supervision - The Professional Counselor

The Common Factors Discrimination Model: An Integrated Approach to Counselor Supervision

Feb 5, 2017 | Volume 7 - Issue 1

A. Elizabeth Crunk, Sejal M. Barden

Numerous models of clinical supervision have been developed; however, there is little empirical support indicating that any one model is superior. Therefore, common factors approaches to supervision integrate essential components that are shared among counseling and supervision models. The purpose of this paper is to present an innovative model of clinical supervision, the Common Factors Discrimination Model (CFDM), which integrates the common factors of counseling and supervision approaches with the specific factors of Bernard’s discrimination model for a structured approach to common factors supervision. Strategies and recommendations for implementing the CFDM in clinical supervision are discussed.

Keywords: supervision, common factors, specific factors, discrimination model, counselor education

Clinical supervision is a cornerstone of counselor training (Barnett, Erickson Cornish, Goodyear, & Lichtenberg, 2007) and serves the cardinal functions of providing support and instruction to supervisees while ensuring the welfare of clients and the counseling profession (Bernard & Goodyear, 2014). Numerous models of clinical supervision have been developed, varying in emphasis from models based on theories of psychotherapy, to those that focus on the developmental needs of the supervisee, to models that emphasize the process of supervision and the various roles of the supervisor (Bernard & Goodyear, 2014). However, despite the abundance of available supervision models, there is little evidence to support that any one approach is superior to another (Morgan & Sprenkle, 2007; Storm, Todd, Sprenkle, & Morgan, 2001). Thus, a growing body of clinical supervision literature underscores a need for strategies that integrate the most effective elements of supervision models into a parsimonious approach rather than emphasizing differences between models (Lampropoulos, 2002; Milne, Aylott, Fitzpatrick, & Ellis, 2008; Morgan & Sprenkle, 2007; Watkins, Budge, & Callahan, 2015). Common factors models of supervision bridge the various approaches to supervision by identifying the essential components that are shared across models, such as the supervisory relationship, the provision of feedback, and supervisee acquisition of new knowledge and skills (Milne et al., 2008; Morgan & Sprenkle, 2007). Other common factors approaches to supervision draw on psychotherapy outcome research, aiming to extrapolate common factors of counseling and psychotherapy—such as the therapeutic relationship and the instillation of hope—to clinical supervision approaches (Lampropoulos, 2002; Watkins et al., 2015)

Although reviews of the supervision literature allude to commonalities among supervision approaches (Bernard & Goodyear, 2014), there is a dearth of published literature offering practical strategies for bridging common factors of counseling and supervision. Perhaps even more limited is literature that addresses the necessary convergence of both common and specific factors, or the integration of common factors of supervision with particular interventions that are applied in various supervision approaches (e.g., role-playing or Socratic questioning; Watkins et al., 2015). In a recent article, Watkins and colleagues (2015) proposed a supervision model that extrapolates Wampold and Budge’s (2012) psychotherapy relationship model to specific factors of supervision, encouraging supervisors to apply such relationship common factors to some form of supervision. However, there remains a need for a structured approach to supervision that integrates the common factors of counseling and supervision with the specific factors of commonly used, empirically supported models of clinical supervision.

Because the common factors are, by definition, elements that are shared among theories of counseling and supervision, it can be argued that common factors approaches can be applied to almost any supervision model. However, we argue for the integration of common factors with the discrimination model for several reasons. First, the relationship has been found to be the essential common factor shared among counseling (Lambert & Barley, 2001; Norcross & Lambert, 2014) and supervision approaches, and is often cited as the most critical element of effective supervision and other change-inducing relationships, such as counseling, teaching and coaching (Lampropoulos, 2002; Ramos-Sánchez et al., 2002). The supervisory roles of teacher, counselor and consultant are built into the discrimination model, providing supervisors with natural avenues for fostering a strong supervisory relationship. However, the proposed Common Factors Discrimination Model (CFDM) expands on the discrimination model by providing specific recommendations for how supervisors might use such roles as opportunities for developing and maintaining the supervisory relationship. Second, we consider Bernard’s (1979, 1997) discrimination model to lend itself well to common factors approaches to supervision, as both are concerned with process aspects of supervision, such as tailoring supervision interventions to the needs of the supervisee. Finally, because the discrimination model is widely used by practicing supervisors (Timm, 2015), common factors approaches are likely to fit naturally with customary supervision practices of more experienced supervisors who espouse the discrimination model, yet the CFDM is concise enough for novice supervisors to grasp and apply. Thus, the purpose of this manuscript is to build on Watkins and colleagues’ (2015) model by presenting the CFDM, an innovative approach to supervision that converges common factors identified in both counseling and supervision and integrates them with the specific factors of Bernard’s (1979, 1997) discrimination model. Specifically, we will (a) review the relevant literature on common factors approaches to counseling and supervision and the discrimination model; (b) provide a rationale for a model of supervision that integrates the specific factors of the discrimination model with a common factors approach; and (c) offer strategies and recommendations for applying the CFDM in clinical supervision.

The Common Factors Approach

The notion of therapeutic common factors resulted from psychotherapy outcome research suggesting that psychotherapies yield equivalent outcomes when compared against each other and, thus, what makes psychotherapy effective is not the differences between therapies, but rather the commonalities among them (Lambert, 1986). Wampold’s (2001) landmark research revealed that the theoretical approach utilized by the therapist (e.g., psychodynamic therapy) explained less than 1% of therapy outcome. In light of these findings, researchers and clinicians have been urged to minimize the importance placed on specific clinical techniques and interventions; instead, an emphasis on the commonalities among therapies that are associated with positive outcomes (Norcross & Lambert, 2011), such as the therapeutic alliance, empathy, positive regard, and collaboration within the therapeutic relationship (Norcross & Lambert, 2014; Norcross & Wampold, 2011), is more useful for describing therapeutic changes.

Among the most influential common factors approaches is Lambert’s model of therapeutic factors (see Lambert & Barley, 2001, for a review). Although lacking in stringent meta-analytic or statistical methods, Lambert and Barley (2001) presented four primary factors that are shared among therapeutic approaches (with the percentage that each factor contributes to therapy outcome indicated): (a) extratherapeutic factors (i.e., factors associated with the client, as well as his or her environment; 40%); (b) common factors (i.e., relationship factors such as empathy, warmth, positive regard, supporting the client in taking risks; 30%); (c) placebo, hope, and expectancy factors (i.e., the client’s hope and expectancy for improvement, as well as trust in the treatment; 15%); and (d) skills/techniques factors (i.e., components specific to various therapies, such as empty chair or relaxation techniques; 15%). Although a variety of common factors have been identified in the psychotherapy outcome research, numerous meta-analyses have identified the therapeutic relationship as the sine qua non (Norcross & Lambert, 2011, p. 12) of common factors that account for positive outcomes irrespective of the specific treatment utilized (Norcross & Wampold, 2011). They stated: “although we deplore the mindless dichotomy between relationship and method in psychotherapy, we also need to publicly proclaim what decades of research have discovered and what tens of thousands of relational therapists have witnessed: The relationship can heal” (Norcross & Lambert, 2014, p. 400).

Although the common factors are necessary for producing positive counseling outcomes, this does not mean that specific factors are irrelevant (Norcross & Lambert, 2011). On the contrary, prior research indicates that engaging in specific treatment interventions is associated with the working alliance and with positive counseling outcomes (Tryon & Winograd, 2011; Wampold & Budge, 2012). Watkins and colleagues (2015) noted that treatment interventions are necessary in maintaining client hope and expectations for positive counseling outcomes, stating, “The specific ingredients create benefits through the common factor of expectations, and respecting that interdependent common/specific factor dynamic is vital to treatment outcome” (p. 221).

Common Factors Approaches to Supervision

Although the concept of common factors in counseling and psychotherapy is not a new one and has been the focus of considerable empirical research (Frank, 1982; Lambert & Barley, 2001; Lambert & Ogles, 2004; Rosenzweig, 1936), applying the common factors approach to clinical supervision is relatively novel (Morgan & Sprenkle, 2007). Counseling and clinical supervision are distinct interventions; however, Milne (2006) makes a case for extrapolating findings from psychotherapy research to supervision, as both share common structures and properties of education, skill development, problem-solving and the working alliance. Furthermore, Bernard and Goodyear (2014) noted, “because therapy and supervision are so closely linked, developments in psychotherapy theory inevitably will affect supervision models” (p. 59).

Despite frequent reference to the similarities among supervision models, literature that specifically addresses common factors of supervision approaches is scarce (Bernard & Goodyear, 2014). In our review of the supervision literature, we identified five articles that endorsed common factors approaches to supervision and counselor training (Castonguay, 2000; Lampropoulos, 2002; Milne et al., 2008; Morgan & Sprenkle, 2007; Watkins et al., 2015). Following Castonguay’s (2000) seminal work on training in psychotherapy integration, Lampropoulos (2002) was among the first to address the parallels that exist between common factors of both counseling and supervision, advocating for a theoretically eclectic approach to supervision and for the prescriptive matching of common factors to supervisee needs. For example, Lampropoulos (2002) suggested that supervisors might integrate psychodynamic theory as a means of increasing supervisees’ awareness of countertransference and attachment patterns, or cognitive theory in order to restructure supervisees’ unhelpful thoughts about counseling and supervision.

In contrast to Lampropoulos’s (2002) model, which extrapolates common factors of counseling to supervision, Morgan and Sprenkle (2007) and Milne and colleagues (2008) endorsed approaches that bridge similarities between supervision models. Morgan and Sprenkle (2007) identified a number of common factors among models of supervision, grouping these factors into the following three dimensions falling on their respective continua: (a) emphasis, ranging from specific clinical competence to general professional competence; (b) specificity, ranging from the idiosyncratic needs of supervisees and clients to the general needs of the profession as a whole; and (c) supervisory relationship, ranging from collaborative to directive. The authors (Morgan & Sprenkle, 2007) then proposed a model of supervision that applies these three dimensions of supervision to the supervisor roles of coach, teacher, mentor and administrator. In contrast, Milne and colleagues (2008) conducted a best evidence synthesis of the supervision literature to summarize the current state of empirical research on supervision practices and applied their findings to a basic model of supervision. Although both models (Milne et al., 2008; Morgan & Sprenkle, 2007) contributed viable descriptive models of common factors approaches to supervision, they were limited in providing specific strategies for supervisors to employ in a given situation. Furthermore, neither model specifically addressed the intersection of common factors of counseling and common factors of supervision. Thus, noting that common factors of counseling and specific factors of supervision approaches are interdependently related, Watkins and colleagues (2015) proposed a common/specific factors model, designating the supervisory relationship as the crowning common factor and encouraging supervisors to apply this relationship-centered model to the specific factors of “some form of supervision” (Watkins et al., 2015, p. 226). Following Watkins and colleagues’ recommendations, we therefore present an integrated approach to supervision by applying the common factors of counseling and supervision to the specific factors of the discrimination model.

The Discrimination Model

The discrimination model (Bernard, 1979, 1997) provides a conceptualization of clinical supervision as both an educational and a relationship process (Bernard & Goodyear, 2014; Borders & Brown, 2005). In essence, the discrimination model involves the dual functions of assessing the supervisee’s skills and choosing a supervisor role for addressing the supervisee’s needs and goals. The supervisee is assessed on three skill areas, or foci: (a) intervention (observable behaviors that the supervisee demonstrates in session, such as demonstration of skills and interventions); (b) conceptualization (cognitive processes, such as the supervisee’s ability to recognize the client’s themes and patterns, as well as the supervisee’s level of understanding of what is taking place in session); and (c) personalization (supervisee self-awareness and ability to adapt his or her own personal style of counseling while maintaining aware-ness of personal issues and countertransference). Furthermore, over 30 years ago, Lanning (1986) proposed the addition of assessing the supervisee’s professional behaviors, such as how the supervisee approaches legal and ethical issues.

When the supervisor has assessed the supervisee’s skill level in each of the three foci, the supervisor utilizing the discrimination model assumes the appropriate role for addressing the supervisee’s needs and goals: (a) teacher (assumed when the supervisor perceives that the supervisee requires instruction or direct feedback); (b) counselor (appropriate for when the supervisor aims to increase supervisee reflectivity, or to process the supervisee’s internal reality and experiences related to his or her professional development or work as a counselor); or (c) consultant (a more collaborative role that is assumed when the supervisor deems it appropriate for the supervisee to think and act more independently, or when the supervisor aims to encourage the supervisee to trust his or her own insights). It is important to note that the supervisor does not take on the singular form of any of the three roles, but rather makes use of the knowledge and skills that are characteristic of each role (Borders & Brown, 2005). The discrimination model is situation-specific; therefore, supervisor roles and foci of assessment might change within a supervision session and across sessions. Consequently, supervisors are advised to remain attuned to the supervisee’s needs in order to attend to his or her most pressing focus area and to assume the most suitable role for addressing these needs rather than displaying strict adherence to a preferred focus or role (Bernard & Goodyear, 2014).

The discrimination model is considered to be an accessible, empirically validated model for supervisors and can be adapted in complexity depending on the supervisor’s level of readiness (Bernard & Goodyear, 2014; Borders & Brown, 2005). Using multidimentional scaling in an empirical study of the discrimination model, Ellis and Dell (1986) provided validation for both the teacher and counselor roles, although the consultant role did not emerge as a distinct role. Their findings are consistent with other studies that provided support for the teacher and counselor roles, but not for the consultant role (Glidden & Tracey, 1992; Goodyear, Abadie, & Efros, 1984; Stenack & Dye, 1982). Thus, the consultant role might be more difficult to distinguish from the teaching and counseling roles, perhaps, as Bernard and Goodyear (2014) noted, because the consultant role requires supervisors to put aside their position of expert or therapist and act more collaboratively with their supervisees. Ellis and Dell provided an alternate (and conflicting) explanation, suggesting that consultation might be an underlying component of both the teaching and counseling roles. These findings indicate a need for future research and possible modification of the discrimination model; however, the discrimination model is generally supported by empirical research.

Rationale for an Integrated Model

Watkins and colleagues (2015) stated: “Akin to the ‘great psychotherapy debate’ about effectiveness (Wampold, 2001), a ‘great psychotherapy supervision debate’ about effectiveness is eminently likely” (p. 17). Several cross-cutting models of clinical supervision have been proposed (Milne et al., 2008; Morgan & Sprenkle, 2007), as well as models that extrapolate common factors of counseling to supervision practices (Lampropoulos, 2002; Watkins et al., 2015); however, there has yet to be a model that systematically converges both. Given the abundance of empirical support for common factors in counseling, we have conceptualized a new model, the CFDM, to integrate a supervision approach that is grounded in effective counseling and supervision practices. Furthermore, Watkins and colleagues encouraged supervisors to apply common factors of counseling to the specific factors of some form of supervision; however, to our knowledge, no such model integrating common factors with the specific factors of an empirically supported model of supervision has been published. Thus, the CFDM combines essential factors of supervision models, converges them with common factors of counseling approaches, and applies them to the specific factors of Bernard’s (1979, 1997) discrimination model for a structured approach that bridges effective elements of both counseling and supervision.

Bernard and Goodyear (2014) pointed to the supervisory relationship as one of the most essential factors in supervision; however, a major criticism of the discrimination model is that the model itself does not thoroughly address the supervisory relationship (Beinart, 2004). Similarly, Freeman and McHenry (1996) found that supervisors ranked the development of clinical skills as their top goal for supervising counselors-in-training and identified that supervision involves taking on the roles of teacher, challenger and supporter, but relationship building did not surface as an emphasis of counselor supervision (Bell, Hagedorn, & Robinson, 2016). Thus, the CFDM builds on the discrimination model by incorporating tenets of the supervisory relationship that are consistent with common factors of counseling and supervision, such as the working alliance (Bordin, 1983), the real relationship (Watkins, 2015), and the instillation of hope (Lambert & Barley, 2001; Lampropoulos, 2002). Historically, the supervision literature suggests that novice supervisors, in particular, might manage feelings of self-doubt and uncertainty by employing a highly structured supervision style, focusing on providing supervisees with feedback on counseling techniques or client diagnosis and placing less emphasis on attending to the supervisory relationship (Hess, 1986; Hess & Hess, 1983). Furthermore, whereas building rapport is a top priority in many therapeutic relationships, counselor supervisors might prioritize other factors instead, such as scheduling, paperwork, and evaluation, before establishing a relationship with the supervisee (Bell et al., 2016). Because the discrimination model is a widely used approach to supervision (Timm, 2015), experienced counselors who wish to incorporate common factors of supervision and counseling into their customary supervision practice will likely find the CFDM to be an intuitive supervision approach. The following section provides a description of the four primary tenets of the CFDM, as well as strategies and recommendations for applying the CFDM in supervision.

The Common Factors Discrimination Model

The CFDM is an innovative model of supervision that aims to integrate the common factors of counseling and supervision with the specific factors of Bernard’s (1979, 1997) discrimination model for a structured, relationship-centered approach to clinical supervision. The CFDM builds on existing supervision models that extrapolate common factors of counseling to supervision practices (Lampropoulos, 2002; Watkins et al., 2015). The CFDM also draws on the discrimination model (Bernard, 1979, 1997) as a method of assessing supervisee needs and tailoring feedback and support accordingly. Although the melding of common factors with the discrimination model has yet to be empirically tested as an integrated approach to supervision, both approaches have received substantial empirical support as standalone models. Empirical research supports common factors approaches to counseling and other change-inducing relationships; however, the CFDM’s underpinnings in the more prescriptive discrimination model provide a structured approach to common factors supervision. In addition, there is evidence to suggest the effectiveness of common factors approaches across cultures (Dewell & Owen, 2015).

We have proposed a model that combines effective common factors of counseling and supervision with the specific factors of Bernard’s (1979, 1997) widely used, empirically supported and accessible discrimination model for a structured approach to common factors supervision. The primary tenets of the CFDM were derived by reviewing the literature on common factors models of supervision and purposively selecting the most common elements, including: (a) development and maintenance of a strong supervisory relationship, (b) supervisee acquisition of new knowledge and skills, (c) supervisee self-awareness and self-reflection, and (d) assessment of supervisees’ needs and the provision of feedback based on the tenets of Bernard’s (1979, 1997) discrimination model. The following section provides a brief fictional case illustration followed by specific strategies for applying the CFDM to supervision. Specific examples for matching common factors with tenets of the discrimination model are provided in Table 1, based on an illustrative case example, followed by a discussion of the primary tenets of the case to the CFDM.

Case Illustration

André, a master’s student in mental health counseling, is completing his first semester of clinical practicum at his university’s community counseling center. Although André demonstrates competency across many clinical and professional domains, as a novice counselor trainee he struggles with reflecting feeling with clients in session. His supervisor has noticed that André tends to sidestep emotional topics in session and, instead of reflecting feeling, responds to emotional content by asking the client unrelated questions or by changing the subject. In the few instances in which he has attempted to reflect feeling, André has been inaccurate in his reflections, undershooting the intensity of the client’s feelings or misreading the client’s emotions altogether. This has sometimes led to tension and frustration between André and his clients. Using the CFDM, his supervisor might utilize the following strategies in supervision with André. In the following section, the case of André is discussed, integrating the primary tenets of the CFDM.

