatrists, depending on the training program of the students). Appropriate and fairly close transactions with the training program are important. As the supervisee moves into Level 2, one or more of these components can be altered. Placing a supervisee who is entering Level 2 in a 50

Goals, Tasks, and Functions

highly ambiguous, open, unstructured, and multidisciplinary setting will almost certainly exacerbate the conflicts and confusion characteristic of this level. The supervisee may be too overwhelmed to stick with it and may escape back to the certainty of Level 1. Or the supervisee may become disenchanted with counseling altogether. Thus, the training program should still be fairly influential, although somewhat more distant. The supervisor and supervisee become closer in size and overlap less, and the supervisor is less involved with the client. At Level 3, a good fit might involve both more distance from the training program and more separation between the supervisor and the supervisee. Matters of individual preference are also important. Some people enjoy the give and take of a setting that employs persons from diverse professions or disciplines. Others prefer to work with colleagues with similar training. What is important is that these issues are considered as selections and assignments to settings are made, and that expectations are made clear to all parties involved. Our preference is to develop a supervisory contract to be signed by both representatives of the training program and practicum setting. As supervisors, we can often be of most help to our supervisees by facilitating their understanding of the total context. With such understanding, both trainees and their supervisors can formulate and implement transactions that are productive and rewarding. These basic considerations set the stage for the application of specific interventions, and most importantly, create the optimal supervision environment for growth. Given the adoption of the American Psychological Association (APA) Guidelines for Clinical Supervision in Health Service Psychology, we would expect to see increasing consideration to guidelines for assessment and feedback, supervisor training and experience level, and knowledge of supervisee development across training sites.

CONCLUSION Again, the overriding goal of the IDM is to encourage and foster trainee development as a therapist from the lower to higher levels. Consequently, all supervisory tasks and functions across settings, using various sources of information, are in service to accurate developmental assessment of 51

Supervision Essentials for the Integrative Developmental Model

our trainees and grounded by the supervisory relationship as a base for all effective intervention. In this manner, we normalize the process of assessment and feedback and demonstrate the critical link between accurate assessment of developmental level to provision of the necessary facilitative, growth-producing supervisory environment. These environments, along with optimal interventions for varying levels of supervisees, are discussed in Chapter 3.

52

3

Supervisory Methods and Techniques

C

reating an optimal supervision environment for upward growth between the developmental levels is the most crucial task for the effective supervisor. Although this overriding task includes the use of work samples in the form of process notes, review of recording sessions, modeling, role-playing, and didactic instruction, we find that various techniques and interventions may be more or less effective depending on the developmental level of the trainee. Consequently, the purpose of this chapter is to define useful types of supervisory interventions and describe the changes in supervisory environments necessary to attend to the varying needs and issues across the three levels of developing therapists. Table 3.1 provides a map for creating optimal supervision environments for therapists of varying levels. Thus, supervisor flexibility in creating the appropriate environment is critical to our approach.

http://dx.doi.org/10.1037/14858-004 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

53

Supervision Essentials for the Integrative Developmental Model

Table 3.1 Methods and Techniques Used in the Supervision of Therapists of Varying Levels Level of

Goal of

Client

therapist

supervision

assignment

Intervention

Mechanism

1. Beginner

Provide structure and keep anxiety manageable

Mild presenting problems or maintenance cases

Facilitative Prescriptive Conceptual Catalytic

Observation (video or live) Skills training Role-playing Interpret dynamics (limited, client or trainee) Readings Group supervision Appropriate balance of ambiguity/ conflict Address strengths, then weaknesses Closely monitor clients

2. Intermediate

Encourage autonomy, particularly during periods of “regression” or stress

Patients with more severe presenting problems than are handled by novice therapists (such as personality disorders)

Facilitative: normalize the process Prescriptive: used only occasionally Confrontive Conceptual: introduce more alternative views Catalytic: process comments, highlight countertransference, affective reactions to client or supervisor

Observation (video or live) Role-playing Interpret dynamics Parallel process Group supervision

54

Supervisory Methods and Techniques

Table 3.1 Methods and Techniques Used in the Supervision of Therapists of Varying Levels (Continued) Level of

Goal of

Client

therapist

supervision

assignment

Intervention

Mechanism

Less of an issue Focus on client types/problems with less experience (e.g., differing cultural background, diagnostic classification)

Facilitative confrontive when necessary Conceptual: from personal orientation Catalytic: in response to blocks or stagnation

Peer supervision Group supervision Strive for integration

3. Advanced

Focus on personal and professional integration and career decisions

Note. From IDM Supervision: An Integrative Developmental Model for Supervising Counselors and Therapists (3rd ed., pp. 73, 110, and 134), by C. D. Stoltenberg and B. W. McNeill, 2010, New York, NY: Routledge. Reprinted with permission.

TYPES OF SUPERVISORY INTERVENTIONS Loganbill, Hardy, and Delworth (1982) described supervision interventions that can form a useful basis for understanding the supervision process. Facilitative interventions are intended to communicate support to the supervisee and encourage development. Praise, reinforcement of appropriate demonstrations of skills, careful and attentive listening, and other indications of appreciation of and consideration for the supervisee characterize these types of interventions and are particularly useful for the beginning trainee. Facilitative interventions also serve to reduce trainee anxiety; develop warmth, acceptance, and trust in the supervisory relationship; and provide time for the reflection and introspection necessary for productive ROA within supervisory sessions. We find that a supervisor’s selfdisclosure of his or her beginning experiences or early struggles can be effective facilitative interventions. Prescriptive interventions provide the supervisee with a specific plan of action for use in a particular situation and are especially useful when 55

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monitoring client welfare. Prescriptive interventions may take the form of providing the supervisee with treatment goals and plans for a particular client or instructing the supervisee to refrain from certain behaviors in sessions. One of our favorite and most effective prescriptive interventions is to not allow any questions in a given session for trainees who ask too many (usually irrelevant) questions, talk too much, or do not engage in empathic listening. Prescriptive interventions are also necessary for Level 1 therapists, who have limited knowledge of therapeutic orientations, interventions, and client dynamics. It is important that the supervisor be prepared to advise the therapist concerning what might be done at a given point with a particular client in the interest of client welfare. It is also best, whenever possible, to present the therapist with multiple alternatives to support early attempts at developing autonomy. By presenting options from which the therapist can select an intervention, supervisors encourage the therapist to assume responsibility for treatment and engage in a critical evaluation of alternatives. Conceptual interventions encourage and develop the trainee’s ability to make conceptual ties between theory and practice, encouraging supervisees to think cognitively and analytically. Conceptual interventions may consist of the supervisor asking for a theoretical explanation for use of a certain technique in sessions or reviewing a written case conceptualization with a trainee that requires similar linkages. The self-focus (or selfconscious) Level 1 trainee will tend to focus primarily on what he or she should do with the client or how anxious he or she is rather than thinking through a rationale for a given intervention. This therapist’s ability to make conceptual ties between theory and practice will be limited, so the supervisor should begin the process of linking the two for the supervisee when the opportunity exists. The better a therapist is able to begin to think of the theory, diagnosis (or conceptualization), and treatment continuum, the more quickly he or she will develop autonomy. Engaging in ROA in supervision via conceptual interventions in sessions with trainees leads to better RIA (when necessary) and to a more adequate KIA in sessions, helping trainees to develop more comprehensive schemata and strengthen links between them. The written Case Conceptualization Format provided in Appendix A provides an example of a formalized conceptual 56

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intervention that we find particularly helpful for case conferencing in a group supervision format. Once trainees are familiar with this written format, it is not unusual for us to simply request during the supervision session that the trainee orally provide a conceptualization of the client being discussed. Confrontive interventions bring together two things for examination, highlighting discrepancies in supervisees’ feelings/emotions with attitudes/ beliefs, and behaviors and actions that may be impairing their therapeutic functioning. Loganbill et al. (1982) provided excellent examples of types of confrontive interventions, ranging from “you say you believe in the resiliency and strength of your client. Yet your behavior toward her is protective and overly cautious” (p. 33; attitudes/behavior), to confrontation regarding the perceptions of the supervisor with trainee attitudes and behavior (e.g., “You seem to be perceiving anger, destructiveness, and hostility from this client, but as I listen to the tape, I perceive a sense of despair, hurt and sadness” [p. 33]). As Loganbill et al. (1982) pointed out, confrontation need not be hostile or punitive but is used to increase self-understanding and insight on the part of trainees, which again stimulates the ROA, leading to more effect RIA and KIA. Confrontive interventions are sometimes appropriate for Level 1 therapists, but they are usually best used when the early anxiety has lifted and some confidence in ability has developed. As the therapist becomes comfortably established in Level 1, he or she can adequately perform (at least by his or her own standards) certain skills and feels confident about understanding the process. At this point an increase in the desire for autonomy will be noted. Therapists who have had the opportunity to experience success in their clinical work and have found that they can be effective may become quite confident and comfortable with their level of understanding and skills. This is the time when confrontation can be effectively used. However, earlier in the training experience, confrontation may freeze the supervisee and halt development. Once the comfort level has grown, confrontation may be necessary to move the therapist beyond what is safe and try new interventions or work with more challenging clients. 57

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We find that the use of video is often important at this stage. This technology enables the supervisee to critically evaluate his or her work and begin the process of focusing attention more on the client and seeing the impact of the interventions. These confrontations typically should not be dramatic or, especially, inflammatory. Simply pointing out mistakes, miscues, or things overlooked by the therapist can provide sufficient confrontation. As suggested previously, confrontation is sometimes necessary when the trainee isn’t intrinsically motivated to learn or grow and has prematurely foreclosed on learning new approaches to therapy. It can also be useful when the supervisee resists using broad therapy skills (e.g., prefers insight and thus interprets too soon) or prefers to stay in the relationshipbuilding stage rather than moving forward. Catalytic interventions are intended to expand the awareness of the therapist in aspects of clinical practice that have escaped his or her attention because of limitations in available awareness as a function of the person’s self-absorption. Catalytic interventions challenge the comfort level of the supervisee or are “concerned with promoting change . . . to get things moving” (Loganbill et al., 1982, p. 35) and may involve questioning, probing, exploring, or raising issues in key areas. Catalytic interventions typically are reserved for late Level 1 therapists rather than beginning ones. Although we use these interventions liberally in Level 2, they also can be useful in redirecting the attention of the advanced Level 1 trainee. Again, this is often made easier by having access to video of the supervisee’s work with clients. Commenting on the therapeutic process, focusing the therapist’s attention on the client’s reactions, or focusing attention on the therapist’s thoughts and feelings at a given point in the session (i.e., ROA) are examples of catalytic interventions that can broaden the view of the trainee. As Loganbill et al. (1982) noted, catalytic interventions accompanied by facilitative interventions together are most effective. A statement to the effect of “I see you making excellent progress working from your interpersonal process orientation. However, you seem reluctant to disclose your feelings and process with your client in the here and now of the session” illustrates both types of interventions in conjunction. We might also use catalytic interventions to highlight the potential for, or the exhibition of any, countertransference 58

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reactions by the therapist. The therapist’s emotional reactions to the client, or the supervisor, can be highlighted and pursued as avenues for exploration of the therapeutic and supervision processes. By pushing the therapist to attend more to the client and understand the clinical process at a more complex level, the supervisor is setting the stage for movement into Level 2. Both confrontive and catalytic interventions are helpful in addressing trainees’ emotional reactions to clients or supervisors, especially in the context of transference or countertransference reactions. However, such interventions may confuse what Bernard and Goodyear (2014) labeled as a “teach versus treat” distinction. That is to say that although important supervisory interventions may take on a therapeutic-like quality, supervisors should never be providing personal psychotherapy to their supervisees because this practice is clearly inappropriate and unethical for any number of reasons (e.g., dual role conflicts [Stoltenberg & McNeill, 2010]). Consequently, although we believe that therapeutic exploration of personal issues for trainees can always be beneficial, any addressing of the personal qualities of developing therapists in training should be limited to the supervisee’s learning relevant to their work with clients as the supervisor deems relevant. In other words, although supervision can at times seem “therapy-like” in its examination of the influence of trainees’ characteristics, thoughts, and feelings in their work with clients, the supervisory environment should never incorporate personal individual psychotherapy.

