Section 4: The Educational/Teaching Role: Key Clinical Knowledge and Skills to Transfer

In order to develop their supervisees and oversee their clinical effectiveness, clinical supervisors - in their teaching or developmental role - need to 1) evaluate where their charges stand in terms of the key clinical knowledge and skills that are used in the field of mental health, 2) build and expand upon that clinical vocabulary, and 3) help supervisees understand how to apply those aptitudes in increasingly effective ways to move towards mastery within the profession. 

The assessment process is the first step in the development of a structured and well-organized learning or development plan that targets the key areas of growth for the supervisee.

For this to occur, supervisors first must have a solid grasp of what constitute the most important knowledge and skills to transfer. As a starting point, it may be helpful to consider what characteristics are present in effective clinicians. Here are guidelines noted by several important contributors to this question:

 

Effective Clinician Characteristics 

- Empathy

- Positive regard

- Respect

- Warmth

- Concreteness

- Immediacy

- Objectivity

- Responsibility

- Confrontation skills

- Genuineness and Congruence

- Sense of humor

- Self-awareness

- Good psychological health

- Competence and knowledge

- Gender, race, cultural awareness

- Clinician powers

- Ethical orientation

- Countertransference awareness

 

(Sources: Corey, G. (2001a). Theory and practice of counseling and psychotherapy. 6th edition. Belmont, CA: Wadsworth 2001a and; Ivey, A. & Ivey, M. (1999). Intentional interviewing and counseling. 4th edition. Pacific Grove, CA: Brooks/Cole; Okun, B. (2002) Effective helping. 6th edition. Pacific Grove, CA: Brooks/Cole)

To gather a more concise picture of what knowledge and skills the supervisee already has and still needs in his/her journey towards mastery, yourceus.com has organized a series of self-inventories to be provided early in the supervisory relationship. These inventories will help assess the level attained by the supervisee in each of the key areas, as well as the readiness of the supervisor to address these areas during the learning or development process.

The inventories cover two different areas: 

1) Core skills

2) Clinical aptitudes

Both of these areas will be evaluated based upon a 5-point Likert scale, with 0 at the bottom indicating a lack of awareness of the key area and 4 at the top indicating sufficient mastery of the key area to teach or mentor other clinicians. Competent clinicians will operate at level 3 for the key areas that are central to their current work position.

Here is that Likert scale for each of the inventories:

Pre-awareness   Level 0 – Not yet aware of what the aptitude involves and/or not yet aware of own areas of strength and weakness, not knowledgeable about what is involved in using aptitude on a consistent basis nor about how to improve aptitude, not yet able to use aptitude with consistency and control

Awareness   Level 1 – Aware of what the aptitude involves and aware of own areas of strength and weakness in defined areas, but not knowledgeable about what is involved in using aptitudes on a consistent basis nor about how to improve aptitude sets, and not yet able to use aptitudes with consistency and control

Knowledge    Level 2 – Aware of what the aptitude involves, aware of own areas of strength and weakness in defined areas, knowledgeable about what is involved in using aptitudes on a consistent basis and about how to improve aptitude sets, but not yet able to use aptitudes with consistency and control

Aptitude / Competency     Level 3 - Aware of what the aptitude involves, aware of own areas of strength and weakness in defined areas, knowledgeable about what is involved in using aptitudes on a consistent basis and about how to improve aptitude sets, able to use aptitudes with consistency and control

Mastery / Mentor Readiness    Level 4 - Aware of what the aptitude involves, aware of own areas of strength and weakness in defined areas, knowledgeable about what is involved in using aptitudes on a consistent basis and about how to improve aptitude sets, able to use aptitudes with consistency and control, sufficient understanding of both subject area and how to impart subject area that the ability exists to educate and mentor others successfully in the development of aptitudes

 

