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Center for Substance Abuse Treatment. Clinical Supervision and Professional Development of the Substance Abuse Counselor. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 52.)

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Clinical Supervision and Professional Development of the Substance Abuse Counselor.

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Part 2, Chapter 1, Clinical Supervision and Professional Development of the Substance Abuse Counselor: A Guide for Administrators

Clinical supervision should be an essential part of all substance abuse treatment programs. Every counselor, regardless of skill level and experience, needs and has a right to supervision. In addition, supervisors need and have a right to their own clinical supervision. For more on the essential nature of clinical supervision, see Appendix B, New York State Office of Alcoholism and Substance Abuse Services Clinical Supervision Statement. Unfortunately, many agencies place a higher priority on administrative tasks (such as case recordkeeping and crisis management), than on clinical supervision. This guide for administrators will assist in developing a rationale for and designing a clinical supervision system for your substance abuse treatment organization. Part 2 provides strategies and tools for implementing effective supervision along with advice on allocating resources for best results.

Benefits and Rationale

A successful clinical supervision program begins with the support of administrators. You communicate the value, benefits, and integral role of clinical supervision in quality care, staff morale and retention, and overall professional development within the context of the organization’s mission, values, philosophy of care, and overall goals and objectives. Being able to discuss specific benefits of clinical supervision will increase the likelihood of internal support, enhance your organization’s ability to deliver quality supervision, and add marketability for funding opportunities.

Administrative Benefits

Clinical supervision enables organizations to measure the quality of services. It ensures that employees follow agency policies and procedures and comply with regulatory accreditation standards while promoting the mission, values, and goals of the organization. Supervision provides administrators with tools to evaluate job performance, maintain communication between administrators and counselors, facilitate conflict resolution, and hold personnel accountable for quality job performance. Clinical supervision is a risk-management tool that increases an organization’s ability to respond to risk, thereby reducing overall liability. It also addresses human resource issues, including staff satisfaction and retention of personnel. Finally, supervision provides marketing benefits by improving the overall reputation of the agency in the community and among other service providers.

Clinical Services Benefits

The goal of clinical supervision is to continuously improve quality client care. Supervision by trained and qualified supervisors helps staff understand and respond more effectively to all types of clinical situations and prevent clinical crises from escalating. It specifically addresses assessment, case conceptualization, treatment strategies, and discharge planning. Supervision aids in addressing the unique needs of each client. It provides a mechanism to ensure that clinical directives are followed and facilitates the implementation and improvement of evidence-based practices (EBPs). “Quality supervision will become a major factor in determining the degree to which EBPs are adopted in community settings” (CSAT, 2007, p. 12). Clinical supervision also enhances the cultural competence of an organization by consistently maintaining a multicultural perspective. “Supervision encourages supervisees to examine their views regarding culture, race, values, religion, gender, sexual orientation, and potential biases” (CSAT, 2007, p. 27).

CSAT’s Technical Assistance Publication (TAP) 21-A, Competencies for Substance Abuse Treatment Clinical Supervisors, defines supervision as a “social influence process that occurs over time in which the supervisor participates with supervisees to ensure quality care. Effective supervisors observe, mentor, coach, evaluate, inspire, and create an atmosphere that promotes self-motivation, learning, and professional development” (CSAT, 2007, p. 3). Also, supervision can improve client outcomes (Carroll, Ball, Nich, Martino, Frankforter, Farentinos, et al., 2006). Finally, supervision increases staff members’ sensitivity and responsiveness to diversity issues among staff, with clients, and between staff and clients.

Professional Development Benefits

Quality clinical supervision has been shown to increase staff retention through professional skills development and increased competency (Bernard & Goodyear, 2004). Supervision provides the forum for expanding current clinical practices, intellectual stimulation, emotional support, and improvement in critical thinking (see CSAT, 2007). Supervision is part of an organization’s career ladder, as it supports staff in obtaining and maintaining professional credentials. It also provides information and guidance about key contextual factors that may influence their work performance such as culture, lifestyles, and beliefs.

Workforce Development Benefits

Supervision by trained and qualified supervisors is an essential tool in the recruitment and retention of personnel, as counselors often rate training and development as critical factors in their selection of employment. In addition, supervision has been shown to improve staff morale and motivation by making staff feel valued and appreciated (Bernard & Goodyear, 2004). It also assists in promoting counselor wellness, and promotes the overall development of the substance abuse treatment field by upgrading the credentials, knowledge, skills, and attitudes of personnel.

Program Evaluation and Research Benefits

Implementation of program evaluation and/or research is often misunderstood by counselors and viewed as more work that is unrelated to quality client care. Supervision can mediate in this area by providing staff with the rationale for the initiative, connecting it to client outcomes, and communicating achievements and challenges to the evaluators. Clinical supervision can also provide the mechanism for data gathering and information retrieval in support of the new projects and programmatic innovations.