Application of the CFDM

The Supervisory Relationship

Bernard and Goodyear (2014) suggested that the supervisory relationship is a critical factor in effective supervision, regardless of the model of supervision that is followed. Thus, the central tenet of the CFDM is the development of a collaborative supervisory relationship that is characterized by the Rogerian conditions of empathy, genuineness, and unconditional positive regard (Lampropoulos, 2002). Utilizing the CFDM with André, the supervisor approaches her supervisory roles of teacher, counselor and consultant with warmth and acceptance as she addresses André’s difficulty reflecting feeling with his client, rather than using a confrontational or critical approach. Furthermore, she explores with André his personal experiences with emotion, taking into consideration his background and cultural factors that could play a role in his relationship with emotion.

The real relationship. The real relationship (Lampropoulos, 2002; Watkins, 2015) refers to a supervisory relationship that is unaltered by transference or countertransference and is characterized by empathy, warmth, genuineness, unconditional positive regard and trust. The expression of humor and optimism also is recommended in developing a common factors-influenced supervisory relationship. Extrapolating from Gelso’s (2014) tripartite model of the psychotherapy relationship, Watkins (2015) defined the real relationship as “the personal relationship between supervisor and supervisee marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that befit the other” (p. 146). Factors of the real relationship are critical in supervision, as they allow supervisees to develop trust in the supervisory relationship and provide safety for supervisees to disclose vulnerabilities, mistakes and personal concerns (Storm et al., 2001).

Because the evaluative and hierarchical nature of supervision might make the supervisory relationship vulnerable to supervisory ruptures (Burke, Goodyear, & Guzzardo, 1998; Nelson & Friedlander, 2001; Safran, Muran, Stevens, & Rothman, 2007), the CFDM utilizes a collaborative evaluation process (Rønnestad & Skovholt, 1993), in which supervisees have the opportunity to practice evaluating their skills independently throughout their training either by journaling or by completing an evaluation form about their session and submitting their self-evaluation to their supervisor. Supervisee self-evaluations are then processed in supervision. The CFDM supervisor in the case illustration might use this strategy with André to allow him to raise self-awareness and to receive regular feedback on his skills. Furthermore, assuming the teacher role of the discrimination model, his supervisor might direct André to conduct a self-assessment of his reflections of feeling following each session, which he could bring into supervision to discuss and receive her feedback.

Because the supervisory relationship is the central tenet of the CFDM, it is advisable to evaluate and monitor the relationship throughout supervision. Furthermore, Lampropoulos (2002) recommended that supervisors identify and attempt to repair ruptures as soon as possible, as ruptures can be deleterious to supervision process and outcome. One such measure for evaluation of the supervisory relationship is the Supervisory Relationship Questionnaire (SRQ; Palomo, Beinart, & Cooper, 2010), a 67-item assessment of the supervisee’s perceptions of the supervisory relationship. Other plausible measures include the Working Alliance Inventory (Bahrick, 1990) and the Revised Relationship Inventory (Schacht, Howe, & Berman, 1988). Allowing André to assess the supervisory relationship and give his supervisor feedback can provide insight into André’s perception of their relationship and can allow the supervisor to consider making changes in her approach, if necessary. This also conveys to André that his feedback is valuable and that their supervisory relationship is collaborative.

The working alliance. The working alliance in supervision refers to the collaborative development of goals and tasks for supervision (Bordin, 1983; Constantino, Castonguay, & Schut, 2002; Lampropoulos, 2002). The working alliance is established in the CFDM by collaboratively developing a supervision contract between the supervisor and the supervisee (Lampropoulos, 2002) at the very beginning of the supervisory relationship. Goals for supervision that are addressed in the contract include evaluating supervisees’ strengths and areas for growth and identifying specific skills to be learned, as well as issues related to supervisee theoretical orientation. The tasks used to reach these goals can include process notes, live supervision, and interpersonal process recall (IPR; Kagan & Kagan, 1997) as a collaborative approach to processing André’s strengths and areas for growth, and for facilitating André’s self-reflection and self-awareness. The purpose of these tasks is to provide structure and opportunities for instruction, feedback, and evaluation, while allowing the supervisee to engage in self-evaluation, application of new skills, corrective action, and exploration of alternative approaches. The CFDM draws from the discrimination model when developing the contract as a means of evaluating supervisee’s three levels of foci (i.e., intervention, conceptualization and personalization). For example, when developing the supervision contract with André, the supervisor would consider André’s current level of competency with regard to techniques and clinical skills, case conceptualization skills, and self-awareness and personal style.

Instillation of hope and the creation of expectations. Frank and Frank (1991) noted the impact of positive expectations and hope in effecting change in counseling. Placebo, hope and expectancy factors emerged as a single common factor among most counseling approaches, with Lambert and Barley (2001) noting that instillation of hope accounts for 15% of client outcome. Watkins (1996) addressed the issue of demoralization in supervision, stating that beginning counselors can experience poor self-efficacy and might feel overwhelmed as they navigate their professional identity development. Watkins (1996) stated that supervisors are able to utilize the supervisory relationship as a means of encouraging supervisees and providing structure within the relationship to foster hope. Recently, Watkins and colleagues (2015) endorsed the creation of expectations and the provision of some method of supervision as a pathway by which supervisee change occurs. CFDM supervisors can incorporate hope and expectancy into supervision by using the consultant role of the discrimination model to explain to supervisees the process of supervision, and by collaborating with supervisees to provide supervision that builds on those expectations. Practical tools that André’s supervisor might implement to promote hope and positive expectations include developing a supervision contract with André or providing him with a professional disclosure statement in order to explain the process of supervision and to set supervisory rituals in motion (Watkins et al., 2015). Lampropoulos (2002) also suggested setting short- and long-term goals with supervisees as a means of instilling hope.

Supervisee Self-Awareness and Self-Reflection

An additional tenet of the CFDM is supervisee self-reflection concerning issues that influence professional development (Lampropoulos, 2002). CFDM supervision emphasizes the importance of encouraging supervisees to explore their strengths and areas for growth, and personal issues that might affect their work in counseling, as well as their therapeutic styles (Lampropoulos, 2002; Milne et al., 2008). The CFDM attempts to facilitate supervisee self-reflection by implementing strategies such as collaborative evaluation and the supervision contract (discussed above). Furthermore, the CFDM utilizes IPR (Kagan & Kagan, 1997), in which the supervisor and supervisee watch videotape of a supervisee’s counseling session together, pausing the tape at moments that either the supervisor or supervisee deems critical for further inquiry and processing. Taking on the role of counselor, the supervisor utilized IPR to explore what André was experiencing during that moment of the counseling session that might have prevented him from demonstrating reflection. Consistent with the common factors model, the supervisor confronted André with warmth, empathy and acceptance.

Acquisition of Knowledge and Skills

According to the discrimination model (Bernard, 1979, 1997), one of the primary roles of the supervisor is that of teacher. Thus, in addition to providing support and feedback, supervisors are in a position to impart knowledge and to facilitate supervisees’ acquisition of skills—a factor of supervision that surfaces in the majority of supervision models (Milne et al., 2008; Morgan & Sprenkle, 2007). Lampropoulos (2002) stated that supervisees might learn through direct instruction, through shaping (i.e., gradual learning of a desired behavior) and through their own personal experience. In addition, supervisees have opportunities to learn by imitating the behaviors of their supervisors and other counselors (Lampropoulos, 2002). Given that skills and techniques factors account for 15% of counseling outcome (Lambert & Barley, 2001), supervisors are in a position to model skills and techniques of counseling in supervision as a means of fostering supervisee learning and skill acquisition. Integrating common factors with the discrimination model, André’s supervisor might take on the role of teacher to watch a video clip with André of a recent counseling session in which André struggled to reflect feeling, directing him to role-play with his supervisor other ways that he could respond to his client when emotional content is disclosed. André’s supervisor also could provide him with a list of “feeling words” or other relevant resources in order to help him to increase his awareness of emotion and to broaden his feelings vocabulary.

Assessment of Supervisee Needs and the Provision of Feedback

A final tenet of the CFDM is assessment of supervisee needs and the provision of feedback utilizing the roles and foci presented in the discrimination model. Using the CFDM, the supervisor would implement tailoring (also referred to in the counseling literature as prescriptive matching)—or adapting supervision to fit the characteristics, worldviews and preferences of the supervisee—as would be done with clients in common factors approaches to counseling (Norcross & Halgin, 1997). In their review of the literature on clinical supervision, Goodyear and Bernard (1998) identified attending to supervisees’ individual differences as an essential component of effective supervision. Furthermore, tailoring is inherent in the discrimination model, which recommends matching the supervisor’s role to supervisee needs (Bernard, 1979, 1997). As a beginning clinician, André might express a greater need for structured, directive supervision compared to more experienced supervisees (Stoltenberg, McNeill, & Crethar, 1994). Because André self-disclosed his perception of emotion and how this relates to his identity as a male, his supervisor should include this in her conceptualization of André and how he approaches work with clients. Furthermore, this is a value that she might continue exploring with André in future supervision sessions if it could have an impact on his clinical work with clients. Multiple supervision models have recommended matching supervision to the supervisee’s therapeutic approach and cognitive and learning styles (e.g., level of cognitive complexity; Loganbill, Hardy, & Delworth, 1982; Stoltenberg, 1981), and Norcross and Halgin (1997) suggested beginning the supervisory relationship with a needs assessment to determine the supervisee’s unique needs, goals and preferences for supervision. Although tailoring can pose unique challenges for supervisors providing triadic or group supervision, individual differences such as supervisees’ level of experience, learning goals, gender and ethnicity can be taken into account in these formats.

Table 1

CFDM: Examples of DM Focus and Role Intersections and Common Factors Strategies (CFS)

Supervisor Roles (DM)
Supervision Focus Area (DM) and CFS	Teacher	Counselor	Consultant
Intervention	André reports that he is uncertain of how to perform a lethality assessment.	André struggles to reflect feeling and meaning with clients.	André is interested in using children’s books in session with elementary-aged children.
Common Factors Strategy:	Supervisor teaches André the necessary steps of assessing for lethality, then the dyad engage in a role play in which the supervisee tests his new knowledge by performing a lethality assessment with the supervisee acting as the client.(Acquisition of New Knowledge and Skills)	Supervisor asks André to reflect on the fact that he demonstrates empathy toward his clients while in supervision but struggles to show empathy by reflecting feeling and meaning in session.(Self-Exploration, Awareness, and Insight)	Supervisor provides André with resources for using bibliotherapy in child counseling and offers to help the supervisee brainstorm methods for utilizing this intervention in counseling.(Acquisition of Knowledge and Skills)
Conceptualization	André struggles to provide client with accurate diagnosis.	André perceives himself as being an ineffective counselor because he has difficulty choosing interventions in session.	André requests more information on client stages of change.
Common Factors Strategy:	Supervisor and André practice diagnosing fictional clients using case studies from a DSM-5casebook. Supervisor then assigns André homework to practice completing a few case studies independently. Supervisor and André review and discuss André’s answers collaboratively during following supervision session.(Acquisition of Knowledge and Skills)	Supervisor reflects supervisee’s feelings of inadequacy, offers encouragement, and normalizes the developmental challenges of supervisees. (Supervisory Relationship – Instillation of Hope and Raising of Expectations)	Supervisor assists supervisee with locating information on client stages of change and discusses with supervisee the idea of conceptualizing client’s progress in counseling within the context of the client’s stage of change. (Acquisition of Knowledge of Skills)
Personalization	André exhibits behaviors that resemble racial microaggressions.	André’s performance anxiety causes him to appear distracted in session.	André shares that a client reminds him of his deceased mother.
Common Factors Strategy:	Supervisor reviews videotape of session with André and identifies an instance in which he exhibits a microaggression toward client. Supervisor gives André feedback on microaggressions and encourages André to engage in self-reflection on personal biases. (Provision of Feedback)	Supervisor reflects André’s feelings of anxiety and asks André to reflect on how his anxiety may be affecting his work with clients. (Supervisory Relationship – The Real Relationship)	Supervisor offers to help André process countertransference and communicates to André that he has handled the situation ethically and professionally by sharing with his supervisor his feelings of countertransference toward his client. (Supervisory Relationship and Provision of Feedback)

Practical Challenges and Limitations

Utilization of the CFDM might pose challenges that warrant discussion. For example, the CFDM might intensify the parallel process due to its similarities to the structures and processes of counseling. Moreover, CFDM’s parallels to counseling might blur the lines between supervision and counseling, making it important for supervisors to clearly delineate the role and functions of supervision. Thus, the CFDM endorses utilizing the Rogerian condition of genuineness to facilitate an open, collaborative discussion between the supervisor and supervisee when potentially problematic issues of parallel processing arise in supervision. Furthermore, the CFDM might be vulnerable to challenges in dual relationships, as the various discrimination model roles that the supervisor might assume could blur the lines between the supervisory relationship versus other relationships that the supervisor might have with the supervisee, such as that of instructor. Therefore, supervisors utilizing the CFDM are encouraged to have an open discussion with supervisees from the beginning of supervision concerning the purposes, limitations and boundaries of the supervisory relationship. Such conversations can be facilitated with the use of a professional disclosure statement that outlines the supervisor’s roles (Blackwell, Strohmer, Belcas, & Burton, 2002; Cobia & Boes, 2000).

Because the central tenet of the CFDM is the identified supervisory relationship, a potential challenge that is perhaps inherent in the CFDM is addressing weaknesses and ruptures in the supervisory relationship. The CFDM might also be challenging for supervisors or supervisees who inherently struggle to establish strong supervisory and therapeutic relationships. Supervisees who demonstrate limited ability to establish a strong therapeutic relationship might benefit from direct instruction on behavioral skills that facilitate the therapeutic relationship, such as reflections of feeling and meaning. Lampropoulos (2002) recommended that gatekeeping measures be implemented for students who consistently demonstrate deficiency in establishing a strong therapeutic relationship with clients. Finally, outcome research is indicated to examine the validity of applying common factors principles of psychotherapy to clinical supervision, as well as the empirical merit of an integrated common factors and discrimination model of supervision.

Conclusion

The supervision literature abounds with approaches for supervising counselors; however, there is little evidence that any one approach outperforms another. Common factors approaches to counseling and supervision draw on the components that are shared among models for a parsimonious approach that places emphasis on the factors that are essential in producing positive counseling and supervision outcomes. However, although such factors are necessary, they are not sufficient for yielding positive change. Therefore, Watkins and colleagues (2015) noted the necessity of applying the specific factors of some form of supervision to a common factors approach. We have responded to this call by presenting the CDFM, which integrates the specific factors of Bernard’s (1979, 1997) discrimination model with the most common elements of counseling and supervision approaches: (a) the supervisory relationship, (b) supervisee acquisition of new knowledge and skills, (c) supervisee self-awareness and self-reflection, and (d) assessment of supervisees’ needs and the delivery of feedback according to the tenets of the discrimination model.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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A. Elizabeth Crunk is a doctoral candidate at the University of Central Florida. Sejal M. Barden is an Assistant Professor at the University of Central Florida. Correspondence can be addressed to Elizabeth Crunk, University of Central Florida, College of Education and Human Performance, Department of Child, Family, and Community Sciences, 4000 Central Florida Blvd., P.O. Box 161250, Orlando, FL 32816-1250, elizabethcrunk@gmail.com.

Clinical Supervisors’ Perceptions of Wellness: A Phenomenological View on Supervisee Wellness

Oct 14, 2016 | Article, Volume 6 - Issue 4

Ashley J. Blount, Dalena Dillman Taylor, Glenn W. Lambie, Arami Nika Anwell

Wellness is an integral component of the counseling profession and is included in ethical codes, suggestions for practice and codes of conduct throughout the helping professions. Limited researchers have examined wellness in counseling supervision and, more specifically, clinical mental health supervisors’ experiences with their supervisees’ levels of wellness. Therefore, the purpose of this phenomenological qualitative research was to investigate experienced clinical supervisors’ (N = 6) perceptions of their supervisees’ wellness. Five emergent themes from the data included: (a) intentionality, (b) self-care, (c) humanness, (d) support, and (e) wellness identity. As counselors are at risk of burnout and unwellness because of the nature of their job (e.g., frequent encounters with difficult and challenging client life occurrences), research and education about wellness practices in the supervisory population are warranted.

Keywords: supervision, wellness, unwellness, phenomenological qualitative research, helping professions

Wellness is an integral component of the counseling profession (Myers & Sweeney, 2004; Witmer, 1985) and is included in ethical codes, suggestions for practice and codes of conduct throughout the helping professions of counseling, psychology and social work (American Counseling Association [ACA], 2014; American Psychological Association [APA], 2010; National Association of Social Workers [NASW], 2008). Yet, individuals in the helping professions do not necessarily practice wellness or operate from a wellness paradigm, even though counselors are susceptible to becoming unwell because of the nature of their job (Lawson, 2007; Skovholt, 2001). As a helping professional, proximity to human suffering and trauma, difficult life experiences and additional occupational hazards (e.g., high caseloads) make careers like counseling costly for helpers (Sadler-Gerhardt & Stevenson, 2011). Further, helpers may be vulnerable to experiencing burnout because of their ability (and necessity because of their career) to care for others (Sadler-Gerhardt & Stevenson, 2011). Compassion fatigue, vicarious traumatization and other illness-enhancing issues often coincide with burnout, increasing the propensity for therapists to become unwell (Lambie, 2007; Puig et al., 2012). Extended periods of stress also can lead to helping professionals’ impairment and burnout and can negatively impact quality of client services (Lambie, 2007). Furthermore, counselors who are unwell have the potential of acting unethically and may in turn harm their clients (Lawson, 2007). Thus, it is imperative that helping professionals’ wellness be examined.

More specifically, counseling professionals are required to follow guidelines that support a wellness paradigm. ACA (2014) states that counselors should monitor themselves “for signs of impairment from their own physical, mental, or emotional problems” (Standard C.2.g.). In addition, counselors are instructed to monitor themselves and others for signs of impairment and “refrain from offering or providing professional services when such impairment is likely to harm a client or others” (ACA, 2014, F.5.b.). The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) supports counselors having a wellness orientation and a focus on prevention (Section II.5.a.) and that counselors promote wellness, optimal functioning and growth in clients (Section II.2.e.). Thus, prevention of impairment and a wellness focus are intertwined throughout the standards of the counseling profession. Consequently, it is unethical for counseling professionals to operate while personally or professionally impaired.

Wellness and Supervision in Counseling

In the following section, the importance of wellness and potential impacts of unwellness in the counseling profession will be discussed. Specifically, stressors contributing to impairment will be highlighted. In addition, supervision within a counseling context and general information regarding the supervisory experience will be reviewed.