INTERVENTIONS FOR EACH THERAPIST LEVEL The effective supervisor can draw on several techniques or mechanisms in clinical supervision. In our opinion, the power is not usually in the technique but in how effectively it is used and for what specific intent. No one technique or mechanism is adequate for all situations. Skilled supervisors use a breadth of mechanisms to further supervisory goals and encourage the growth of the trainee. Although we discuss numerous mechanisms, our list is neither exhaustive nor prescriptive. The mechanism chosen at any given point in time for work with a particular therapist depends on 59

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available resources, the current needs of the situation, and the personal attributes of the supervisor and supervisee. Level 1 A consistent finding in the empirical literature on clinical supervision and a basic tenet of our developmental model since its inception is that the supervisor of Level 1 therapists needs to provide structure for the super­ vision experience, as well as assist the supervisees in structuring their clinical work. This structure removes some of the uncertainty from the process and helps limit the anxiety associated with early training. This level of therapist typically views the supervisor as a role model and perhaps an expert. At a minimum, the supervisor usually is seen as knowing more about clinical practice than do the supervisees. This is, of course, usually a positive experience for beginning supervisors. It can also be rewarding for experienced supervisors, although the degree of dependency of some beginning therapists can become tiresome for the supervisor who is continually working with this level of therapist. Confidence can build slowly, although sometimes it comes far too quickly, with Level 1 trainees. Becoming a therapist can be viewed as something more threatening and much more an extension of one’s personality than other learning experiences. Thus, for some trainees, criticism of their therapy skills is viewed as criticism of them and their level of maturity rather than a comment on what they have learned and what they have left to learn. This perspective can be attenuated somewhat by approaching this early training with supervisees as a process of learning skills and behaviors (e.g., empathic listening). By breaking down the process into fairly discrete and observable actions, it becomes less threatening and more easily learned. As the clarity of understanding concerning at least some of the processes associated with clinical practice develops, the trainee’s confidence builds. It is often facilitative to work from a fairly consistent and rudimentary framework to allow understanding of theory and skills to proceed at an acceptable speed to enable the trainee to function adequately in the 60

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domain of interest. For example, an initial focus on fundamental counseling skills, such as listening, attending to the relationship, and communicating empathy, can reduce the complexity of the therapeutic process to an understandable level. Behaviors that encourage the client to explore issues and that communicate attentiveness and concern on the part of the therapist can move the therapy process along, even if these behaviors are performed without the optimal level of underlying understanding. It is possible, of course, for a novice therapist to learn to reflect content and some client feelings without a deep understanding of the client’s experience or true empathy, which will develop with time. It is also important to encourage early responsibility for one’s role in the therapeutic process. Although considerable information will need to be conveyed to the Level 1 therapist by the supervisor through fairly didactic means, supervisors should remain alert for the opportunities to encourage supervisees to engage in problem solving about their clinical work and engage in a self-examination. This process needs to be carefully monitored so that it facilitates early attempts at autonomy without endangering the client or confusing the therapist or frustrating his or her development. Some appropriate risk taking can also be encouraged because trainees may tend to stay with what is initially mastered rather than explore new skills or interventions. Remember that a facilitative level of discomfort or disequilibrium is necessary for growth. On the other hand, sufficient information and experience need to be assimilated for the trainee to be able to develop useful and relevant schemata related to clinical practice. A careful balance must be maintained. In terms of client assignment, it is not always possible to exert total control over the types of clinical experiences available to Level 1 supervisees. In the best of all worlds, which is rarely possible, it is probably most beneficial for clients with fairly mild presenting problems (certain “V” codes, problems in living, mild depression) to be assigned to beginning therapists. Sometimes “maintenance” cases are appropriate, even if the level of pathology is significant. In these latter cases, the primary goal may be monitoring the client with limited expectations for improvement. The goal is to assign clients to the therapists who will present minimal 61

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risks and have some potential for positive therapeutic experiences. With mildly troubled clients who have adequate personal resources, fundamental counseling skills implemented by the therapist can result in significant improvement. Other clients whose problems are fairly specific (e.g., simple phobias) can benefit from a structured approach to therapy (e.g., various forms of exposure therapies) that can be quickly learned and adequately implemented by the beginning therapist. Clients with whom the therapists can develop a degree of comfort in the therapy situation and with whom they can practice some fundamental skills are ideal for beginners. Late Level 1 trainees transitioning to Level 2 will benefit from slightly more difficult and complex client cases. Observation of the clinical work of Level 1 (and Level 2) therapists is imperative. Although some training settings rely heavily on verbatims (i.e., attempts by the trainee to write down everything that was said during a given session) or other variations on self-report, these are inadequate. Level 1 therapists are not able to perceive accurately what they are doing in the session, let alone what is going on with the client. Supervisors who rely solely on trainee perceptions and their memories will be supervising in the dark. Observation is crucial, whether it is by video or direct observation or is immediate or delayed. To know what actually occurred in a session, supervisors need to see it or, at a minimum, hear it. Basic skills training is necessary in the early stages of development for nearly any domain. Although we believe that treatment manual approaches can be helpful in providing structure appropriate for Level 1 trainees, there is a growing body of evidence in the area of common factors related to the effectiveness of psychotherapy across various orientations and the limitations or lack of variance accounted for by specific techniques in therapy and manualized approaches (Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001). Castonguay, Boswell, Constantino, Goldfried, and Hill (2010) made a strong case that training in skills that enhance the working alliance should be a focus of clinical supervision and that supervisees should become aware of their own rigid use of some techniques when faced with ruptures in the working alliance, which may lead to further deterioration of the relationship, resulting in poorer outcomes. 62

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Consequently, skills training related to the establishment of the therapeutic relationship, therapist qualities, and so forth, as articulated in recent statements of evidence-based psychology practice (EBPP; American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006), should be implemented in supervision, along with roleplaying therapy interactions, reversing roles, and playing those interactions out again, all of which can be useful in building the skills necessary for early work in therapy. Level 1 therapists have limited information regarding clinical practice at their disposal. They are often eager to learn and respond well to lists of readings or other resources the supervisor provides. However, it is important to keep the breadth of this material somewhat limited. For example, the novice therapist may have difficulty integrating cognitive therapy material with interpersonal process readings. It may be better to initially stay largely within a given orientation or a common factors framework and expand the range of information and resources as the therapist is able to implement material that has already been presented. Group supervision can be a good mechanism for learning for the Level 1 trainee. Appropriately handled group supervision can present additional options for interventions, other conceptualization perspectives, and additional skills to practice. It can also serve as a supportive atmosphere for exploring the clinical process and one’s understanding of it. If not handled carefully, however, group supervision can become an aversive situation that adds to the therapist’s anxiety level. The supervisor must take care to encourage positive feedback and constructive comments while normalizing the growth process for the supervisees. Competition is common and, if left unfettered, can create a negative environment that does more harm than good. Similarly, allowing or encouraging group supervision to morph into group counseling can be destructive or, at a minimum, nonfacilitative of growth and learning. Consequently, we believe that group supervision of Level 1 trainees is most effective when a homogenous group at the same level of development focuses on Level 1 issues and when group supervision complements individual supervision. 63

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We also need to be constantly aware of striving for the facilitative balance of ambiguity and conflict versus clarity and comfort. Too much ambiguity, anxiety, or disequilibrium will frustrate trainees and inhibit their growth. Too much perceived clarity or naive understanding of the process, comfort, and confidence also will stagnate growth. The balance must be struck and restruck throughout the supervision process. Related research has demonstrated that the optimal approach to providing feedback for beginning therapists may be to highlight strengths and positive behaviors first, then move on to areas where growth has yet to occur or corrective feedback is needed (Stoltenberg & Delworth, 1987). This process sets up the supervisee to hear what the supervisor has to say. By first acknowledging areas of strength, supervisors reinforce the initial attempts at competence and early development of confidence. They are informing the supervisee that they are aware of the progress he or she has made and the skills already developed. Then focusing on areas for growth can build on these strengths and remind the therapist that development is not complete and there is more to learn. A similar approach is the “feedback sandwich,” by which a positive statement is followed by a recommendation for growth, and ending with another positive statement. Finally, supervisors must always take great care to monitor client welfare. They have the dual responsibilities of encouraging and enhancing supervisee growth while maintaining quality control of the services provided to clients. Success in supervision of Level 1 therapists results in increased confidence in their ability to understand and implement interventions. Although this understanding is limited in terms of complexity and breadth, the troublesome anxiety has diminished while motivation remains good, the self-focus has lessened, and the movement toward some autonomy has begun. It is at this point that some Level 1 therapists may appear overconfident or even cocky to their supervisors. Here is where the increasing attention to client reactions, assigning more difficult cases, and expanding the therapist’s views of clinical processes are crucial. It is time to “shake the tree” and move the therapist to the next level. There is often some resistance to the realization that therapy is complex and simple solutions are 64

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few, but the change is necessary for the therapist to continue to develop and not stagnate at a rather perfunctory stage of development. We have experienced some resistance from trainees at this point when their early understanding of the therapy process is challenged through attempts to broaden their understanding. Most respond positively, but for some the discomfort from experiencing disequilibrium is difficult.

Level 2 One of the basic tenets of the integrative developmental model (IDM) is that the supervision environment should change in response to the differing needs, issues, and perceptions of the developing supervisee. The supervisor must be extremely vigilant in early supervision sessions to (a) assess carefully the current level of functioning of the therapist for the particular domain of interest, (b) be prepared to make a shift in supervisory style to respond effectively to the changing needs of the Level 2 therapist, and (c) facilitate development to the higher levels. The characteristics of the Level 2 therapist have led Stoltenberg and Delworth (1987) to characterize this stage as one of “trial and tribulation” and liken it to a period of “therapist adolescence.” Typically, therapists who have progressed through two to three semesters of supervised practicum or 1 to 2 years of post-master’s degree work begin to demonstrate characteristics of Level 2 structures in one or more domains of practice. Thus, the task of the supervisor with Level 2 supervisees is to provide a fine balance between guidance and support, and a degree of autonomy and challenge in fostering the independence and confidence of the therapist. Supervisors must recognize and provide a supervisory environment that is qualitatively different from that of the Level 1 therapist by increasing autonomy and decreasing structure. Highly structured directives and didactic advice appropriate for Level 1 supervisees are likely to be met by resistance and even anger by the Level 2 therapist. Of course, the supervisor must always be aware of the overriding concern regarding issues of client welfare by providing appropriate structure and guidance in domains where the supervisee is in need 65

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of further development. Although Level 2 characteristics may be in play, it is important for the supervisor to assess the adequacy of the breadth and depth of supervisee understanding of the processes associated with the domain of interest. Expanding the repertoire of the trainee’s skills and understanding may also be in order. Level 2 therapists will not always be receptive to the kind of guidance supervisors provide to Level 1 therapists, even when it is necessary. Thus, the supervisor must be prepared to articulate his or her rationale for providing direction in certain situations and respond to supervisee resistance and anger in a nondefensive, facilitative manner. In introducing new conceptualizations and interventions coming from orientations with which the supervisee isn’t as familiar, these introductions can be viewed as merely extensions of the supervisor’s preferences, and not as important skills and knowledge for professional development. For neophyte supervisors, Level 2 therapists often provide the first difficult test of their supervisory skills and patience. In most training agencies, Level 2 supervisees, because of the amount of their prior experience, typically are assigned clients with higher degrees of psychopathology or exhibiting other challenges to the therapist; such client types may be less amenable to change through the facilitative skills and structured approaches applied during Level 1. The Level 2 therapist may also be receiving training and experience in a wider variety of modalities (e.g., individual, group, marital and family counseling) and in domains that may be unfamiliar. In postgraduate job settings, however, therapists may not be receiving training and exposure across various modalities, and they may exhibit Level 2 structures in only a couple of the broader domains (e.g., intervention skills competence) consistent with job requirements. In addition, in these settings therapists may be functioning at Level 3 in any number of domains, but in seeking additional expertise in a new modality, they may function at Level 2 (or lower) in the newer domain. An increased diversity of clientele and presenting concerns is exciting and challenging, as well as frustrating and anxiety producing. Previously effective counseling behavior (or behavior perceived as such) may prove less than adequate in ameliorating more complex client problems. As a result, client assignment should reflect a blend of cases with 66

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which the therapist exhibits confidence and independence, with more difficult challenging cases requiring the application of underdeveloped skills. These considerations allow the supervisee to consolidate previously learned skills, while challenging the supervisee’s ability to respond in a flexible manner to new problem situations. Training agencies that assign clients exclusively on a “space available” or “next-in-line” basis miss crucial opportunities to attend to or enhance the development of the Level 2 supervisee and may actually impede growth. Research investigations appear to indicate that support is a necessary ingredient across all developmental levels (Kennard, Stewart, & Gluck, 1987; Rabinowitz, Heppner, & Roehlke, 1986; Worthen & McNeill, 1996). Thus, facilitative interventions that express ongoing support and concern for supervisee development continue to remain important for the Level 2 therapist, especially during times of supervisor–supervisee conflict. A little added support and overt expression of this support by “normalizing the struggle” (Worthen & McNeill, 1996) does wonders for the fluctuating motivation level of the Level 2 therapist. Sharing or disclosing one’s own past experiences or difficulties with similar issues can serve to accomplish this function, particularly if the supervisee sees the supervisor’s experiences as relevant. Prescriptive interventions, although required slightly less frequently for Level 2 therapists than for Level 1 therapists, are necessary at times to encourage growth across the domains. That is, the Level 2 therapist requires supervisor knowledge and expertise across relevant domains. Although prescriptive interventions run the risk of eliciting extrinsic motivation, if care is taken to encourage identification and internalization of the learning, the trainee will positively respond and engage in careful information processing regarding the experience. However, prescriptive interventions suggested for domains in which Level 2 therapists adequately function, so the interventions are seen only as the supervisor’s preference for an approach, run the risk of eliciting trainee reactance and defensiveness and impeding supervisee growth and progress. In addition, even with the lack of active resistance, reduced learning may occur that frustrates the development of the trainee. “Going through the motions” 67

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isn’t adequate for facilitative learning to occur. It is especially important in utilizing prescriptive interventions with Level 2 supervisees to offer multiple alternatives and encourage some collaborative decision-making while allowing for some autonomous choices. Conflicts over supervisor prescriptions are usually defused when the supervisor is able to articulate a clear, cogent rationale, underscoring the importance of the interventions for client welfare. To enhance growth, Level 2 therapists must be challenged to provide their rationales for responding to various client concerns. This is especially true for cases in which supervisees may resist input, feel uncertain, or become angry and impatient. This can be characterized as amotivation, lack of motivation, or controlled motivation. At this level, encouraging trainees to assume more responsibility for their work, including offering rationales for decisions they make, is likely to enable greater movement toward intrinsic motivation and an internal locus of control regarding their role in the counseling process. Here again, moving trainees beyond their comfort zone, with support, can elicit growth. Thus, for Level 2 supervisees, conceptual interventions can be effective in encouraging them to articulate their own or alternative intervention plans. In addition, introducing different conceptualizations of the same client and associated treatment approaches by supervisors serves to challenge the supervisees and expand their level of understanding. It is important, however, that conceptual interventions be accompanied by high levels of support and empathy so they are not misinterpreted by supervisees as covert or disguised prescriptive interventions or demonstrations of the supervisor’s superior conceptual or diagnostic skills (again, seen as controlled motivation). This could elicit defensive (resistant or avoidant) reactions. Level 2 therapists may be most susceptible to overt or covert client manipulations because of their tendency to overaccommodate the client’s perspective, setting the stage for countertransference reactions. Thus, the increased use of catalytic interventions with Level 2 therapists, in the form of process comments by supervisors, can increase supervisees’ self-awareness when they are enmeshed in only the client’s viewpoint. Supervisor comments often are directed to the therapist’s reactions and 68