Key Issues for Administrators in Clinical Supervision

Administrative and Clinical Tasks of Supervisors

Supervisors wear many hats. In most organizations, the administrative and clinical supervisor is the same person (see also the section that follows, Administrative and Clinical Supervision, p. 89). Most clinical supervisors still carry a client caseload (albeit reduced somewhat from that of a line counselor), perform administrative duties, write grant proposals, serve as project managers, and supervise the clinical performance of counselors. Each role involves different expectations and goals. It is important for administrators to be aware of each of these roles and for supervisors to be prepared to perform effectively in administrative, organizational, and clinical roles.

Kadushin (1976) outlines multiple administrative tasks for a clinical supervisor: staff recruitment and selection; orientation and placement of employees; work planning and assignments; monitoring, coordinating, reviewing, and evaluating work; staff communication both up and down the chain of command; advocating for client and clinician needs; acting as a buffer between administrators and counselors; and acting as a change agent and community liaison. Munson states, “As part of their administrative responsibilities, supervisors are often required to manage program transitions and modifications. Departments and programs can be altered, restructured and merged” (1979, p. 72).

Assessing Organizational Structure and Readiness for Clinical Supervision

In implementing a clinical supervision program, an important first step will be to evaluate the agency’s preparedness to support the functions of clinical supervision by identifying the agency’s culture and organizational structure. Organizational readiness scales and attitude inventories can be helpful in the process of assessing and adopting EBPs. You need to assess the following:

  • How decisions are made within the organization (centralized versus decentralized, vertical or horizontal).
  • How authority is defined and handled (top down, bottom up, through the chain of command, or ad hoc).
  • How power is defined and handled (reward, coercion, legitimate power through status, prestige, titles, expert power through skills and experience, or referent power through respect for an individual—or all of the above).
  • How information is communicated (structured/formal/informal, on a need-to-know basis, bidirectional feedback and communication).
  • How the organizational structure influences supervisory relationships, process, and outcome.
  • The overall cultural proficiency of the organization.

The following organizational issues should be considered by an agency before a clinical supervision system is implemented:

  • Organizational context. How consistently do staff adhere to agency philosophy and culture? To what extent will clinical supervisors teach and support this philosophy?
  • Clinical competence. What specific knowledge, skills, and attitudes are expected of substance abuse counselors? What is each counselor’s baseline competence and learning style? What is the level of cultural competence of staff?
  • Motivation. How should the staff’s motivation and morale be characterized?
  • Supervisory relationships. What is the nature of relationships between administrators and front-line workers? How healthy or unhealthy are those relationships?
  • Environmental variables. To what extent do administrators expect supervisors to proactively teach ethical and professional values? Do staff have a common set of goals? How does the organization promote professional development? How is progress toward those goals monitored and supported? What is the cultural, racial, religious, gender, and sexual orientation mix of the clients served by the organization?
  • Methods and techniques. How familiar is the organization with individual, group, and peer supervision? How familiar is the organization with case progress note review, case consultation methods, direct observation, live supervision, audio- or videotaping, and role playing?

Assessing an organization’s readiness for a clinical supervision system may also include such questions as: “What stage of readiness for implementing a clinical supervision system are the board of directors, other administrative staff and clinical supervisory staff (if any), direct care staff, and support personnel? What are some of the organizational, administrative, and clinical barriers to implementing a clinical supervision system?” Potential barriers include lack of familiarity with supervision methods and techniques, the need for further training of supervisors, and lack of technical equipment such as video cameras. It is helpful to develop a timeframe for addressing the most important barriers. What would you as an administrator like to see happen and who should be part of the process for implementing clinical supervision? (See Tools 1 and 2 in chapter 2.)

Administrative and Clinical Supervision

This section is a comprehensive look at the issues facing supervisors in their dual roles. In the substance abuse treatment field, one of the major challenges facing supervision is the reality that most supervisors perform both administrative and clinical supervisory functions. The numerous conflicts and ambiguity that result from these roles can pose serious problems for administrators, supervisors, and supervisees. Determining the distinction between the roles of clinical and administrative supervision can be difficult because there are no uniform definitions of these functions. Most writing on administrative supervision is in the context of the evaluative and record-keeping functions of a supervisor.

To the extent possible, administrative supervision should be distinguished from clinical supervision. Bradley and Ladany (2001) state that administrative supervisors “help the supervisee function effectively as a part of the organization,” with an emphasis on “organizational accountability, case records, referrals, and performance evaluations” (p. 5). In contrast, clinical supervisors focus on the services received by the client, including the therapeutic relationship, assessment, interventions, and client welfare. While these tasks may be seen as substantially different, many are complementary. Therefore, you and the supervisors need to be mindful of the different roles and of the inherent ethical, relational, and role conflict issues. Best supervision practices will work to keep the dual roles as clear as possible.

Legal and Ethical Issues for Administrators

You play a vital role in clarifying legal and ethical issues for your organization, especially for clinical supervisors and counseling personnel. You are invaluable in providing information and support for supervisors and staff.

