Starring in the 1991 film The Search for Signs of Intelligent Life in the Universe, Lily Tomlin said, I've always wanted to be somebody. Now I see I should have been more specific. As I look at the Blended Model of Clinical Supervision that I developed in the early 1990s, I see that perhaps I should have been more specific. Since the development in the 1980s of the Blended Model of Clinical Supervision for substance abuse counselors and its publication in Clinical Supervision in Alcohol and Drug Abuse Counseling (Powell & Brodsky, 1993; Powell, 1998), there remains a dearth of literature on clinical supervision in the substance abuse field.

Despite the phenomenal expansion of psychotherapeutic approaches and theories and, in turn, supervision approaches in the mental health field in the past 30 years, the substance abuse field has done little exploration of supervisory models and theories. Training models such as the Clinical Preceptorship Program and Clinical Supervision Training Program, both developed by ETP Inc., and the Wisconsin Training Program (Foundation for Addictions Research and Education, 1998) have been developed based on the International Certification and Reciprocity Consortium Role Delineation Study (IC&RC, 1992). However, hardly any writing has been done on theoretical models for supervision, other than the Blended Model.

Why a new model?
To meet the evolving demands of the substance abuse field, a new form of the Blended Model of Clinical Supervision is required. During the 1990s, significant changes have impacted substance abuse treatment and the health care delivery system. One of the most significant, although subtle, changes in physical and behavioral health treatment has been a further incorporation of spiritual issues into therapy.

For a basic review of the Blended Model the reader is referred to Clinical Supervision in Alcohol and Drug Abuse Counseling (Powell, 1998). This article will begin where the old Blended Model left off. Utilizing the groundbreaking work of Hubble, Duncan, and Miller in The Heart and Soul of Change (2000), the New Blended Model incorporates recent findings regarding what brings about change in people, as well as issues related to spirituality and therapy. This article explores those psychological and spiritual foundations of the new model.

Part I: Psychological foundations — “The Big Four” primary factors affecting change
New understanding of what brings about change in people forms the psychological basis of the New Blended Model of Clinical Supervision. Researchers (Hubble, Duncan, & Miller, 2000) have identified “the Big Four” primary factors that affect change:

1. Client/extratherapeutic factors account for 40 percent of the change that occurs in treatment. These factors consist of the individual’s strengths, the supportive elements in the person’s environment, his or her stage of readiness for change, and even chance events. These can include the apparent serendipitous events, as well as persistence, faith, and job changes. All of these factors relate to the client and not the actions of the counselor.
   
   For too long, we have thought that change is the result of some magical cure or words uttered by a skilled clinician, leaving out the client’s role in the change process. We came to believe that, when treatment succeeds, it is the result of the counselor’s actions. However, research indicates that if change occurs, it is the client who is the magician who has utilized his or her unique healing power. The counselor (or supervisor, in the case of clinical supervision) sets the stage and assists in safeguarding the conditions under which the client’s (or counselor’s) magic can operate.
   
   Additional client/extratherapeutic factors affecting treatment are the presence of underlying personality disorders; the client’s senses of faith and personal responsibility; the client’s persistence; and the length of time the disorder has persisted. Further factors include the presence of high-remission disorders, such as depression, anxiety, phobias, obsessive compulsive disease, and addictions. The client’s strengths and even fortuitous events are central. Key to treatment outcome is the identification of not only what clients need but also what clients already have in their lives to help them reach their goals. Trainees ask questions such as, “How do you motivate clients? Or resistant supervisees?” The fact is — you cannot motivate anyone, because everyone is already motivated by something; your task is to find out what motivates them.
   
2. Relationship factors are the most significant issues in therapy outcome, accounting for 30 percent of the change. Carl Rogers and others knew a long time ago that the affective qualities of the therapist impact treatment outcome. Research now indicates that the factors affecting the effectiveness of therapy include caring, empathy, warmth, acceptance, mutual affirmations, and encouragement of risk-taking. It appears that different types of clients react differently to a variety of therapeutic interventions, or that their impact is mediated by various client factors.
   