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feelings toward clients in moment-to-moment session interactions of which therapists may be only marginally aware. Helping supervisees sort out their emotional reactions to the client (e.g., empathy, idiosyncratic emotional reactions, generalized emotional reactions) can be productive through ROA. Encouraging supervisees to increase the focus on the client with a goal of experiencing primal empathy and attunement may help them develop better skills at empathic accuracy in their work. This focus can significantly broaden their understanding of their clients and yield important perceptions for conceptualization and treatment. Process comments may also be issued in the form of a direct challenge to stir things up in Level 2 therapists and, in essence, force them to focus on and monitor their feelings and reactions during an interpersonal interaction. This can help provide an impetus to move away from an exclusive focus on the client’s perspective and move to a consideration of the adequacy of the client’s social cognition and social facility. Examination of moment-tomoment reactions is best achieved through the review of recorded counseling session excerpts in a search for expanded learning and increased self-insight and understanding of the client. Process-type comments may also be employed to assist the supervisee in examining the dynamics of the supervisory relationship. Challenging catalytic or conceptual types of supervisor interventions can be uncomfortable for supervisees who are sensitive to evaluation because they may perceive that the supervisor is questioning their skills or knowledge. Nevertheless, what is comfortable, reassuring, or viewed positively by supervisees often is not what produces further growth. Challenge within a supportive supervisory environment is needed for the Level 2 supervisee to progress to higher levels of competence. Supervisors who use what the trainee may perceive as confrontational types of interventions do not need to present them in a punitive, aggressive, or superior manner. In our experience, powerful confrontations can be presented to supervisees in a low-key, straightforward manner. In most cases, the content of the confrontation is sufficient to produce the needed challenge or internal conflict in the supervisee, which may be facilitated by an honest discussion of a therapist’s strengths and weaknesses across the domains. 69

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However, Level 2 therapists often are taken off guard or initially react defensively to confrontive interventions, perceiving them as a threat to their autonomy. Thus, it is important for supervisors to process these reactions in the here and now; at other times, supervisors may need to back off and let understanding occur more slowly. Some less sensitive or reactive trainees require more forceful confrontations, ones in which supervisors challenge and directly follow up on recommendations to produce the challenge or conflict necessary to stimulate growth. However, it is not unusual for Level 2 therapists to return to a subsequent supervision session having carefully considered and processed the supervisor’s confrontive intervention. It is during this stage of development that the therapist is likely to engage in the most pronounced resistance toward the supervisor. Supervisees may selectively present cases with which they feel successful and avoid those with which they have difficulties. This choice is often a manifestation of confusion, a premature sense of autonomy, an inadequate understanding of the therapy process, or a lack of insightful self-awareness. In asserting their independence, therapists in some situations may avoid discussion of cases if they suspect the supervisor will challenge their choice of interventions (controlled motivation or amotivation). However, this growing desire for independence may limit the therapist’s awareness of what should be addressed in supervisory sessions, leading to avoidance of clients with whom the supervisee has become impatient or angry. At times the only way to fully assess therapist functioning is to require, at a minimum, recording of all ongoing clients so that the supervisor can monitor all cases at any time within the supervision session. In other words, identifying the difficult cases and issues that are impeding growth in the supervisee at this stage is paramount to the Level 2 therapist’s overall development. It is also important to remain sensitive to the therapist’s uncertain confidence, motivation, and fear of negative evaluation. Thus, it is extremely important to continue to monitor the therapist’s progress during this stage primarily through live supervision formats or reviewing session recordings. In our experience, it is not uncommon for supervisors to back off these activities as advanced therapists are viewed 70

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as “knowing what they are doing.” At this stage it is not adequate simply to respond to what supervisees may present in session or request direction on. Supervisors should not allow too much autonomy across cases by simply discussing clients, relying on therapists’ self-reports of ongoing client interactions, or monitoring progress notes. Thus, it is inappropriate to allow the Level 2 therapist a completely free hand in working with clients. Although we want to support trainees in their independence at this stage and encourage risk taking with clients, we still need to be careful in how we protect clients while encouraging therapist growth. Group supervision in the form of ongoing case conferences utilizing the Case Conceptualization Format (see Appendix A) for formal presentations by Level 2 supervisees also serves to augment and increase exposure to, and discussion of, a variety of client concerns, populations, and treatment approaches. It also provides for appropriate questioning and challenge from colleagues, peers, and other professional personnel. Again, the written case conceptualization format in particular serves as an excellent formal conceptual intervention in which the Level 2 trainee is required to pull information from diverse sources (e.g., client reports, objective psychological instruments, therapist perceptions) and integrate and synthesize this information into a coherent conceptualization of a client leading to a diagnosis and treatment plan (see Appendix A for a model format). A couple of relevant prescriptive, as well as conceptual, adjuncts to this exercise include the requirement of at least one objective instrument assessing personality functioning (e.g., the MMPI–2), along with research articles from the recent literature that provide some evidence-based support for the supervisee’s proposed treatment goals and plans. The goal of these assignments is to facilitate exposure to a wider array of information, treatment approaches, and procedures. This exposure is intended to elicit a more broad perspective from the Level 2 therapist who is focusing too much on the client’s view. The primary objective of supervision with Level 2 trainees is to set the stage for the transition to Level 3 by promoting a sense of conditional autonomy and confidence in domains in which they exhibit competence. We also want to stimulate a sense of responsibility and acceptance of the need to seek direction in less well-developed domains. By the 71

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end of Level 2, supervisees come to the realization that some fluctuations in motivation levels are a normal reaction to the realization of the complexities and confusion they are encountering. This results in a stabilization of motivation at a higher level as they enter into Level 3. Finally, the supervisee at this point is more open to self-exploration and able to consider perspectives other than the client’s by recognizing and acknowledging his or her own personal reactions and countertransference manifestations, as well as social cognition and facilitation characteristics of the client. This therapist, however, may still find it difficult to identify and act on these reactions in a therapeutic manner within the here and now of a therapy session (RIA). Thus, the Level 2 therapist continues to build on these foundations toward an orientation to practice in Level 3 that includes elements of personal and professional development. The transition to Level 3 therapist, like the transition from Level 1 to Level 2, is extremely dependent on the quality of the supervision received. Lack of attention to the variety of issues characteristic of the Level 2 supervisee or laissez-faire supervision during this important stage leads to what we characterize as the Pseudo Level 3 therapist. This individual is able to talk a good game and perhaps write convincing reports. However, close examination of in-session behavior of this type of therapist indicates that he or she has avoided dealing with the necessary development of an intensive focus on the client. Insufficient understanding of the client’s world and a lack of true empathy keep this therapist functioning more at an advanced Level 1 than either Level 2 or 3. To summarize, supervision of the Level 2 therapist provides quite a contrast to that needed for the Level 1 supervisee, requiring considerable skill, flexibility, and perhaps a sense of humor to successfully negotiate this difficult stage. As a result, the Level 2 supervisee may provide too much of a challenge for inexperienced supervisors or as an initial supervisory assignment for supervisors in training. However, a successful transition by a Level 2 therapist to Level 3 can result in some of the most rewarding experiences we have as supervisors. 72

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Level 3/3i Supervisors who have the opportunity to work with more advanced trainees are those most likely to encounter Level 3 therapists. Although we note that levels of therapist development are not synonymous with a particular number of practica, years of experience, or age, trainees (old and young, highly experienced or inexperienced) move at their own speed through the developmental levels. However, we can encourage this growth by providing appropriate supervision. Thus, we cannot say that all therapists will reach Level 3 at a particular point in their training or at some time after they complete formal training. Indeed, some therapists never fully integrate into Level 3 in many, if any, domains of practice. Nevertheless, most therapists enter Level 3 in at least one or two domains after a few years of supervised experience. In doctoral programs, we believe this occurs with some regularity during the predoctoral internship year. In master’s or educational specialist programs, we expect initial entry into Level 3 in some domains after 2 or 3 years of postdegree supervision. It is important to keep in mind, however, that the quality of the supervision provided, as well as the type of clinical experience, will have an impact on the speed and extent of professional development. Thus, some therapists will not reach these benchmarks in the noted periods of time or may attain them more quickly than do others. For the Level 3 therapist, most of the structure is typically provided by the supervisee rather than the supervisor. This level of therapist more accurately knows what he or she needs from supervision at any given time and can effectively use this consultation to advance his or her professional development. We also experience an increasing focus on personal and professional integration for therapists who are functioning at Level 3 in at least a couple of domains. If the therapist is still in a training setting, considerable attention may be paid to career decisions, although seasoned therapists often experience a change in professional direction and may choose to process this issue in collegial supervision. It is important, as always, not to assume that a therapist who is competent in one or more domains and functioning at Level 3 is necessarily functioning at that high level across other domains. Even when this high 73

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level is apparent across a number of domains, the work of integration and movement to Level 3i remains an important focus of supervision. For the more experienced therapist, it becomes increasingly common to be involved in supervising other professionals. Thus, providing supervision introduces another domain of professional development that interacts with therapist development in a number of ways. In addition, we need to be effective evaluators of supervisees who are expected to be functioning at Level 3 to be certain that they have indeed reached that plateau and are not stagnating in late Level 1 and masquerading as Level 3 while actually being Pseudo Level 3. Again, this takes the form of a through and complete evaluation of a trainee across the eight domains. The Level 3 therapist is more inclined to view the supervisor as a senior colleague than as an unassailable expert or perfect role model. Supervision becomes more of a process of give and take, with the role of “expert” occasionally switching from the formal supervisor to the formal supervisee, depending on the issues being addressed. Many of our advanced supervisees have had extensive experience before we begin working with them, and some of this experience is likely to be in areas in which our own skills and knowledge are limited. When the opportunity is available, supervision of Level 3 therapists can productively reflect a mentoring relationship, characterized by a fairly nondirective consultative role for the supervisor, who is attentive and invested in the general professional development of the supervisee as well as assisting him or her to acclimate to the particular clinical environment. It is not uncommon for some regression to occur when even experienced therapists enter a new environment. Support and availability of a supervisor or mentor can make this transition brief and allow the therapist to reestablish prior levels of functioning within the new environment. Before we examine specific interventions and mechanisms for supervising Level 3 therapists, it is useful to recall some of the important characteristics of this level of supervisee. As we have already noted in this chapter, the Level 3 therapist is able to build an effective therapeutic alliance with the client and gather extensive therapy-related information. The effortless use of therapy skills creates a facilitative environment and encourages 74

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candid client disclosures. The therapist’s ability to focus intently on the client (attunement), first developed in Level 2, enables a deep understanding of the client’s perceptual world, as well as an empathic awareness of the client’s emotional experience. Unlike with the Level 2 therapist, these data are more accessible to the Level 3 therapist because of his or her ability to pull back and reflect during the therapy process (RIA) and assess his or her own reactions to the client (high road processing). Thus, this therapist can take a personal inventory of his or her cognitive and affective reactions to the client and use this information therapeutically with an awareness of the possible influences of countertransference issues. Finally, the Level 3 therapist is able to take a more objective third-person perspective on the therapeutic process as well as access memory to retrieve relevant, clinically related information learned over the years. This ability allows the therapist to integrate important sources of information in his or her work: the client, the therapist reactions, the interaction between therapist and client, and professional knowledge. Which types of clients are most suitable for the continued development of Level 3 therapists is less of an issue than for therapists at lower levels. This therapist, at least in the domains within which he or she is functioning at Level 3, has considerable ability to work effectively with a range of clients. Still, if possible, selection of clients with whom the therapist has less experience or who reflect different cultural backgrounds, diagnostic classifications, and so forth, will help consolidate gains and set the stage for his or her movement into Level 3i. Because Level 3 therapists are unlikely to be functioning at this level across all domains, including modalities of therapy and various types of clients, it is particularly important to be aware of areas where the therapist is functioning at lower levels and work to encourage growth to bring the therapist up to Level 3. Thus, client assignment may focus on areas where Level 3 has not yet been attained. The types of interventions discussed previously remain useful categories for examining how supervisors can most effectively work with Level 3 therapists. Facilitative interventions remain useful. We never really grow out of an appreciation for support and caring within the supervision environment. They are less crucial in terms of protecting fragile therapeutic 75

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egos because the Level 3 therapist has developed considerable confidence based on understanding and abilities, but facilitative interventions remain effective in moving the relationship along and promoting self-disclosure and self-examination. Motivation has become more autonomous, representing intrinsic and internalized extrinsic motivations. Prescriptive interventions are rarely used in domains in which the therapist has reached Level 3 but may be used with respect to domains for which the therapist has not yet developed to this degree. In general, however, this level of therapist is able to select among options and usually will seek consultation in determining alternatives rather than asking for specific directions. Confrontive interventions are still occasionally necessary. We are all susceptible to making mistakes, being misguided, or putting our own needs first from time to time. The supervisor can feel free to confront this therapist across nearly any issue and expect that the confrontation will be met with a careful analysis. Defensiveness will usually be limited, although some Level 3 therapists may feel so confident or knowledgeable that they focus little on certain input, particularly if it is dramatically different from their own perspective, and thus they may be resistant to criticism or engage in biased processing. At these times, confrontation may be necessary to encourage the therapist to scan relevant schemata and carefully examine alternatives. Catalytic interpretations will most often be used in response to blocks or stagnation. As skilled as the Level 3 therapist is, he or she may still have issues that can interfere with effective therapy. These may be unresolved historical issues, or they may be a function of recent life events. It is more likely, however, that the Level 3 therapist will be aware of these and the need to address them in supervision or therapy than will either the Level 1 or Level 2 therapist. As noted in Table 3.1, the range and number of specific mechanisms used in supervision have been reduced as we moved from Level 1 to Level 2 and now to Level 3 therapists. A primary reason is that techniques are less necessary and specific instructional technology less important as the skill level increases and the information base expands. With Level 3 therapists, 76

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again, the most common approach to supervision is collegial, which relies less on monitoring the therapist’s behavior with clients or engaging in direct observation. Many of the mechanisms we have discussed will remain useful but are less crucial at this point. Therapists still benefit from observing their work on video or having it observed by others live and getting input from a colleague or supervisor concerning interventions. As skilled as the Level 3 therapist is at pulling back in the session and taking an objective view of the process (RIA), it is still helpful to augment that perspective by watching ones work on video (allowing for ROA). Observing others also can be helpful, particularly as doing so relates to expanding one’s repertoire of skills and orientations. In addition, using video or direct observation is crucial in identifying Pseudo Level 3 therapists who have not progressed beyond late Level 1 or early Level 2 structures. A common form of supervision with experienced Level 3 therapists is informal, collegial group supervision. Here the opportunity exists for colleagues to consult and challenge each other, as well as provide support. The primary advantage to this continued supervision is to work toward integration across domains and to share clinical experiences, insights, and problems with colleagues. Some settings are not conducive to open sharing and self-disclosure. This is unfortunate because it sets up an adversarial relationship among the staff or a sense of isolation that inhibits growth and does little to make the work environment enjoyable. Striving for integration across domains to move toward Level 3i is the goal of supervision with Level 3 therapists and should be the goal of the supervisees as well. Therapists who reach this level within domains now focus on developing the ability to move seamlessly from one domain to another. The supervisor can benefit the therapist by eliciting this focus in supervision and pushing the therapist to build stronger linkages between the schemata developed in response to training and experience within given domains, to make them more accessible across domains. In other words, the goal is to reduce the compartmentalization of knowledge and information so that it becomes readily activated in numerous clinical situations. For example, the Level 3i therapist is able to consider the 77

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assessment process and the information it yields with diagnostic impressions and data-based useful conceptualizations, and effectively use these in a supervisory or consultation context. The interpersonal power of the supervisor will rest on the therapist’s perception of his or her therapeutic expertise and supervisory skills. Level 3 therapists readily evaluate the skills of the supervisor, and should the supervisor fall short, will ignore, circumvent, or actively challenge this authority. An ineffective supervisor may fool a Level 1 therapist much of the time and a Level 2 therapist some of the time, but rarely for very long will one fool a Level 3 therapist. Although the amount of structure to be provided and the responsibility one needs to assume for active supervision is reduced for this level of therapist, the knowledge base and the level of integration must be high for one to effectively supervise. Thus, a Level 3 therapist can be supervised effectively only by another Level 3 therapist, and it is done best by a Level 3i supervisor.