Wellness and the Counseling Profession

The counseling profession was founded on a wellness philosophy, with holistic wellness including personal characteristics, such as nutritional wellness, physical wellness, stress management and self-care (Puig et al., 2012), and other realms including spiritual, occupational and intellectual well-being (Myers & Sweeney, 2008). According to Carl Rogers (1961), personal characteristics influence counselors’ ability to help others. For instance, individual wellness may influence how knowledgeable, self-aware and skillful supervisees are in relation to working with clients (Lambie & Blount, 2016). Counselors who are well are more likely to be helpful to their clients (Lawson & Myers, 2011; Venart, Vassos, & Pitcher-Heft, 2007), and counselors’ mental health and wellness impacts the quality of services clients receive (Roach & Young, 2007). Therefore, counselor preparation programs and supervisors should discuss wellness and areas in which impairment could arise when training students to become counselors and supervisors (Roach & Young, 2007). Though wellness is a core aspect of counselor training and preparation, many practicing counselors report their colleagues to be stressed (33.29%), distressed (12.24%) and impaired (4.05%; Lawson, 2007).

Individuals who are attracted to and enter into helping fields often appear to have severe adjustment and personality issues, and these individuals may range from students entering into programs to faculty members employed by institutions (Witmer & Young, 1996). In addition, counselors are often remiss about taking their own advice about wellness (Cummins, Massey, & Jones, 2007) and frequently preach wellness to their clients but do not practice wellness personally (Myers, Mobley, & Booth, 2003). Many counselors do not see their own impairment or are unwilling to take the steps to get help (Kottler, 2010), supporting the importance of supervisors identifying and addressing their supervisees’ impairment. Consequently, counselors seeing clients in agency settings, private practices and other settings may experience stressors that are influencing their wellness and, in parallel, the wellness of their clients.

With the counseling profession having a wellness undertone, counselors are expected to promote well-being in their clients and model appropriate wellness lifestyles. Nevertheless, counselors experience job stressors that impact their abilities to be effective helping professionals (Puig et al., 2012). Counselors face several stressors within their career such as managed care, financial limitations, high caseloads, severe mental disorders in clientele and lack of support (O’Halloran & Linton, 2000). Other factors impacting counselors and mental health professionals include: (a) compassion fatigue (Perkins & Sprang, 2012), (b) unhappy workplace relationships (Lambie, 2007), (c) vicarious trauma (Trippany, White Kress, & Wilcoxon, 2004), and (d) general fatigue (Lambie, 2007). Moreover, these systemic factors contribute to increased likelihood for counselors to experience burnout and impairment, impacting their clients’ therapeutic outcomes (Puig et al., 2012). Furthermore, counselors may not disclose their impairment because of denial, shame, professional priorities, lack of responsibility and fear of reprisal (Kottler & Hazler, 1996).

Counselor impairment occurs when counselors ignore, minimize and dismiss their personal needs for health, self-care, balance and wellness (Lawson, Venart, Hazler, & Kottler, 2007). Lawson and colleagues (2007) stated counselors need awareness of their personal wellness and should work to maintain their wellness. In addition, ACA (2014) states that counselors are responsible for seeking help if they are impaired and that it is the duty of colleagues and supervisors to recognize professional impairment and take appropriate action (Standard C.2.g.). Thus, counselors and supervisors are responsible for not only maintaining their personal wellness, but are also responsible for monitoring the wellness or impairment of their colleagues. One of the platforms for monitoring counselor wellness is supervision.

Supervision

ACA (2014) stipulates that supervision involves a process of monitoring “client welfare and supervisee clinical performance and professional development” (Standard F.1.a.). Supervision is an integral component of the counseling profession, involving a relationship in which an experienced professional facilitates the development of therapeutic competence in another (Bernard & Goodyear, 2014). Furthermore, supervision is fundamental in developing and evaluating counselors’: (a) skills (Borders, 1993), (b) wellness (Lenz, Sangganjanavanich, Balkin, Oliver, & Smith, 2012), and (c) development into competent and effective counselors (Swank, Lambie, & Witta, 2012). Clinical supervisors are tasked with evaluating their supervisees’ effectiveness in addition to their level of wellness (Puig et al., 2012). Consequently, stressors, such as personal and cultural issues, addictions, burnout, and other counseling-related occupational challenges, may negatively influence supervisees’ wellness and ability to be effective helping professionals.

Supervision “provides a means to impart necessary skills; to socialize novices into particular profession’s values and ethics; to protect clients; and finally, to monitor supervisees’ readiness to be admitted to the profession” (Bernard & Goodyear, 2014, p. 5). Supervisors have the unique opportunity to operate from a wellness paradigm, socialize their supervisees to wellness practices, monitor supervisee wellness, and gauge how supervisees’ wellness influences client outcomes (Lambie & Blount, 2016). As a result, supervisors who operate from a wellness paradigm and evaluate their supervisees’ wellness may influence the wellness of supervisees’ clients by encouraging positive client outcomes (Lawson, 2007; Lenz & Smith, 2010). As such, supervisee and supervisor wellness is an important component of counselor preparation programs and clinical supervision (Lenz et al., 2012).

Counselor educators (Wester, Trepal, & Myers, 2009), clinical supervisors (Lenz & Smith, 2010; Storlie & Smith, 2012), counselors-in-training (Myers & Sweeney, 2004; Smith, Robinson, & Young, 2007), and licensed counselors (Lawson, 2007; Myers et al., 2003) face challenges in obtaining optimal well-being (e.g., high caseloads, proximity to client trauma, empathizing with students and clients). Supervisors play an integral role in counselor trainee development and can model appropriate wellness behaviors for their supervisees. Furthermore, supervisors have the unique opportunity to work closely with their supervisees and provide an in-depth look at how emerging counselors are learning about wellness behaviors, partaking in wellness actions and promoting wellness in their clients. Nevertheless, no available research has examined experienced clinical supervisors’ perceptions of their supervisees’ wellness. Because clinical supervisors have a close relationship with their supervisees, their perceptions of their supervisees’ wellness can provide important information for the counseling profession. Therefore, the following research question guided our investigation: What are clinical mental health supervisors’ experiences with their supervisees’ wellness?

Methodology

Identifying themes related to clinical supervisors’ experiences of their supervisees’ wellness provides insights for both supervisors and supervisees. The researchers followed a psychological phenomenological methodology (Creswell, 2013a; Moustakas, 1994), allowing for both the meaning (themes) and the essence (experience) of the participants to be examined. In phenomenological research, researchers attempt to identify the essence of participants’ experiences surrounding a phenomenon. By developing interview questions and using an interview protocol technique (Creswell, 2013b), the researchers petitioned participants’ (i.e., clinical supervisors) direct and conscious experiences (Hays & Wood, 2011) to assess their perceptions of their supervisees’ wellness (see Table 1). The following section includes discussion on: (a) epoche and bracketing, (b) participants, (c) procedure, (d) qualitative data analysis and (e) trustworthiness.

Epoche

The first course of action in phenomenological analysis is called epoche (Patton, 2015); therefore, the research team members are described with some of their potential biases. The research team consisted of two counselor educators, a counselor education doctoral candidate, and a counseling master’s student (one man and three women), all of whom identify as Caucasian. All of the researchers were affiliated with the same institution, a large, public, CACREP-accredited university located in the Southeastern United States. In addition, biases relating to the effectiveness of supervisory styles were discussed, and bracketing throughout the data analysis was implemented in order to minimize bias and allow for participant perspectives to be at the forefront. Participant experiences were documented in personal interviews and in the form of collaborative discussions.

Participants

The participants consisted of clinical supervisors who were purposefully selected from a Department of Health and Human Services counseling professional list from a large, southeastern state. Initial criteria for participation in the investigation included: (a) being clinical supervisors for 10 or more years and (b) being in an active supervisory role (i.e., providing supervision). Twenty-six participants initially responded, with 17 individuals meeting the necessary requirements for participation. The final sample consisted of six clinical supervisors, based on individuals who agreed to participate.

Criterion were established to support interviewing only “experienced” supervisors (i.e., supervisors with extensive supervision experience) and participants’ mean number of years of experience as clinical mental health supervisors was 21.2 years. Four of the experienced supervisors identified as female and two identified as male, and their ages ranged from 49 years to 63 years (M = 56.5 SD = 4.93). In addition, four of the participants identified as Caucasian (n = 4), one participant identified as Hispanic (n = 1), and one participant identified as Other (n = 1; i.e., chose not to disclose). The participants represented the following theoretical approaches: humanistic/Rogerian (n = 3), integrative/eclectic (n = 2) and cognitive-behavioral (n = 1). Primary supervision models for the clinical supervisors included: eclectic/integrative (n = 4), person-centered (n = 1) and solution focused (n = 1). The participants served as clinical supervisors at six different mental health agencies throughout a large southeastern state, supporting transferability of the findings.

In reference to wellness, the participants were asked to evaluate their level of wellness prior to participating in the interview process. Specifically, participants were asked to define what wellness meant for them as well as elaborate on the specific areas they felt influenced their wellness. Participants then rated on a 5-point Likert scale their level of overall wellness (i.e., 1 indicating very low wellness, 5 indicating very high wellness). Four of the six participants rated their overall wellness as 5 (very high wellness), while the remaining two individuals rated their overall wellness as 3 (average wellness) and 4 (high wellness) respectively. Thus, the participants reported having average to high levels of personal wellness.

Procedure

Before conducting the investigation, Institutional Review Board (IRB) approval was obtained. Following IRB approval, the researchers employed purposeful sampling (Hays & Wood, 2011) to recruit participants by accessing a public listing of all mental health practitioners in a southeastern state in the United States. The Department of Health and Human Services counseling professional list was utilized, which included e-mail addresses, telephone numbers and mailing addresses of potential participants. Twenty-six participants met the initial response criteria (i.e., 10 or more years of supervisory experience). Snowballing also was used to recruit additional participants (i.e., asking participants for a name of an individual who might fit the study criteria). However, of the 26 participants, 17 supervisors responded with complete general demographic questionnaires and sufficient number of years as supervisors (i.e., minimum of 10 years). Six individuals fit the final purposive sampling criteria for participating in the investigation (e.g., had over 10 years of clinical mental health supervisory experience, still practicing as supervisors in diverse agencies, and having a complete general demographic form).

The first round of data collection was essential in confirming the eligibility of the participants (e.g., completion of the general demographic questionnaire and informed consent form). The demographic questionnaire consisted of questions about personal wellness, ethnicity, theoretical orientation, age, gender and primary population served. Following completion of the initial documents, individual interviews were scheduled. The second round of data collection involved face-to-face or Skype interviews with each participant, where participants were asked the general research question: What are your experiences with your supervisees’ wellness? The researchers also had nine supporting interview questions, which were developed through a rigorous process involving: (a) researchers’ development of an initial question blueprint derived from the literature reviewed for the study, (b) experts’ review and modification of the initial questions, and (c) an initial pilot group testing the questions. The experts were comprised of educators with experience in conducting qualitative research, experience providing supervision and familiarity with the wellness paradigm.

The interview protocol included instructions for the interviewer, research questions, probes to follow the research questions (if needed), space for recording comments, and space for reflective comments to ensure all interviews followed the same procedure (Creswell, 2013a). The general interview questions were developed to aid in addressing the overall question of supervisors’ perceptions of their supervisees’ wellness and all individual interviews were audio recorded and then transcribed. The final list of interview questions is presented in Table 1. The researchers conducted all interviews individually, and to support the effectiveness of gathering the participants’ experiences, member checking was implemented (Creswell, 2013a). Specifically, all participants were e-mailed a copy of their interview transcription, along with a statement of themes and interpretation of the interview’s meaning. All participants (N = 6) responded to member checking and stated that their transcribed interview was accurate and agreed with the themes derived from their interviews.

Table 1

Interview Question Protocol

Data and Rationale	Draft Interview Questions	Prompts and Elicitations
Values (gaining perceptions)	1. What does wellness mean to you?	Wellness, health, well-being
Beliefs, Values (learning expectations, perceptions)	2. What influences wellness in counselors?	Counselor-specific wellness
Values (gaining perceptions)	3. What is the most important aspect of wellness?	Crucial component(s)
Values, (gaining perceptions, opinions)	4. Is wellness the same or different for everyone?	Wellness looks like . . . individualized
Experiences, Values (what influences clients)	5. Does wellness influence your supervisees’ client(s)?	Wellness impacts clients, or supervisees’ clients
Experiences, Values (gaining information on standards of wellness and if they are being upheld)	6. Do you feel your supervisees uphold to standards of wellness in the counseling field?	Meeting standards, CACREP, ACA Ethics
Beliefs, Experiences (expectations of supervisors, experiences)	7. What does unwellness in counseling supervisees look like?	Depiction of unwellness
Beliefs, Experiences (expectations, experiences of seasoned counselors)	8. What does unwellness in counselors-in-the field look like?	Unwellness “picture”
Values, Beliefs (gaining other information relating to wellness)	9. Is there anything else you would like to tell me about wellness?	Personal wellness philosophy
Note: Draft Interview Questions were used in all participant interviews.

Data Analysis

The researchers followed Creswell’s (2013a) suggested eight steps in conducting phenomenological research: (a) determining that the research problem could best be examined via a phenomenological approach (e.g., discussed the phenomenon of wellness and its relation to the counseling field and in the supervision of counselors); (b) identifying the phenomenon of interest (wellness); (c) bracketing personal experiences with the phenomenon; (d) collecting data from a purposeful sample; (e) asking participants interview questions that focused on gathering data relating to their personal experiences of the phenomenon; (f) analyzing data for significant statements (horizontalization; Moustakas, 1994) and developing clusters of meaning; (g) developing textural and structural descriptions from the meaning units; and (h) deriving an overall essence. In order to maintain organization, the researchers implemented color-coding of statements by selecting one color for initial significant statements or codes (e.g., step f), another color for textural descriptions (e.g., what participants experienced in step g) and a final color to represent structural descriptions (e.g., how participants experienced the phenomenon in step g) of the data (Creswell, 2013a). Finally, the researchers determined an overall essence (step h) based on the structural descriptions of the participants’ interview transcriptions. Following individual coding (i.e., steps f, g, and h), the researchers discussed their initial results and discrepancies, evaluating these discrepancies until reaching consensus.

Trustworthiness

The researchers established trustworthiness by bracketing researcher bias, implementing written epochs, triangulating data, implementing member checking, and providing a thick description of data (Creswell, 2013a; Hays & Wood, 2011). Coinciding with Denzin and Lincoln (2005), the researchers triangulated data collection using (a) a general demographic questionnaire, (b) semi-structured interviews and (c) open-ended research questions. Epochs allowed the researchers to increase their awareness on any biases present and set aside their personal beliefs. Member checking was employed in order to confirm the themes were consistent with the participants’ experiences. As such, participants were provided the opportunity to voice any concerns or discrepancies in their interview transcripts and in their derived meaning statements. The participants indicated no discrepancies or concerns. A thick description (detailed account of participants’ experiences; Lincoln & Guba, 1985) of the data was supported by the participants’ statements and derived themes. In addition, an external auditor was used to evaluate the overall themes and essence of the interviews and to mitigate researcher bias. The external auditor examined the transcripts separate from the other research members in order to evaluate the effectiveness of the derived themes and participant experiences.

Results

Following audio recording and transcription of the participant interviews, the researchers examined the participants’ responses and generated narratives of the emergent phenomena. As a result, themes of supervisees’ wellness from the clinical mental health supervisors’ experiences were derived and included: (a) intentionality, (b) self-care, (c) humanness, (d) support and (e) wellness identity. The themes are discussed in detail below.

Intentionality

Intentionality was defined as the supervisor purposefully utilizing supervisory techniques and behaviors that elicit self-awareness and understanding in their supervisees (i.e., both of self and of their clients). The process of intentionality involved the supervisor actively engaging supervisees in discussions about wellness as well as actively modeling for the supervisees. Within the interviews, supervisors alluded to a parallel process that occurred between the supervisor–supervisee and supervisee–client dyads. When the supervisor intentionally modeled appropriate wellness between self and supervisee, the supervisee could then implement similar wellness activities between self and client. Reflecting on the process of supervisory modeling, Supervisor #1 stated:

The supervisor . . . has a lot . . . a lot of influence . . . checking in, what are you doing to take care of yourself? You seem really stressed, what is your wellness plan? What is your stress management? How do you detach yourself and unplug yourself from your responsibilities with your clients at work . . . to take care of you?

As depicted, the supervisor intentionally asked the supervisee questions relating to personal wellness and started a conversation about supervisees separating themselves from their work life. Supervisor #2 confirmed the importance of modeling as evidenced by the statement, “you can’t preach to someone to do something if you are not doing it yourself.” In other words, the supervisor alluded to the idea that supervisors must model appropriate professional and personal behaviors to their supervisees. Additionally, the supervisors discussed the impact of a trickledown effect (e.g., parallel process): how the supervisor approaches supervisees in turn affects how supervisees approach their clients. For instance, if the supervisor exhibited signs of burnout, then the behaviors would directly impact their relationship and understanding of the supervisee, which would indirectly impact their supervisee’s clients. Supervisor #3 noted that the wellness of supervisees influenced client wellness by saying “Oh, I can definitely see when my supervisees are unwell and how that directly influences their work with clients. It’s like they’re (supervisees) not on top of their game . . . like they’re not as effective with clients.” Furthermore, supervisors noted the use of direct interventions to help supervisees gain increased self-awareness after recognizing supervisees’ potential unwellness. Supervisor #5 stated in reference to a conversation with a supervisee, “I want you to be in the field to better help people by helping yourself and looking at your own issues.” Thus, supervisors need to be intentional when helping supervisees become more effective and more well in both their personal and professional lives.

Self-Care

Self-care was defined as the necessity of taking care of one’s self in order to be a better asset to supervisees and clients. The self-care theme supported the idea that “you cannot give away that which you do not possess” (Bratton, Landreth, Kellam, & Blackard, 2006, p. 15), which is consistent in the counseling and other helping professional literature (Lawson, 2007). In other words, we must take care of ourselves before we are able to care for others. Self-care is delineated from the theme of intentionality in this investigation in that supervisors reflected the importance of their own self-awareness to gauge wellness, especially to alleviate the potential for burnout. For example, Supervisor #4 stated, “If I’m not well, I can’t really help someone else get well.” Whereas the theme of intentionality reflects encouraging supervisees’ self-awareness, the self-care theme notes the importance of supervisors being self-aware and the specific actions supervisors felt they and their supervisees could take to promote self-care in their own lives. As Supervisor #6 said, “it’s an incredible field and it can be a very, very draining field if you aren’t careful, if you don’t take care of yourself.” Through the supervisors’ process of reflection and recognition, they were able to respond with care and compassion to their supervisees. However, as Supervisor #5 indicated when reflecting on counselor and supervisor burnout,

[It] happens to every single counselor, they’re going to experience compassion fatigue at some point in their career because it is a burnout job, and so to recognize . . . the signs . . . sometimes it takes someone else to point it out to us.