   Key, though, is whether the client feels compassion, caring, warmth, accurate empathy, congruence, positive regard, genuineness, and acceptance. Conversely, when clients are pulled into hostile exchanges, arguments, or inappropriate confrontations, they resist change. We tend to blame such reactions on client resistance, lack of motivation, or denial, when in fact we have established a defensive, hostile, and confrontational environment, diminishing the probability of change. Most importantly, it is not our perception of the relationship that matters most — it is how the client feels about the quality of the therapeutic relationship.
   
   The non-specific counselor factors affecting therapy are the counselor’s personality as well as the counselor’s providing time and a safe place to talk, being a good listener, understanding the needs of the client, and offering coaching, teaching, and opportunities for self-help. With experience and training, counselors can learn to better understand the client’s experiences.
   
   What does not work in treatment is attributing failure to the client through words such as “he’s not ready for treatment.” It also does not work to argue with the client, to be hostile, passive, defensive, or to ignore the client’s feelings, to have negative confrontations, or to offer mechanical responses. Some of the trends that do not seem to work: a strict adherence to the medical model of therapy (wherein the counselor prescribes a solution for the client’s problem, and client issues are viewed as sickness or illness); the empirically validated treatment approach (much loved by managed care); and protocol-driven treatment. When training counselors, warning signs for supervisors ought to be compassion fatigue, in which the counselor feels over-stressed; becomes abusive, critical, or confrontational; ignores the client’s feelings; and offers mechanical responses.
   
3. Placebos, hope, and expectancy account for 15 percent of the change in therapy. The client contributes to the placebo effect when he or she has a sense of optimism, self-healing, self-efficacy expectancy, and a belief that he can successfully perform a behavior (the opposite of placebo is nocebo, the lack of hope in a positive outcome). Hope is how people think about the possibility of attaining their goals and is a common factor in all change. Expectancy research has shown that clients model their counselors’ patterns of thinking. When we stop believing that our clients can succeed in recovery, the clients sense this and, in turn, lose hope.
   
   Alcohol and drug abuse counselors have subtle and not so subtle ways of conveying disappointment and discouragement with client behavior. In so doing, we fail to promote a sense of hope for our clients. One of the easiest and most effective techniques a counselor can use is to continue to encourage clients with words such as “I know you can do this. You have done it before. Keep it up.” Counselors can contribute to the placebo effect through offering support, mutual agreement, partnership, empathic communication, clear expectations, and empowerment.
   
   In substance abuse treatment, the first stage of change is that of discovery, which involves instilling a sense of hope, discovering that change is possible. Recovery happens after the initial affects of placebo are realized. It is important for a counselor to enter into the client’s subjective world and the personal meaning of their symptoms. Counselors need to offer a holding environment where hope grows through healing rituals and an orientation to the future, highlighting the client’s sense of personal control. Research clearly shows that the higher the alliance between patient and caregiver, the better the outcome; and the higher the alliance with the caregiver, the more powerful the placebo effect. Now the bad news.
   
4. Model/technique factors ac-count for only 15 percent of therapeutic change. Following years of emphasis on learning skills and techniques in therapy, the data indicate that after years of squabbling about which therapeutic approach is better, the fact remains that they all seem to have relatively the same outcome. Technique is important in activities such as history-taking, maintaining confidentiality, adhering to legal and ethical standards, and accurate patient placement.
   