CONCLUSION In this chapter, we specified and characterized the variety of interventions and considerations for working with supervisees, along with the creation of supervisory environments to best foster and enhance development through the levels. In the next chapter, we demonstrate and provide examples of these interventions through the examination of supervision session transcriptions and the accompanying DVD with trainee Nahal Kaivan.

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Structure and Process of Supervision—Supervising Nahal

I

n this chapter, we refer to the supervisory session recorded for the APA DVD The Integrative Developmental Model of Supervision (available at http://www.apa.org/pubs/videos/4310948.aspx) to demonstrate multiple aspects of the model, including assessment of trainee developmental level, types of interventions, the use of the supervisory relationship, and attention to crucial issues of diversity. Viewing the 45-minute session available on the DVD will provide the reader additional context for the excerpted material included here; however, the reader will be able to understand the illustrations provided without access to the full transcript.

THE SUPERVISEE Dr. McNeill has known Nahal Kaivan, a third-year, Iranian American, female student, since she entered the counseling psychology program in which he teaches. She has been a student in several of his classes, most recently a http://dx.doi.org/10.1037/14858-005 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

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seminar in clinical supervision. Thus, Nahal is familiar with the integrative developmental model (IDM), as well as other models of supervision and training issues covered in the class. In class, Nahal is always involved and invested, readily contributing to class discussions. At the time of this recording, Dr. McNeill previously had supervised Nahal’s clinical work while teaching her first-year, second-semester, doctoral-level practicum course along with members of her second-year cohort. This program accepts students with both bachelor’s and master’s degrees and evaluates previous course work for potential credit. However, the program does not accept previous practicum/clinical experience for credit in the required doctoral practicum sequence. The rationale for this policy is that the more clinical experience, the further along the trainee is to becoming a skilled clinician. Consequently, when students enter the program, they may have been exposed to previous course work in counseling theories, a lab-type course focused on the teaching of basic facilitative skills, psychological assessment, and so forth via their master’s degree course work. Students entering with the bachelor’s degree take these courses in their first year of the doctoral program. All students in a given cohort then enroll in their first practicum course in the second year of our program in a University Counseling Center setting. Thus, although Nahal is “officially” considered a third-year student entering advanced practicum, because of her previous practicum experience in her master’s degree program, she possesses more applied clinical experience than do others in her cohort at the bachelor’s degree level and a wider breadth and diversity of clinical experience than do many master’s level students (see Appendix B—Supervisee Information Form for Nahal).

ASSESSMENT OF DEVELOPMENT LEVEL As mentioned in Chapter 2, accurate assessment of trainee developmental level is a critical activity in working from the IDM. As Nahal’s previous practicum instructor, Dr. McNeill had access to work samples in the form of recorded sessions, Nahal’s contributions to case conferences in class, and written case conceptualizations using the previously discussed format (see Appendix A) required for Dr. McNeill’s class. Dr. McNeill considers 80

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the domain/skill of case conceptualization to be a crucial one for clinicians. Thus, for case conferences in clinical practicum-type courses, Dr. McNeill requires students on the day of their individual presentations to provide a written copy of their case conceptualization for all members of class to introduce the client they are presenting, and the class watches recorded excerpts from a selected session. All class members then provide feedback and comments on the session. In addition, the written conceptualization in the format is turned in to Dr. McNeill along with the complete recorded session for detailed evaluation and feedback. It is not unusual for students to be required to rewrite their conceptualizations a number of times. Dr. McNeill warns them that rewrites are the norm, rather than the exception. In the supervision session presented, Nahal has provided her written case conceptualization of the client Sabrina1 to Dr. McNeill. Nahal’s Supervisee Information Form (see Appendix B) shows the quantity of her previous experience and provides a description of it. Dr. McNeill uses this form on a regular basis in individual supervision and practicum courses to get a quick picture of the trainees’ previous clinical experience, most importantly previous supervised experience. Dr. McNeill considers this information, along with work samples in the form of recordings and written materials, when making an assessment of supervisee developmental level.

THE SUPERVISION SESSION Because this was the first meeting of the semester, Dr. McNeill and Nahal began with a check-in and ongoing assessment to review her past experience via the Supervisee Information Form and her recent summer practicum experience. As part of Dr. McNeill’s assessment of Nahal’s developmental level, he asked her to describe her strengths and weaknesses as a therapist. He had two goals in mind. First, he wanted her to engage in a self-evaluation that would provide him with information regarding domains in which she was asking for additional guidance. Second, based Nonessential factors about this client have been disguised, and the name is a pseudonym.

1

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on his evaluation of Nahal’s developmental level, he wanted to gain a sense of her insight and self-awareness of her strengths and weaknesses as compared with his perceptions. From the start, he was attempting to build a positive supervisory relationship, primarily through facilitative inter­ ventions in the form of supportive statements. Examples of various types of supervisory interventions are identified in the transcript. Dr. McNeill: Hi Nahal. It’s good to see you. Nahal: You as well, Dr. McNeill. Dr. McNeill: How are you doing? Nahal: I’m well. How are you? Dr. McNeill: Good. Nahal: Good. Dr. McNeill: Let’s start by sort of reviewing a little bit from last year. Nahal: Sure. Dr. McNeill: Okay, and then let’s get caught up . . . a little bit with the activities that you’ve been involved in clinically this summer as well. Nahal: Okay. Dr. McNeill: So, you put in a year of your first doctoral practicum. [But] it is obvious you [have] brought in a good number of previous experiences and hours. I see on my information form here that all of your previous experience has been supervised, and that you’ve already got about 500 hours over 4 years of experience. Nahal: Mm hmm. Dr. McNeill: That’s great. I didn’t realize it was adding up so much. Nahal: Yeah, slowly. [laughs] Dr. McNeill: Tell me, Nahal, in terms of the kinds of populations that you provided services to, in age, racial [and] ethnic background, various types of problems, diagnostic classifications, etc. 82

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Nahal: Sure. When I was in my master’s program, I worked primarily with the monolingual Spanish-speaking Latino community. That was a mandated population. And in addition to the Latinos I worked with, I worked with other people of color. A few Middle Eastern clients, Armenians as well, and most of my work was with youth and adolescents in my master’s program, and some of my work was with families. So, a lot of the presenting concerns were Axis I,2 for the most part. Adjustment . . . different, as well as in the agency that I worked in last year during my beginning practicum. No complex cases, or not very many anyways, while I worked with youth and adolescents. Mainly just issues at school, families, intergenerational challenges, some struggles with poverty of course, and immigration stressors. That was the main work I did in my master’s program and then in the doctoral program last year during my beginning prac. Experience, like I said mainly just Axis I, adjustment, some depression, some anxiety, and that was about it. Dr. McNeill: Okay. And you averaged what? About three to four clients a week last year for practicum experience? Nahal: Yeah, yeah. About five to six. Dr. McNeill: Much diversity in terms of ethnic background? Nahal: No. Dr. McNeill: Oh, it’s okay. It’s not unusual here of course. Nahal: Yeah. No. Dr. McNeill: But you’ve had, it seems like, pretty extensive experience with Latino populations with your experience in San Diego. Nahal: Yes, in Southern California I got to work with a good amount of Latino youth and families. So it was a very rewarding experience.

2

Note: Here and elsewhere, Nahal and Dr. McNeill use the “Axis” terminology that existed in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) to conceptualize and differentiate mild and moderate clinical syndromes from more severe disorders. This format was eliminated in DSM–5. Also note that starting October 1, 2015, providers are required to use the World Health Organization’s Inter­ national Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD–10) system to diagnose illness.

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Dr. McNeill: Okay, and you are bilingual and you’ve been able to provide services in Spanish. That’s very impressive. [Here the supervisor offers a facilitative intervention.] Nahal: I’ve tried to provide services in Spanish. Yeah, I’m intermediate in Spanish. Comfortably intermediate, and I’ve worked with monolingual Spanish speakers, and I have also have provided therapy in Farsi. Dr. McNeill: Oh, you have as well? Oh, that’s excellent experience then. Okay, so you’re trilingual. Nahal: Sort of. Dr. McNeill: Give yourself credit [facilitative, again]. Nahal: I’m going to try. Dr. McNeill: Okay, your Spanish is probably better than mine, and your peers who are bilingual say Nahal speaks really good Spanish. Nahal: Yeah, they are probably lying to you. Dr. McNeill: I don’t think so. You are what we consider around here as a third-year doctoral student going into your so-called first advanced practicum. Nahal: Sure. Dr. McNeill: I think you obviously bring in, again, more experience and a good diversity of experience for a level of where we kind of consider you with your cohort. Nahal: Yeah. Dr. McNeill: Okay, probably more experience than your peers as I’ve seen it. Nahal: Okay. Dr. McNeill: Okay. So, you know, of course, that I work from the IDM Nahal. You’ve been very immersed in it recently because we talked about it in practicum and how that helps us to normalize the process of development that everybody goes through. 84

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Nahal: Sure. Dr. McNeill: And then, of course, you were in the supervision course last semester, so we really got into the issues then in depth. So, what I would like you to do is give me an assessment of your strengths and weaknesses consistent with the model across domains. Nahal: Okay. Dr. McNeill: Where you see yourself as needing areas of improvement. Nahal: Okay. So, I’ll give you some ideas, and then maybe you can give me some feedback on whether you think I am meeting the mark a little bit. Dr. McNeill: Okay. Nahal: Okay. So, when I look at the IDM, it’s really helpful to me because I think that I fall into the Level 2 category mostly. I look at the different domain areas like intervention skills and competence, so it says an increased comfort with a variety of intervention skills, although not consistently connected to an overriding theoretical orientation. So, I do have my sort of, you know, faddish things I like to pick and pull from and that’s certainly true of me. Dr. McNeill: Mm hmm. Nahal: Something I will say is a growth area of mine is that I’m hoping to . . . I’m honest about where I am at in my theoretical orientation. Dr. McNeill: Mm hmm. Nahal: I am not as rooted as I’d like to be, but I am open about where I am with it developmentally. So I am hoping that with that I’ll grow in that area. Assessment techniques, you know of my last year, beginning practicum experience. I was at a site where assessment was not really something that we students could do. We were indoctrinated to believe that assessment is a tool for pathologizing clients for the most part and that it doesn’t have a place in the center. Dr. McNeill: Okay. Nahal: So I don’t feel like I am where I should be with assessment. 85

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Dr. McNeill: Okay. Nahal: Where I’m at as an advanced practicum student. I don’t really feel like I can identify when a client should, when I should be administering an assessment with a client, and what assessments would be appropriate with them. Dr. McNeill: Mm hmm. Nahal: Though I’ve taken the classes, and I’ve had positive experience in both of the classes, conceptualizations I subscribe to, or I say that I conceptualize from an IBT [interactive–behavioral therapy] framework, but I’m not very strong right now with case conceptualizing from IBT, from that orientation. Dr. McNeill: Mm hmm. Nahal: Let’s see what else . . . So, the other thing too that [I] identify with in the IDM is that I have a tendency to write more vague treatment goals and plans. So, I’ll do something in my treatment goal like working on the relationship. I’ll write that as one of my treatment goals. And so, so far I’ve kind of used . . . that as, well, it’s broad and general enough that I can go in different directions with it. But I’ve learned that it’s not really that helpful, and it’s kind of deflating to see when it doesn’t go, go as well as it could have if maybe it was more specific. Dr. McNeill: Mm hmm. Nahal: Yeah. I think those are the main things. And then the one thing that I’m struggling with currently is the interpersonal assessment domain because, you know, it talks about overidentification with clients or underidentification with clients, and so one of my clients that I want to talk to you about today highlights my need to develop in that domain. Dr. McNeill: Mm hmm. Nahal: But I don’t know. What do you think about so far about my strengths and my weaknesses? Dr. McNeill: Well, I think that you’ve articulated areas for improvement. How about strengths? 86

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Nahal: I think I’m really organized, and I think a lot about process, and I think a lot about my clients in between sessions. And I’m really committed to my growth and development as a clinician. And I think I’m pretty honest about, you know, accepting feedback, though sometimes it can be difficult, and using that to move forward in a positive growth direction. Dr. McNeill: Good. Important to be aware of what you do well as opposed to focusing too much on where your weakness are. You know, because everybody has areas for improvement. Nahal: Sure. Dr. McNeill: And the areas that you’ve mentioned . . . assessment. You know I come from a very different place, where I see assessment as being advantageous. I see it as being very routine in any number of formats. I don’t see it as being harmful, or I don’t think there’s any evidence that it’s ever harmful, to a client. Nahal: Yeah. Dr. McNeill: You also know that I’m very big on case conceptualization. Nahal: Sure. Dr. McNeill: Okay. And using that as a base to bring us back to what we’re trying to do treatment wise, to make treatment plans and set treatment goals, or if we feel stuck, to come back to those skills of conceptualization and diagnosis and not necessarily all from DSM–5 [Diagnostic and Statis­ tical Manual of Mental Disorders, Fifth Edition] categories, and that I link that pretty closely with assessment as well. Nahal: Yeah. Dr. McNeill: So yeah. Those are all things certainly we can work on this semester and maybe give you a little bit of perspective. Nahal: Sure. Like many trainees, Nahal found it easy to be self-critical and focus on her weaknesses, which Dr. McNeill prefers to conceptualize as areas for improvement. Consequently, he asked Nahal to also identify strengths. 87

