True clinical supervision has become an endangered item on the menu of services available within the addiction treatment and recovery support communities. Meant to assure the safety, quality and effectiveness of treatment services, it is often seen either as a primarily administrative function or as an expendable luxury in times of tight budgets and increasing service demands. While it can be a powerful instrument in managing and assuring continuous improvement in service delivery, it is all too often low priority in the face of administrative demands, a resistant organizational culture, limited supervisory competence, and counselors hesitant to fully engage in a mentoring experience.

In this article we ask administrators, supervisors and counselors to reflect on how their organization’s values, structure and practices define clinical supervision. We want you to consider the function of supervision in assuring quality clinical care, in supporting implementation of evidence-based and consensus-based practices, and in promoting the continuous improvement of clinical skills and services. In short, we ask whether it is worth the investment of time and effort it might take to modify your agency culture and offer more genuine clinical supervision.

The Center for Substance Abuse Treatment is in the process of publishing a Technical Assistance Publication (TAP) that will identify Competencies for Substance Abuse Treatment Clinical Supervisors. The TAP succinctly describes the knowledge and skills essential to the competent practice of clinical supervision in treatment settings. Such a document is central to enhancing our understanding of “who” is the clinical supervisor, “what” is their role, and “how” they should carry out their responsibilities. Armed with this information, organizations can make informed decisions on how to design and implement a clinical supervision model that best fits their situation.

Agency considerations
A number of organizational factors influence the role, specific goals, and functions of clinical supervision. Service demands, management policies, budget pressures, and the skills of incumbent supervisors all can contribute to determining the type and extent of supervision available within a treatment setting. Organizations also must take into account the degree to which regulatory and accreditation requirements prescribe clinical supervision. There may be role definitions, standards, and minimal expectations to consider. At the same time, conflicts may exist within the agency between meeting direct service needs and the time needed to provide clinical supervision. The availability of qualified and skillful supervisors also can be a limiting factor. Whatever the case, the treatment organization defines and determines the availability of clinical supervision to its direct service staff.

In effective organizations ongoing learning is often the norm. Such organizations embrace new information and integrate what is relevant into day-to-day operations. Their clinical supervisors recognize the need for firsthand information about staff performance. They observe clinical services, provide feedback and coaching to the service providers, and facilitate the ongoing development of staff skills. Staff members typically demonstrate a willingness to examine assumptions and beliefs, and remain open to improvements in clinical protocol. Proactive, planned clinical supervision can significantly move an organization from a reactive, crisis-oriented framework to one that is more qualitative, and future focused.

In today’s service environment, the supervisor’s role in the adoption of innovative clinical interventions and programs is especially critical. In response to both internal and external pressure to continuously improve engagement, retention and outcomes, agencies are working to infuse practices with demonstrated efficacy into their service designs. The effectiveness of any adoption process often hinges on the availability of observation, feedback and coaching from knowledgeable supervisors (Miller, et al, 2004; Sholomskas, et al, 2005). Adoption processes take time. The development of new skills or familiarity with new methods is not typically achieved by attending a brief training course. Rather, the effective implementation of even the simplest of protocols will take mentoring and shaping before the practice is maximally effective. The availability of clinical supervision is one of the keys to effective implementation.

Another important consideration is the organization’s responsibility to safeguard against legal and ethical liabilities. Without active clinical supervision, legal issues of direct and vicarious liability and ethical breaches can exponentially increase without management’s knowledge, and cause serious harm to the clients being served. The observation and documentation of supervisory activities helps decrease liability, and creates a record of the supervisory process, supervisee development, and staff learning needs.

A thoughtful, planned process
Organizations may need to do a number of things to smoothly transition from existing practice to a more intensive model of clinical supervision. For planning purposes implementation can be divided into phases based on organizational development and need: Phase I) Organizing and Creating Structure; Phase II) Enhancing the Working-Learning Alliance; Phase III) Preparation and Setting Goals; and Phase IV) Improving Performance.

Phase I seeks to create policy and procedures that define a coherent process, including explaining the rationale, purpose and methods for delivering clinical supervision; assuring that agency management fully understands and supports the changes that need to be made; working with and training supervisors to build new knowledge and skills; and orienting clinicians to the rationale and new procedures.

Phase II focuses on assessing the relationships between supervisors and supervisees, and devising interventions to strengthen the alliance. Agencies have often found that cementing these building blocks facilitates the alignment of agency and individual professional development goals. Additionally, a focus on the supervisor-supervisee alliance will model the importance of the counselor-client alliance, a research-supported critical factor in successful outcomes.

Phase III seeks to provide focused training in clinical supervision methods, increasing direct observation of clinical services, and incorporating feedback into a professional development plan for each supervisee.

Phase IV sustains the continuous development of supervisory practices, and acknowledges and celebrates improvements in key clinical indicators such as engagement and retention rates and service outcomes. The broader goal is to create a continuous learning culture within the agency that encourages professional development, service improvement, and a quality of care that maximizes benefits to the agency’s clientele.

Is clinical supervision worth the investment?
The degree of change an organization will need to undertake depends on the nature of current supervisory practice. The more administrative the supervisory style, the more change will be needed to effect true clinical supervision. At a minimum, management will need to examine organizational culture, existing policy and procedures, position descriptions, direct service expectations and time allocated to the delivery of clinical supervision.

Time is a significant issue. Proactive, planned clinical supervision takes considerably more time than what is typically allotted in community agencies. That time, however, is best considered an investment that will potentially return benefits of improved service, a more skillful workforce, fewer performance problems and better clinical outcomes.

If agency management clarifies expectations for both the delivery and outcome of clinical supervision prior to its implementation, staff buy-in is likely to increase. Our experience tells us that when an organization invests in altering its clinical supervision practices in the directions noted here, the return on investment is many times its original cost.

Pamela Mattel LCSW, CASAC is the Executive Deputy Director of Basics, Inc. in New York, and has been providing administrative and clinical supervision for over 20 years. She is actively involved in workforce development efforts in Pamela Mattel LCSW, CASAC is the Executive Deputy Director of Basics, Inc. in New York, and has been providing administrative and clinical supervision for over 20 years. She is actively involved in workforce development efforts in New York State and recently participated on the expert panel for the upcoming CSAT TAP on clinical supervision competencies.

Steven L. Gallon PhD is director of the Northwest Frontier ATTC and is active in the development of materials, training programs and technical assistance services that promote the adoption of “best practices” in community addiction treatment settings. He chaired the ATTC committee that authored The Change Book — A Blueprint for Technology Transfer (2000), and was a member of the committee that developed the Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice.

This article is published in Counselor,The Magazine for Addiction Professionals, June 2006, v.7, n.3, pp.52-53.

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