It is crucial to take care of oneself in counseling and be open to feedback from others who may see our behaviors from an objective standpoint. Furthermore, the supervisors noted the critical impact of taking care of themselves through activities outside of the workplace and leaving client and supervisee concerns at work. For example, Supervisor #3 noted:

I feel you need to take care of yourself, you need to do stuff for you . . . I’m clear to sit down with all of them [supervisees] and say . . .what are you going to . . . do good for yourself today . . . what are you going to do for you?

By creating differentiation between personal and professional life, supervisors and supervisees are able to rejuvenate, leading to better care for supervisees as Supervisor #1 indicated:

I do feel there are many ways to go about it . . . there’s a whole mindfulness movement, and yoga . . . animals . . . those are all ways we can go ahead and keep ourselves well. I think play is a component of keeping yourself well and . . . there are different definitions of play, but I would define it as when you’re so involved in doing something that you lose track of time. That could be art activities . . . dancing, doing something fun with your dog . . . playing games . . . being involved in something where time stands still and you’re totally in the moment. . . . I think that’s another key piece of really staying well.

As a result, the self-care theme involves supervisors identifying and implementing strategies to keep themselves well, as well as supervisees engaging in activities to support their own self-care journeys. Similar to other wellness research in the helping professions (Lawson, 2007; Myers & Sweeney, 2005b; Skovholt, 2001), self-care is paramount to supporting personal wellness, as well as having the capacity to promote wellness in others—supervisors with supervisees and in parallel, supervisees with clients.

Humanness

Humanness was defined as the supervisors’ and supervisees’ culture, history, background and the influences of previous life experiences on the therapeutic relationship. Our past actions, memories and families of origin influence our worldview and current functioning. As Supervisor #3 noted, “I define wellness on a personal level, it has to do with me and my personhood, it is unique and is based on my wants and needs.” In reference to the influence of individuals’ history and background, Supervisor #2 stated, “for myself definitely it was pretty much the way I grew up . . . it depends on the population, it depends on where they were raised. . . . There’s just too many dependent variables for it.” At times, supervisors noted that these factors lead to unintentional blindness between and within the dyad (i.e., supervisor–supervisee, supervisee–client). Supervisor #3 noted that “we all have biases, we all have prejudices on some level. Are you willing to acknowledge that you are struggling with this, but I am willing to work on this, willing to go to workshops or go into therapy?” Without reflection or self-awareness, supervisors and supervisees are susceptible to similar roadblocks and “stuckness” as their clients. For instance, Supervisor #4 noted the influence of current life events impacting her overall wellness:

I think to add to that, it is the nature of our human experience. . . . we are going to go through phases in our lives where things are affected to the point to where you would say this aspect of my life is not well right now.

Thus, supervisors perceive both their humanness (e.g., backgrounds and cultures) and their supervisees’ humanness qualities as influential to the therapeutic relationship and important in supervisees’ actions in counseling situations as well as personal settings (Lambie, 2006).

Support

Support was defined as leaning on and connecting with others (e.g., peer-to-peer, colleagues, friends, partners). Supervisors emphasized the importance of both themselves and their supervisees developing and maintaining significant relationships within the context of their job and outside the work setting. Supervisor #6 reflected that “support is integral to . . . overall wellness and, being that we are social creatures . . . support [is] really important for us.” Relationships at work can be crucial for processing tough client cases and personal issues that appear to be encroaching upon work with clients. For example, Supervisor #3 emphasized, “I think there has to be a support system of counselors who have been in the field . . . and having your own therapist.” At the same time, social relationships outside work are equally important. Similar to self-care and intentionality, separating personal life and professional life aids the supervisor and supervisee in leaving client cases at work and enjoying life beyond the role as a counselor. Within the literature, the influence of support aids supervisors and supervisees in achieving wellness and minimizing the likelihood of counselor burnout (Lambie, 2007; Lee, Cho, Kissinger, & Ogle, 2010).

Wellness Identity

Wellness identity was defined as the supervisors and supervisees operating from a wellness platform. Supervisors noted the necessity of holding this wellness platform in the forefront of conversations with students, other supervisors, and other therapists and counselors. As Supervisor #3 reflected,

We practice a strengths-based model and we see that the wellness model is depicted much, much more not only in the literature but also in the things that come about. . . . I’d rather see research in wellness rather than case research in defects.

Through attaching wellness to one’s identity as a counselor, supervisors and supervisees are compelled to continuous self-reflection on how external factors impact their work with supervisees and clients. Supervisor #1 stated “wellness is who we are, if we find ourselves straying, we probably need to re-evaluate things.” Furthermore, supervisors indicated in their interviews that wellness is an important topic for counselors and counselor educators to reflect upon and teach and discuss with students and supervisees. For instance, Supervisor #2 stated in relation to the idea of a wellness identity: “It comes from the teaching that one receives in the classroom. . . . I think that the issues have really brought it to the forefront and it has allowed us to teach wellness and to talk about it. I think teaching is the driving force.”

As shown in the wellness identity theme, all of the supervisors supported the idea that having a wellness base from which helpers operate is important. Additionally, the participants noted the importance of an open dialogue on wellness between supervisors and supervisees and, coinciding with Granello (2013) and Roach and Young (2007), stressed the idea that as a supervisor, wellness education can play a key role in promoting healthy helping professionals.

Discussion

The results from this study provided the data to answer the research question: What are clinical mental health supervisors’ experiences with their supervisees’ wellness? Experienced supervisors (e.g., 10 or more years of supervisory experience) discussed areas that influenced their wellness as well as their supervisees’ wellness. Furthermore, several themes that supported an essence of supervisee wellness (Hays & Wood, 2011; Moustakas, 1994) were derived. In interviewing the supervisors, the themes of (a) intentionality, (b) self-care, (c) humanness, (d) support and (e) wellness identity were derived from the data analysis. From the results of this study, implications for clinical supervisors and counselor educators, limitations of the research investigation, and areas for future research were derived.

Implications for Clinical Supervisors and Counselor Educators

The counseling field is grounded in holistic wellness (Myers & Sweeney, 2004). Therefore, our findings reflected the theme that wellness is important to the counseling profession and in supporting supervisors’ and supervisees’ overall growth. Scholars in the helping fields (Keyes, 2002, 2007; Myers, Sweeney, & Witmer, 2000) and professional guidelines (ACA, 2014; CACREP, 2015) support the necessity of a wellness focus, identifying that a lack of a wellness focus may lead to unwellness and burnout (Bakker, Demerouti, Taris, Schaufeli, & Schreurs, 2003). Thus, creating and maintaining a wellness identity in supervision can aid in supporting holistic wellness in supervisees. In addition, self-care can be important for counselors, as they are not immune to difficult experiences and life events faced by their clients (Venart et al., 2007). Supervisor #6 noted that burnout was an inevitable part of working as a counselor and, similarly, researchers have identified that burnout can influence counselors’ work with their clients (Lambie, 2007; Puig et al., 2012). Thus, wellness provides the foundation of helping professionals’ work with clients (Venart et al., 2007), and exploration of counselor burnout and other negative consequences of counselor unwellness warrants attention.

The clinical supervisors in our investigation indicated a need for counselor educators to be more intentional in their focus and inclusion of wellness with the therapeutic relationship. In order to mitigate the effects of burnout and unwellness in supervisees, a wellness course or a wellness plan for counselors-in-training over the duration of their preparation program is suggested to support counselor educators in preparing future clinicians with a mindset of reflection, process and activities to enhance wellness. By implementing a wellness focus throughout preparation programs, supervisees can learn about the positive and negative influence of their wellness choices, as well as the effects their wellness may have on their colleagues and clients. Furthermore, wellness plans could be implemented throughout the program to promote wellness awareness in supervisees. Classroom discussions and wellness groups could also aid in supporting students in their wellness growth and development throughout their program while providing counselors-in-training with the tools to share their knowledge and promote wellness in others.

Supervisors also can mitigate the effects of unwellness by continuously evaluating their current levels of functioning through formal assessments such as the Five Factor Wellness Inventory (5F-Wel; Myers & Sweeney, 2005a), or the Helping Professional Wellness Discrepancy Questionnaire (HWPDS; Blount & Lambie, in press) or informal assessments such as wellness journaling or implementing wellness plans. Supervisors also may choose to include wellness in their supervision sessions by assessing pre- and post-wellness levels in supervisees, operating from a wellness-supervision paradigm (e.g., the Integrative Wellness Model; Blount & Mullen, 2015; Wellness Model of Supervision; Lenz & Smith, 2010), having educational discussions on the holistic components of wellness, and modeling appropriate wellness behaviors. Thus, there are numerous actions supervisors can take to promote individual wellness, include wellness in their supervision, and promote wellness in their supervisees.

Supervision is crucial to counselor development (Bernard & Goodyear, 2014). CACREP (2015) Standards and licensure requirements emphasize the importance of supervision throughout trainees’ growth and establishment as a professional counselor. ACA (2014) emphasizes additional professional development and supervision throughout counselors’ careers, stating that counselors should “regularly pursue continuing education activities including both counseling and supervision topics and skills” (Standard F.2.a.). Even though the field of counseling is grounded in a wellness paradigm (ACA, 2014; CACREP, 2015), the process of supervision does not always support a wellness focus, as supervisors do not model wellness for their supervisees or stress the importance of counselor well-being. According to the supervisors in our investigation, wellness should be integrated and discussed within the supervision realm. Further, clients are more likely to benefit from a well counselor (Lawson, 2007) and as such, counselor educators and supervisors face the challenge of promoting effective, well therapists-in-training. The wellness process, however, typically occurs in a negative trickledown method (e.g., burned out supervisors modeling inappropriate wellness behavior for trainees who in return model inappropriate wellness for clients).

Counselor educators can break the cycle of negatively modeling wellness by incorporating wellness throughout the trainees’ experience in their preparation programs and by modeling wellness and self-care. Through the wellness paradigm, counselor educators can begin to change the thought process of trainees’ own reluctance to engage in self-care and work to change the “do as I say” mentality (i.e., telling clients or trainees to be well when we are not well ourselves), which is present throughout the helping professions (Lawson, 2007; Witmer & Young, 1996). Based on our results, the counseling profession should embrace the belief that “you cannot give away that which you do not possess” (Bratton et al., 2006; p. 238). By adapting a wellness framework, the benefits of the wellness paradigm at the beginning of trainees’ careers is significant, impacting other counselors and clients that enter into their path in a positive way.

Expanding beyond supervisors, therapists-in-training and practitioners, wellness practices can be influential on a larger scale. Counseling and counselor education programs, as well as respective professional organizations, can use wellness philosophies and practices to promote self-care in their members. In addition, organizations can support strong wellness identities in their helping professionals by upholding their ethical standards, promoting wellness-related actions, and educating new professionals on the importance of practicing wellness in their personal and professional lives. As voiced by many of the supervisors interviewed in our study, professional organizations can support their members by encouraging wellness identities and offering platforms for individuals to form relationships with other practitioners in the field. Practitioners can use the connections to exchange wellness ideas and practices, and offer support as professionals. Finally, supervisors can be integral in promoting their supervisees’ wellness throughout the career, supporting the services they provide to diverse clients.

Limitations

We followed steps to support the trustworthiness of the data; however, some limitations are noted. Given that the first author is invested in the wellness approach to counseling, researcher bias may have occurred. However, the research team implemented steps to mitigate the role of bias. For instance, researcher bias was bracketed at the forefront of the interviews and an external auditor reviewed interviews to note themes separate from the research team. As with all qualitative research, the results from our study are not generalizable. Nevertheless, the six clinical mental health supervisors worked in six different mental health agencies, supporting the transferability of the findings (Yardley, 2008). In addition, the sample size for the investigation met the criteria outlined for qualitative analyses (5–25 participants; Polkinghorne, 1989), yet all of the participants volunteered for participation and may have had a greater interest in wellness than those who did not volunteer. Finally, even with a small sample size (N = 6), the researchers believed that saturation of the themes occurred by implementing rigorous data analytic procedures (i.e., coding for themes and essence) and reaching an inability to glean new information from the coding (Guest, Bunce, & Johnson, 2006).

Areas for Future Research

In relation to future research endeavors, participants in this study emphasized the importance of wellness-related research in counseling. Given that the counseling field is grounded in a wellness model (Myers & Sweeney, 2005b; Witmer, 1985) and that limited studies on wellness are available, quantitative and/or qualitative studies examining the overall effect of wellness within the supervisory relationship are needed. Further, researchers might assess the degree to which supervisors or supervisees actually engage in wellness behaviors. As with most qualitative studies, our findings reflect a starting point for quantitative research, focusing on the identified themes across supervisors and supervisees. Future researchers could examine the parallel process between (a) educator and student and (b) supervisor and supervisee that takes place when trusting and safe relationships are established (Bernard & Goodyear, 2014). Furthermore, future researchers could assess differences in supervisors or supervision styles in supervisors with formal supervision courses versus no formal experience; or similar studies with supervisors who have participated in a wellness course versus those who have not. In addition, future research could focus on client outcomes when one party (i.e., counselor) models appropriate wellness and a different counselor does not model these qualities. Future researchers are also encouraged to assess the effect of the five identified themes on client outcomes and/or student progress within counselor education programs.

In summary, “it is not possible to give to others what you do not possess” (Corey, 2000, p. 29); therefore, we must take care of ourselves before we are fully capable to help others. As such, it is important to bring wellness to the forefront of clinical supervision and remain engaged in promoting personal wellness and the wellness of others. Thus, assessing and evaluating wellness in all supervisors and supervisees (counselors) is integral in providing quality supervision and efficacious counseling services and protecting client welfare. By increasing awareness on wellness themes, such as self-care, support, wellness identity, and humanness, along with operating intentionality, clinical supervisors can support their supervisees in achieving greater levels of wellness.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

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Ashley J. Blount, NCC, is an Assistant Professor at the University of Nebraska Omaha. Dalena Dillman Taylor is an Assistant Professor at the University of Central Florida. Glenn W. Lambie, NCC, is a Professor at the University of Central Florida. Arami Nika Anwell is a recent graduate of the University of Central Florida. Correspondence can be addressed to Ashley Blount, 6001 Dodge Street, RH 101E, Omaha, NE 68182, ablount@unomaha.edu.

Examining the Practicum Experience to Increase Counseling Students’ Self-Efficacy

Jul 14, 2016 | Article, Volume 6 - Issue 2

James Ikonomopoulos, Javier Cavazos Vela, Wayne D. Smith, Julia Dell’Aquila

Master’s level counseling programs accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP, 2016) require students to complete practicum and internship courses that involve group and individual or triadic supervision. Although clinical supervision provides students with effective skill development (Bernard & Goodyear, 2004), counseling students may begin practicum with low self-efficacy regarding their counseling abilities and skills. Given the importance of clinical supervision and counselor self-efficacy, it is surprising that there are limited studies that have examined the impact of supervision and practicum experience from the perspectives of supervisees. Almost all studies within this domain are qualitative and involve personal interviews with supervisees or supervisors (e.g., Hein & Lawson, 2008). In order to fill a gap in the literature and document the impact of the practicum experience, this study examined the effectiveness of the practicum experience encompassing direct counseling services, group supervision and triadic supervision to increase counseling students’ self-efficacy. First, we provide a literature review regarding group supervision, triadic supervision and counselor self-efficacy. Next, we present findings from a study with 11 counseling practicum students. Finally, we provide a discussion regarding the importance of these findings as well as implications for counseling practice and research.

Supervision in Counselor Education Coursework

CACREP requires an average of one and a half hours of weekly group supervision in practicum courses that involves an instructor with up to six counseling graduate students (Degges-White, Colon, & Borzumato-Gainey, 2012). Borders et al. (2012) identified that group supervisors use leadership skills, facilitate and monitor peer feedback, and encourage supervisees to take ownership of group process in group supervision. Borders and colleagues (2012) identified several benefits in group supervision, including exposure to multiple counselor styles and ability to learn about various educational issues. There also were challenges such as limited helpful feedback, brevity of case presentations, timing of group meetings and lack of educational opportunities. In another study, Conn, Roberts, and Powell (2009) compared hybrid and face-to-face supervision among school counseling interns. There were similarities in perceptions of quality of supervision, suggesting that distance learning can provide effective group supervision. CACREP counseling programs also require students to receive one hour of weekly supervision from a faculty member or doctoral student supervisor. Triadic is one form of supervision that involves a process whereby one supervisor meets and provides feedback with two supervisees (Hein & Lawson, 2008). Hein and Lawson (2008) explored supervisors’ perspectives on triadic supervision and found increased demands on the role of the supervisor. For example, supervisors felt additional pressure to support both supervisees in supervision. Additionally, Lawson, Hein, and Stuart (2009) investigated supervisees’ perspectives of triadic supervision. Noteworthy findings included: some students perceived less time and attention to their needs; importance of compatibility between supervisees; and careful attention must be given when communicating feedback, particularly if negative feedback must be given.

Finally, Borders et al. (2012) explored supervisors’ and supervisees’ perceptions of individual, triadic and group supervision. Benefits included vicarious learning experiences, peer-learning opportunities, and better supervisor feedback, while challenges included peer mismatch and difficulty keeping both supervisees involved.

Counselor Self-Efficacy

One of the most important outcome variables in counseling is self-efficacy. Bandura (1986) defined self-efficacy as individuals’ confidence in their ability to perform courses of action or achieve a desired outcome. Self-efficacy in counselor education settings might influence students’ thoughts, behaviors and feelings toward working with clients (Bandura, 1997). In the current study, counseling self-efficacy is defined as “one’s beliefs or judgments about his or her capabilities to effectively counsel a client in the near future” (Larson & Daniels, 1998, p. 1). Counselor self-efficacy also can refer to students’ confidence regarding handling the therapist role, managing counseling sessions and delivering helping skills (Lent et al., 2009). In higher education settings, researchers identified relationships between practicum students’ counseling self-efficacy and various client outcomes in counseling (Halverson, Miars, & Livneh, 2006). Self-efficacy also is positively related to performance attainment (Bandura, 1986), perseverance in counseling tasks, less anxiety (Larson & Daniels, 1998), positive client outcomes (Bakar, Zakaria, & Mohamed, 2011), and counseling skills development (Lent et al., 2009). Halverson et al. (2006) evaluated the impact of a CACREP program on counseling students’ conceptual level and self-efficacy. Longitudinal findings showed that counseling students’ perceptions of self-efficacy increased over the course of the program, primarily as a result of clinical experiences.

In another investigation, Greason and Cashwell (2009) examined mindfulness, empathy and self-efficacy among masters-level counseling interns and doctoral counseling students. Mindfulness, empathy and attention to meaning accounted for 34% of the variance in counseling students’ self-efficacy. Finally, Barbee, Scherer, and Combs (2003) investigated the relationship among prepracticum service learning, counselor self-efficacy and anxiety. Substantial counseling coursework and counseling-related work experiences were important influences on counseling students’ self-efficacy.