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He strongly agreed with Nahal’s self-assessment and was impressed with her level of self-awareness. Consequently, his assessment was that she was performing as an advanced Level 2 therapist overall. In the domains of intervention skills competence, interpersonal assessment, individual differences, treatment goals and plans, and professional ethics, Dr. McNeill viewed Nahal as performing as an advanced Level 2 therapist across all overriding structures of motivation, dependency–autonomy, and selfawareness. Across the domains of assessment techniques, client conceptualization, and theoretical orientation, he viewed Nahal as performing at Level 2 across the domains of motivation and self-awareness, and Level 1 related to dependency–autonomy. He also thought that the two of them had a strong, facilitative working supervisory relationship. As a result of Dr. McNeill’s assessment of Nahal as an advanced Level 2 trainee, in this session he was attempting to provide the appropriate supervision environment characterized by less structure; more autonomy; a mix of challenging conceptual, confrontive, and catalytic interventions, always with accompanying high levels of support, encouraging reflection-on-action (ROA). The two continued the session by addressing Nahal’s summer clinical experience. Dr. McNeill: Okay. Now I forgot to ask you about your summer experience. Did that help you at all in terms of shoring up any deficits that you see experience wise? Nahal: Well, it was a really enjoyable experience, like my beginning practicum experience was, in terms of seeing clients. I think that has always been really enjoyable for me and really meaningful to me. What has been a common theme in my master’s work and in my beginning practicum work here and unfortunately in my summer practicum, is that I’ve been supervised by predominately white females. Dr. McNeill: Mm hmm. Nahal: And I think that you know the intersection of the way that I perform my gender as a woman, and my race, and my ethnicity, maybe the 88

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fact that we [at this University] are a predominately white community and we’re small. Dr. McNeill: Mm hmm. Nahal: That has been a little, I think, difficult for my supervisors and also for me. And I think it’s been hard to develop, I think, as a clinician while there’s this background of lack of responsiveness in the environment, and yeah a lot of just unresponsiveness in terms of my cultural differences and in being a woman of color. That’s been really hard and that one of the reasons I’m looking forward to doing supervision with you is because you are a person of color, and I’ve talked to you in passing about some of the things that I struggle with as a clinician here. At this point, Nahal raises a number of issues regarding individual differences related to her experiences and development as a therapist. As we note in Chapter 5, because of the difficulties surrounding dialogues on multi­ cultural issues, supervisors must be comfortable initiating such dialogues and responding to them in a facilitative manner. Thus, Dr. McNeill wanted Nahal to know that her experiences as a trainee of color were appropriate for their supervision sessions, so he invited her to discuss them; he also wanted to make sure she knew those were important issues for their supervision sessions in relation to her personal and professional growth as a therapist. Dr. McNeill: Okay, good. I know that you have a very strong commitment to multicultural issues, issues of diversity in other words. I also know that you are very strong in your own sense of ethnic identity. And I want you to know, too, that any of those kinds of issues related to your identity, your feelings of belongingness, or alienation from the larger community either here on campus or in town . . . those are things that we can talk about in here as well because those are issues related, at least from my standpoint, to that merging of personal and professional growth, and as they, you know, especially impact your work, you know, with clients. In the next excerpt, Nahal demonstrated a good advanced Level 2 sense of self-awareness and insight given her personal countertransference 89

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reaction as a woman of color and “as a social activist” and what would be an appropriate therapeutic intervention with regard to the current case. Dr. McNeill attempted to encourage ROA in Nahal by asking her to place herself back in a moment of interaction with her client and recall her feelings and reaction. Nahal: Yeah, so you know about my client Sabrina. I’ve talked about her a couple times now. Something happened recently in one of our sessions that was a little bit off-putting to me. We were having a session, and she was telling me about something. I don’t remember what it was exactly, but she was talking about something, and her phone rang during the session. And I noticed that she was caught off guard by her phone ringing. And she kind of looked at her phone and was distracted and then tried to continue telling me her story after the phone stopped ringing. And so I asked her you know, I said, you seem distracted after the phone call, as a result of the phone call you received just now. And she said yeah, it’s weird, it was this guy that I went to school with. And then she proceeded to say, you know I’m not racist at all, and my family is not racist at all, but this guy is an African American male who my family just loves. They love him so much, and he is one of my good friends in my undergraduate program. But you know, I have some uncles who wouldn’t be okay with me being friends with African Americans, and my dad, he’s not a racist, but he wouldn’t be okay with me dating this guy. Dr. McNeill: Mm hmm. Nahal: “This African American male.” And so then immediately for me, I just felt like I couldn’t really hear a lot of the other stuff that she was saying cause she kind of tried to move on from that and go back to her original story. Dr. McNeill: Mm hmm. Nahal: And I felt this piece of me just reacting to what she saying in that moment, and I’m thinking like, okay, if we were in any other context but this one, my immediate reaction and my attention to what was going inside of myself would have been a little different. You know, I would have 90

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been more apt to respond more immediately. And so I’m thinking inside of myself, and I asked her at that point then, what is it like then, as you say this to me, I wonder what it’s like for you then to work with me, a woman of color, as I am woman of color. And she said, uh uh . . . And she’s kind of fumbling around and getting uncomfortable. And so I notice immediately I have this decision to make. There’s this social justice piece of me that says I’m going to show you what’s up right now and use this a learning opportunity, a teaching opportunity for you. And then there’s this other part of me that’s thinking, okay, she’s getting uncomfortable, it’s not really therapeutic. She’s fumbling around in her words, and I don’t want to make her feel uncomfortable, and so we kind of moved on from there. And this sort of . . . is part of a bigger issue that I’ve had with her and other white clients who I perceive that they don’t really take me seriously as a woman of color. And I get the sense that she comes into session trying to be my friend and trying to have this sister of color who she comes to talk to on a weekly basis. So that was just kind of like the cherry on top for me, and [an] example of this feeling that I had going into my work with her every week. Dr. McNeill: Mm hmm. If you put yourself back in that moment. What was that reaction like for you? Nahal: It was uncomfortable and upsetting because I’m like [sigh] I have to deal with this here, too? Dr. McNeill: Mm hmm. Nahal: You know, I’m in this session with this client, I’m a visible minority, and also with her not taking me seriously, like somehow she felt like she had a pass to just kind of say that to me like I shouldn’t react to it or that I’d be like, oh yeah I know exactly what you’re talking about. Dr. McNeill: Uh huh. Nahal: When that wasn’t really the situation at all. Dr. McNeill: Mm hmm. Nahal: So there’s my inclination to, you know, if we were in a public setting where I’d say you know what you just said was really off putting to me. And I don’t really appreciate that at all and in pretty, very direct words. 91

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But I didn’t think that knowing her, I’ve [seen] her now for eight sessions. I don’t think that would have been something that would have been reparable at a later time, put in those words and in that way. Dr. McNeill: Or it seems like, well due to other complicated factors, your relationship wasn’t at that point where you could talk about those issues. Nahal: Sure. Yeah. Dr. McNeill: And that is what we’ve talked about before as her sort of steering things away from therapy in there to more of a social relationship because you knew each other outside of therapy before she came in. Nahal: Yeah. So you know that we did an activity together once outside of . . . and you know the community is so small here. I was partnered up with her. And there wasn’t much opportunity to connect on a personal level, but she encountered me in a different space. So I think, in the initial session, where I checked in with her and said well . . . you know, cause we didn’t know how to place each other, and then as we started talking, we said okay you were here, I was there. And I said, well, what is it like for you to be doing work with me in this very different space now where I’m going to be your therapist? And she said no, I think it’s great. You know, I think it’s wonderful that we knew each other from another context. Dr. McNeill: Mm hmm. Nahal: And I think progressively from there it’s just been difficult to get her to take me seriously, not just from that, but I also perceive it to be because, and maybe I’m misperceiving this or projecting too much, because I’m a woman of color. It’s hard for her to see me as a professional. Dr. McNeill: Okay. First of all, I think it’s very tough when we encounter those types of situations. I think, we’re all, and for me personally, I’m still kind of taken aback when someone expresses ethnocentric or sometimes blatantly racist views in session. And sometimes I still don’t know quite how to react [again, a facilitative intervention]. Nahal: Yeah. 92

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Dr. McNeill: And because of my mixed ethnic background, some people don’t always see me as a Chicano. You know that it’s normal to struggle with those kinds of situations. Nahal: Yeah. Dr. McNeill: But kind of back to the issue for you, it feels like, or it seems like you feel like you are having to prove yourself in therapy, kind of like you feel like you have to prove yourself to others outside of therapy. [Note the shift here to a confrontive intervention.] Nahal: Yeah. And I think that also, Dr. McNeill, it also has to do with, like, in my beginning practicum experience, and I think there were some sprinkles of this in my master’s program, where I also was supervised by primarily white, you know, Anglo people of European backgrounds. I was kind of told my dark features, my presentation as a woman of color, can be too assertive at times. And that in order for me, for my TQ, my therapeutic quotient to like, to be high, I need to kind of tone it down a little bit or make sure that clients aren’t seeing the angry person that a lot of other people were telling me I looked like or I presented as. Dr. McNeill: Mmmm. Nahal: And you know, that’s kind of a hard thing to deal with, too. How do I change that I’m a dark featured person, or that I talk the way that I do, or that I perform my gender the way that I do. You know, and so, to me sometimes maybe I’m overcompensating with my white clients and being really, really friendly with them because I don’t want to scare them in the therapeutic space. Dr. McNeill: Mm hmm. Nahal: So it has been me trying to prove that I am therapeutic. You know, I’m not scary. I’m not going to do anything to you. Dr. McNeill: Okay. So I wonder Nahal . . . If you know, in one sense you’re kind of buying into that stereotype that’s been placed on you. [Here the supervisor shifts to a catalytic intervention.] Nahal: Yeah. 93

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Dr. McNeill: And I say that because I don’t see you as an angry minority. My experience of you is that you express yourself very well, very assertively, appropriately assertive across a variety of situations where I’ve seen you, in class, I’ve viewed your sessions (facilitative). So, what you do you think about that (catalytic)? Nahal: Well, that really nice to hear that from you, but I think it’s hard to believe that when so many people are saying that to me. And they are all mostly white people. And those are the people who are like, who are running the system that I was a part of in my beginning practicum experience. And the people who are supervising me were also primarily white. And so it’s, so I want to believe that, but I think, yeah, I did buy into that because it’s like from the top down this is the message that I’m receiving. So it’s hard to own those more positive pieces of my difference when they’re not, my difference isn’t really being embraced. Dr. McNeill: Okay. It’s hard, I know, not to internalize . . . Nahal: Yeah. Dr. McNeill: Those kinds of perceptions . . . , but at the same time, and I see you doing this to an extent in terms of trying to examine how those perceptions fit or maybe don’t fit for you. But it’s also important, like I think you are doing, to examine how those impact your therapeutic skills. Is there anything you know, as you place yourself back in the situation with Sabrina, that you would have liked to do differently at that point and be therapeutic but not sort of, overreact, or react as you would, maybe overreact isn’t the best word, but react as you would say if it was an encounter outside of a therapeutic situation? Again, Nahal demonstrated excellent self-awareness within the domain of professional ethics regarding dual role conflicts and therapeutic implications. Dr. McNeill’s personal self-disclosure (i.e., “I am still kind of taken aback . . .”) at this point regarding clients’ ethnocentric or racist views in sessions represents a facilitative intervention designed to “normalize the struggle.” As we discuss in Chapter 5, research suggests that intermediate and advanced trainees appreciate and benefit from these 94

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types of facilitative interventions. This intervention then set the stage to implement a confrontive intervention as Dr. McNeill challenged Nahal to respond to his observation that she feels a need to “prove herself to others” in fighting the perception that she needs to tone down her commitment to multicultural issues. Dr. McNeill’s next question to Nahal (in which he wonders if she is internalizing the stereotype of the “angry minority” that other people have placed on her) again represents a confrontive type of supervision intervention. Dr. McNeill’s follow-up intervention was catalytic in nature as he asked her reaction to his previous intervention. Dr. McNeill’s intervention attempts here were to help Nahal move beyond internalization of what he viewed as stereotypes of women of color. Dr. McNeill viewed Nahal as engaging in an appropriate selfexamination regarding these issues, but in a catalytic sense, he also wanted her to examine how such issues affect her therapeutic work, in this case in encouraging more ROA as he challenged Nahal to formulate an appropriate therapeutic intervention. In addition, in the examination of the parallel process in Nahal’s urge to react in the session as she would outside the session, it is important to tie Nahal’s behavior to the therapeutic issue at hand and not risk “therapizing” the supervisee. Dr. McNeill also wanted Nahal to examine how her reaction affects her therapeutic work; in this case in encouraging more ROA as he challenged Nahal via a conceptual intervention to formulate an appropriate therapeutic intervention from her interpersonal process therapy (IPT) orientation. Nahal: I guess I struggle with that because of the feedback that I received and wondering how appropriate a process comment would have been, like a process disclosure of me saying, well when I hear you say that it’s really hurtful for me as a person of color, and I wonder if you considered that before, before you said it, or if it’s something that you would consider now and we can talk about. Maybe that would have been a more appropriate [thing] to say, but I was, I think I was just so taken back that it’s happening in this other space, and that my fears, I guess, or that my biases were being reaffirmed in that moment. 95