You and your supervisors need to define and document (in writing) the legal and ethical standards for the agency. You can draw from the staff’s professional codes of ethics as well as accepted best practices. All personnel should be consistently and continually trained in the agency’s legal and ethical standards, as well as in changing case law and legislation affecting clinical practice. You need to reinforce your support for supervisors who face situations where legal and ethical issues may arise. You should help supervisors develop a process for ethical decisionmaking as supervisors as well as a process for teaching ethical decisionmaking to counselors.

Among the key issues for you and your supervisors are the following:

  • Direct and vicarious liability. Important factors affecting liability include the supervisor’s power of control; the counselor’s duty to perform a clinical service; the time, place, and purpose of the service; the motivation for responding the way the counselor responded; and the supervisor’s expectations for action. Critical legal questions for administrators are: Did you make a reasonable effort to supervise? Was there any dereliction of duty? Did treatment create any harm, wrongdoing, or damage to the client, the organization, or the community? Did you and the supervisor give appropriate advice concerning the counselor’s actions? Were tasks assigned to staff that were outside their scope of competence?

Confidentiality. Has the organization adhered to all laws of confidentiality (i.e., the Health Insurance Privacy and Portability Act [HIPAA], 42 CFR, Part 2)? To what extent has the organization balanced the counselor’s and client’s right to privacy and performance review? Has the organization adhered to its duty to warn, to report, and to protect?

  • Informed consent and due process. This requires that supervisees and clients be fully informed as to the approach and procedures of the agency’s actions (see Tools 4 and 19). Have the clients and counselors been informed about treatment parameters and supervision requirements? Have all required forms and documents been read and signed by all relevant parties? Is there a fair process that encourages conflict resolution and ensures the person a process of appeals?
  • Supervisor and counselor scope of competence. Are supervisors and counselors operating within their scope of practice and competence? Are supervisors and counselors meeting minimal standards of competence regarding cultural and contextual awareness, knowledge, and skills? Are they effectively working within the wider client systems and networking appropriately with wider community services and institutions?
  • Dual relationships. A dual relationship exists when a supervisor and supervisee or counselor and client have an additional relationship outside the primary professional relationship. Guidelines for supervisory relationships prohibit supervising current or former clients (a difficult issue in the substance abuse field where it is not uncommon for an agency to hire and supervise former clients in recovery). Do any supervisors have current or former romantic or sexual partners, business associates, family members, or friends among their supervisees? Is the distinction clear between the teaching and supervisory roles when students are being supervised? Are supervisors mindful of crossing over from the supervisory relationship to social activities with supervisees that may impair objectivity? Do supervisors avoid excessive self-disclosure in supervision and avoid comments or actions that might be interpreted as sexual? Do you and your supervisors respect and recognize professional boundaries in all aspects of your relationships? When in doubt, do you consult with colleagues?

You should provide comprehensive legal and ethical orientation to all employees, review codes of ethics at the time of hire, and require employees to sign a statement that they will abide by these codes. You will want to review agency adherence to these codes periodically under the umbrella of a quality assurance or compliance program. Clinical supervisors should be proactive and provide documentation that describe and conceptualize client problems addressing potential legal and ethical dilemmas, document all clinical directives given, and offer counselors a written summary of recommendations. Finally, you should review liability insurance coverage and suggest that supervisors and counselors maintain their own personal professional liability and malpractice insurance.

For further legal and ethical issues, the reader is referred to the forms in this section.

Diversity and Cultural Competence

An important responsibility for supervisors is to continually improve their cultural competence in order to teach and support staff. Cultural competence is gained through education and training, supervised clinical work, and ongoing exposure to the population being served. All potential supervisors should be required to receive training in cultural competence. It is the supervisor’s responsibility to initiate discussions of differences in race, ethnicity, gender, religion, socioeconomic status, sexual orientation, or disability regarding both clinical work with clients and supervisory and team relationships. This promotes the acceptance of diversity and cultural issues as appropriate topics of discussion and allows the supervisor the opportunity to model culturally competent behaviors.

To appreciate the importance of cultural competence, counselors must first recognize “the power of their own cultural assumptions to influence their thinking and their interactions with others” (Bernard & Goodyear, 2004, p. 118). From there, supervisors can help supervisees understand how their own diversity variables affect their interactions with clients. Administrators should be watchful for problems that can arise in the supervisory relationship when supervisors are of a different race, culture, or ethnicity than their supervisees. Fong and Lease (1997) have identified four areas that might present challenges:

  1. Unintentional racism. Well-intentioned supervisors who are unaware of how their racial identity affects their relationships with supervisees may avoid talking about race or culture.
  2. Power dynamics. The power differential in the supervisory relationship may be exaggerated in dyads where the supervisor is part of the dominant group and the supervisee is a member of a minority group.
  3. Trust and vulnerability. Supervisees who are in a vulnerable position are, at the same time, encouraged to trust their supervisors, when they may have little reason to do so.
  4. Communication issues. Differing communication styles among cultural groups can result in misunderstandings.