   The findings that technique is not a major factor in therapeutic change have a significant impact on counselor training and clinical supervision. In fact, it may be said that technique is what we use until the real supervisor/counselor shows up. Great teachers have taught us to learn technique, master technique, then transcend technique. This does not mean technique is unimportant. Instead, counselors need to find a model that fits with the client and reflects the above common factors. The counselor needs to match his or her interventions to the client’s stage of change. To isolate specific techniques without greater attention to the basic skills is misguided if not completely illusory. (Hubble, Duncan & Miller, 2000)

What counselors should learn from supervision
The implications of these findings about how people change are dramatic and far-reaching for training and clinical supervision. Instead of our usual focus on teaching skills and techniques, clinical supervisors ought to be training counselors to:

• Be attuned to the client’s feelings, how to establish rapport, and how to demonstrate caring, compassion, and empathy.
• Find a collaborative rather than combative metaphor for treatment; they must learn the more subtle interpersonal aspects of the therapeutic relationship.
• Learn how to develop and monitor the therapeutic alliance, how to assess difficulties with that alliance, and how to repair alliance ruptures.
• Become familiar with social support networks, community services, family, and community resources to enhance the potential for success.
• Reconsider the conventional wisdom suggesting that it is the client’s fault when treatment does not meet the desired outcome. To break from this conventional wisdom, counselors must embrace the attitude that if there is any magic in treatment, it is the magic brought by the client and not the counselor.
• Promote the client’s sense of personal control and empowerment. By encouraging clients to see their own gains, counselors can convey positive expectations and hope, helping the client to find his or her own solutions.
• Focus on the future, especially on the client’s ability to overcome the past; they must develop an attitude that the client is capable of finding his or her own solutions, always expecting the client to get better. Far too often in the addictions field, we predict relapse and failure instead of the possibility of success.
• Learn effective intervention with clients needing fewer than 10 sessions (the majority of the clients seen); often, simply scheduling an appointment begins the change process. Although a certain number of clients (20-30 percent) need treatment for more than 25 sessions, counselors need to be adept at working with short-term and long-term clients, and have the ability to know the difference.
• Learn diagnostics, but not too soon. As important as diagnostics are, supervisors must delay teaching them for fear that counselors will too quickly begin assessing and making value judgments about clients. Diagnostics should be taught after the basic affective qualities for counselors are well established.
• Be able to adapt the relationship to different clients and their needs. The most important question a counselor can ever ask a client is, “What do you want?” followed by “How can I help you get there?”
• Remember that the earlier change happens in treatment, the more likely the outcome will be positive; it is not the counselor who can make the client work, but the client who makes the counselor work.

Part II: Spiritual foundations — “Contemplative supervision (and therapy)”
Unlike the original Blended Model of Clinical Supervision, the New Blended Model integrates spiritual aspects of change. The term for this integration is “contemplative therapy” or “contemplative supervision” — it is based on a different viewpoint of how and why people change, what they want, and what truly is important in treating people.
Contemplative supervision removes from the supervisor “the need” to be the expert who has all the answers for the counselor; it empowers counselors to find their own answers and approaches. It is a commitment to healing by enhancing the isomorphic relationship between the counselor and supervision, and counselor and client. Contemplative supervision models a healthy therapeutic alliance that puts counseling and supervisor in a larger, more global context and dialogue, where individuals realize that their lives are not just about themselves, but that they are part of the larger story of life.

The original Blended Model assumed that counselors possessed magic to treat the body and mind of the client. The New Blended Model recognizes that the original model omitted perhaps the most important aspect of treatment: the spiritual dimension. Traditional supervision and therapy address the efficiency of a person’s functioning. In contrast, the contemplative approach looks at the dynamic process of what one wants, delineated in the research presented in the first part of this article. While traditional counseling and supervision looks at how one should live, contemplative work looks at why one should live. Fundamental to this process is the integration of the body, mind, and spirit, always seeking to accommodate the client or supervisee’s state of readiness for change.

The key to positive outcome in supervision (and in therapy) is to identify not what people need, but what they already have to work with and for them. Supervision must accommodate the supervisee’s state of readiness for change and his or her unique goals.

Principles of contemplative supervision (and therapy)

• Begin with a basic question: what is health? While this might seem elementary, it is essential that we understand from the beginning the “health” that we are trying to accomplish. For the author, health is “when the mind is present in the heart —when the mind, body, and spirit are integrated.” This means that health is present when an individual is at peace with his or her mind, body, and spirit, even if one of those elements is experiencing pain or suffering.
• Do not seek to offer answers. Too often, as supervisors or counselors, we feel that we need to be the expert. Instead of offering answers, offer mystery, compassion, wonder, openness, simple presence, and waiting alongside the person. Much of life cannot be explained, only experienced.
• Practice contemplative listening. The Latin root of the word “listening” is the same root as “obedient,” “to give as a gift.” Contemplative listening is to hear without an agenda, without a compulsion to help, by abandoning our desire to be wise, comforting, and knowledgeable. The practice involves being receptive to visual, auditory, kinesthetic, and intuitive cues. Contemplative listening allows one to see the world, in Buddhist terms, through beginner’s eyes, and to be open and receptive to life’s hidden meanings. This aids in finding meaning and purpose in life, being mindful of the present moment, and being fully present and attentive to the meta-messages in communication. It is a way of seeking further collaboration and compassion in the supervisory and therapy systems.
• Recognize that supervision is as much about love as it is skill. If expertise cures, healing comes from the sharing of experiences and wounds. Counselors need to learn the appropriate use of self-disclosure. Self-disclosure does not involve always telling one’s own stories, and oozing all over with one’s own wounds — it means being present in love, allowing the still, small voice within us to emerge, and trusting that voice and sharing experiences whenever appropriate.
• Acknowledge the most important phrases a supervisor or counselor can ever learn: “I don’t know” and “I could be wrong.” Often, an unanswered question is a fine traveling companion — a truth known by all the great teachers of the world, from Buddha to Jesus. This is so because counseling is about intimacy, and at the heart of intimacy is vulnerability. To maximize vulnerability, we need to inspire wisdom by letting the question be (as an agreement by both to ponder and search for meaning) versus getting involved in a potential power struggle. In the words of great philosophers of our day, John Lennon and Paul McCartney, “There will be an answer, let it be.” We also know similar wisdom in the Serenity Prayer.