Purpose of Study

This study evaluated practicum experiences by using a single-case research design (SCRD) to measure the impact on students’ self-efficacy. In a recent special issue of the Journal of Counseling & Development, Lenz (2015) described how researchers and practitioners can use SCRDs to make inferences about the impact of treatment or experiences. SCRDs are appropriate for counselors or counselor educators for the following reasons: minimal sample size, self as control, flexibility and responsiveness, ease of data analysis, and type of data yielded from analyses. In the current study, the rationale for using an SCRD to examine the effectiveness of the practicum experience and triadic supervision was to provide counselor educators with insight regarding potential strategies that increase students’ self-efficacy. With this goal in mind, we implemented an SCRD (Lenz, Perepiczka, & Balkin, 2013; Lenz, Speciale, & Aguilar, 2012) to identify and explore trends of students’ changes in self-efficacy while completing their practicum experience. We addressed the following research question: to what extent does the practicum experience encompassing direct counseling services, group supervision and triadic supervision influence counseling graduate students’ self-efficacy?

Methodology

Instructors of record for three practicum courses formulated a plan to investigate the impact of the practicum experience on counseling students’ self-efficacy. We focused on providing students with a positive practicum experience with support, constructive feedback, wellness checks and learning experiences. With this goal in mind, we implemented a single case research design (Hinkle, 1992; Lenz et al., 2013; Lenz et al., 2012) to identify and explore trends of students’ changes in self-efficacy while completing their practicum experience. We selected this design to evaluate data that provides inferences regarding treatment effectiveness (Lenz et al., 2013). All practicum courses followed the same course requirements, and instructors shared the same level of teaching experience.

Participant Characteristics

We conducted this study with a sample of Mexican American counseling graduate students (N = 11) enrolled in a CACREP-accredited counseling program in the southwestern United States. This Hispanic Serving Institution had an enrollment of approximately 7,000 undergraduate and graduate students (approximately 93% of students at this institution are Latina/o) at the time of data collection. As a result, we were not surprised that all of the participants in the current study identified as Mexican American. Fifteen participants were solicited; four declined to participate. Participants (four men and seven women) ranged in age from 24 to 57 (M = 31; STD = 9.34). All participants were enrolled in practicum; we assigned participants with pseudonyms to protect their identity. Participants had diverse backgrounds in elementary education, secondary education, case management and behavioral intervention services. Participants also had aspirations of obtaining doctoral degrees or working in private practice, school settings, and community mental health agencies.

Instrumentation

Counselor Activity Self-Efficacy Scale. The Counselor Activity Self-Efficacy Scale (CASES) is a self-report measure of counseling self-efficacy (Lent, Hill, & Hoffman, 2003). This scale consists of 31 items with a 10-point Likert-type scale in which respondents rate their level of confidence from 0 (i.e., having no confidence at all) to 9 (i.e., having complete confidence). Participants respond to items on exploration skills, session management and client distress (Lent et al., 2003), with higher scores reflective of higher levels of self-efficacy. The total score across these domains represents counseling self-efficacy. Reliability estimates range from .96 to .97 (Greason & Cashwell, 2009; Lent et al., 2003). We used the total score as the outcome variable in our study.

Treatment

Over the course of a 14-week semester, participants received 12 hours of triadic supervision and approximately 25 hours of group supervision. We followed Lawson, Hein, and Getz’s (2009) model through pre-session planning, in-session strategies, administrative considerations and evaluations of supervisees. During triadic supervision meetings with two practicum students, the instructor of record conducted wellness checks assessing students’ well-being and level of stress, listened to concerns about clients, observed recorded sessions, provided support and feedback, and encouraged supervisees to provide feedback. The instructor of record also facilitated group supervision discussions on clients’ presenting problems, treatment planning, note-writing, and wellness and self-care strategies. All practicum instructors collaborated and communicated bi-weekly to monitor students’ progress as well as students’ work with clients. All students obtained a minimum of 40 direct hours while working at their university counseling and training clinic, where services are provided to individuals with emotional, developmental, and interpersonal issues. Treatment for depression, anxiety and family issues are the most common issues. The population receiving services at this counseling and training clinic are mostly Mexican American and Spanish-speaking clients who are randomly assigned to a practicum student after an initial phone screening.

Procedure

We evaluated treatment effect using an AB SCRD (in our case, we referred to this more precisely as BT for baseline and treatment), using scores on the CASES as an outcome measure. During an orientation before the semester, practicum students were informed that their instructors were interested in evaluating changes in self-efficacy. Students who agreed to participate in the current study completed baseline measure one at this time. Following this, we selected a pseudonym to identify each participant when completing counselor self-efficacy activity (CSEA) scales throughout the study. The baseline phase consisted of data collection for 3 weeks before the practicum experience. The treatment phase began after the third baseline measure, when the first triadic supervision session was integrated into the practicum experience. Individual cases under investigation were practicum students who agreed to document their changes in self-efficacy while completing the practicum experience. Given that participants serve as their own control group in a single case design, the number of participants in the current study was considered sufficient to explore the research question (Lenz et al., 2013).

Data Collection and Analysis

We implemented an AB, SCRD (Lundervold & Belwood, 2000; Sharpley, 2007) by gathering weekly scores of the CASES. We did not use an ABA design with a withdrawal phase given that almost all students enrolled in internship immediately after the semester. As a result, we did not want to collect data that would have tapped into students’ internship experiences. After three weeks of data collection, the baseline phase of data collection was completed. The treatment phase began after the third baseline measure where the first triadic supervision session occurred. After the 13th week of data collection, the treatment phase of data collection was completed due to nearing completion of the semester, for a total of three baseline and ten treatment phase collections. We did not collect additional treatment data points given that students were scheduled to begin internship at the conclusion of the semester. We only wanted to measure the impact of the practicum experience.

Percentage of data points exceeding the median (PEM) procedure was implemented to analyze the quantitative data from the AB single case design (Ma, 2006). A visual trend analysis was reported as data points from each phase were graphically represented to provide visual representations of change over time (Ikonomopoulos, Smith, & Schmidt, 2015; Sharpley, 2007). An interpretation of effect sizes was conducted to determine the effectiveness of triadic supervision integrated into the practicum experience when comparing each phase of data collection (Sharpley, 2007). Interpreting effect sizes for the PEM procedure yields a proportion of data overlap between a baseline and treatment condition expressed in a decimal format that ranges from zero and one. Higher scores represent greater treatment effects while lower scores represent less effective treatments. This procedure is conceptualized as the analysis of treatment phase data that is contingent on the overlap with the median data point within the baseline phase. Ma (2006) suggested that PEM is based on the assumption that if the intervention is effective, data will be predominately on the therapeutic side of the median. If an intervention is ineffective, data points in the treatment phase will vacillate above and below the baseline median (Lenz, 2013). To calculate the PEM statistic, data points in the treatment phase on the therapeutic side of the baseline are counted and then divided by the total number of points in the treatment phase. Scruggs and Mastropieri (1998) suggested the following criteria for evaluation: effect sizes of .90 and greater are indicative of very effective treatments; those ranging from .70 to .89 represent moderate effectiveness; those between .50 to .69 are debatably effective; and scores less than .50 are regarded as not effective

Results

Figure 1 and Table 1 depict estimates of treatment effect using PEM across all participants. Detailed descriptions of participants’ experiences are provided below.

Participant 1

Jorge’s ratings on the CASES illustrate that the practicum experience involving triadic supervision and group supervision was very effective for improving counselor self-efficacy. Before the treatment phase began, three of Jorge’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123, which considers an individual to have low counseling self-efficacy for the CASES. Evaluation of the PEM statistic for the CASES (1.00) indicated that 10 scores were on the therapeutic side above the baseline (total scale score of 217). Scores above the PEM line were within a 122-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring exploration skills.

Participant 2

Gina’s ratings on the CASES illustrate that the practicum experience involving triadic supervision and group supervision was moderately effective for improving counselor self-efficacy. Before the treatment phase began, three of Gina’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (0.77) indicated that seven scores were on the therapeutic side above the baseline (total scale score of 194). Scores above the PEM line were within a 99-point range. Trend analysis depicted a consistent level of improvement following the second treatment measure. The majority of improvement in confidence was found on items measuring exploration skills, session management and client distress.

Participant 3

Cecilia’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving counselor self-efficacy. Before the treatment phase began, three of Cecilia’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (1.00) indicated that 10 scores were on the therapeutic side above the baseline (total scale score of 177). Scores above the PEM line were within a 162-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring exploration skills and session management.

Figure 1.

Graphical Representation of Ratings for Counselor Activity Self-Efficacy by Participants

Table 1

Participants’ Sessions and Their CASES Total Scale Score for Counselor Activity Self-Efficacy

Participant 4

Natalia’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving her counselor self-efficacy. Before the treatment phase began, two of Natalia’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (1.00) indicated that nine scores were on the therapeutic side above the baseline (total scale score of 138). Scores above the PEM line were within a 155-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring exploration skills.

Participant 5

Yolanda’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving counselor self-efficacy. Before the treatment phase began, three of Yolanda’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (0.90) indicated that nine scores were on the therapeutic side above the baseline (total scale score of 295). Scores above the PEM line were within a 27-point range. Trend analysis depicted a minimal level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring exploration skills.

Participant 6

Leticia’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving her counselor self-efficacy. Before the treatment phase began, three of Leticia’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (1.00) indicated that 10 scores were on the therapeutic side above the baseline (total scale score of 293). Scores above the PEM line were within a 43-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring client distress.

Participant 7

Robert’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving counselor self-efficacy. Before the treatment phase began, three of Robert’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (1.00) indicated that 10 scores were on the therapeutic side above the baseline (total scale score of 197). Scores above the PEM line were within a 96-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring client distress.

Participant 8

George’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving his counselor self-efficacy. Before the treatment phase began, three of George’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the counselor activity self-efficacy measure (1.00) indicated that ten scores were on the therapeutic side above the baseline (total scale score of 300). Scores above the PEM line were within a 24-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring exploration skills.

Participant 9

Jeremy’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving his counselor self-efficacy. Before the treatment phase began, two of Jeremy’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (0.90) indicated that nine scores were on the therapeutic side above the baseline (total scale score of 142). Scores above the PEM line were within a 201-point range. Trend analysis depicted a consistent level of improvement following the second treatment measure. The majority of improvement in confidence was found on items measuring session management and client distress.

Participant 10

Brittney’s ratings on the CASES illustrate that the practicum experience and triadic supervision were moderately effective for improving her counselor self-efficacy. Before the treatment phase began, three of Brittney’s baseline measurements were below the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (0.88) indicated that eight scores were on the therapeutic side above the baseline (total scale score of 94). Scores above the PEM line were within a 132-point range. Trend analysis depicted a consistent level of improvement following the fourth treatment measure. The majority of improvement in confidence was found on items measuring session management.

Participant 11

Jessica’s ratings on the CASES illustrate that the practicum experience and triadic supervision were very effective for improving her counselor self-efficacy. Before the treatment phase began, three of Jessica’s baseline measurements were above the cut-score guideline on the CASES with a total scale score of 123. Evaluation of the PEM statistic for the CASES (1.00) indicated that 10 scores were on the therapeutic side above the baseline (total scale score of 186). Scores above the PEM line were within a 71-point range. Trend analysis depicted a consistent level of improvement following the first treatment measure. The majority of improvement in confidence was found on items measuring exploration skills.

Discussion

The results of this study found that in all 11 investigated cases, the practicum experience ranged from moderately effective (PEM = .77) to very effective (PEM = 1.00) for improving or maintaining counselor self-efficacy during practicum coursework. For most participants, counseling self-efficacy continued to improve throughout the practicum experience as evidenced by high scores on items such as “Helping your client understand his or her thoughts, feelings and actions,” “Work effectively with a client who shows signs of severely disturbed thinking,” and “Help your client set realistic counseling goals.” Participants shared that the most helpful experiences during practicum to improve their counselor self-efficacy came from direct experiences with clients. This finding is consistent with Bandura’s (1977) conceptualization of direct mastery experiences where participants gain confidence with successful experiences of a particular activity. Participants also shared how obtaining feedback from clients on their outcomes and seeing their clients’ progress was important for their development as counselors. Other helpful experiences included processing counseling sessions with a peer during triadic supervision, and case conceptualization and treatment planning during group supervision. Obtaining feedback during triadic supervision from peers and instructors after observing recorded counseling sessions also was beneficial.

Qualitative benefits of supervision included vicarious learning experiences, peer-learning opportunities and better supervisor feedback (Borders et al., 2012). Findings from this study extend qualitative findings regarding benefits of the practicum experience and triadic supervision. The results of this study yielded promising findings related to the integration of triadic supervision into counseling graduate students’ practicum experiences. First, the practicum experience appeared to be effective for increasing and maintaining participant scores on the CSEA scale. Inspection of participant scores within treatment targets revealed that the practicum experience was very effective for nine participants and within the moderately effective range for two participants.

Lastly, informal conversations with participants indicate that triadic supervision provided participants with an opportunity to receive peer feedback. Participants also commented that weekly wellness checks were important due to stress from the practicum experience. Trends were observed for the group as a majority of participants improved self-efficacy consistently after their fourth treatment measure. In summary, direct services with clients, triadic supervision with a peer and group supervision as part of the practicum experience may assist counseling graduate students to improve self-efficacy.

Implications for Counseling Practice

There are several implications for practice. First, triadic supervision has been helpful when there is compatibility between supervisor and supervisees (Hein & Lawson, 2008). Compatibility between supervisees is helpful, as participants shared how having similar knowledge and experience contributed to their development. While all participants in the current study selected their partner for supervision, Hein and Lawson (2008) commented that the responsibility to implement and maintain clear and achievable support to supervisees lies heavily on supervisors. As a result, additional trainings should be offered to supervisors regarding clear, concise and supportive feedback. Such trainings and discussions can focus on clarity of roles and expectations for both supervisor and supervisee before triadic supervision begins. More training in providing feedback to peers in group supervision also can be beneficial as students learn to provide feedback to promote awareness of different learning experiences. We suggest that additional trainings will help practicum instructors and students identify ways to provide clear, constructive and effective feedback.

Practicum instructors can administer weekly or bi-weekly wellness checks and discuss responses on individual items on the Mental Well-Being Scale to monitor progress (Tennant et al., 2007). Additionally, counselor education programs would benefit from bringing self-efficacy to the forefront in the practicum experience as well as prepracticum coursework. Findings from the current study could be presented to students in group counseling and practicum coursework to facilitate discussion regarding how the practicum experience can increase students’ self-efficacy. Part of this discussion should focus on assessing baseline self-efficacy in order to help students increase perceptions of self-efficacy. As such, counselor educators can administer and interpret the CSEA scale with practicum students. There are numerous scale items (e.g., silence, immediacy) that can be used to foster discussions on perceived confidence in dealing with counseling-related issues. Finally, CACREP-accredited programs require 1 hour of weekly supervision and allow triadic supervision to fulfill this requirement. We recommend that CACREP and non-CACREP-accredited programs consider incorporating triadic supervision into the practicum experience and suggest that triadic supervision as part of the practicum experience might help students’ increase self-efficacy.

Implications for Counseling Research

The practicum experience seemed helpful for improving counseling students’ self-efficacy. However, information regarding reasons for this effectiveness of the practicum experience and triadic supervision was not explored. Qualitative research regarding the impact of the practicum experience on counselors’ self-efficacy can provide incredible insight into specific aspects of group or triadic supervision that increase self-efficacy. Second, more outcome-based research with ethnic minority counseling students is necessary. There might be aspects of group or triadic supervision that are conducive when working with Mexican American students (Cavazos, Alvarado, Rodriguez, & Iruegas, 2009). Third, exploring different models of group or triadic supervision to increase counseling self-efficacy is important. As one example, researchers could explore the impact of the Wellness Model of Supervision (Lenz & Smith, 2010) on counseling graduate students’ self-efficacy. Finally, all participants in our study attended a CACREP counseling program with mandatory individual or triadic supervision. Comparing changes in self-efficacy between students in CACREP and non-CACREP programs where weekly individual or triadic supervision outside of class is not mandatory would be important.

Limitations

There are several limitations that must be taken into consideration. First, we did not use an ABA design with withdrawal measures that would have provided stronger internal validity to evaluate changes to counselor self-efficacy (Lenz et al., 2012). Most practicum students in our study began internship immediately after the conclusion of the semester. As a result, collecting withdrawal measures in an ABA design would have tapped into students’ internship experiences. Second, although three baseline measurements are considered sufficient in single-case research (Lenz et al., 2012), employing five baseline measures might have allowed self-efficacy scores to stabilize prior to their practicum experience (Ikonomopoulos et al., 2015).

Conclusion

Based on results from this study, the practicum experience shows promise as an effective strategy to increase counseling graduate students’ self-efficacy. Implementing triadic supervision as part of the practicum experience for counseling students is a strategy that counselor education programs might consider. Provided are guidelines for counselor educators to consider when integrating triadic supervision into the practicum experience. Researchers also can use different methodologies to address how different aspects of the practicum experience influence counseling students’ self-efficacy. In summary, we regard the practicum experience with triadic supervision as a promising approach for improving counseling graduate students’ self-efficacy.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

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James Ikonomopoulos, NCC, is an Assistant Professor at the University of Texas Rio Grande Valley. Javier Cavazos Vela is an LPC-Intern at the University of Texas Rio Grande Valley. Wayne D. Smith is an Assistant Professor at the University of Houston–Victoria. Julia Dell’Aquila is a graduate student at the University of Texas Rio Grande Valley. Correspondence concerning this article can be addressed to James Ikonomopoulos, University of Texas Rio Grande Valley, Department of Counseling, Main 2.200F, One West Univ. Blvd., Brownsville, TX 78520, james.ikonomopoulos@utrgv.edu.

The Benefits of Implementing a Feedback Informed Treatment System Within Counselor Education Curriculum

Mar 24, 2016 | Article, Volume 6 - Issue 1

Chad M. Yates, Courtney M. Holmes, Jane C. Coe Smith, Tiffany Nielson

Implementing continuous feedback loops between clients and counselors has been found to have significant impact on the effectiveness of counseling (Shimokawa, Lambert, & Smart, 2010). Feedback informed treatment (FIT) systems are beneficial to counselors and clients as they provide clinicians with a wide array of client information such as which clients are plateauing in treatment, deteriorating or at risk for dropping out (Lambert, 2010; Lambert, Hansen, & Finch, 2001). Access to this type of information is imperative because counselors have been shown to have poor predictive validity in determining if clients are deteriorating during the counseling process (Hannan et al., 2005). Furthermore, recent efforts by researchers show that FIT systems based inside university counseling centers have beneficial training features that positively impact the professional development of counseling students (Reese, Norsworthy, & Rowlands, 2009; Yates, 2012). To date, however, few resources exist on how to infuse FIT systems into counselor education curriculum and training programs.

This article addresses the current lack of information regarding the implementation of a FIT system within counselor education curricula by discussing: (1) an overview and implementation of a FIT system; (2) a comprehensive review of the psychometric properties of three main FIT systems; (3) benefits that the use of FIT systems hold for counselors-in-training; and (4) how the infusion of FIT systems within a counseling curriculum can help assess student learning outcomes.

Overview and Implementation of a FIT System

FIT systems are continual assessment procedures that include weekly feedback about a client’s current symptomology and perceptions of the therapeutic process in relation to previous counseling session scores. These systems also can include other information such as self-reported suicidal ideation, reported substance use, or other specific responses (e.g., current rating of depressive symptomology). FIT systems compare clients’ current session scores to previous session scores and provide a recovery trajectory, often graphed, that can help counselors track the progress made through the course of treatment (Lambert, 2010). Some examples of a FIT system include the Outcome Questionnaire (OQ-45.2; Lambert et al., 1996), Session Rating Scale (SRS; Miller, Duncan, & Johnson, 2000), Outcome Rating Scale (ORS; Miller & Duncan, 2000), and the Counseling Center Assessment of Psychological Symptoms (CCAPS; Locke et al., 2011), all of which are described in this article.

Variety exists regarding how FIT systems are used within the counseling field. These variations include the selected measure or test, frequency of measurement, type of feedback given to counselors and whether or not feedback is shared with clients on a routine basis. Although some deviations exist, all feedback systems contain consistent procedures that are commonly employed when utilizing a system during practice (Lambert, Hansen, & Harmon, 2010). The first procedure in a FIT system includes the routine measurement of a client’s symptomology or distress during each session. This frequency of once-per-session is important as it allows counselors to receive direct, continuous feedback on how the client is progressing or regressing throughout treatment. Research has demonstrated that counselors who receive regular client feedback have clients that stay in treatment longer (Shimokawa et al., 2010); thus, the feedback loop provided by a FIT system is crucial in supporting clients through the therapeutic process.

The second procedure of a FIT system includes showcasing the results of the client’s symptomology or distress level in a concise and usable way. Counselors who treat several clients benefit from accessible and comprehensive feedback forms. This ease of access is important because counselors may be more likely to buy in to the use of feedback systems if they can use them in a time-effective manner.

The last procedure of FIT systems includes the adjustment of counseling approaches based upon the results of the feedback. Although research in this area is limited, some studies have observed that feedback systems do alter the progression of treatment. Lambert (2010) suggested that receiving feedback on what is working is apt to positively influence a counselor to continue these behaviors. Yates (2012) found that continuous feedback sets benchmarks of performance for both the client and the counselor, which slowly alters treatment approaches. If the goal of counseling is to decrease symptomology or increase functioning, frequently observing objective progress toward these goals using a FIT system can help increase the potential for clients to achieve these goals through targeted intervention.

Description of Three FIT Systems

Several well-validated, reliable, repeated feedback instruments exist. These instruments vary by length and scope of assessment, but all are engineered to deliver routine feedback to counselors regarding client progress. Below is a review of three of the most common FIT systems utilized in clinical practice.

The OQ Measures System

The OQ Measures System uses the Outcome Questionnaire 45.2 (OQ-45.2; Lambert et al., 1996), a popular symptomology measure that gauges a client’s current distress levels over three domains: symptomatic distress, interpersonal relations and social roles. Hatfield and Ogles (2004) listed the OQ 45.2 as the third most frequently used self-report outcome measure for adults in the United States. The OQ 45.2 has 45 items and is rated on a 5-point Likert scale. Scores range between 0 and 180; higher scores suggest higher rates of disturbance. The OQ 45.2 takes approximately 5–6 minutes to complete and the results are analyzed using the OQ Analyst software provided by the test developers. The OQ 45.2 can be delivered by paper and pencil versions or computer assisted administration via laptop, kiosk, or personal digital assistant (PDA). Electronic administration of the OQ 45.2 allows for seamless administration, scoring and feedback to both counselor and client.

Internal consistency for the OQ 45.2 is α = 0.93 and test-retest reliability is r = 0.84. The OQ 45.2 demonstrated convergent validity with the General Severity Index (GSI) of the Symptom Checklist 90-Revised (SCL-90-R; Derogatis, 1983; r = .78, n = 115). The Outcome Questionnaire System has five additional outcome measures: (1) the Outcome Questionnaire 30 (OQ-30); (2) the Severe Outcome Questionnaire (SOQ), which captures outcome data for more severe presenting concerns, such as bipolar disorder and schizophrenia; (3) the Youth Outcome Questionnaire (YOQ), which assesses outcomes in children between 13 and 18 years of age; (4) the Youth Outcome Questionnaire 30, which is a brief version of the full YOQ; and (5) the Outcome Questionnaire 10 (OQ-10), which is used as a brief screening instrument for psychological symptoms (Lambert et al., 2010).

The Partners for Change Outcome Management System (PCOMS)

The Partners for Change Outcome Management System (PCOMS) uses two instruments, the Outcome Rating Scale (ORS; Miller & Duncan, 2000) that measures the client’s session outcome, and the Session Rating Scale (SRS; Miller et al., 2000) that measures the client’s perception of the therapeutic alliance. The ORS and SRS were designed to be brief in response to the heavy time demands placed upon counselors. Administration of the ORS includes handing the client a copy of the ORS on a sheet of letter sized paper; the client then draws a hash mark on four distinct 10-centimeter lines that indicate how he or she felt over the last week on the following scales: individually (personal well-being), interpersonally (family and close relationships), socially (work, school and friendships), and overall (general sense of well-being).

The administration of the SRS includes four similar 10-centimeter lines that evaluate the relationship between the client and counselor. The four lines represent relationship, goals and topics, approach or methods, and overall (the sense that the session went all right for me today; Miller et al., 2000). Scoring of both instruments includes measuring the location of the client’s hash mark and assigning a numerical value based on its location along the 10-centimeter line. Measurement flows from left to right, indicating higher-level responses the further right the hash mark is placed. A total score is computed by adding each subscale together. Total scores are graphed along a line plot. Miller and Duncan (2000) used the reliable change index formula (RCI) to establish a clinical cut-off score of 25 and a reliable change index score of 5 points for the ORS. The SRS has a cut-off score of 36, which suggests that total scores below 36 indicate ruptures in the working alliance.

The ORS demonstrated strong internal reliability estimates (α = 0.87-.096), a test-retest score of r = 0.60, and moderate convergent validity with measures like the OQ 45.2 (r = 0.59), which it was created to resemble (Miller & Duncan, 2000; Miller, Duncan, Brown, Sparks, & Claud, 2003). The SRS had an internal reliability estimate of α = 0.88, test-retest reliability of r = 0.74, and showed convergent validity when correlated with similar measures of the working alliance such as the Helping Alliance Questionnaire–II (HAQ–II; Duncan et al., 2003; Luborsky et al., 1996). The developers of the ORS and SRS have also created Web-based administration features that allow clients to use both instruments online using a pointer instead of a pencil or pen. The Web-based administration also calculates the totals for the instruments and graphs them.

The Counseling Center Assessment of Psychological Symptoms (CCAPS)

The CCAPS was designed as a semi-brief continuous measure that assesses symptomology unique to college-aged adults (Locke et al., 2011). When developed, the CCAPS was designed to be effective in assessing college students’ concerns across a diverse range of college campuses. The CCAPS has two separate versions, the CCAPS-62 and a shorter version, the CCAPS-34. The CCAPS-62 has 62 test items across eight subscales that measure: depression, generalized anxiety, social anxiety, academic distress, eating concerns, family distress, hostility and substance abuse. The CCAPS-34 has 34 test items across seven of the scales found on the CCAPS-62, excluding family distress. Additionally, the substance use scale on the CCAPS-62 is renamed the Alcohol Use Scale on the CCAPS-32 (Locke et al., 2011). Clients respond on a 5-point Likert scale with responses that range from not at all like me to extremely like me. On both measures clients are instructed to answer each question based upon their functioning over the last 2 weeks. The CCAPS measures include a total score scale titled the Distress Index that measures the amount of general distress experienced over the previous 2 weeks (Center for Collegiate Mental Health, 2012). The measures were designed so that repeated administration would allow counselors to compare each session’s scores to previous scores, and to a large norm group (N = 59,606) of clients completing the CCAPS at university counseling centers across the United States (Center for Collegiate Mental Health, 2012).

The CCAPS norming works by comparing clients’ scores to a percentile score of other clients who have taken the measure. For instance, a client’s score of 80 on the depressive symptoms scale indicates that he or she falls within the 80^th percentile of the norm population’s depressive symptoms score range. Because the CCAPS measures utilize such a large norm base, the developers have integrated the instruments into the Titanium Schedule ™, an Electronic Medical Records (EMR) system. The developers also offer the instruments for use in an Excel scoring format, along with other counseling scheduling software programs. The developers of the CCAPS use RCI formulas to provide upward and downward arrows next to the reported score on each scale. Downward arrows indicate the client’s current score is significantly different than previous sessions’ scores and suggests progress during counseling. An upward arrow would suggest a worsening of symptomology. Cut-off scores vary across scales and can be referenced in the CCAPS 2012 Technical Manual (Center for Collegiate Mental Health, 2012).

Test-retest estimates at 2 weeks for the CCAPS-62 and CCAPS-34 scales range between r = 0.75–0.91 (Center for Collegiate Mental Health, 2012). The CCAPS-34 also demonstrated a good internal consistency that ranged between α = 0.76–0.89 (Locke et al., 2012). The measures also demonstrated adequate convergent validity compared to similar measures. A full illustration of the measures’ convergent validity can be found in the CCAPS 2012 Technical Manual (Center for Collegiate Mental Health, 2012).

Benefits for Counselors-in-Training

The benefits of FIT systems are multifaceted and can positively impact the growth and development of student counselors (Reese, Norsworthy, et al., 2009; Schmidt, 2014; Yates, 2012). Within counselor training laboratories, feedback systems have shown promise in facilitating the growth and development of beginning counselors (Reese, Usher, et al., 2009), and the incorporation of FIT systems into supervision and training experiences has been widely supported (Schmidt, 2014; Worthen & Lambert, 2007; Yates, 2012).

One such benefit is that counseling students’ self-efficacy improved when they saw evidence of their clients’ improvement (Reese, Usher, et al., 2009). A FIT system allows for the documentation of a client’s progress and when counseling students observed their clients making such progress, their self-efficacy improved regarding their skill and ability as counselors. Additionally, the FIT system allowed the counselor trainees to observe their effectiveness during session, and more importantly, helped them alter their interventions when clients deteriorated or plateaued during treatment. Counselor education practicum students who implemented a FIT system through client treatment reported that having weekly observations of their client’s progress helped them to isolate effective and non-effective techniques they had used during session (Yates, 2012). Additionally, practicum counseling students have indicated several components of FIT feedback forms were useful, including the visual orientation (e.g., graphs) to clients’ shifts in symptomology. This visual attenuation to client change allowed counselors-in-training to be more alert to how clients are actually faring in between sessions and how they could tailor their approach, particularly regarding crisis situations (Yates, 2012).

Another benefit discovered from the above study was that counseling students felt as if consistent use of a FIT system lowered their anxiety and relieved some uncertainty regarding their work with clients (Yates, 2012). It is developmentally appropriate for beginning counselors to struggle with low tolerance for ambiguity and the need for a highly structured learning environment when they begin their experiential practicums and internships (Bernard & Goodyear, 2013). The FIT system allows for a structured format to use within the counseling session that helps to ease new counselors’ anxiety and discomfort with ambiguity.

Additionally, by bringing the weekly feedback into counseling sessions, practicum students were able to clarify instances when the feedback was discrepant from how the client presented during session (Yates, 2012). This discrepancy between what the client reported on the measure and how they presented in session was often fertile ground for discussion. Counseling students believed bringing these discrepancies to a client’s attention deepened the therapeutic alliance because the counselor was taking time to fully understand the client (Yates, 2012).

Several positive benefits are added to the clinical supervision of counseling students. One such benefit is that clinical supervisors found weekly objective reports of their supervisees helpful in providing evidence of a client’s progress during session that was not solely based upon their supervisees’ self-report. This is crucial because relying on self-report as a sole method of supervision can be an insufficient way to gain information about the complexities of the therapeutic process (Bernard & Goodyear, 2013). Supervisors and practicum students both reported that the FIT system frequently brought to their attention potential concerns with clients that they had missed (Yates, 2012). A final benefit is that supervisees who utilized a FIT system during supervision had significantly higher satisfaction levels of supervision and stronger supervisory alliances than students who did not utilize a FIT system (Grossl, Reese, Norsworthy, & Hopkins, 2014; Reese, Usher, et al., 2009).

Benefits for Clients

Several benefits exist for counseling clients when FIT systems are utilized in the therapeutic process. The sharing of objective progress information with clients has been found to be perceived as helpful and a generally positive experience by clients (Martin, Hess, Ain, Nelson, & Locke, 2012). Surveying clients using a FIT system, Martin et al. (2012) found that 74.5% of clients found it “convenient” to complete the instrument during each session. Approximately 46% of the clients endorsed that they had a “somewhat positive” experience using the feedback system, while 20% of clients reported a “very positive” experience. Hawkins, Lambert, Vermeersch, Slade, and Tuttle (2004) found that providing feedback to both clients and counselors significantly increased the clients’ therapeutic improvement in the counseling process when compared to counselors who received feedback independently. A meta-analysis of several research studies, including Hawkins et al. (2004), found effect sizes of clinical efficacy related to providing per-session feedback ranged from 0.34 to 0.92 (Shimokawa et al., 2010). These investigations found more substantial improvement in clients whose counselors received consistent client feedback when compared with counselors who received no client feedback regarding the therapeutic process and symptomology. These data also showed that consistent feedback provision to clients resulted in an overall prevention of premature treatment termination (Lambert, 2010).

Utilization of FIT Systems for Counseling Curriculum and Student Learning Outcome Assessment

The formal assessment of graduate counseling student learning has increased over the past decade. The most recent update of the national standards from the Council for Accreditation of Counseling and Related Educational Programs (CACREP) included the requirement for all accredited programs to systematically track students at multiple points with multiple measures of student learning (CACREP, 2015, Section 4, A, B, C, D, E). Specifically, “counselor education programs conduct formative and summative evaluations of the student’s counseling performance and ability to integrate and apply knowledge throughout the practicum and internship” (CACREP, 2015, Section 4.E). The use of continuous client feedback within counselor education is one way to address such assessment requirements (Schmidt, 2014).

Counseling master’s programs impact students on both personal and professional levels (Warden & Benshoff, 2012), and part of this impact stems from ongoing and meaningful evaluation of student development. The development of counselors-in-training during experiential courses entails assessment of a myriad of counseling competencies (e.g., counseling microskills, case conceptualization, understanding of theory, ethical decision-making and ability to form a therapeutic relationship with clients; Haberstroh, Duffey, Marble, & Ivers, 2014). As per CACREP standards, counseling students will receive feedback during and after their practicum and internship experiences. This feedback typically comes from both the supervising counselor on site, as well as the academic department supervisor.

Additionally, “supervisors need to help their supervisees develop the ability to make effective decisions regarding the most appropriate clinical treatment” (Owen, Tao, & Rodolfa, 2005, p. 68). One suggested avenue for developing such skills is client feedback using FIT systems. The benefit of direct client feedback on the counseling process has been well documented (Minami et al., 2009), and this process can also be useful to student practice and training. Counseling students can greatly benefit from the use of client feedback throughout their training programs (Reese, Usher, et al., 2009). In this way, counselors-in-training learn to acknowledge client feedback as an important part of the counseling process, allowing them to adjust their practice to help each client on an individual basis. Allowing for a multi-layered feedback model wherein the counselor-in-training can receive feedback from the client, site supervisor and academic department supervisor has the potential to maximize student learning and growth.

Providing students feedback for growth through formal supervision is one of the hallmarks of counseling programs (Bernard & Goodyear, 2013). However, a more recent focus throughout higher education is the necessity of assessment of student learning outcomes (CACREP, 2015). This assessment can include “systematic evaluation of students’ academic, clinical, and interpersonal progress as guideposts for program improvement” (Haberstroh et al., 2014, p. 28). As such, evaluating student work within the experiential courses (e.g., practicum and internship) is becoming increasingly important.

FIT systems provide specific and detailed client feedback regarding clients’ experiences within therapy. Having access to documented client outcomes and progress throughout the counseling relationship can provide an additional layer of information regarding student growth and skill development. For instance, if a student consistently has clients who drop out or show no improvement over time, those outcomes could represent a problem or unaddressed issue for the counselor-in-training. Conversely, if a student has clients who report positive outcomes over time, that data could show clinical understanding and positive skill development.

Student learning outcomes can be assessed in a myriad of ways (e.g., FIT systems, supervisor evaluations, student self-assessment and exams; Haberstroh et al., 2014). Incorporating multiple layers of feedback for counseling students allows for maximization of learning through practicum and internships and offers a concrete way to document and measure student outcomes.

An Example: Case Study

Students grow and develop through a wide variety of methods, including feedback from professors, supervisors and clients (Bernard & Goodyear, 2013). Implementing a FIT system into experiential classes in counseling programs allows for the incorporation of structured, consistent and reliable feedback. We use a case example here to illustrate the benefits of such implementation. Within the case study, each CACREP Student Learning Outcome that is met through the implementation of the FIT system is documented.

A counselor educator is the instructor of an internship class where students have a variety of internship placements. This instructor decides to have students implement a FIT system that will allow them to track client progress and the strength of the working alliance. The OQ 45.2 and the SRS measures were chosen because they allow students to track client outcomes and the counseling relationship and are easy to administer, score and interpret. In the beginning of the semester, the instructor provides a syllabus to the students where the following expectations are listed: (1) students will have their clients fill out the OQ 45.2 and the SRS during every session with each client; (2) students will learn to discuss and process the results from the OQ 45.2 and SRS in each session with the client; and (3) students will bring all compiled information from the measures to weekly supervision. By incorporating two FIT systems and the subsequent requirements, the course is meeting over 10 CACREP (2015) learning outcome assessment components within Sections 2 and 3, Professional Counseling Identity (Counseling and Helping Relationships, Assessment and Testing), and Professional Practice.

A student, Sara, begins seeing a client at an outpatient mental health clinic who has been diagnosed with major depressive disorder; the client’s symptoms include suicidal ideation, anhedonia and extreme hopelessness. Sara’s initial response includes anxiety due to the fact that she has never worked with someone who has active suicidal ideation or such an extreme presentation of depressed affect. Sara’s supervisor spends time discussing how she will use the FIT systems in her work with the client and reminds her about the necessities of safety assessment.