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Dr. McNeill: Mm hmm. Sure, and certainly it’s not easy to react and think like that in the moment. Nahal: Yeah. Dr. McNeill: But, you know, as you are articulate, your response now and it’s always easier to articulate your response now . . . it’s always easier after the fact. Nahal: Right. Dr. McNeill: After we’ve had some time and even a little distance, after a given session. But no, I think that you formulated a very good response. The only thing I can think of to maybe enhance that would be preface it a little bit. Nahal: Yeah. Dr. McNeill: “Sabrina, I really appreciate your honesty in sharing this kind of situation with me, and here’s how it impacts me. And I wonder what your response is to that.” Nahal: Yeah, that sounds a lot better than what I said. That was awesome. Dr. McNeill: And sometimes that, of course, can turn around a relationship. Or it can be one of those impactful moments you know that brings you to a different level, which you’ve been struggling with her for eight sessions. Nahal: Yeah, yeah. Dr. McNeill: So just a possibility there, but I liked how you formulated that on your own especially. Dr. McNeill thought Nahal formulated an excellent intervention that could have been used in the past moment in the therapeutic encounter. After he gave Nahal an opportunity to formulate her response, he provided some feedback and a bit of guidance concerning the implementation of her IPT response; he also responded to Nahal’s direct questions/requests for guidance related to his previous assessment of her developmental level and appropriate guidance/feedback in the relevant domains of case 96

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conceptualization and theoretical orientation. The two of them then proceeded to a discussion of additional aspects of Nahal’s presented case, during which Dr. McNeill again challenged her to formulate responses/ interventions from her chosen theoretical orientation, with the balance of support and challenge in the form of facilitative, catalytic, conceptual, and confrontive interventions, which characterized this supervision session and stimulated ROA. Nahal continued to reflect on her actions in the session as she attempted to formulate a response from her IPT orientation in response to Dr. McNeill’s conceptual intervention. Very much reflective of a Level 2 trainee independent who is some domains, Nahal requested guidance in this domain. After validating her appropriate ROA, Dr. McNeill responded with a suggested enhancement to her intervention. Dr. McNeill: Okay. Now, you are working to develop your interpersonal process orientation. Nahal: Yeah. Dr. McNeill: I’ve seen you being able to progress. It seems like you are becoming increasingly comfortable with that orientation, and you’ve been able to make some process comments in the moment, and follow up on some of those. Okay, in this situation, what would your IPT orientation suggest as an intervention [conceptual]? Nahal: With the termination issue? Dr. McNeill: More so in terms of that balance. Oh what’s a good word? Incongruence as what you are experiencing as a social encounter and a therapeutic encounter and some of the frustration that comes with that? Nahal: Yeah. Dr. McNeill: What would be a good process kind of intervention there [conceptual]? Nahal: I might say something like “Sabrina, I’d like to take a risk and share with you how I’m feeling about the way that our meetings have been going thus far. I get the impression that our goals might be different 97

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in this space. And that for you it’s really beneficial for you to maybe come in and small talk and share with me some things that have happened for you during the week, but I don’t really feel like I’m being of service to you in any way or that I’m doing my job, so to speak. And so I’m wondering if what might be more beneficial for you is if you find some resources within the community and connect with people on a social level. Because as you know, we’ve talked about this in the beginning of our work together. It isn’t really possible for us to engage as friends. And even using the therapeutic room and space to engage as if we are friends makes me feel like I’m misleading you.” Dr. McNeill: Okay, okay. [laughs] Nahal: That’s a really long process. [laughs] Dr. McNeill: I was going to say . . . now keep it brief! [laughing] Maybe stick to the first part there. But I think that what you’ve articulated is a good process conceptualization of your perception of what’s happening in the therapy session between you two. Nahal: Yeah. Okay. Dr. McNeill: Once again, think in terms of a preface. “Sabrina, I really appreciate that you show up here every week. You seem to like to come in here and have that commitment. Here is something I’d like to talk about.” Nahal: Yeah, yeah. That’s really helpful because then it sort of warms up the feedback. Yeah. I like that. Dr. McNeill: But no, I really like the way you articulated that at the beginning. “I want to take a risk here.” I think that communicates that you are speaking, you know, from the heart very much a part of that very close, interpersonal level. Nahal: Yeah. At this point, Dr. McNeill wanted to continue to respond and provide guidance relevant to one of Nahal’s previous questions in regard to confronting the disturbing racial/cultural interaction in a future session with 98

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her client Sabrina. He used a confrontive and a catalytic intervention to challenge Nahal to think of how intervening would affect the therapeutic encounter because it appears to be a leftover issue from her perspective. Nahal again demonstrated her high level of self-awareness in acknowledging that bringing the issue up with her client would be more in her self-interest than in the interest of her client, and Nahal was able to further explore the effects on the therapeutic relationship. Dr. McNeill: Now, you mentioned previously the issue of the cultural differences and those offensive kinds of remarks and whether to pursue that again. Nahal: Yeah. Dr. McNeill: Okay, hard call. A number of issues there—you are getting ready to terminate. Nahal: Yeah. Dr. McNeill: Is it something that you feel . . . necessary to revisit at this point? Okay, in other words, is it necessary to go back or see if it comes up again, and then think back to what you’ve prepared as potentially an intervention there that you know that you would articulate in an appropriate way [confrontive]? Nahal: Yeah. Dr. McNeill: Okay, but another thing to consider is how it impacts the therapy if it’s still on your mind [catalytic]. Nahal: Yeah. Well, to address the first part of what you said, I think that in terms of action steps moving forward. I don’t, you know, as I think about that while you were saying that, I think it would serve me more to bring it up again at this point, but certainly if she brings it up. I will reference the last time that it happened and then practice what we talked about in here. The discussion between Dr. McNeill and Nahal then proceeded to the issue of “difficult dialogues” with clients around issues of race and culture. 99

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Again, Dr. McNeill wanted Nahal to know that their supervision sessions were a time when they could have such dialogues, and Nahal expressed appreciation for validation in the sharing of these issues. Dr. McNeill: And I would see this encounter, even though it’s a tough one, and again, like we talk about a lot in class, those issues of race, stereotypes, racism are very difficult conversations. Nahal: Right. Dr. McNeill: In the social realm, our clients bring those issues to the therapeutic realm. But nonetheless, we need to be prepared about how we do react and what is maybe the appropriate way to react within the therapeutic realm. And just like it is outside of the therapeutic realm, it is difficult inside as well. Nahal: Yeah. Yeah. Dr. McNeill: You know, I think looking at this as a good learning experience where you weren’t harmful in any way. Nahal: Oh great . . . [laughs] Dr. McNeill: But try to be ready because it is going to come up again. People bring in those stereotypes, people sometimes . . . it’s amazing what they assume that you might just readily agree with. Nahal: Yeah. And it’s nice to be validated by you and to talk openly with you about this because I’ve certainly never had conversations like this in the past in other supervision experiences. Before the session ended, Dr. McNeill wanted to address Nahal’s request for guidance in the domain of case conceptualization as he challenged Nahal to provide a conceptualization of Sabrina. Again, he stressed conceptualizing Sabrina from an IPT perspective to meet Nahal’s expressed supervisory needs, and Dr. McNeill thought she did good job with this conceptual intervention. Dr. McNeill’s final conceptual intervention involved my request for Nahal to first describe the nature and type of distress along certain dimensions leading to a DSM–5 or International Statistical Classification 100

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of Diseases and Related Health Problems, 10th Revision (ICD–10) diagnosis. The first of these dimensions concerns if the distress is acute (i.e., short term, recent onset) versus chronic (i.e., long term, gradual onset). The next dimension involves the type of distress on a continuum of mild to severe. In addition, Dr. McNeill asked for a judgment related to egosyntonic versus ego-dystonic distress. Clinicians have used this distinction over a number of years because certain disorders can be characterized by perceptions and behaviors that can be described along this continuum. Ego-dystonic distress is characterized by patient recognition of the problem as something that is distressing and that the client wants to change; clients usually are willing to take responsibility in addressing destructive behavioral patterns. In contrast, ego-syntonic distress is characterized by a lack of insight into a problem consistent with one’s self image and a tendency to externalize responsibility of the problem by blaming others. Although the multiaxial system was discontinued in DSM–5, Dr. McNeill believes that conceptualizing client problems along these dimensions helps trainees in differentiating between disorders. By nature, Axis I disorders tend to be characterized by acute-onset, moderate to severe distress and are ego-dystonic in nature. Axis II disorders are more chronic, described as mild to moderate in level of distress, and ego-syntonic in nature. Dr. McNeill asks his students in their written conceptualizations to start off with an overall statement of client distress conceptualized on these dimensions before providing an integrated conceptualization. Because of the low distress level for Sabrina and the possible ego-syntonic type of distress, Dr. McNeill encouraged Nahal to consider the possibility of an Axis II diagnosis. At this point, we turn to a recorded session of the client to confirm or disconfirm our hypotheses. In summary, Dr. McNeill’s supervision of Nahal in the session described in this chapter represents his work with a Level 2 advanced trainee with typical interventions and the appropriate supervision environment. Had he been working with a Level 1, Level 3, or Level 3i supervisee, the super­ vision environment and types of interventions would have varied accordingly because such adaptations to trainee level are the heart of the IDM.

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ommon issues that supervisors encounter across various approaches to clinical supervision include dealing with “difficult” and/or impaired trainees; such issues can create conflicts or ruptures in the supervisory relationship. Other issues faced by supervisors include power and evaluation, especially as they relate to the provision of negative feedback, and navigation through difficult dialogues regarding multicultural, legal, and ethical issues. Our intent in this chapter is to examine these issues and how we deal with them within the context of the integrative developmental model (IDM).

DIFFICULT ISSUES IN SUPERVISION Of course, all human relationships/dyads at times may be characterized by conflict. The supervisory relationship is no exception. Such conflict can take the form of supervisor and/or supervisee defensiveness, resistance,

http://dx.doi.org/10.1037/14858-006 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

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differing personality styles, impairment, and skills deficits. There is an increasing amount of literature on what recently has been characterized as the “difficult” trainee (e.g., Falender & Collins, 2004; Forrest & Campbell, 2012). Although we do not want to discount the existence of difficult trainees (and we all likely have encountered some), as we have noted, the IDM conceptualizes conflict as a normal process of counselor development, with certain types of conflict (e.g., dependency–autonomy) varying across developmental levels. Consequently, we believe that a well-qualified (i.e., trained) supervisor who has conducted an accurate assessment of his or her trainee, provided the appropriate supervision environment with ongoing feedback, and attended to the supervisory relationship can greatly reduce the potential for conflict. However, some situations provide challenges to supervisors. For example, with beginning trainees, the overriding concern is client welfare, so supervisees may need to implement supervisor recommendations via prescriptive interventions. This type of intervention may be a challenge for supervisors who are uncomfortable providing direct advice that might be construed as negative by the supervisee. However, keep in mind that the Level 1 trainee is looking to you as the expert for advice and does not have the clinical exposure or experience across domains of practice. It is especially important to provide a concrete example of and model the “right” way to intervene for a beginner. At Levels 2 and 3, supervisors want to engage supervisees in a dialogue more congruent with their abilities, using more process interventions via conceptual or catalytic interventions as advanced trainees demonstrate the self-awareness necessary to engage with and appreciate these types of conversations. Worthen and McNeill’s (1996) phenomenological study provided some data and direction relevant to these suggestions from the perspective of supervisees. In that study, the authors asked intermediate and advanced trainees to describe the process of “good supervision.” Results indicated that intermediate trainees (advanced practicum) experienced a fragile and fluctuating level of confidence and a generalized state of disillusionment and demoralization regarding their ability to provide therapeutic interventions. In addition, they were anxious and sensitive to 104

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supervisor evaluation. Trainees felt their anxiety level decreased when supervisors helped to “normalize” their struggles as part of their ongoing development. They also characterized the optimal supervisory relationship as one experienced as empathic, nonjudgmental, and validating, with the supervisor providing encouragement to explore and experiment. These conditions appeared to set the stage for a nondefensive analysis as the trainees’ confidence strengthened. Participants also reported an increased perception of therapeutic complexity, an expanded ability for therapeutic conceptualizing and intervening, a positive anticipation for reengaging in previously encountered difficulties and issues with which they had struggled, and a strengthening of the supervisory alliance. Worthen and McNeill (1996) also found that intern-level trainees exhibited a basic sense of confidence and autonomy, and inadequacies were identified as domain specific. As a result of increased levels of insight and self-awareness, these trainees not only displayed openness, but also preferred to further acknowledge and confront issues of transference– countertransference, therapy-supervision overlap, and parallel processes in supervisory and client relationships. They also reported previous unrewarding supervision experience, perhaps resulting in an aversion to overt evaluation and a strong desire for more rewarding supervision. In common with less-experienced trainees, the interns viewed good super­ vision as being characterized by an empathic, nonjudgmental relationship with encouragement to experiment and explore, and they were pleased when their struggles were normalized. As a result, positive outcomes of good supervision events were similar to those of their less-experienced peers. In addition, their confidence was affirmed, and they reported an increased impetus for refining a professional identity. These types of experiences in supervision often represent a “critical incident” related to turning a conflictual situation into a productive learning experience. Using qualitative methodologies, Nelson, Barnes, Evans, and Triggiano (2008) and Grant, Schofield, and Crawford (2012) explored experienced supervisors’ perspectives and how conflict was managed within the context of the supervisory relationship. These expert supervisors reported engaging in a variety of facilitative behaviors, including naming 105

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the difficulty, validating and normalizing, processing the conflict, being attuned to the developmental and relational needs of the supervisee, providing support, anticipating potential difficulties, exploring the parallel process, facilitating reflectivity in both the supervisor and supervisee, and seeking supervision/consultation on supervision. These empirical findings have important implications for dealing with conflict, especially around issues of power, evaluation, and negative feedback. Our overarching recommendations in dealing with these issues are to step back and reflect on the following: Your assessment of the developmental level of your trainee. Has it changed over time? Do you need to reassess? 77 Are you providing the appropriate and facilitative supervision environment for the level of your trainee? What modifications do you need to make? 77 What is the current state of the supervisory relationship? Take charge and responsibility to examine your relationship with your supervisee because trainees lack the power to initiate such discussions. 77 Is there an overriding concern regarding client welfare? 77

MULTICULTURAL ISSUES As presented in Chapter 2, we monitor development across the domain of individual differences related to an understanding of gender, ethnicity, socioeconomic status, and cultural influences on individuals. This domain is especially relevant because evidence-based psychology practice “involves consideration of the client’s values, religious beliefs, world views, goals, and preferences for treatment with the psychologist’s experiences and understanding of the available research” (American Psychological Association [APA], 2006, p. 278). This includes individual client characteristics, such as gender, gender identity, culture, ethnicity, race, age, family context, religious beliefs, and sexual orientation, as well as the impact of these variables on the treatment process, relationship, and outcome (APA, 2000, 2002b). As Stoltenberg and McNeill (2010) noted, most training programs include course work on the counseling 106