How to develop contemplative habits

• Begin with a nonjudgmental, authentic presence. Contemplative supervisors and counselors teach through being, with an accepting attitude that promotes empathy and understanding between parties. They start with openness and willingness to understand the person’s emotional, psychological, physical, social, and spiritual dimensions as they impact on their health. They remember that people don’t care how much you know until they know how much you care.• Root wisdom in all ways of knowing: observation, logical inference, behavioral learning (affective, emotional, and physical), and intuition. The goal of supervision should not be the autonomy of the individual self but the realization of one’s essential rootedness and relatedness in something broader than the self. Contemplative supervision requires a sense of willing surrender to otherness and not willful mastery of the situation. The greatest gift we can give to a supervisee or client is our wholeness or health, the integration of our body, mind, and spirit. Skilled helpers are in touch with their own pain, allowing them to be compassionate toward another’s pain and wounds.
• Seek transformation (for the self and counselor or client) and not simply behavioral change. Transformation occurs through the process of letting go — we grow through what we let go of versus what we gain. Counselors and clients need to learn what happens in the transformative process. And in most situations, what we need to do is let go of pain in our lives. Change is always about what people are to do with their pain; unless we transform our pain, we transmit it, in behavior toward ourselves, counselors, or clients.
• Continually ask: To what am I attached today that might get in my way of listening and showing compassion? Too often we have images of ourselves as great therapeutic wizards, all knowing, all-powerful. These images of success may cloud our awareness of our attachments and inhibit our ability to respond from our heart.
• Understand and teach the power of silence. We need to learn silence in supervision and in therapy, to be comfortable in the silence, trusting that there is a power at work within the person and the space between us that will bring about change. Begin supervision and/or counseling sessions in silence, leaving space for the unique spirit of the individual sitting before you to emerge. Seek stillness, within yourself and the environment in which you are working; trust that something is at work at all times, promoting change, especially in silence. The difference between remaining silent and passive waiting is in the quality of attentiveness.
• Engage in and encourage constant self-reflection. We need to ask ourselves questions such as what is my purpose? What keeps me going day-to-day? Why do I do what I do? What motivates me to do what I do? What am I searching for today? What gives me meaning in what I am currently doing? How do I want to be remembered as a person, a counselor, and a professional? What am I currently trying to reach? What is waiting to happen in my life right now? What would be unlived if it all ended today? What do you love today? What gives you a sense of significance in life? When you find that, let it lead you to where you need to be.
• Develop contemplative listening skills. To develop these, supervisors and counselors need to have their own spiritual practice that includes the process of deeper listening. We cannot take someone to a place that we have not been to ourselves. Set aside quiet, contemplative times when you can listen to your heart. Out of stillness within, supervisors and counselors can spontaneously project a sense of peace, well-being, and centeredness. In addition, contemplative listening involves storytelling and the use of metaphors as a way of unraveling truth within the other. Through these means, supervisors and counselors are able to search and find meaning in despair and gather in the vicissitudes of others without imposing their own will.
• Remain open to and passionate about exploring existential questions for themselves. Contemplative supervisors and counselors are courageous in opening the discussion with others, and demonstrate wisdom in understanding how to help others integrate the insights gained and to move forward.
• Avoid using the relationship to pursue your own spiritual agenda (i.e., to push a particular religious belief system, structure, or self-help orientation). We cannot teach other people to be spiritual — because they already are.

To become a contemplative supervisor and/or counselor, it is necessary to ex-plore your own spiritual journey through stillness, meditation, and reflection. Many training programs for contemplative listening are available, including: Buddhist meditation programs, the Shalem Institute for Spiritual Formation in Maryland, Spiritual Directors International, and many local training programs in spiritual listening. On this journey, it is advised to have a guide to support you in learning contemplative listening. Having a spiritual director is an excellent place to start.

An ever-changing model
The New Blended Model of Clinical Supervision is much like life — it is a work in progress, ever-changing, always seeking to reflect the deeper movement occurring in us. As we grow as counselors and supervisors, it is important to explore these deeper, contemplative dimensions, rooted in spiritual truths and good science regarding what brings about change in people, physically, socially, emotionally, and most importantly, spiritually.

David J. Powell, PhD, is president of the Clinical Supervision Institute, a division of the International Center for Health Concerns, Inc., and a member of the clinical advisory board of eGetgoing.com. For further information on the contemplative model of supervision and listening, or for recommendations on programs of study, e-mail This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Foundation for Addictions Research and Education, Ltd. (1998). Wisconsin Clinical Supervision Training Project. Available: http://www.fare-wi.org/FARERtoPWIClinSup
TrngModelSummary.htm
Hubble, M. A., Duncan, B. L. & Miller, S. D. (Eds.) (2000). The Heart and Soul of Change. Washington, DC: American Psychological Association.
International Certification & Reciprocity Consortium (1992). Role delineation study.
Powell, D. J. & Brodsky, A. (1993). Clinical Supervision in Alcohol and Drug Abuse Counseling: Principles, Models, Methods. Lanham, MD: Lexington Books.
Powell, D. J. (1998). Clinical Supervision in Alcohol and Drug Abuse Counseling: Principles, Models, Methods. Reprint edition. San Francisco, CA: Jossey-Bass.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2003, v.4, n.6, pp. .

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miran mcclendon  - substance abuse counselor   |74.236.229.xxx |2008-08-10 19:53:10 Good information. I am currently reading the book "Clinical Supervision in Alcohol and Drug Abuse Counseling" by David J. Powll. Reply 0   0

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