In her initial sessions with her client, Sara incorporates the OQ 45.2 and the SRS into her sessions as discussed with her supervisor (CACREP Section 2.8.E; 2.8.K). However, after a few sessions, she does not yet feel confident in her work with this client. Sara feels constantly overwhelmed by the depth of her client’s depression and is worried about addressing the suicidal ideation. Her instructor is able to use the weekly OQ 45.2 and SRS forms as a consistent baseline and guide for her work with this client and to help Sara develop a treatment plan that is specifically tailored for her client based upon the client’s symptomology (CACREP Section 2.5.H, 2.8.L). Using the visual outputs and compiled graphs of weekly data, Sara is able to see small changes that may or may not be taking place for the client regarding his depressive symptoms and overall feelings and experiences in his life. Sara’s instructor guides her to discuss these changes with the client and explore in more detail the client’s experiences within these symptoms (CACREP Section 2.5.G). By using this data with the client, Sara will be better able to help the client develop appropriate and measureable goals and outcomes for the therapeutic process (CACREP Section 2.5.I). Additionally, as a new counselor, such an assessment tool provides Sara with structure and guidance as to the important topics to explore with clients throughout sessions. For example, by using some of the specific content on the OQ 45.2 (e.g., I have thoughts of ending my life, I feel no interest in things, I feel annoyed by people who criticize my drinking, and I feel worthless), she can train herself to assess for suicidal ideation and overall diagnostic criteria (CACREP Section 2.7.C).

Additionally, Sara is receiving feedback from the client by using the SRS measure within session. In using this additional FIT measure, Sara can begin to gauge her personal approach to counseling with this client and receive imperative feedback that will help her grow as a counselor (CACREP, Section 2.5.F). This avenue provides an active dialogue between client and counselor about the work they are doing together and if they are working on the pieces that are important to the client. Her instructor is able to provide both formative and summative feedback on her overall process with the client using his outcomes as a guide to her effectiveness as a clinician (CACREP, Section 3.C). Implementing a FIT system allows for the process of feedback provision to have concrete markers and structure, ultimately allowing for a student counselor to grow in his or her ability to become self-reflective about his or her own practice.

Implications for Counselor Education

The main implications of the integration of FIT systems into counselor education are threefold: (1) developmentally appropriate interventions to support supervisee/trainee clinical growth; (2) intentional measurement of CACREP Student Learning Outcomes; and (3) specific attention to client care and therapeutic outcomes. There are a variety of FIT systems being utilized, and while they vary in scope, length, and targets of assessment, each has a brief administration time and can be repeated frequently for current client status and treatment outcome measurement. With intentionality and dedication, counselor education programs can work to implement the utilization of these types of assessment throughout counselor trainee coursework (Schmidt, 2014).

FIT systems lend themselves to positive benefits for training competent emerging counselors. Evaluating a beginning counselor’s clinical understanding and skills are a key component of assessing overall learning outcomes. When counselors-in-training receive frequent feedback on their clients’ current functioning or session outcomes, they are given the opportunity to bring concrete information to supervision, decide on treatment modifications as indicated, and openly discuss the report with clients as part of treatment. Gathering data on a client’s experience in treatment brings valuable information to the training process. Indications of challenges or strengths with regard to facilitating a therapeutic relationship can be addressed and positive change supported through supervision and skill development. Additionally, by learning the process of ongoing assessment and therapeutic process management, counselor trainees are meeting many of the CACREP Student Learning Outcomes. The integration of FIT systems into client care supports a wide variety of clinical skill sets such as understanding of clinical assessment, managing a therapeutic relationship and treatment planning/altering based on client needs.

Finally, therapy clients also benefit through the use of FIT. Clinicians who receive weekly feedback on per-session client progress consistently show improved effectiveness and have clients who prematurely terminate counseling less often (Lambert, 2010; Shimokawa et al., 2010). In addition to client and counselor benefit, supervisors also have been shown to utilize FIT systems to their advantage. One of the most important responsibilities of a clinical supervisor is to manage and maintain a high level of client care (Bernard & Goodyear, 2013). Incorporation of a structured, validated assessment, such as a FIT system, allows for intentional oversight of the client–counselor relationship and clinical process that is taking place between supervisees and their clients. Overall, the integration of FIT systems into counselor education would provide programs with a myriad of benefits including the ability to meet student, client and educator needs simultaneously.

Conclusion

FIT systems provide initial and ongoing data related to a client’s psychological and behavioral functioning across a variety of concerns. They have been developed and used as a continual assessment procedure to provide a frequent and continuous self-report by clients. FIT systems have been used effectively to provide vital mental health information within a counseling session. The unique features of FIT systems include the potential for recurrent, routine measure of a client’s symptomatology, easily accessible and usable data for counselor and client, and assistance in setting benchmarks and altering treatment strategies to improve a client’s functioning. With intentionality, counselor educator programs can use FIT systems to meet multiple needs across their curriculums including more advanced supervision practices, CACREP Student Learning Outcome Measurement, and better overall client care.

Conflict of Interest and Funding Disclosure

The author reported no conflict of interest

or funding contributions for the development

of this manuscript.

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Chad M. Yates is an Assistant Professor at Idaho State University. Courtney M. Holmes, NCC, is an Assistant Professor at Virginia Commonwealth University. Jane C. Coe Smith is an Assistant Professor at Idaho State University. Tiffany Nielson is an Assistant Professor at the University of Illinois at Springfield. Correspondence can be addressed to Chad M. Yates, 921 South 8th Ave, Stop 8120, Pocatello, Idaho, 83201, yatechad@isu.edu.

Development of an Integrative Wellness Model: Supervising Counselors-in-Training

Feb 9, 2015 | Article, Volume 5 - Issue 1

Ashley J. Blount, Patrick R. Mullen

Supervision is an integral component of counselor development with the objective of ensuring safe and effective counseling for clients. Wellness also is an important element of counseling and often labeled as the cornerstone of the counseling profession. Literature on supervision contains few models that have a wellness focus or component; however, wellness is fundamental to counseling and the training of counselors, and is primary in developmental, strengths-based counseling. The purpose of this article is to introduce an integrative wellness model for counseling supervision that incorporates existing models of supervision, matching the developmental needs of counselors-in-training and theoretical tenets of wellness.

Keywords: supervision, wellness, counselors-in-training, integrative wellness model, developmental

The practice of counseling is rich with challenges that impact counselor wellness (Kottler, 2010; Maslach, 2003). Consequently, counselors with poor wellness may not produce optimal services for the clients they serve (Lawson, 2007). Furthermore, wellness is regarded as a cornerstone in developmental, strengths-based approaches to counseling (Lawson, 2007; Lawson & Myers, 2011; Myers & Sweeney, 2005, 2008; Witmer, 1985; Witmer & Young, 1996) and is an important consideration when training counselors (Lenz & Smith, 2010; Roach & Young, 2007). Therefore, a focus on methods by which counselor educators can prepare counseling trainees to obtain and maintain wellness is necessary.

Clinical supervision is an integral component of counselor training and involves a relationship in which an expert (e.g., supervisor) facilitates the development of counseling competence in a trainee (Loganbill, Hardy, & Delworth, 1982). Supervision is a requirement of master’s-level counseling training programs and is a part of developing and evaluating counseling students’ skills (Borders, 1992), level of wellness (Lenz, Sangganjanavanich, Balkin, Oliver, & Smith, 2012), readiness for change (Aten, Strain, & Gillespie, 2008; Prochaska & DiClemente, 1982) and overall development into effective counselors (Bernard & Goodyear, 2014). Supervisors use pedagogical methods and theories of supervision to assess and evaluate trainees with the goal of enhancing their counseling competence (American Counseling Association [ACA], 2014; Bernard & Goodyear, 2014). The method or theory of supervision relates to the interaction between counselor educators and counseling trainees and is isomorphic to a counselor using a theory with a client.

The number of supervision theories and methods has increased over recent years. In addition, integrated supervision models have been established with a focus on specific trainee groups (e.g., Carlson & Lambie, 2012; Lambie & Sias, 2009) or specific purposes (e.g., Luke & Bernard, 2006; Ober, Granello, & Henfield, 2009). These integrated models combine the theoretical tenets of key models with the goal of formulating a new perspective for clinical training that adapts to the needs of the supervisee or context. Lenz and Smith (2010) and Roscoe (2009) suggested that the construct of wellness needs further clarification and articulation as a method of supervision. Currently, a single model of supervision with a wellness perspective is available (see Lenz & Smith, 2010). However, it does not specifically apply to master’s-level counselors-in-training (CITs) or focus on the wellness constructs highlighted in the proposed integrative wellness model (IWM). Therefore, this manuscript serves to review relevant literature on supervision and wellness, introduce the IWM, and present implications regarding its implementation and evaluation.

Supervision

ACA (2014), the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009), and the Association for Counselor Education and Supervision (ACES; 2011) have articulated standards for best practices in supervision. For example, ACES’ (2011) Standards for Best Practices Guidelines highlights 12 categories as integral components of the supervision process. The categories include responsibilities of supervisors and suggestions for actions to be taken in order to ensure best practices in supervision. The ACA Code of Ethics (2014) states that supervision involves a process of monitoring “client welfare and supervisee performance and professional development” (Standard F.1.a). Furthermore, supervision can be used as a tool to provide supervisees with necessary knowledge, skills and ethical guidelines to provide safe and effective counseling services (Bernard & Goodyear, 2014).

Supervision has two central purposes: to foster supervisees’ personal and professional development and to protect clients (Vespia, Heckman-Stone, & Delworth, 2002). Supervisors work to ensure client welfare by monitoring and evaluating supervisee behavior, which serves as a gatekeeping tool for the counseling profession (Robiner, Fuhrman, Ristvedt, Bobbit, & Schirvar, 1994). Thus, supervisors protect the counseling profession and clients receiving counseling services by providing psychoeducation, modeling appropriate counselor behavior, and evaluating supervisees’ counseling skills and other professional behaviors. In order to do this, supervisors and supervisees must have a strong supervisory relationship that supports positive supervision outcomes (Rønnestad & Skovholt, 2003).

Supervision is a distinct intervention (Borders, 1992) that is separate from teaching, counseling and consultation. Supervision is unique in that it is comprised of multifaceted (e.g., teacher, counselor and consultant) roles that occur at different times throughout the supervision process (Bernard, 1997). Bernard’s (1979, 1997) discrimination model (DM) of supervision is an educational perspective positing that supervisors can match the needs of supervisees with a supervisor role and supervision focus. The DM is situation specific, meaning that supervisors can change roles throughout the supervision session based on their goal for supervisee interaction (Bernard, 1997). Therefore, supervisees require different roles and levels of support from their supervisors at different times throughout the supervision process, which can be determined by a process of assessment and matching of supervisee needs.

According to Worthen and McNeill (1996), supervision varies according to the developmental level of trainees. Beginning supervisees need more support and structure than intermediate or advanced supervisees (Borders, 1990). Additionally, supervisors working with beginning supervisees must pay more attention to student skills and aid in the development of self-awareness. With intermediate supervisees, supervision may focus on personal development, more advanced case conceptualizations of clients and operating within a specific counseling theory (McNeill, Stoltenberg, & Pierce, 1985). Advanced supervisees work on more complex issues of personal development, parallel processes or a replication of the therapeutic relationship in a variety of settings (e.g., counseling, supervision; Ekstein & Wallerstein, 1972), and advanced responses and reactions to clients (Williams, Judge, Hill, & Hoffman, 1997). Consequently, supervision progresses from beginning stages to advanced stages for supervisees, with a developmental framework central to the process. Supervision is tailored to the specific developmental level of a supervisee, and tasks are personalized for needs at specific times throughout the supervision process. Developmental stages in supervision have been identified as key processes that counselor trainees undergo (e.g., Rønnestad & Skovholt, 2003; Stoltenberg & McNeill, 2012), a conceptualization that necessitates a supervision model that aids supervisees in a developmental fashion.

Recent models of supervision represent trends toward integrative and empirically based supervision modalities (e.g., Bernard & Goodyear, 2014; Lambie & Sias, 2009). The current integrated model of supervision draws from the theoretical tenets of the DM (Bernard, 1979, 1997), matching supervisee developmental needs (Lambie & Sias, 2009; Loganbill et al., 1982; Stoltenberg, 1981) and wellness constructs (Lenz et al., 2012; Myers, Sweeney, & Witmer, 1998). Wellness is a conscious, thoughtful process that requires increased awareness of choices that are being made toward optimal human functioning and a more satisfying lifestyle (Johnson, 1986; Swarbrick, 1997). As such, the IWM includes wellness undertones in order to support optimal supervisee functioning. This article presents the IWM’s theoretical tenets, implementation and methods for supervisee evaluation. In addition, a case study is presented to demonstrate the IWM’s application in clinical supervision.

Theoretical Tenets Integrated Into the IWM of Supervision

The DM (Bernard, 1979, 1997) is considered “one of the most accessible models of clinical supervision” (Bernard & Goodyear, 2014, p. 52) and includes the following three supervisor roles: teacher, counselor and consultant. In the teacher role, the supervisor imparts knowledge to the supervisee and serves an educational function. The counselor role involves the supervisor aiding the supervisee in increasing self-awareness, enhancing reflectivity, and working through interpersonal and intrapersonal conflicts. Lastly, the consultant role provides opportunities for supervisors and supervisees to have discussions on a balanced level (Bernard, 1979). The three roles are used throughout the supervision process to promote supervisee learning, growth and development.

The DM of supervision is situation specific in that supervisors enact different roles throughout the supervision session based on the observed need of the supervisee (Bernard & Goodyear, 2014). As needs arise in supervision, the supervisor decides which role is best suited for the issue or concern. This process requires the supervisor to identify or assess a need and to make a decision regarding the appropriate role (i.e., teacher, counselor or consultant) to facilitate appropriate supervision. Furthermore, the use of supervisory roles is fluid, with its ebb and flow contingent upon the supervisee needs or issues. For example, if a supervisee is struggling with how to review informed consent, a supervisor can use the teacher role to educate the student on how to proceed, and then address the supervisee’s anxiety about seeing his or her first client using the counseling role. The DM roles are integrated into the IWM, and supervisors alternate between roles to match supervisee needs throughout the supervision process.

Developmental Tenets

The authors of developmental models have suggested that counseling trainees progress in a structured and sequential fashion through stages of development that increase in complexity and integration (e.g., Blocher, 1983; Loganbill et al., 1982; Stoltenberg, 1981; Stoltenberg & McNeill, 2010). In early experiences, supervisees engage in rigid thinking, have high anxiety and dependence on the supervisor, and express low confidence in their abilities (Borders & Brown, 2005; Rønnestad, & Skovholt, 2003; Stoltenberg & McNeill, 2012). Moreover, supervisees have limited understanding of their own abilities and view their supervisor as an expert (Borders & Brown, 2005; Stoltenberg & McNeill, 2010). Struggles between independency and autonomy, as well as bouts of self-doubt, occur during the middle stages of counselor development (Borders & Brown, 2005; Stoltenberg & McNeill, 2010). In addition, counselors experience decreased anxiety paired with an increase in case conceptualization, skill development and crystallization of theoretical orientation (Stoltenberg & McNeill, 2010). Thinking becomes more flexible and there is an increased understanding of unique client qualities and traits (Borders & Brown, 2005). The later stages of counselor development are marked by increased stability and focus on clinical skill development and professional growth, which promotes a flexibility and adaptability that allows for trainees to overcome setbacks with minimal discouragement (Stoltenberg & McNeill, 1997). Furthermore, supervisees focus on more complex information and diverse perspectives as they learn to conceptualize clients more effectively (Borders & Brown, 2005).

In summary, supervisees’ movement through the developmental stages is marked by individualized supervision needs. Structured, concrete feedback and information are desired in early supervision experiences (Bernard, 1997; Stoltenberg & McNeill, 2010). The middle stages have a general focus on processing the interpersonal reactions in which supervisees engage, and supervisors provide support to help supervisees increase their awareness of transference and countertransference (Borders & Brown, 2005; Stoltenberg, 1981). Toward the later stages of supervision, supervisees seek collaborative relationships with supervisors. This collaboration provides supervisees with more freedom and autonomy, which allows them to progress through the stages as they begin to self-identify the focus of their supervision (Borders & Brown, 2005).

Similar to the IWM, models of supervision that are development-focused derive from Hunt’s (1971) matching model that suggests a person–environment fit (Stoltenberg, McNeill, & Crethar, 1994). The matching model advocates that the developmental level of supervisees should be matched with environmental or contextual structures to enhance the opportunity for learning (Lambie & Sias, 2009). Specifically, the developmental models account for trainees’ needs specific to their experience level and contextual environment, with the goal of matching interventions to support movement into more advanced developmental levels (Bernard & Goodyear, 2014; Stoltenberg & McNeill, 2012). The IWM derives its developmental perspective from the unique levels trainees experience during supervision and the cycling and recycling of stages that occurs (Loganbill et al., 1982).

Wellness and Unwellness

Wellness is a topic that has received much attention in counseling literature (Hattie, Myers, & Sweeney, 2004), including several perspectives on how to define wellness (Keyes, 1998). Dunn (1967) is considered the architect of the wellness crusade and described wellness as an integration of spirit, body and mind. The World Health Organization (1968) defined health as more than the absence of disease and emphasized a wellness quality, which includes mental, social and physical well-being. Cohen (1991) described wellness as an idealistic state that individuals strive to attain, and as something that is situated along a continuum (i.e., people experience bouts of wellness and unwellness). Witmer and Sweeney (1992) depicted wellness as interconnectedness between health characteristics, life tasks (spirituality, love, work, friendship, self), and life forces (family, community, religion, education). Additionally, Roscoe (2009) depicted wellness as a holistic paradigm that includes physical, emotional, social, occupational, spiritual, intellectual and environmental components. Witmer and Granello (2005) stated that the counseling profession is distinctively suited to promoting health and wellness with a developmental approach and, coincidentally, supervision could serve as a tool to promote wellness in supervisees as well as in clients receiving counseling services.

Smith, Robinson, and Young (2007) found that counselor wellness is negatively influenced by increased exposure to psychological distress. Furthermore, research has shown that counselors face stress because of the nature of their job (Cummins, Massey, & Jones, 2007). Increased stress and anxiety associated with counseling may have deleterious effects on counselor wellness, and supervisors and supervisees who are unwell may adversely impact their clients. In addition, Lawson and Myers (2011) suggested that increasing counselors’ wellness could lead to increased compassion satisfaction and aid counselors in avoiding compassion fatigue and burnout. Thus, supervisee and supervisor wellness should be an important component of counselor training and supervision. The IWM makes counselor wellness a focus of the supervision process.

Supervision literature contains few supervision models that include wellness components and/or focus on wellness as a key aspect of the supervision experience (e.g., Lenz et al., 2012; Lenz & Smith, 2010). Nevertheless, the paradigm of wellness has emerged in the field of counseling and is primary in developmental, strengths-based counseling (Lenz & Smith, 2010; Myers & Sweeney, 2005). The CACREP 2009 Standards note the importance of wellness for counseling students and counselor educators by promoting human functioning, wellness and health through advocacy, prevention and education. To illustrate, the CACREP 2009 Standards include suggestions of facilitating optimal development and wellness, incorporating orientations to wellness in counseling goals, and using wellness approaches to work with a plethora of populations. The overall goal of wellness counseling is to support wellness in clients (Granello & Witmer, 2013). However, if supervisees seeing clients are unwell, how efficient are they in promoting wellness in others? In order to support development of wellness in supervisees, the IWM incorporates the five wellness domains of creative, coping, physical, essential and social (Myers, Luecht, & Sweeney, 2004) by implementing the use of the Five Factor Wellness Evaluation of Lifestyle (5F-Wel; Myers et al., 2004). In addition, supervisees can use a starfish template (Echterling et al., 2002) to gauge their own wellness and prioritize the constructs that influence their personal and professional levels of wellness and unwellness, as well as create plans to increase their overall wellness.

Implementing the IWM

The IWM was created to offer an integrative method of supervision that is concise and easy to facilitate. Specifically, the IWM consists of several processes, including supervisory relationship development, evaluation of developmental phase, allocation of supervision need, and assessment and matching of wellness intervention. The following section outlines each process.

Supervisory Relationship Development

Rapport building and relationship development between supervisor and supervisee constitute a critical step in supervision (Hird, Cavalieri, Dulko, Felice, & Ho, 2001). Similar to counseling, establishing a strong, trusting supervisory relationship is essential because the relationship is an integral component of the supervision experience (Borders & Brown, 2005; Rønnestad & Skovholt, 1993). During initial sessions, supervisors describe the process of the IWM to supervisees in order to maintain open, transparent communication and to promote a safe environment for supervisees to learn, share emotions and feelings, and develop counseling skills. It is hoped that modeling appropriate professional behaviors and setting up supervision sessions to promote a trusting environment will aid in the overall development of counseling supervisees and matriculate into their normal routines as professional counselors. As with counseling, supervisors can promote a strong relationship with supervisees by focusing on the core conditions of empathy, genuineness and unconditional positive regard (Rogers, 1957). Open communication and supervisor authenticity are just two examples of processes that help develop a sound supervisor–supervisee relationship.

Evaluation of Developmental Phase

Supervisee development is an important consideration in the IWM. The IWM divides supervisee development into three phases that consist of distinct developmental characteristics. Similar to Stoltenberg and McNeill’s (2010) suggestion and other integrative models (e.g., Carlson & Lambie, 2012; Young, Lambie, Hutchinson, & Thurston-Dyer, 2011), the phases in the IWM are hierarchical in nature, with the highest phase (phase three) being ideal for developed supervisees. In addition, the IWM acknowledges the preclinical experiences (e.g., lay helper; Rønnestad, & Skovholt, 2003) of supervisees as valuable and relevant to their development. In the IWM, it is important to acknowledge and address the experiences that supervisees have had prior to their work as counselors because they may impact perceptions and expectations.

For example, supervisors can facilitate activities to promote awareness of how supervisees influence counseling sessions. To illustrate, supervisees may participate in activities highlighting culture, family-of-origin, character strengths and bias, and evaluate how those factors may influence their counseling skills, views of clients and interactions with clients, peers and supervisors. One example of a technique that can generate conversation on the aforementioned areas is the genogram (Lim & Nakamoto, 2008). Supervisees can use the genogram to map out their family history, life influences and path to becoming a counselor during a supervision session. Ultimately, the genogram can be used as a tool to assess where supervisees are developmentally and what might have contributed to their worldview and presence as counselors. With any technique used during the supervision process, the goal of increasing awareness is emphasized. Furthermore, supervisees can implement these activities for use with their own clients. Ultimately, supervisors work to facilitate supervisee progression toward being more self-actualized, self-aware counselors. Table 1 provides descriptions of awareness of well-being, developmental characteristics, supervisory descriptors and supervision considerations for each developmental phase.

Table 1

IWM Phases of Supervisee Development

	Awareness of Well-being		Developmental Characteristics	Supervisory Descriptors	Supervision Considerations

Phase 1		Low awareness	Low independenceIncreased anxietyFollows the lead of others Low self-efficacy	SupportiveEducationalStructured	Live supervisionFeedbackPsychoeducation Modeling
Phase 2		Pursuit of awareness	Seeking independenceModerate anxietyMakes attempts to lead Modest self-efficacy	Generating awarenessCelebrating successesChallenging	Advanced skill feedbackChallenge awareness
Phase 3		Increased awareness	Mostly independentNominal anxietyLeads others Moderate–high self-efficacy	Increased mutualityCollaborative	Active listeningConsultation

One way supervisors seek to assess supervisees’ developmental phase is through active inquiry. Similar to Young and colleagues’ (2011) recommendations, the assessment of supervisees’ developmental phase is achieved through the use of questioning, reflecting, active listening and challenging incongruences. In addition, direct and intentional questions are used to target specific topics. For example, a supervisor seeking to assess the wellness of a supervisee might ask, “How are you feeling?” and then if there is incongruence, the supervisor might state, “You’re saying that you feel ‘fine,’ but you appear to be anxious tonight.” Based on supervisee reaction, the supervisor can judge the level of awareness the trainee has into his or her own well-being. Additionally, supervisors might want to ask about specific issues such as planned interventions, diagnostic interpretations or theoretical orientation. For example, a supervisor might ask, “How do you plan to assess for suicide?” Then, based on the trainee’s reaction (e.g., asking for help, giving a tentative answer or giving a confident answer) the supervisor can determine his or her developmental phase.

Supervisors also can assess supervisee developmental phase through evaluation. By observing a supervisee in a number of settings (e.g., counseling, triadic supervision, group supervision), supervisors can gauge where he or she is developmentally. Furthermore, observing the supervisee’s counseling skills, professional behaviors and dispositions (Swank, Lambie, & Witta, 2012) can provide increased insight into what phase the supervisee is experiencing at that particular point in time.

Allocation of Supervision Need

The allocation of supervision need is the next process in the IWM of supervision. The supervisor assesses the developmental phase of the supervisee and then provides a supervision intervention (contextual or educational) with the goal of supporting and/or challenging the supervisee (Lambie & Sias, 2009). Phase one of supervisee development is marked by high anxiety, low self-efficacy, decreased awareness of wellness and poor initiative. The supervision environment is one of structure with prescribed activities. Activities to support growth in phase one include live supervision, critical feedback, education on relevant issues, and modeling of behavior and skill.

Gaining insight into trainee wellness also is critical. Supervisors can use insight-oriented activities such as scrapbook journaling, which allows supervisees to gain awareness through the use of multiple media such as photos, music, quotes and poems in the journaling process (Bradley, Whisenhunt, Adamson, & Kress, 2013), or openly discussing the supervisee’s current state of wellness to help foster an increased awareness of it. Supervisees in this developmental phase can be encouraged to explore the five wellness domains (creative self, coping self, social self, essential self, physical self) and begin increasing awareness of their current level of wellness. An example of an activity for assessing supervisee wellness is the starfish technique, which is adapted from Echterling and colleagues’ (2002) sea star balancing exercise. Within this technique, supervisees receive a picture of a five-armed starfish marked with the five wellness constructs (creative, coping, physical, essential, social; Hattie et al., 2004; Myers et al., 2004) and are asked to evaluate the areas that influence or contribute to their overall wellness. Following this, supervisors and supervisees can pursue a discussion regarding the constructs. After the discussion, supervisees redraw the starfish with arm lengths representing the amount of influence that each construct has on their overall wellness or change the constructs into things that they feel better represent their personal wellness. Figure 1 is an example of a supervisee’s initial starfish. Figure 2 is the redrawn wellness starfish based on prioritizing or changing the wellness constructs; this supervisee’s redrawn starfish prioritizes social, physical and creative aspects. In contrast, nutritional and emotional constructs are depicted as smaller arms, indicating areas for growth or a potential imbalance.

Supervisees’ progression to higher levels of development is facilitated through educational and reflective interventions that their supervisors deliver. Phase two of supervisee development is marked by increased autonomy and self-efficacy, decreased anxiety, and attempts to lead or take initiatives. The context of supervision is less concrete and structured but still supportive and encouraging. Supervisees may seek independence, as well as reassurance that they are correct when working through challenges (Borders & Brown, 2005). Supervisors can provide feedback on advanced skills, challenge supervisee awareness and foster opportunities for supervisees to take risks (i.e., challenge, support; Lambie & Sias, 2009). Supervisees in phase two have an increased awareness of their well-being but may be reluctant to integrate support strategies. Therefore, supervisors may integrate activities, assignments or challenges to enhance supervisees’ wellness. For example, supervisors can have supervisees create wellness plans or discuss current wellness plans. Thus, the supervisor can hold the supervisee accountable for personal well-being.

Supervisees in phase three exhibit high autonomy and self-efficacy, low anxiety, and greater efforts to lead (Borders & Brown, 2005). The supervision environment is less structured and the supervisor assumes a consultative role. In addition, the supervisee may serve as a leader by supporting less developed peers. Interventions at this level take the form of consulting on tough cases, working through unresolved issues and providing guidance on advanced skills. Furthermore, supervisees have higher awareness of their wellness and its implications on their work with clients. Finally, supervisees in this phase seek to minimize negative well-being and may need encouragement to overcome this challenge.

Assessment and Matching of Wellness Interventions

Evaluation is a key component of the supervision process (Borders & Brown, 2005) and therefore, wellness, supervisee skill level and supervisor role are assessed in the IWM. A key feature of the IWM is the emphasis on promoting supervisee wellness. Therefore, the IWM emphasizes the evaluation of supervisees and matching of wellness interventions. Furthermore, it is important to assess supervisees’ counseling skills throughout the supervision process to provide formative and summative feedback.

The IWM utilizes the five factors of the indivisible self model (Myers & Sweeney, 2004, 2005) as points of assessment. Furthermore, the development of personal well-being is dependent upon education of wellness, self-assessment, goal planning and progress evaluation (Granello, 2000; Myers, Sweeney, & Witmer, 2000). Therefore, the IWM utilizes these aspects of wellness development as a modality for enhancing supervisee well-being. Supervisees are viewed from a positive, strengths-based perspective in the IWM and thus, activities in supervision should highlight positive attributes, increase understanding of supervisees’ level of wellness and promote knowledge of holistic wellness. Wellness plans (WPs) and the starfish activity are used to assess supervisee wellness by promoting communication and self-awareness in the supervision session. Furthermore, both evaluations are valuable self-assessment measures for supervisees and allow for initial wellness goal setting. WPs should be developed during early supervision sessions and used as a check-in mechanism for formative wellness feedback. Concurrently, the starfish assessment can be used early on to gauge initial wellness and areas for wellness growth.

Progress evaluation is assessed with the 5F-Wel (Myers et al., 2004), a model used to consider factors contributing to healthy lifestyles. The 5F-Wel is a frequently used assessment of wellness and is based on the creative, coping, essential, physical and spiritual self components of the indivisible self model (Myers et al., 2004; Myers & Sweeney, 2005). Supervisees take this assessment during the initial and final sessions to assess their wellness. Myers and Sweeney (2005) have reported the internal consistency of the 5F-Wel as ranging from .89 to .96.

Supervisee counseling skills should be evaluated using a standardized assessment tool. For example, the Counselor Competency Scale (CCS; Swank et al., 2012) can be used as a formative (e.g., midterm or weekly) and summative (e.g., end of semester) assessment of supervisee competencies. In addition, the CCS examines whether supervisees have the knowledge, self-awareness and counseling skills to progress to additional advanced clinical practicum or internship experiences. The CCS assesses supervisee development of skill, professional behavior and professional disposition (Swank et al., 2012). Therefore, supervisors can utilize the CCS to match and support supervisees’ growth by taking on appropriate roles (i.e., teacher, counselor, consultant) to enhance work on specific developmental issues.

Evaluation allows supervisors to monitor supervisee development of career-sustaining mechanisms that enhance well-being, as well as counseling skills, dispositions and professional behaviors. Specifically, the goals of supervisee development are to increase or maintain level of wellness and increase or maintain counseling skills by the end of the supervision process. However, if a supervisee does not improve well-being, the WP should be reevaluated and a remediation plan set so that the supervisee continues to work toward increased wellness. Similarly, if a student does not meet the minimal counseling skill requirements, a remediation plan can be created to support the student’s continued development.

Matching. Supervisors gain a picture of where counseling trainees are developmentally based on the assessment and evaluation process. Then supervisors can match supervisee developmental levels (of skill and wellness) by assuming the appropriate role (i.e., counselor, teacher, consultant) and using the role to provide the appropriate level of support for each trainee. This process allows for individualization of the supervision process and for supervisors to tailor specific events, techniques and learning experiences to the needs of their supervisees. Furthermore, matching supervisee developmental needs and gauging levels of awareness and anxiety allows for appropriate discussions during supervision. Discussing wellness during the latter part of supervision is appropriate for beginning counselors who may be anxious about their skills and work with clients (Borders, 1990) and may not absorb information about their wellness. Each supervisee is an individual, and as a result, it is important to make sure that the supervisee is ready to hear wellness feedback during the supervision session.

IWM: Goals, Strengths and Limitations

The overall goals of the IWM of supervision are for supervisees to increase their wellness, progress through developmental stages and gain counseling skills required to be effective counselors. Additionally, supervisors using the IWM can aid supervisees in increasing wellness awareness via completion of wellness-related assessments (e.g., WPs and starfish technique). Furthermore, supervisors can work to increase supervisees’ self-awareness and professional awareness of counseling issues such as multicultural wellness concerns, the therapeutic alliance, becoming a reflective practitioner, and positive, strengths-based approaches of counseling under the IWM framework.

The IWM is innovative in that it is one of a few supervision models to contain a wellness component. Additionally, the IWM tenets (i.e., wellness, discrimination, development) are empirically supported on individual levels. Furthermore, the IWM includes techniques and assessments for promoting open communication relating to supervisee wellness and counseling skills, and therefore supports supervisory relationships and greater self-awareness, and ultimately allows supervisors to encourage and promote wellness.

As with all models of supervision, the IWM has limitations. Specifically, the IWM may not be applicable to advanced counselors and supervisees. The IWM includes three developmental phases, which are applicable to CITs. In addition, the model may not be as beneficial to supervisees who already have a balanced wellness plan or practice wellness, because the wellness component may be repetitive for such individuals. Additionally, all aspects of the IWM might not be effective or appropriate across all multicultural groups (i.e., races, ethnicities, genders, religions). For example, in relation to wellness, supervisees may not adhere to a holistic paradigm or believe in certain wellness constructs. Lastly, the IWM is in its infancy and empirical evidence directly associated with the integrative prototype does not exist. Nevertheless, supervisors using the IWM can tailor the wellness, developmental and role-matching components to meet specific supervisee needs. The following case study depicts the use of the IWM with a counseling supervisee.

Case Study

Kayla is a 25-year-old female master’s-level counseling student taking her first practicum course. She is excited about the idea of putting the skills she has learned during her program into practice with clients. However, Kayla also is anxious about seeing her first clients and often questions whether she will be able to remember everything she is supposed to do. People tell her she will be fine; however, Kayla questions whether she will actually be able to help her clients.

In addition to the practicum course, Kayla is taking three other graduate courses. She has a full-time job and is in a steady relationship. Family is very important to her, but since beginning her graduate program, she has been unable to find enough time to spend with friends and family. Kayla feels the pull between these areas of her life and struggles to find a balance between family, school, work and her partner.

Kayla is in phase one (i.e., high anxiety); therefore, her supervisor assumes the counselor and teacher roles most often, to match Kayla developmentally. This choice of roles allows Kayla to receive appropriate levels of support and structure to help ease anxiety. During this phase, the supervisor introduces a WP to Kayla and has her complete the 5F-Wel and starfish activity. After discussing the supervisory process and explaining the IWM, Kayla and the supervisor have a conversation about the areas influencing her overall wellness. Based on her starfish results, Kayla is encouraged to develop a WP that coincides with the areas depicted on the starfish, emphasizing those that she wishes to develop further. Additionally, the 5F-Wel provides a baseline of well-being to use in future sessions. Along with the wellness focus, the supervisor explains how imbalance or unwellness influences counselors and, in turn, how it can influence clients.

Initial supervision sessions will continue to provide Kayla with appropriate levels of support and psychoeducation so that she will be able to transition from low awareness to a greater sense of counseling skill awareness and increased mindfulness regarding her overall wellness. If the supervisor and supervisee are able to establish a strong working relationship, it is expected that Kayla will eventually move developmentally into phase two, where she will continue to gain insight into her counseling and wellness, begin to increase her autonomy, and work on increasing self-efficacy.

Implications for Counseling

The IWM integrates developmental and DM supervision tenets with domains of wellness. A supervision model that incorporates wellness is a logical fit in counseling and counselor education, where programs can and should address personal development through wellness strategies for CITs (Roach & Young, 2007). Furthermore, the IWM supports the idea that wellness is important. According to White and Franzoni (1990), CITs often show higher psychological disturbances than the general population. Cummins, Massey, and Jones (2007) highlighted the fact that counselors and CITs often struggle to take their own advice about wellness in their personal lives. Thus, while counseling is theoretically and historically a wellness-oriented field, many counselors are unwell and failing to practice what they preach (Lawson, Venart, Hazler, & Kottler, 2007; Myers & Sweeney, 2005). Implementing the IWM can aid in supporting overall wellness in supervisees as well as educating CITs to practice wellness with their clients and with themselves.

In relation to developmental matching and DM roles, counseling supervisors using the IWM have the following theoretical issues (e.g., Bernard, 1997; Myers et al., 2004; Myers & Sweeney, 2005) to facilitate: supervisee change, skill development, increased self-awareness and increased professional development. The IWM is a holistic, strengths-based model that focuses on supervisee development, matching supervisee needs through supervisor role changing, and wellness to promote knowledgeable, well and effective counseling supervisees.

Conclusion

The IWM is designed to integrate wellness, developmental stages and role matching to allow supervisors to encourage holistic wellness through supervision. Wellness has a positive relationship with counselors’ increased use of career-sustaining mechanisms and increased professional quality of life (Lawson, 2007; Lawson & Myers, 2011). Likewise, increased professional quality of life has been shown to make a positive contribution to counselors’ self-efficacy and counseling service delivery (Mullen, 2014). Therefore, it is logical to promote wellness and career-sustaining behaviors throughout the supervision process.

In summary, the IWM offers a new, integrated model of supervision for use with CITs. Supervisors using the IWM have the unique opportunity to operate from a wellness paradigm, familiarize their supervisees with wellness practices, and monitor supervisees’ wellness and how their wellness influences their client outcomes, while simultaneously supporting supervisee growth, counseling skill development and awareness of professional dispositions.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.

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Ashley J. Blount, NCC, is a doctoral student at the University of Central Florida. Patrick R. Mullen, NCC, is an Assistant Professor at East Carolina University. Correspondence can be addressed to Ashley J. Blount, The Department of Child, Family, and Community Sciences, University of Central Florida, P.O. Box 161250, Orlando, Florida, 32816-1250, ashleyjwindt@gmail.com.

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