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issues of diverse populations, along with the infusion of diversity issues across courses. Although Level 1 trainees are often increasingly exposed to these issues as their training progresses, their own cultural backgrounds may serve as the “ground” on which a given client is viewed as the “figure.” Many trainees, even with today’s strong emphasis on multicultural issues, may assume that they share a similar worldview with most of their clients, not acknowledging the importance of differences in background, culture, gender, sexual orientation, or physical or mental abilities, and so on. On the other hand, trainees are often highly motivated to learn about other cultures, genders, people with disabilities, and other important individual differences. In therapy, however, these therapists may see themselves as having little or nothing in common with clients from different backgrounds or life circumstances, which can make therapy appear to be an overwhelming task. They may attempt to use what they have learned in multicultural courses and apply fairly rigid, although often positive, stereotypes to their clients. Gradual exposure to more diverse client types in both individual client assignment and group case conferences helps to appropriately challenge this rigidity. For example, Inman and Kreider (2013) provided an excellent illustration of multicultural competent supervision via the discussion of multiple identities and critical events in a Level 1 trainee. In terms of awareness of issues surrounding lifestyle, gender, socioeconomic status, and culture or ethnicity, Level 2 supervisees are typically more willing to acknowledge the influence of sociocultural and environmental variables on behavior and the limitations of conventional counseling modalities for working with diverse clientele. However, they are still vacillating between general culture-specific characteristics they believe apply to all individual members of various groups and the idea that every client is so unique that defining cultural values, attitudes, and behaviors may be ignored. As a manifestation of this confusion, they may apply new information garnered from other training experiences (e.g., in-service training, workshops, course work) in a rigid and stereotypical fashion. 107

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Alternatively, despite their attempts to understand diverse clientele, Level 2 therapists may be overwhelmed with what they perceive to be yet another dimension of behavior they need to understand and integrate into their work. Thus, they may believe that differences between cultural groups are so vast they are incapable of understanding the experience of a client with a background different from their own. Lopez and colleagues (1989) provided a useful conceptualization of development in this domain and suggested that therapists at this level feel “over-burdened” by issues of culture or individual differences as an extension of the search for culture-specific or ethnic components. This burden is a necessary step that is characteristic of the Level 2 supervisee’s struggle with confusion and ambivalence. However, it is within this domain that some of the most crucial and productive work of Level 2 is done. Although the therapist may be confused and vacillating, he or she simultaneously has greater openness and interest in learning about other groups and exhibits a genuine attempt to understand the varieties of human experience and the effects on the counseling process. Thus, it becomes crucial for supervisors to strike while the iron is hot. Supervisors must encourage the attempts of Level 2 supervisees to understand and intervene to resolve conflicts and increase knowledge in this important domain. If previous supervised practice has effectively attended to this important domain of individual differences, the Level 3 therapist has developed an understanding of the influences of culture, gender, sexual orientation, and environment on the individual. Stereotypic thinking has been replaced with a breadth of knowledge regarding how various factors can affect the behavior and development of the individual client. Knowing patterns of value structures and traditions for various cultures and differences that can occur between genders in terms of biological and social factors enables this therapist to understand how circumstances or contexts serve as modifiers for diagnosis and treatment. In addition, therapists at this stage of development entertain more than one interpretation of clients’ observed behavior and collect clinical data to test their cultural hypotheses (Lopez et al., 1989). If a Level 3 therapist is struggling in this domain, his or her level of self-awareness is high such that any concerns 108

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will be openly discussed with his or her supervisors and attended to in a growth-seeking manner.

SUPERVISORY RELATIONSHIPS WITH DIVERSE THERAPISTS In our recent reviews (Stoltenberg & McNeill, 2010, 2012) of the increasingly growing literature regarding multicultural issues within the supervision environment, we were pleased to see recent research and theory in areas of bilingual supervision (Verdinelli & Biever, 2009), mentoring of culturally diverse trainees (Alvarez, Blume, Cervantes, & Thomas, 2009), and multicultural competency enhancement (Ober, Granello, & Henfield, 2009). Moreover, findings revealed that when receiving culturally responsive supervision, trainees of all backgrounds feel supported. Such support positively affects the supervisee, the supervisory relationship, and client outcomes and leads to satisfaction with supervision for majority and minority trainees (Gomez, 2003; Inman, 2006). However, in our reviews, we also noted that culturally diverse therapists are often faced with struggles to assert their unique needs and make others aware of the multicultural implications of course material, counseling theories, and interventions, especially in response to notions of color blindness in psychological intervention and assessment. It appears that many culturally diverse therapists experience varying degrees of discrimination, isolation, racism, and differential treatment, resulting in feelings of confusion, anger, outrage, and discouragement. These therapists also may or may not choose to disclose these experiences and feelings, and program faculty, directors of training, and clinical supervisors may remain unaware of the problem. For example, Burkard et al. (2006) found that culturally diverse trainees experienced more incidences of “culturally unresponsive” supervision in which cultural issues were ignored, actively discounted, or dismissed by supervisors, with adverse consequences for the supervisee, the supervisory relationship, and/or client outcomes, than did their European American counterparts. In addition, an investigation by Constantine and Sue (2007) indicated that culturally diverse trainees, in this case African Americans, continue to 109

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experience racial microaggressions from White supervisors, who make invalidating racial–cultural statements and stereotypic assumptions about Black clients and Black supervisees and offer culturally insensitive treatment recommendations that have detrimental effects on the trainee and supervisory relationship. Given some of the continuing experiences of culturally diverse supervisees, much work is needed. This is particularly salient within the context of training and supervision. Specifically, although we believe that program advisers, directors, or mentors could serve this role in their relationships with culturally diverse students, it seems that the intensive, interpersonally focused nature of the supervisory relationship lends itself well to the personal developmental issues of the ethnic minority supervisee. It is extremely important to acknowledge that supervisees lack power in relationships with supervisors. As a result, they may be reluctant to express their feelings in relation to issues of race, culture, gender, and lifestyle. For supervisors, such discussions may be unfamiliar and uncomfortable and therefore avoided. Supervisors may also view these issues as personal in nature and outside the traditional purview of clinical supervision, which attends only to client issues and concerns. Thus, to address diverse therapists’ needs, it is incumbent on supervisors to take responsibility for creating a supervisory relationship and environment in which these needs and issues are viewed as relevant to supervisees’ personal and professional development and openly dealt with and met. We are pleased to see that the literature appears to reflect a growing consensus regarding the responsibility of the supervisor in initiating such potentially difficult dialogues with diverse trainees (e.g., Bernard & Goodyear, 2014; Gatmon et al., 2001; Pfohl, 2004), along with the effectiveness of supervisor interventions related to multicultural competence (Soheilian, Inman, Klinger, Isenberg, & Kulp, 2014). We believe that in most circumstances, supervisors who are simply willing to listen are able to create a conducive environment because supervisees desire a confidential outlet to express their feelings and perceptions.

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In other scenarios, the supervisor may need to advocate on the part of the supervisee to address blatant examples of discrimination or negative acts of prejudice that exist within academic departments or work settings. To provide this relationship, supervisors must be knowledgeable about traditional counseling models, recognizing the Eurocentric influence on these models, and multicultural theory, competencies, and interventions, as well as competencies related to multicultural clinical supervision (Falender, Burnes, & Ellis, 2013). The case discussion provided in Chapter 4 demonstrates the complexities of these considerations in the supervisory session with Nahal.

LEGAL AND ETHICAL CONSIDERATIONS Professional ethics is one of the most important of the eight domains. We are particularly concerned with how professional ethics and standards of practice intertwine with personal ethics in the development of the therapist, thus affecting all of the work performed by trainees. Level 1 therapists, although aware of relevant ethical codes and standards of practice, will not have had the experience required to integrate professional ethics with personal and professional values and identity. Consequently, we cannot emphasize enough the responsibility of the supervisor to be constantly vigilant, via monitoring of client sessions, case notes, and so forth, for potential ethical conflicts that may arise. This needs to be done in conjunction with introducing relevant guidelines to trainees and encouraging them to report potential ethical issues in their work with clients. As Stoltenberg and McNeill (2010) and others (e.g., Saccuzzo, 2002) pointed out, the supervisor can be held legally responsible for anything done or not done by the supervisee, whether or not the supervisor has any knowledge of this commission or omission. This consideration also applies from ethical and client welfare perspectives. In her excellent book The Ethics of Supervision and Consultation, Thomas (2010) addressed ethical considerations across developmental levels via the IDM through illustrative case studies and discussion. She

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noted that for Level 1 trainees, their limited experience and anxiety make them particularly vulnerable to naïve mistakes and not knowing what to ask their supervisors regarding ethical conflicts. Moreover, supervisors may be gratified by the deference, admiration, and dependency of Level 1 trainees, thereby unconsciously reinforcing dependency and discouraging professional growth. Here, close monitoring is recommended. Level 2 trainees who come to overidentify with their clients’ perspectives may place more emphasis on client welfare in situations in which client and therapist/supervisor welfare may be stake. At times, they may view ethical standards as limitations imposed on practice that may be violated and justified by exceptions to the rule, and they may challenge the supervisor regarding the “rules.” The challenge in working with Level 2 trainees is to provide some autonomy in ethical decisionmaking while continuing to closely monitor for potential ethical and legal issues and considerations. As Thomas (2010) pointed out, supervisors of Level 2 trainees must be able to withstand challenges from the supervisee. “Fear of or discomfort with conflict or with the supervisee’s dissatisfaction or disappointment may result in a supervisor becoming over accommodating with supervisees, ignoring questionable behavior, or capitulating to supervisee resistance to monitoring” (p. 86). Similarly, Level 2 trainees may have difficulties establishing boundaries within the context of client relationships, and supervisor attempts to require or model boundaries may be mistaken by a Level 2 supervisee as a lack of empathy. Thomas (2010) also noted that the Level 2 supervisees’ tendencies to overidentify with and overaccommodate clients lead to ambiguous boundaries between their personal and professional lives and their own issues and their clients’ problems, which can cause supervisees to feel overwhelmed or emotionally exhausted. As a way to cope, the desire to debrief (inappropriately) with a spouse or friend becomes strong. We agree with Thomas’ recommendation that supervisors stay vigilant for such reactions and emphasize to supervisees that the appropriate place to debrief and process reactions is in group or individual supervision, 112

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which must be provided; supervisors also must encourage appropriate self-care. Chapter 4 highlights some of these issues as supervisee Nahal successfully negotiates supervisor challenges in the domain of professional ethics. Level 3 therapists have gradually acquired a thorough knowledge and complex understanding of ethical guidelines and decision-making to guide their work and know when to consult when faced with new or unfamiliar situations. This understanding reflects a broad perspective on the rights of individuals and the responsibility of the profession. Thomas addresses a possible exception to this rule: a supervisee develops a clinical blind spot, resulting in compromised objectivity or effectiveness. Such a blind spot must be addressed by supervisors. Finally, Stoltenberg and McNeill (2010) noted that, in too many instances, justifications are made for violations of ethical principles on the grounds that a supervisor or faculty member committed the same act (e.g., by engaging in dual/multiple role relationships). Ladany, LehrmanWaterman, Molinaro, and Wolgast (1999) examined the prevalence of supervisor ethical violations through the eyes of their supervisees, with 51% of trainees reporting having experienced at least one ethical violation by their supervisor, with 6% of the violations involving dual role conflicts, such as attempting to befriend the supervisee, and 8% concerning lack of modeling ethical behavior and responding to ethical concerns. In reviewing the literature on the effects of ethical breaches on supervisees, Goodyear and Rodolfa (2012) noted the variety of damage that can occur to the supervisee, supervisor–supervisee relationships, and the supervisees’ evolving understanding of ethical behavior. Goodyear and Rodolfa also cited multicultural competence and supervisee monitoring and evaluation as particular areas of ethical concern in supervision. We can only hope that future surveys of ethical behaviors related to supervision will reflect the positive effects of increased supervisor training. Consequently, we continue to caution supervisors to be extremely aware that their behavior serves as a model for all levels of supervisees and an essential quality of effective supervisors (Barnett, Cornish, Goodyear, & Lichtenberg, 2007). 113

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CONCLUSION In summary, common concerns in applying the IDM in supervision encompass a variety of training issues, including conflict, evaluation, multicultural concerns, and ethical considerations, that often intersect, resulting in complexities that require thoughtful negotiation and intervention. Our approach in most situations is to view these difficult issues as part of the normal process of therapist development. They also represent the everyday tasks and work, with challenges and opportunities, that supervisors perform in the mentoring process to positively contribute to the rewarding journey of trainees becoming master therapists.

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6

Research/Support for the Integrative Developmental Model and Future Directions

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n examining research support for the integrative developmental model (IDM), we believe it is important to consider the empirical support, via recent reviews of the literature, and influence of developmental conceptualizations on contemporary thinking and practical application in the field of clinical supervision and training. At the same time, it is important for the refinement and evolution of the IDM that we point out the limitations of what is known and make recommendations for future research related to our model. That is our intention in this chapter.

EMPIRICAL EVIDENCE AND IMPACT Early work on developmental models of supervision was reviewed by Worthington (1987), and later by Stoltenberg, McNeill, and Crethar (1994), who reached similar conclusions—that there is support for general developmental models. “Specifically, perceptions of supervisors and http://dx.doi.org/10.1037/14858-007 Supervision Essentials for the Integrative Developmental Model, by B. W. McNeill and C. D. Stoltenberg Copyright © 2016 by the American Psychological Association. All rights reserved.

