Chapter 13 - Supervision

Ongoing supervision is a necessary and important part of counselor training and support. A problem sometimes seen in the addiction field is a lack of adequate supervision. Also, counselor stress and burnout are commonplace. This constellation of phenomena - lack of adequate supervision, stress, and burnout - are seen frequently.

The ultimate goal of supervision is to enhance the quality of patient care. Two primary foci help to achieve this goal. First, it is centrally important to provide support and encouragement for the counselor and to promote the opportunity for counselors to expand their skills. Second, it is important for the supervisor to have the opportunity to review the clinical status of the patients and to offer suggestions or corrections.

The format of supervision in this model is for each individual counselor to have a supervisor and to meet with that supervisor once a week to review counseling sessions. We recommend that the individual counseling sessions be audiotaped and some of them reviewed by the supervisor. The supervisor should listen to a certain percentage of the sessions in their entirety and then rate them for adherence to the counseling manual. Then feedback can be given to the counselor, based on his or her adherence to the model of addiction counseling, as well as other relevant clinical issues.

This manual is accompanied by an adherence scale (see Appendix) to assess the counselor's level of adherence and compliance in providing addiction counseling based on this model. The adherence scale has two primary uses: training and supervision, which is important in clinical as well as research programs, and measurement of treatment differentiability, which is particularly important in research studies comparing different models of treatment. Here, we discuss only the clinical use of the adherence scale.

The scale is designed to target and make explicit the specific kinds of interventions that are central to addiction counseling. Counselors are rated, on 7-point scales, on the frequency and quality (which are interpreted as adherence and competence) of relatively specific types of interventions recommended in the manual. Counselors should be clear about what types of interventions they should be employing if they are using this approach. The scale also identifies types of interventions that should not be used because they are not theoretically consistent with this approach. Furthermore, the adherence scale is intended to guide trainers or supervisors in their duties supervising other addiction counselors. To this end, fairly specific instructions also are provided for how to rate the interventions correctly.

Although the adherence scale identifies the types of interventions that are necessary to conduct good addiction counseling as described by this manual, not every type of intervention highlighted should be employed in every session. Patients do differ from one another. Different issues arise for individual patients at different points in treatment, and as various life events impact on the treatment. The adherence scale lists the repertoire of interventions that addiction counselors will be making in the string of counseling sessions. But, overall, the patient's individual needs in treatment should influence how and in what sequence these interventions actually are done.

The adherence scale, developed based on the IDC approach has been evaluated with regard to its psychometric properties (Barber et al. 1996). There was satisfactory interjudge reliability, which indicates that the scale can be used reliably to assess adherence and competence for IDC techniques.

Also, there was a fairly high level of internal consistency within the five main and two secondary subscales: monitoring drug use behaviors, encouraging abstinence, encouraging 12-step participation, relapse prevention, educating the client, miscellaneous, and things that should not be done. This finding supports the grouping of items into subscales, which then creates an easier way of understanding the theoretical types of interventions in this model.

Substantial correlations between adherence and competence imply that experts in the field thought that counselors who made better use of the interventions identified in the manual also were more skillful in their counseling style in general. This finding suggests that the IDC model incorporates many of the valuable ideas and interventions in the area of addiction counseling. Further, it probably suggests that skilled addiction counselors will be fairly comfortable employing this approach because it is consistent with what good counselors generally try to do.

Finally, the adherence scale has shown good discriminant validity, implying that experts in the field can distinguish this model from other treatment models, including cognitive therapy and supportive-expressive psychodynamic therapy. For the original research, we compared these different treatments for cocaine addiction and determined that IDC was particularly effective.

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