An excellent exercise for you and your supervisors is to evaluate how supervisors measure up to multicultural supervision competencies. Bradley and Ladany (2001) list the following in what they term the “supervisor-focused personal development” domain:

  • “Supervisors actively explore and challenge their own biases, values, and worldview and how these relate to conducting supervision;
  • Supervisors actively explore and challenge their attitudes and biases toward diverse supervisees;
  • Supervisors are knowledgeable about their own cultural background and its influence on their attitudes, values, and behaviors;.
  • Supervisors possess knowledge about the background, experiences, worldview, and history of culturally diverse groups; and
  • Supervisors are knowledgeable about alternative helping approaches other than those based in a North American and Northern European context” (pp. 80–81).

Developing a Model for Clinical Supervision

An organization must develop a model for clinical supervision that best fits its needs. What are its underlying needs, goals, and objectives? What models are available to assist in reaching your organizational goals? The model should be selected in light of the organization’s mission, philosophy of treatment, and orientation. You need to assess the organization’s readiness for implementing a supervision system and barriers that might impede the process. What are the organization’s capacities for implementation? Once implemented, how will the program’s quality be evaluated? How will continuous quality improvement strategies be incorporated into the supervision model? And if the program is successful, how will it be sustained?

An effective model for clinical supervision will keep the target clear: ensuring that the client receives better treatment as a result of the clinical supervision system. In addition:

  • It will begin with the supervisors’ unique management or leadership style, their levels of proficiency in supervision, the organization’s philosophy about clinical supervision, and the specialized client needs for clinical services.
  • It will improve counselor competence, make work more manageable, encourage staff to stretch beyond their current capabilities, build mastery and growth, and meet the needs of the client, counselor, agency, and credentialing bodies.
  • It will encourage supervisees to grow professionally in their understanding of culture, race, religion, gender, and sexual orientation as these issues are present clinically.

Implementing a Clinical Supervision Program

TAP 21-A (CSAT, 2007) describes the importance of using a clearly articulated process for implementing a new model of clinical supervision in both State and local agency settings as follows: “If agencies are to improve their supervisory practices by adding activities identified as clinical supervision competencies, a set of guidelines is needed to support the development of an implementation plan” (p. 7). To ensure a smooth transition to the new supervision program, an agency will need to perform the following tasks: [d]efining or clarifying the rationale, purpose and methods for delivering clinical supervision; [e]nsuring that agency management fully understands and supports the changes that need to be made; [p]roviding training and support in supervisory knowledge and skill development; and [o]rienting clinicians to the new supervision rationale and procedures” (p. 7). These tasks are part of an implementation process whereby the changes are introduced over a limited period of time that allows for procedures to be developed and tested and clinicians to provide feedback and adjust to the supervisory process. “The broad goal is to create a continuous learning culture within the agency that encourages professional development, service improvement, and a quality of care that maximizes benefits to the agency’s clients” (p. 8).

More detailed guidelines for implementing and phasing a clinical supervision system into existing processes include:

  1. You need to be clear as to the organization’s goals of supervision, viewing supervision as a way of supporting and reaching the agency’s mission.
  2. You should be familiar with the skills and competencies outlined in TAP 21-A (CSAT, 2007) and other experience and/or credentialing requirements. The competence of the designated supervisors is central to the successful design and implementation of the program. In some cases, agencies will need to invest in additional training for potential clinical supervisors. Ask yourself the following about your supervisors:
    • Has the supervisor had formal training and is he or she credentialed in counseling, substance abuse, and clinical supervision?
    • At what level of supervision proficiency are the clinical supervisors?
    • Has the supervisor received supervision of his or her clinical skills?
    • What is the supervisor’s relationship with staff?
    • What is his or her level of cultural proficiency and ability to work with culturally diverse clients?
  3. It is essential that a clear statement of support from senior administration be provided both verbally and in writing to all levels of administration, counselors, and support staff. This statement should provide a rationale (see p. 95) for implementing clinical supervision. The importance of this step cannot be overemphasized.
  4. The next step in implementing a clinical supervision system is to create a Change Team from within your organization to spearhead the effort. Selecting the appropriate agency representatives to be the link between you and the supervision system will ensure internal communication and support. The Team should comprise individuals committed to quality care and the supervision process. They need to be somewhat familiar with the process of supervision and have a clinical background. Supervisors need to have a thorough understanding of the agency’s model and techniques of supervision. The Change Team leader will ensure participation and followup with the organization’s clinical supervisors. Planning specific steps to ensure sustainability of the system is integral to long-term success.
  5. You, the Change Team, and clinical supervisors should read and understand the importance of the standards outlined in TAPs 21 (CSAT, 2006) and 21-A (CSAT, 2007). Each counselor should have a copy of TAP 21 (Addiction Counseling Competencies—The Knowledge, Skills, and Attitudes of Professional Practice [CSAT, 2006]). It is important for clinical supervisors to meet with the Change Team to discuss the skills and competencies in TAP 21-A, and to identify both the organization’s strengths and areas needing improvement. The Team should draft formal policies and procedures to articulate expectations and guidelines.
  6. An all-staff meeting should feature the organization’s view of clinical supervision and how it will implement the supervision system. The formal policy and procedure should be distributed and discussed. All clinical staff involved in the system should attend this briefing, presented by the Change Team leader and key clinical supervisors.
  7. Provide necessary training, time, and funding for supervisors. Because the training requirement for credentialing as clinical supervisors is typically participation in a 30-hour class on supervision, you need to ensure that all supervisors receive training before proceeding to comprehensive implementation.
  8. If the organization is sizable or the clinical staff is large, it is sometimes helpful to initiate a pilot supervision system in selected units of the organization. This is an issue that can be addressed by the Change Team. If organizational staff are particularly resistant to implementing the supervision program, it may be helpful to demonstrate the efficacy of a quality supervision program via a pilot program.
  9. Supervisors should prioritize discussing the supervisory agreement or contract with each supervisee and invest time to determine the training needs and goals for each counselor. This is the beginning of an Individual Development Plan (IDP), outlining the counselor’s knowledge, skills, attitudes, and cultural competence. It is essential that the supervisor observe the counselor in action before rating her or his abilities. Rating scales provide the baseline from which to begin supervision. Both supervisors and counselors should develop and complete rating scales and IDPs. Dialog on areas of agreement and disagreement at the outset form a vital part of the supervision process. This discussion also provides the supervisor with an opportunity to praise staff members for their strengths.
  10. Supervisors should schedule formal, frequent, and regular individual supervisory sessions. These sessions, similar to individual sessions with clients, need to be respected and protected from unnecessary interruptions or distractions. The supervisory sessions should be documented and follow the prescribed focus outlined in the IDP.
  11. To begin direct observation, design an implementation strategy (assuming the organization has recognized the value of direct observation; see Part 1, chapter 1), and establish a weekly rotation schedule for the observation of each counselor over the next 3 months. Initially, the clinical supervisor can provide direct observation feedback to counselors individually and then move toward a group supervision model whenever practical and possible to promote team building and efficiency. To help with sustainability, the supervisor should discuss supervision at every opportunity. Staff needs to see that supervision will be conducted on a regular basis, and that frequency will be determined by the agency’s needs and those of the individual counselor and team.
  12. Provide feedback and review the IDP. Through the observation, the supervisor and counselor can discuss the strengths and challenges of the counselor’s performance. The developing IDP should outline in detail the areas for improvement and how these changes will be further observed and monitored. Learning goals evolve as continued observation leads to further suggestions for improving performance.
  13. Supervisors should document their direct observation using various forms that exist for this purpose. The documentation should include times of meetings and observation, a brief statement of the content of the clinical session observed, review procedures (audio or video tape), feedback provided, and mentoring and teaching offered.
  14. Incentive plans can be developed to encourage counselors to become seriously involved in their professional development.
  15. Create a sustainable treatment team. Over time, some staff will leave and others will join the team. It is important for you and your supervisors to work with the team to create an atmosphere of learning that supports the agency’s commitment to clinical supervision. This means including the clinical supervision policy and procedures in the orientation of new staff. It definitely means that the team will continue to meet for supervision on a regular basis.
  16. Develop a system of supervision of clinical supervisors, particularly for those who are new to their role. Supervisors need to continually build and improve their supervisory skills as well as have a forum to discuss staff challenges. Some agencies have created supervisory peer groups where the supervisors present and receive feedback on their supervision, other agencies hire a consultant to provide supervision, while some regional coalitions have established monthly forums.

Some of the primary elements in a supervision of supervisors system include:

  • Direct observation. This may best be done by periodically (e.g., once a calendar quarter) videotaping a supervision session and having the supervisor’s supervisor review the videotape. They then discuss what occurred during the supervision, with the supervisor’s supervisor providing feedback and recommendations.
  • Competencies. It is important that the supervisors of supervisors be Level 3 counselors and preferably Level 3 supervisors (see Figures 5 and 6 in Part 1, chapter 1). They need to be certified clinical supervisors and to have had supervision as supervisors themselves so they have experience with this type of supervision. Administrators should give them the responsibility and authority to perform this task and to require that tapes be provided for review in a timely fashion. Supervisors should develop the competencies sufficient to attain their credentials as a certified clinical supervisor.
  • Record-keeping system. A logging system should maintain records on the initial counselor–supervisor sessions and the supervision of supervisors sessions.
  • Recruiting personnel. If your agency does not have an internal person to provide the supervisor’s supervision, it is recommended that you contract for such services with external sources. Over time, the external supervisor should train an internal person to assume this role.

Phasing in a Clinical Supervision System

The steps below have been found to be helpful in phasing in clinical supervision systems in an orderly manner. Although the list is provided sequentially, the needs of an agency will determine the timeframe and selection of objectives.

Phase I: Organization and Creation of a Structure

  • Assess and describe the agency culture (including assets and deficits), selecting assets to build on and/or deficits for remediation regarding clinical supervision.
  • Assess the facility’s policies and procedures to determine the feasibility and practicality of a clinical supervision system (i.e., presence of clinical supervisory staff, availability of direct observation technology, etc.).
  • Examine job descriptions to determine staff scope of practice and competence.
  • Reach consensus among the Change Team about the definition of clinical supervision and its key components for that agency.
  • Publicize this consensus statement to all personnel, introducing staff to the new supervisory model and clearly communicating expectations for the delivery and outcomes of clinical supervision before program implementation.
  • With all personnel, discuss and introduce clinical supervision policies and procedures.
  • Review the organization’s cultural competence as it relates to the client populations served.
  • Develop documentation and accountability systems.

Phase II: Implementation

  • Implement a supervisory contract, including informed consent, with all staff to improve the supervisory working alliance.
  • Assess the quality of the supervisory relationship and devise interventions to strengthen the learning alliance.
  • Conduct counselor assessments to establish competency baselines.
  • Design initial supervisory goals and measurable objectives for each counselor.
  • Use strengths-based approaches where appropriate and possible in clinical supervision, supporting counselors’ positive actions with clients.
  • Develop a system of supervision of supervision. Some programs use the same taping and monitoring systems for supervisors that are used between counselors and clients, with supervisors expected to videotape their supervision sessions at least once a month, and receive supervision of their supervision by the team of supervisors and/or their supervisor.

Phase III: Establishing a Training Plan and Learning Goals

  • Complete a written IDP for each counselor.
  • Provide focused, on-the-job training.
  • Identify clinical supervision quality indicators to monitor the quality assurance program for the agency.
  • Periodically review job descriptions and evaluation procedures to ensure that counselor competencies are sound. Review the counselor’s ability to perform the TAP 21 competencies, the activities and functions performed by a substance abuse counselor that form the basis of the standards required in many States for credentialing. Also see the Northwest Frontier Addiction Technology Transfer Center Performance Rubric at http://www.nfattc.org.

Phase IV: Improving Performance

Proficiency in the Addiction Counseling Competencies (CSAT, 2006) and the International Certification and Reciprocity Consortiums 12 Core Functions should be the subject of continuous assessment and professional development during clinical supervision. Additional specific performance concerns include:

  • Continually align the clinical supervision goals to the agency’s mission, values, and approach;
  • Create risk management policies and practices and monitor adherence;
  • Address the cultural competence of personnel in supervision;
  • Consistently address a deepening of counselor knowledge, skills, and attitudes about legal and ethical issues;
  • Use formative and summative evaluation and feedback procedures to inform the clinical supervision process;
  • Develop quality improvement plans for the agency, including clinical supervisory procedures;
  • Overtly address and encourage counselor and staff wellness programs;
  • Invest in counselor and staff training; and
  • Foster your staff from within, continually seeking individuals with the potential to become tomorrow’s supervisors.

Documentation and Record Keeping

Overseeing documentation and record keeping is an essential administrative task, as maintaining a supervisory record has multiple purposes for administrators, supervisors, and counselors. One of the primary purposes of documentation is to serve as the legal record for the delivery of supervision: a reasonable effort was made to supervise. The supervisory record is also important in developing a thoughtful plan for both quality client care and professional development. The supervisory record serves to:

  • Improve client care.
  • Model good record-keeping procedures for personnel.
  • Afford and enhance ethical and legal protection.
  • Provide a reliable source of data in evaluating the competencies of counselors.
  • Provide information concerning staff ability to assess and treat clients.
  • Reflect staff understanding of the dynamics of behavior and the nature and extent of the problems treated.
  • Assess staff cultural competence and proficiency.
  • Provide information about the clinical supervisor’s ability to assess counselor competencies and the nature of the clinical supervisory relationship.
  • Provide information about the clinical supervisor’s clinical and supervisory competence.

A good clinical supervision record should include the following elements:

  • Requirements for counselor credentialing (certification/licensure) and the extent to which each counselor meets those requirements.
  • The counselor’s regularly updated resume and a brief summary of his or her background and clinical expertise.
  • A copy of the informed consent document, signed by the supervisor and the supervisee.
  • A copy of the clinical supervision contract, signed by the supervisor and the supervisee.
  • The IDP, updated minimally twice a year and preferably every 3 months.
  • A copy of the formative and summative evaluations the supervisor has given to the supervisee and all relevant updates to these evaluations.
  • A log of clinical supervision sessions, dates, times; a brief summary of key issues discussed; recommendations given by the supervisor and actions taken by the counselor; documentation of cancelled or missed sessions by either the supervisor or supervisee; and actions taken by the supervisor when supervision sessions are missed.
  • A brief summary of each supervision session, including specific examples that support learning goals and objectives.
  • A risk management review summary, including concerns about confidentiality, duty to warn situations, crises, and the recommendations of the supervisor concerning these situations.

The entire documentation record can be brief and in summary form. (See Tools 10–12 in Part 2, chapter 2, including checklists and summary statements to reduce the volume of work for the supervisor.)

Evaluation

Although training in how to conduct productive and constructive evaluations of personnel is rare, evaluation of personnel is a critical administrative task of supervisors and administrators. The goals of evaluation include, but are not limited to, reviewing job performance; assessing progress toward professional development goals; eliciting future learning goals; assessing fitness for duty and scope of competence; and providing feedback to staff on adherence to agency policies, procedures, and values.

There are a number of issues that shape the feedback process, including:

  • How does the agency define a “good” counselor? What knowledge, skills, and attitudes are critical? What level of cultural competence is needed?
  • How does a supervisor measure general affective qualities, such as counselor’s empathy, respect, genuineness, concreteness for clients?
  • What standardized tools will be used to support the evaluation? There are few evaluation instruments with psychometric validity or reliability.

The IDP can be the basis for evaluation. Each counselor should have a development plan that takes into consideration her or his counseling developmental level (see Stoltenberg, McNeill, & Delworth, 1998), learning needs and styles, job requirements, client needs, and the agency’s overall goals and objectives. A sample IDP is provided in chapter 2 (Tool 15).

How do administrators and supervisors evaluate personnel and assess job performance? There are two forms of evaluation: formative and summative. Formative evaluation focuses on progress, is regularly provided, and gives feedback to the employee regarding his or her attainment of the knowledge, skills, and attitudes necessary to the job. It addresses the question, “Are you going in the right direction?” The quality of the supervisory relationship determines the success of the formative evaluation process.

Summative evaluation is a formal process that rates employees’ overall ability to do their job and their fitness for duty. It answers the question, “Does the employee measure up?” In substance abuse counseling, summative evaluation takes into account many variables: the range and number of clients seen, the issues and problems addressed by the counselor, the general themes in training and supervision, skill development, self-awareness, how learning goals have been translated into practice, and the employee’s strengths, expertise, limitations, and areas for future development. Summative evaluation also addresses the nature of the supervisory relationship and goals for future training.

The best evaluations occur when there is open exchange of information and ideas between the supervisor and counselor, where specific examples are gleaned from the ongoing supervisory documentation, and expectations are again reviewed and agreed upon. Some organizations have moved to 360-degree assessments, with input from many layers of the organization. Tool 13 in chapter 2 is a counselor evaluation of a supervisor. The quality and quantity of feedback from a supervisor is an important part of supervision, according to supervisees (Bernard & Goodyear, 2004). Formalized feedback and evaluation is designed to review the ongoing, frequent feedback provided over time in a supervisory system (see Tool 14).

Conducting an evaluation involves exercising authority and power. When supervisors evaluate counselors, they are also evaluating themselves and their effectiveness as supervisors with particular supervisees. The evaluation process brings up many emotions for both parties. In providing feedback, supervisors should:

Provide positive, as well as constructive, feedback:

  • Differentiate between data-based and qualitative judgments about job performance.
  • State observations clearly and directly.
  • Prioritize key areas for review rather than flood the counselor with an all-inclusive review.

Supervisees prefer:

  • Clear explanations.
  • Written feedback whenever possible.
  • Feedback matched to their counseling development level.
  • Encouragement, support, and opportunities for self-evaluation.
  • Specific suggestions for change.

Feedback should be:

  • Frequent.
  • As objective as possible.
  • Consistent.
  • Credible.
  • Balanced.
  • Specific, measurable, attainable, realistic, and timely: SMART.
  • Reduced to a few main points.

Supporting Clinical Supervisors in Their Jobs

Being a supervisor in any setting is a difficult job. The supervisor represents the concerns of administrators, counselors, and clients. Supervisors advocate on behalf of those above and below them in the organization chart. Hence, it is imperative that you provide support for the clinical supervisor in the agency and in the job.

To show support for clinical supervision, review the organization’s receptivity to supervision: Is its climate for change, tolerance, and commitment conducive to efficient implementation of a clinical supervision system? Also, assess the magnitude of the proposed supervision system and the critical factors needed for success. “The agency structure and the supervisory program within it define the parameters of the supervisory relationship. Decision-making processes, autonomy within units, communication norms, and evaluative structures are all relevant to the supervisory function” (Holloway, 1995, p. 98).

To assess the organization’s receptivity to supervision, you should address the following issues:

  1. To what degree does the organization value accountability and have clear expectations of its personnel?
  2. How is supervision tied to an employee’s ongoing performance improvement plan or performance incentive program?
  3. To what extent does the organization have efficient and effective systems in place to manage day-to-day operations?
  4. To what extent does the organization view itself as a learning environment, encouraging inquisitiveness, creativity, innovation, and professional development?
  5. To what extent does the organization value upward and downward communication and relationships by creating opportunities for staff to be heard? Does the organization understand that the learning alliance and relationship is key to successful supervision?
  6. In what ways is the organization a dynamic, growing organism that values everyone’s contribution?
  7. To what extent does the organization “provide diversity training and other experiences that empower [a counselor] to become an advocate for the organization’s target population and an agent of organizational change” ? (CSAT, 2007, p. 31)
  8. How does the organization view teamwork, and what structures are in place to support the team-building process?
  9. How do lines of authority and communication operate in the organization? How do formal and informal decisionmaking processes that influence the supervisors’ functions work?
  10. To what extent do administrators know about and understand the process and practices of clinical supervision? What training do they need in this regard?
  11. What is the common ground in understanding the relationship between the administrative and clinical functions of the supervisor?
  12. If the organization does not have trained and motivated clinical supervisors, what is your plan for recruiting new supervisors and/or training current supervisors who will be able to take on this new responsibility?
  13. Are the job descriptions and roles clear, current, and accurate for all personnel?
  14. How much supervision of their supervision will the supervisors receive from administrators or other consultants?

You support clinical supervision when you help supervisors build an organizational climate in which they can do quality work. This entails the following factors:

  1. Allocating time for clinical supervision. Since supervision is not (in most cases) a revenue-generating activity, administrators may tend to minimize the importance of quality clinical supervision and fail to provide the needed time to “make a reasonable effort to supervise.” A matrix presented in Part 1, chapter 1 gives guidelines to supervisors for organizing their time and providing quality supervision.
  2. Making clinical supervision an agency priority. You can support the clinical supervisor with a clear statement of the importance of supervision and provide the resources needed to perform this function. This might include the acquisition of taping equipment, provision of one-way mirrors, etc. Staff need to hear unequivocally that supervision is a necessity and a requirement for all personnel, regardless of years of experience, academic background, skill and counselor developmental levels, and status within the organization. Supervisors also need supervision.
  3. Supporting creative methods for supervision. As this TIP advocates for direct methods of supervision through one-way mirrors, video/audio taping, and live observation, you can state clearly that “at our agency we observe.” Other methods for clinical supervision might include group or peer supervision models (see Part 1, chapter 1).
  4. Building and supporting a record-keeping process for clinical supervision. This entails providing time and tools for the documentation related to clinical supervisory and administrative functions. Supervisory notes need to be integrated with clinical notes and human resource files. One good documentation system is the Focused Risk Management Supervision System (FoRMSS; Falvey, Caldwell, & Cohen, 2002). Assisting in organizing the supervisory process by investing in activities that will increase productivity over time, setting and adhering to priorities, and increasing coping skills repertoire to manage multiple tasks through cross-training and team building. You also need to periodically review job descriptions, personnel strengths and aptitudes, and cultural competence, and reorganize workloads accordingly. You should periodically review the purpose and function of every meeting and seek to streamline meeting times for economy and efficiency.
  5. Assisting supervisors in implementing agency priorities, such as the adaptation of EBPs to fit the agency’s goals and objectives. Hence, if an organization is implementing an EBP, it is imperative that supervisors also be trained in how to supervise that practice, perhaps even before counselors are trained.
  6. Assisting supervisors in other personnel functions, such as working with impaired professionals and providing an employee assistance program (EAP) as a resource to supervisors and supervisees. You and your supervisors need to work together when staff are involved in ethical or legal issues that might impair the organization’s function and credibility, and the supervisor needs to keep the administrator informed of all actions taken throughout the process.
  7. Supporting supervisors in developing cultural competence within the organization. This entails hiring culturally competent clinical supervisors and staff and providing personnel training on cultural issues. It also requires supporting supervisors in developing and improving cultural competence in counselors.

Professional Development of Supervisors

You both support clinical supervisors in their function and monitor their professional development and performance by:

  • Building a system to monitor, evaluate, and provide feedback to clinical supervisors. Supervision of one’s supervision is lacking in many organizations. Every clinical supervisor is entitled to and needs to have some form of supervision of their supervision, either live or online.
  • Creating IDPs with all supervisors. Even as every client needs a treatment plan and every staff member needs an IDP, every clinical supervisor also needs an IDP. Supervisors’ IDPs are jointly developed and monitored by the clinical supervisor and his or her supervisor.
  • Helping supervisors develop a professional identity as a supervisor. This entails encouraging the supervisor to be credentialed as a clinical supervisor. They should also receive ongoing training required for recertification.
  • Providing time for them to work with a mentor (either someone within the organization or an outside consultant).
  • Requiring an annual minimum number of clinical supervision training hours.
  • Offering time and resources for supervisors to participate in State or local support groups for supervisors.
  • Providing job performance evaluations on a regular and timely basis.

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