Core Skills Self-inventory

The Core Skills Self-inventory covers areas concerned with the ability to use the self in interaction with clients, as well as executive function and other high order skills that underlie the capacity to apply clinical skills and techniques. Where gaps exist in these core skills, there will be significant obstacles to the application of clinical skills. Here are the different key areas that supervisors will want to assess through the use of this instrument, rated using the scale indicated above:

 

Core Skills Self-inventory

Self-management Skills:  ____Self-awareness   ____Emotional and behavioral control skills, including: emotional self-regulation, sustained attention, task initiation and task switching, delay of gratification, and goal-directed persistence   ___Self-motivation skills   ___Time management and organizational skills   ___Countertransference management

 

Attunement Skills: ___Attending ___Focusing  ___Listening and observing ___Joining ___Empathizing  ___Use of silence   ___Validating  ___Affirming  ___Projecting warmth and immediacy

 

Skills in managing the holding environment: ____Establishing professional authority  ___Directing focus    ___Goal setting   ___Confronting   ___Limit setting   ___Redirecting   ___Enhancing motivation   ___Amplifying discrepancies  ___Managing resistance

 

Core Communication Skills: ___Control of verbal dimension of communication: word choice, concept choice, shared connotations, shared metaphors  ___Control of vocal dimension of communication: tone of voice, volume, pitch, inflections, pacing  ___Control of physical dimension of communication: facial expressions, body posture, use of gestures, appearance and comportment  ___Control of global dimension of communication: Context, timing, implicit and inferred rules and covenants for communication ___Gathering information  ___Active listening ___Reflecting  ___Giving feedback  ___Clarifying  ___Questioning (Open-ended vs. closed questions) 

 

Clinical Communication Skills: ___Reframing   ___Interpreting ___Educating/psychoeducation  ___Emotional clarification ___Modeling   ___Use of imagery/visualization ___Use of metaphor  ___Anchoring or organizing constructs  ___Use of humor  ___Self-disclosure  

 

Critical Thinking Skills: ___Knowledge of the methods of logical inquiry and reasoning ___Gathering and assessing relevant information ___Formulating hypotheses clearly and precisely  ___Testing information against relevant criteria and standards ___ Identifying and challenging assumptions ___Understanding the importance of context ___Imagining and exploring alternatives   ___Anticipating consequences and outcomes of alternatives  ___Awareness of one’s own beliefs, values, and prejudices

 

Uses of this Tool

This tool is not just a vehicle for gathering information about the core skills of the supervisee to use in the development of a learning plan. It is also an educational tool for the supervisee to use in expanding his/her broader understanding of exactly what is involved in high level clinical work. There will be items on this inventory that many supervisees may not have heard of, thought about, or realized are an important aspect of being a master clinician.

This will also be a helpful tool for demonstrating progress in terms of the supervisee’s development. Supervisors can ask that these inventories be filled out at various points in the course of supervision so that the ratings can be compared and progress charted in a consistent format.

This tool is also a good instrument for the supervisor to assess his/her own readiness to provide a full-throated learning or development plan to the supervisee. A supervisor may discover that he/she is not at the level of mastery or mentor readiness where the supervisee is most in need of help and support. 

Finally, this tool, in conjunction with the inventory for clinical skills, may also be helpful in terms of prioritizing, sequencing and pacing the development work that needs to occur. It will provide a more detailed record of all of the key elements that need to be considered in the process of developing a clinician, so that important elements are less likely to be overlooked or forgotten.

 

Foundation of Clinical Aptitudes Self-inventory

The Foundation of Clinical Aptitudes Self-inventory addresses key skills and aptitudes involved in the provision of clinical services: assessment and diagnosis, clinical roles, schools of treatment, factors in treatment success, capacity to engage in research, and the key ethical principles and aptitudes that are essential to good practice.

 

Foundation of Clinical Aptitudes Self-inventory

Diagnostic, Assessment and Evaluation Aptitudes:   ___Major developmental theories, including normative development of cognition and affect; major models of stages of development, including cognitive development, emotional development, personality development, moral development, social development; stages of relationships and family life stages

___Psychological disorders and most recent knowledge about etiology and of and neuroscientific understandings about psychological disorders, including personality disorders, mood disorders, thought disorders, anxiety disorders, addictions, eating disorders, conduct and behavioral disorders 

___Recent advances in understanding of the science of neurocognitive disorders and neurodevelopmental disorders, including learning disorders and Sensory Processing Disorders

___Assessment and diagnostic aptitudes, including how to conduct a bio-psycho-social-spiritual assessment, how to conduct treatment planning, how to diagnose and use the Diagnostic and Statistical Manual, including expanded section on Z-codes

___Available objective measurement tools that may be appropriately used by Master’s level mental health clinicians

___Influence of biological, medication, systems, social, cultural and religious and spiritual factors on cognitive, affective and behavioral aspects of client presentation

 

Core Foundational Clinical Knowledge: ___Attachment and object relations theory, and emotional modulation and granularity and their applications in clinical practice

___Foundational knowledge of neuroscience, including affective neuroscience, and its relation to clinical practice

___Current models and knowledge base for addressing addiction and substance abuse, including DiClemente’s stages of change, Motivational Interviewing, and current medications used in the treatment of substance use disorders and detoxification

___Updated information about substances currently being abused, including street drugs, club drugs, and prescription drugs

___Updated information about psychotropic medications and the appropriate role of the clinician in addressing medication issues

___Foundational knowledge about verbal and non-verbal aspects of communication, and conflict resolution

___Best practices in parenting and parenting strategies, incorporating attachment theory, object relations theory, learning theory, and child and adolescent cognitive and emotional developmental knowledge

 

Treatment Aptitudes - Three Roles of Clinical Work:   ___Remedial role: focus on working with individuals and groups to assist them in addressing or solving problems using techniques and approaches from major theories of treatment, e.g., CBT, solution focused treatment, psychodynamic, systems, Dialectical Behavioral Therapy, Acceptance and Commitment Therapy, and Exposure Response Prevention

___Preventive role: focus on helping people to make changes in their personal and interpersonal lives to minimize or eliminate the occurrence of problems in the future using preventive approaches, e.g., relapse prevention, bully-proofing, assertiveness training, emotional clarification and granularity skills

___Educative-developmental role: focus on working with individuals and groups to enhance or improve their lives, using teaching and educational approaches drawn from a substantial knowledge base in areas related to clinical work, e.g., child development, stages of relationships, substance abuse, and learning theory, including cognitive and motivational aspects of learning 

 

Treatment Aptitudes - Major Factors in Treatment: ___Support Factors: catharsis; identification with therapist; mitigation of isolation; positive relationship; reassurance; structure; therapeutic alliance; therapist/client active participation; therapist expertness; therapist warmth, respect, empathy, acceptance, genuineness; and trust.

___ Learning Factors: advice; affective experiencing; assimilation of problematic experiences; changing expectations for personal effectiveness; cognitive learning; corrective emotional experience; exploration of internal frame of reference; feedback; insight; and rationale.

___Action Factors: behavioral regulation; emotional regulation; cognitive mastery; encouragement of facing fears; taking risks; mastery of efforts; modeling; practice; reality testing; success experience; and working through

___Leadership Factors: management and regulation of self; development and use of executive function skills; generation of professional authority; capacity for effective direction of focal attention; management of the holding environment

 

Treatment Aptitudes - Major Theories and Schools of Treatment:  ____ Psychodynamic perspectives: focus on unconscious factors that motivate behavior with attention given to the events of the early years of life as determinants of later personality development. 

____ Cognitive/behavioral perspectives: focus on the role of thinking and belief systems as the root of personal problems, applying learning and reinforcement principles to address problems. 

____ Humanistic perspectives: focus creating one’s own destiny by taking personal responsibility for one’s life and finding meaningful life goals. 

____ Transpersonal perspectives: focus on the quality of the person-to-person therapeutic relationship believing clients have the capacity for self-direction without active clinician intervention or direction. 

____ Systems perspectives: focus on the importance of understanding individuals in the context of their surroundings including gender-role socialization, race and culture, family, and other systems.

____Techniques and approaches: knowledge of foundational clinical techniques and approaches, i.e., communication skills, attuned listening, active listening, reframing, interpretation, self-disclosure, humor, metaphor, paradox, psychoeducation, redirection, etc.; application of clinical techniques within models of treatment; context and timing for use of clinical techniques

____Case Conceptualization skills: knowledge of how to apply case assessment and diagnosis to conceptualize a case and develop a treatment plan that utilizes the most appropriate treatment approach and techniques for the assessed client problems

 

Research Aptitudes   ___Evaluating emerging research related to clinical practice in order to remain current in terms of clinical competence

___Understanding levels of intervention and type 1 and type 2 errors and their implications for applications of emerging knowledge

___Integrating emerging material from research into clinical approaches and techniques

___Conducting an effective search for best practices research resources

___How to compose and organize a research project for internal and external validity

 

Ethical Aptitudes:  ____Code of ethics for your profession and how to apply it in clinical practice, including knowledge of roles and boundaries with clients, supervisees, peers, and the public; how to manage competing obligations to multiple codes of ethics, legal versus ethical concerns, obligations to employers, diverse populations within the framework of the dominant culture; ethical obligations in administrative roles and in research and writing

____Core ethics knowledge base, including stages of ethical decision making, competing principles and interests in ethical dilemmas, who the client is and when the client is a client, differences between moral, legal and ethical considerations, special considerations in working with diverse populations

____How to establish the ethical framework of a treatment relationship, including reaching informed consent agreements, establishing safety and privacy guidelines, and clarification about the nature of the treatment process

____The major ethical decision-making models, including models for working with diverse populations

____Laws and statutes relevant to clinical practice in GA, including duty to warn and duty to protect, privacy and confidentiality, rights of minors, age of majority, populations with special protections, and protection of privacy and confidentiality when using electronic modes of communication

____Common ethical violations and how to prevent them, including boundary and dual role violations, scope of practice, competence

____Best practices in ethical record keeping, including knowledge of HIPAA compliant releases of information, assessment, treatment planning, progress notes, statements of understanding/privacy notification, discharge summaries

 

A Few Words on the Big Picture within the Development/Teaching Role 

In addition to the responsibilities held by the conscientious supervisor to transfer key knowledge and skills, there is a responsibility to prepare the supervisee for the fluid state of knowledge in the 21^st Century. Because knowledge is evolutionary in nature, it will continue to change over time. However, we cannot work confidently at anything if we do not have some belief in the validity and effectiveness of what we are doing in our work at any particular point in time. The search for an answer to this quandary brings us to an important philosophical concept known as temporary essentialism. (Source: Kottler, J and Jones, WP, Doing Better: Improving Clinical Skills and Professional Competence, 2003, NY: Brunner-Routledge)

Temporary essentialism looks for that space where “knowing and doubting are balanced.” We have to work with our knowledge base with great confidence and assuredness – right up to the point where we discard it as not being good enough because we have come across something better. We understand that our knowledge will change and evolve, but we need enough certainty in our knowledge and skills to give the client confidence that we know what we are doing. 

We also need to have the self-confidence and self-assurance to address this changeable nature of knowledge with our supervisees and to have them address it comfortably with their clients. This will operate in conjunction with an ongoing search for knowledge and skills that are demonstrated to be more effective in the mission of clinical work: helping clients to improve their mental health.

Currently, there are well over four hundred and fifty different approaches to clinical intervention, covering clinical work with a variety of different populations, supported by different theoretical underpinnings, and championed by different individuals, schools, and formal organizations dedicated to validating and increasing the influence of the particular approach in question. There are literally hundreds of professional journals pumping out research and commentary on these different approaches.

Some of the approaches in question have been relatively thoroughly examined and researched to determine their effectiveness. However, the information is constantly evolving. Approaches that were once in favor are reconsidered, as the research points out problems and limitations. Other approaches - typically newer or emerging methods - appear regularly on the scene with promises of improved methods for intervening – faster, more precisely targeted, more useful for certain populations, but with effectiveness questionable or unproven.

The conscientious professional is caught between two forces that operate in a state of dynamic tension. We are ethically obliged to operate in the best interests of our clients by offering only those services that are demonstrated to be effective. Effectiveness is clarified over time by the accumulation of research and studies probing the validity of the approaches in the real world.

If we operate with approaches that do not meet the effectiveness test, we risk wasting the time and resources of our clients - if not, in fact, putting our clients in harm’s way - thereby placing ourselves at ethical risk by failing to observe our professional commitment to putting the safety, rights and needs of the client first.

We are also ethically obligated to replace intervention approaches that are less effective with intervention approaches that are more effective. When new methods and approaches are developed that offer the option of better or faster outcomes, we are expected to let go of our attachment to our prior methods and begin to incorporate the improvements from the new methods.

This often places a personal burden on us as professionals. As professionals, we sometimes dedicate both time and money to becoming proficient in specific methods and approaches to clinical intervention. However, the primacy of the client’s right to effective treatment supersedes our right us to hold on to modes of intervention that are outdated – or that are outright ineffective or even harmful. Our ethical obligation is to adapt and stay current, while holding on to only what is effective.

This means not only relatively continuous adaptation of our methods, but also continuous scrutiny of what is happening in the profession. This is difficult on several fronts.

Firstly, we are expected to stay abreast of changes in the field in this area: new and emerging intervention approaches, what the most recent research demonstrates with regard to both current and emerging approaches, revisions to theories and practices as a result of updated information. The list is extensive, as is the amount of time needed to gather and process the emerging information.

Second, we are also expected to possess the wisdom to know when an emerging approach has been sufficiently demonstrated to be superior – as well as valid and effective - to warrant and justify replacing what we are already using. We are likewise expected to have the wisdom to decline the impulse to jump on the bandwagon of a new treatment approach in a premature way. Any practitioner who has been in practice for any length of time has likely had the experience of seeing other professionals become early adopters of a new approach - only to see that approach fall out of favor as research fails to prove its effectiveness or validity – or overturns it entirely. 

Third, we are expected to be able to integrate the new material that is continuously emerging with what we already know and use. The principle in play here is to hold onto what is useful and valid from our current knowledge base and skill sets, add in what is valid and useful from the new material, fill in the gaps and spaces between the old and new, and resolve places where conflicts or inconsistencies arise.

Fourth, we are expected to tolerate and manage our own emotional responses to the inconvenience of constant demands for change and evolution in our profession. Making changes to our own deeply held knowledge can be particularly unsettling and painful.

We are also expected to protect the client from the disappointment, distress and/or discouragement that we experience from having to discard our carefully cultivated – and sometimes expensively paid for - knowledge base and skill sets in order to replace them with what has been determined to be better, more accurate and more effective.

(We also have to manage the complex set of feelings that accompanies the occasional need to explain to our clients why the approaches we have been holding out as evidence of our wonderful clinical expertise have been relegated to the dust bin of history.)

Fifth, we are expected to hold onto an overall conceptual framework of what we are doing with our interventions – even as our deep knowledge changes and evolves - that simultaneously allows us to engage in our work with our clients with confidence and professional authority while also engaging in a continuous process of assimilation and accommodation of new ideas and approaches.

These understanding are an essential part of the learning process for the supervisee to carry forward, over and above the knowledge base and skill sets for clinical work. The goal of supervision is to create an independent practitioner ready to take on current and emerging mental health challenges, using continuously evolving sources of knowledge and skills.

 

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