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supervisees are consistent with developmental theories, the behavior of supervisors changes as counselors gain experience, and the supervision relationship changes as counselors gain experience” (Stoltenberg et al., 1994, p. 419). Other reviews of the supervision literature (Ellis & Ladany, 1997; Ellis, Ladany, Krengel, & Schult, 1996) observed that there are problems with the methodology of the studies and that the IDM has not yet been adequately investigated. However, we need to consider that most models of supervision, including common psychotherapy-based conceptualizations, have generated little, if any, empirical investigation and/or support. Based on the number of empirical studies on IDM and therapist development, we maintain that the IDM is the most investigated model of supervision with the most support to date (Inman & Ladany, 2008). Consistent with developmental approaches to supervision, studies indicate that supervisees of different levels of professional development require different approaches to supervision that enhance their learning and growth (Stoltenberg & McNeill, 2012). Inman and Ladany (2008) summarized this literature as indicating that beginning supervisees require more structured supervision, which often includes more specific instruction and the supervisor assuming most responsibility for the process of supervision, than do advanced supervisees. Moreover, as supervisees develop, their ability to engage in productive reflection and cognitive complexity increases. Thus, supervision should vary with the developmental level of the supervisee. However, research findings are not totally consistent. For example, not all investigations have been supportive of matching supervision environment to supervisee level (Ladany, Walker, & Melincoff, 2001; Sumerel & Borders, 1996). Other studies have indicated that additional factors, such as supervisee reactance potential and crisis situations (Tracey, Ellickson, & Sherry, 1989), familiarity of the supervisee with particular client issues (child abuse; Leach, Stoltenberg, McNeill, & Eichenfield, 1997), and severity of individual cases (Zarski, Sand-Pringle, Pannell, & Lindon, 1995), may override supervisee developmental level considerations regarding what supervision environment supervisees prefer. Stoltenberg and colleagues (Stoltenberg & Delworth, 1987; Stoltenberg & McNeill, 2010; Stoltenberg, McNeill, & Delworth, 1998) suggested that supervisee developmental level and needs and the associated facilitative supervision environments vary by domain and 116

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may require differing supervision environments for various client issues within a given supervision session. Thus, more advanced supervisees may reflect a breadth of professional development across domains and consequently may require different supervision environments at different points in time, depending on the focus in supervision. Stoltenberg (2008) described a supervision case study that exemplifies this effect. The trainee had considerable experience working with individual clients and was functioning solidly at Level 2 with most of his current client load (mostly striving for autonomy, assuming responsibility, etc.). However, when a couple was assigned to him, he came to supervision asking for prescriptive input and wanted didactic instruction, clearly showing Level 1 characteristics for a modality with which he had limited experience. Similar qualities were noticed in a qualitative study on the IDM extending over an academic year (Ashby, Stoltenberg, & Kleine, 2010). The salient fact is that for supervisees, the level of skills across different domains of practice was affected by context and varied somewhat by developmental level. For the more advanced trainees in this study, their expectations for supervision (degree of structure, instruction, confidence, etc.) occasionally vacillated between desiring the structure of Level 1 and the relative autonomy of Level 2, depending on the difficulty of client and/or modality of treatment, whereas less experienced trainees were less variable in their needs and behavior. Most recently, Bernard and Goodyear (2014) generated a number of conclusions based on the research to date regarding developmental conceptualizations of the supervision process. For example, they suggested that supervised experience results in developmental advances for trainees. Experience level typically is paired with certain developmental characteristics, including increases in self-awareness, consistency in the execution of counseling interventions, and autonomy. Perhaps most importantly, Bernard and Goodyear concluded that appropriate supervisor interventions are required for growth to occur. Consequently, we see the influence of developmental approaches in the design of practicum competencies for the American Psychological Association (APA) in terms of “the value of developmentally informed and sequenced education and training” (Hatcher & Lassiter, 2007, p. 51), and stages of professional development for competency benchmarks (Fouad et al., 2009). Most recently, the 117

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Guidelines for Clinical Supervision in Health Service Psychology (APA, 2014) acknowledged that supervision “uses a developmental and strengths based approach” (p. 35), addresses “considerations of developmental level of the trainee” (p. 36) in regard to training and competence as a supervisor, and accounts for supervisee developmental level in providing feedback.

FUTURE DIRECTIONS We recently reviewed the current literature in the area of clinical supervision and training (Stoltenberg and McNeill, 2012) and concluded that although much has been accomplished, more work is needed in research and responding to challenges in the practice of supervision as well as other models. Consequently, we recommend the following. First, consistent with emerging work on competencies benchmarks, examining issues for particular levels of supervisee development is important (Stoltenberg &McNeill, 2010). For instance, how do various characteristics, components, and factors influence the learning process for supervisees at different junctures in their professional growth? What are domain-by-domain idiosyncrasies? It is important to carefully operationalize these competencies for various training environments and understand the impact of attending to and evaluating these competencies for clinical supervision. Thus, the question to ask is, “Does engaging in this process produce greater professional development than current supervision-asusual approaches” (Stoltenberg & McNeill, 2012). Second, longitudinal studies are needed to understand challenges and experiences associated with the IDM. Specifically, how does the timelimited nature of specific supervision relationships influence trainee learning and development? What challenges occur across supervision relationships? How does the focus on a particular domain in prior supervision dyads affect the focus and learning in subsequent dyads and across training experiences (from entry to graduate school to advanced professional status)? Third, consistent with new Guidelines for Clinical Supervision in Health Service Psychology (APA, 2014), we and others (e.g., Watkins, 2012) have emphasized the practice of clinical supervision as a distinct domain of 118

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professional practice that requires specialized training. In terms of training required to become a competent supervisor, Stoltenberg and McNeill (2010) devoted a full chapter to supervisor training from a domain-specific, developmental perspective, noting that the process of supervision increasingly has become recognized as the most crucial activity associated with training programs, as evidenced by the role that supervised training plays in establishing therapeutic competence. In reviewing the recent literature on supervisor development, Inman et al. (2014) concluded that there is some evidence for general support of supervisor developmental models with participants transitioning from a sense of role ambiguity to a sense of confidence and competence. In addition, Scott, Ingram, Vitanza, and Smith (2000) reported that counseling psychology programs are more likely to offer training and courses in supervision than are clinical psychology programs, despite the APA’s (2002a) Committee on Accreditation inclusion of and guidelines for training in this area. Although we hope that more recent surveys might reflect more widespread training in supervision, in our experience it is all too common to encounter predoctoral interns and recent postdegree practitioners who lack the basics of formal course work comprising conceptual/ didactic training and experiential training via supervision practica before providing clinical supervision to trainees. In other words, it appears that much training in supervision in accredited programs is provided via brief seminars or workshops, often subsumed under general practicum course structures. Such circumvention of training in supervision does not allow aspiring supervisors the time or exposure to develop an adequate knowledge base or acquire the necessary skills. We emphasize that training to be a competent supervisor should include individual and group “supervision of supervision,” in which recordings of supervisory sessions are reviewed and evaluated. Such training is important because research indicates that, similar to other domains of development, experience in conducting supervision alone doesn’t appear to influence supervisor development (Stevens, Goodyear, & Robertson, 1998). Both experience and training are needed to enhance a supervisor’s sense of self-efficacy in the supervision process, which has been found to result in a more supportive and less critical or dogmatic approach. Our hope is that 119

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adoption of the APA Guidelines for Clinical Supervision in Health Service Psychology will not only increase the awareness of training program personnel and site visitors of the importance of supervisor training but also stimulate research on supervisor developmental models and the types of training experiences that contribute to supervisors being effective. Fourth, we and others have identified the supervisory alliance as foundational to the supervisory relationship. How are all of the factors affected by individual characteristics of the supervisor and supervisee, including issues of diversity, cultural influences, and personal growth and adjustment? Such research concerning the nature of the supervisory relationship will provide much-needed, nuanced information for those of us who emphasize the primacy of the supervisory alliance as analogous to the psychotherapeutic alliance. Fifth, authors (Morgan & Sprenkle, 2007; Norcross & Halgin, 1997) have highlighted common factors across supervision models that contribute to supervision outcomes. For instance, Lampropoulos (2002) noted the following common factors: the supervisory relationship (“real” relationship, working alliance, transference/countertransference); support and relief from tension, anxiety, and distress; instillation of hope and raising of expectations; self-exploration, awareness, and insight; theoretical rationale and ritual for supervision; exposure and confrontation of problems; acquisition and testing of new learning; and mastery of the new knowledge. To this list, we add the supervisory domain-specific factors, such as supervisee development and supervisor training, for consideration. The work undertaken on common factors in psychotherapy has stimulated considerable discussion and debate. Is the search for common factors in supervision a productive path toward understanding and optimizing the supervision process? In summary, we believe that the IDM has withstood the test of time in terms of heuristic value and empirical support. However, many areas of research still need to be addressed in more detail, especially when we view our overriding task to be producing effective therapists. Despite these challenges and needs for more research in a variety of areas, we view the theory and practice of supervision from a developmental point of view as one of considerable strength. It is our hope that this volume provides useful information for clinical supervisors, supervisees, and researchers. 120

Appendix A: Case Conceptualization Format1

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his format is intended to help the therapist collect and integrate information relevant to case conceptualization, diagnosis, and treatment. It is not intended to serve as a concise summary of client attributes and treatment data but rather to organize a breadth of information and stimulate understanding and decision-making.  1. Clinic Data:  1) Therapist name   2)  Status (1st practicum, intern, staff, etc.)   3)  Agency/clinic site   4)  Number of sessions with client   5)  Type of sessions (individual, group, marital, family)  2. Client Demographic Data:   1)  Name (initials or altered name for confidentiality)   2)  Date of birth/age  3) Sex  4) Ethnicity  5) Marital status   6)  Children (in and out of home, ages, sex)

 From IDM Supervision: An Integrative Developmental Model for Supervising Counselors and Therapists (3rd ed., pp. 267–270), by C. D. Stoltenberg and B. W. McNeill, New York, NY: Routledge. Copyright 2010 by Routledge. Reprinted with permission.

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appendix a

 7) Living situation a) house, apartment . . . b) people living in the home and relationship to client  3. SES Data:  1) Occupational status a) client b) family members   2)  Average family monthly income   3)  Transportation status (drives own car, public transport)   4) Other economic resources (own house, savings, family support . . . )   5)  Economic stressors (debts, child support . . . )  4.  Presenting Problem(s): This section should include a description of the problem areas (listed separately)  from the client’s perspective, particularly noting the client’s view of their order of importance. Suggested items to focus on include:   1)  Were there precipitating factors?   2)  How long have problems persisted?   3) Have problems previously occurred? What were the circumstances?   4)  In what way, if any, do the problems relate to each other?  5. Relevant History: This section will vary in comprehensiveness according to depth and length of treatment and will vary in focus according to theoretical orientation and the specific nature of the problems. Suggested foci include:   1)  Family and relationship history a) Family of origin/developmental issues b) Past marriages/significant relationships (duration, sexual functioning, dissolution factors, sexual preference . . . ) c) Children (from current and prior relationships and current status) d) Current family status and structure   2)  Cultural history and identity a) Issues of ethnicity and race b) Identification/acculturation  3) Educational history a) Childhood/developmental b) Adulthood/current status 122

appendix a

 4) Vocational history (types, stability, satisfaction . . . )   5) Medical history (acute/chronic illness, hospitalizations, surgeries, major patterns of illness in family, accidents, injuries, with whom/ where/how often receive medical care . . . )   6) Health practices (sleeping, eating patterns, tobacco use, exercise . . . )   7) Mental health history (prior problems, symptoms, diagnoses, evaluations, therapy experiences, past prescribed medications, current and family of origin mental health histories)   8) Current medications (doses, purposes, physician, compliance, effects, side effects . . . )   9) Legal history (arrests, DUIs, jail/prison, lawsuits, any pending legal actions) 10) Use/abuse of alcohol or drugs (prescription or illegal). Family (current and origin)  alcohol/drug history.  6.  Interpersonal Factors: This section should include a description of the client’s orientation toward others in his or her environment, including:   1)  Manner of dress  2) Physical appearance  3) General self-presentation   4) Nature of typical relationships (dependent, submissive, aggressive, dominant, withdrawing . . . )   5)  Behavior toward therapist (therapeutic alliance . . . )  7. Environmental Factors:   1) Elements in the environment, not mentioned, that function as stressors to the client; those centrally related to the presenting problems and more peripheral   2) Elements in the environment, not previously mentioned, that function as support for the client (friends, family, recreational activities . . . )  8. Personality Dynamics:   1) Cognitive factors: This section will include any data relevant to thinking and mental processes, such as: a) Intelligence b) Mental alertness c) Persistence of negative cognitions 123

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d) Positive cognitions e) Nature and content of fantasy life f) Level of insight (awareness of changes in feelings, behavior, reactions of others, understanding of the interplay . . . ) g) Capacity for judgment (ability to make decisions and carry out practical affairs of daily living)  2) Emotional factors: a) Typical or most common emotional states b) Predominant mood during interviews c) Appropriateness of affect d) Range of emotions client can display e) Cyclical aspects of client’s emotional life  3) Behavioral factors: a) Psychosomatic symptoms b) Existence of problematic habits or mannerisms  9. Testing: Present both past and recent testing.   1)  Methods or instruments   2)  Evaluator, location, dates, reasons for testing  3) Results 10.  Life Transition/Adaptation Skills:   1) Coping skills: Concrete efforts to deal with distressing situations (e.g., anticipation, preparation, response)   2) Social resources: Summary of supportive social networks   3) Psychological resources: Adaptive personality characteristics (e.g., self-efficacy, hardiness, optimism) 11. Formal Diagnosis: ICD–10 or DSM–5 diagnosis, checklist of symptoms/criteria showing how client meets diagnostic criteria. 12. Therapist’s Conceptualization of the Case: This section will include a summary of the therapist’s view of the problems and their effects on the client. Include only the most central and core dynamics of the client’s personality, relationships, and environmental influences. Note the interrelationships among the major factors. What are the common themes? What ties it all together? This is a synthesis of all the relevant data and the essence of the therapist’s understanding of the client. 124

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13. Treatment Plan: Based on the above information, describe the treatment plan you will follow to address the presenting and emerging problems. Make it consistent with the theoretical orientation utilized and available empirical evidence. Estimate the number and types of sessions needed to address the issues. 14.  Questions/Issues: Note the questions you have regarding this case and any issues you would like to address during the case conference.

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Appendix B: Supervisee Information Form for Nahal Supervisee Information Form This form can be used to collect relevant background information from supervisees for decision making in practicum, internship, and postdegree supervision. This information helps the supervisor to make an initial assessment of the developmental level of the supervisee. Date: 09/02/14 Name: Nahal Kaivan Educational status (for example, year in program, years past degree, and so on): MA Psychology, Currently a 3rd year doctoral student in Washington State University’s Counseling Psychology Doctoral Program. Ethnicity: Iranian American Highest degree earned: M.A. Psychology Hours of individual counseling or psychotherapy experience: 500 Over how many years? over 4 years Hours of group counseling or psychotherapy experience: