Developing integration skills: the role of clinical supervision.

Tan, Siang-Yang

The present article addresses three areas: learning integration as students, learning integration skills as students and trainees through integrative clinical supervision, and learning to become an integrative clinical supervisor. It focuses on developing integration skills in students and trainees through Christian or integrative clinical supervision in five major aspects or areas of integration: presuppositional, theoretical, intervention, therapeutic relationship, and personal (Gingrich & Worthington, 2007). Three major models of how to effectively conduct Christian clinical supervision are reviewed (Aten, Boyer, & Tucker, 2007; Campbell, 2007; Gingrich & Worthington, 2007) The role of personal mentoring and transformational supervision (Johnson, 2007) is highlighted in the development of integration skills in students, because they learn integration mostly through personal relationships with mentors who model integration for them (Sorensen, Derflinger, Bufford, & McMinn, 2004).

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The literature on the integration of Christian faith or Christian spirituality and clinical supervision has been limited or sparse, but recently some significant contributions have been made in a special issue of the Journal of Psychology and Christian clinical supervision edited by Jamie D. Aten and Michael W. Mangis. Topics covered in this special issue include: philosophical foundations for clinical supervision from a Christian worldview (Bufford, 2007);a developmental model of the religious and spiritual development of supervisees (Ripley, Johnson, Tatum & Davis, 2007); a Christian relational and developmental perspective on creating healthy Supervisory environments (Butman & Kruse, 2007); conceptual framework for Christian integration in clinical supervision (Aten,Boyer, & Tucker 2007); integrating Christianity throughout the supervisory process (Campbell, 2007); the use of spiritual disciplines in clinical supervision (Tan, 2007b); training and preparing supervisors to integrate psychology and Christianity (Jones, 2007); and research considerations in clinical supervision and the integration of faith into clinical practice (Gingrich & Worthington, 2007). Further research on and development of Christian clinical supervision are however, still needed.

The crucial role of clinical supervision in learning therapy skills (e.g. see Bernard & Goodyear, 2004) as well as integration skills (e.g. see walker, Gorsuch & Tan, 2005) has been emphasized in the literature. Walker et al. (2005), in a study of 100 therapists sampled mainly from alumni of an explicitly Christian religious clinical psychology doctoral program that is APA- accredited, found that integration and theology coursework did not significantly correlate with the explicit or direct and overt use of religious and spiritual interventions in therapy. However, clinical training with religious clients (measured by the number of contact hours with religious clients) and intervention- specific training with religious and spiritual supervision hours devoted to religious and spiritual interventions in therapy) did significantly correlate with more frequent use of religious and spiritual petency. In a subsequent study of 1d62 student therapists from three explicitly Christian religious clinical psychology doctoral programs that are APAti-accredited, Walker, Gorsuch, Tan, and Otis (2008) found that intervention-specific way of helping train therapists to explicitly use religious and spiritual interventions in therapy. These two studies by Walker and colleagues focus more specifically on explicit integration skills in intervention or therapy.

The need to pay more attention to spirituality and religion in clinical supervision in general has been emphasized in recent years in the literature on clinical supervision (e.g., see Brawer, Handel, Fabricatore, Roberts & Wajda-Johnston, 2002; Falender & Shafranske, 200, 2007; Hage 2006 see also Bernard &Goodyear, In fact, there is now a small but growing literature on spirituality and religion in general in clinical supervision, especially from a multi- cultural perspective (e,g., see Atem& Thumme, 2003; Frame, 2001; Hage, Hopson, Siegel, payton, & DeFanti, 2006; Miller, Korinek, & Ivey, 2004,2006; polanski,2003).

It is important and appropriate therefore to focus on the crucial role of clinical supervision in developing integration skills in students and trainees The present article reviews several models for conducting integrative or Christian clinical supervision, with a focus on developing integration skills in students and trainees in five major aspects of areas of integration: presuppositional, theoretical, intervention, therapeutic relationship, and personal (Gingrich & Worthington, 2007,p.346).

DEVELOPING INTEGRATION SKILLS

Integration skills in specific areas such as presuppositional, theoretical, intervention, therapeutic relationship, and personal (Gingrich &Worthington, 2007) can be developed in students through various means or methods. Students can learn integration skills (see also Stevenson, Eck, & Hill, 20070 through methods such as classroom instruction or coursework, online instruction, reading and writing research, mentoring by professors or teachers, conferences, personal therapy and modeling by therapists, peer learning, and clinical supervision including mentoring by clinical supervisors in what Johnson (2007) has called transformational supervision. This special issue of the Journal of Psychology and Theology focuses on teaching integration of learning integration in some of these ways. Clinical supervision, however, has a particularly crucial role in developing integration skills in students.

THE CRUCIAL ROLE OF CLINICAL SUPERVISION

Holloway (1992) has described clinical supervision as "the critical teaching method" (p. 177) in the training of clinicians. It has been found to be "a central component in the training of graduate students in clinical, counseling, and school psychology" (Romans, Boswell, Carlozzi, & Ferguson, 1d995, p. 407). More recently, Goodyear (2d007) has asserted that clinical supervision is psychology's signature pedagogy" (p.273) as a crucial and profession-specific teaching method or instructional strategy.

Clinical supervision can be defined as "a process whereby a person in a supervisory role facilitates the professional growth of one or more designated supervisees and strengthen their professional attitudes and values as they provide clinical services to their clients" (Cohen, 2004,p.3). In another definition of clinical supervision, Bernard and Goodyear (2004) emphasized that the supervisory relationship,

Is evaluative; extends over time; and has the simultaneous purposes of enhancing the professional of the more junior person(s), monitoring the quality of professional services offered to the clients that she/he, or they see, and serving as a gatekeeper for those who are to enter the profession(p.8)

Clinical supervision is not only essential in the teaching and learning of clinical skills (Bernard & Goodyear, 20040. It is essential also in addressing issues of spirituality and religion in general, especially in the training of psychologists, but this has not always been done in a coherent, practice, or systematic way (Brawer et al., 2002, Hage, 2006; see also Russell & Yarhouse, 2006).

Since clinical supervision in such an essential part of the training of all clinical practitioners, it is imperative for clinical supervisors to be trained to be effective or competent and ethical supervisors (Barnett, 2007).Competencies or key skills for effective and ethical clinical supervision have been described in the literature (e.g., see Falender et al., 2004,2007). Goodyear(2007) has suggested that such clinical supervisor competencies can be divided into two major types: relationship and technical knowledge/skills. Many psychologists and therapists end up doing some clinical supervision in their professional work, but not all have had formal training in clinical supervision (Scott, Ingram, Vitanza, & Smith, 2000). Clinical supervision is now seen by many to be a core competency area for all clinical practitioners that should be an integral and mandatory part of the clinical training curriculum of every graduate school (Falender et al., 2004). Likewise. Christian clinical supervisions should be seen as a core competency area in the training of all Christian clinical practitioners or therapists. Training in Christian clinical supervision that integrates Christian faith or spirituality and clinical supervision (see Jones, 2007) should therefore be included in the clinical training curriculum of every Christian graduate program or school.

CHRISTIAN CLINICAL SUPERVISION

Christian clinical supervision or Christian integration in clinical supervision (Aten et al., 2007) of Christian counselors has common but also unique or distinct features when compared to clinical supervision in general. Holeman (2002) has noted:

In many ways, supervision for Christian counselors is identical to supervision in other settings. The tasks, strategies, and responsibilities are basically the same. Conversely, supervision for Christian counselors is distinct in that the supervisor and supervisee can openly access the power of the Holy Spirit ... supervision can therefore directly address the spiritual issues that are present for counselor and clients. Supervision can also serve as a context for the integration of theology, biblical studies, and clinical practice ... Theological conversations are as appropriate as clinical conversations. Furthermore, supervisors can model the application of counseling techniques that are congruent with Christian counseling practice, such as therapeutic uses of prayer, Bible study, forgiveness, and clinical discussions about such topics as sin and grace. (p. 675)

Christian clinical supervision therefore focuses not only on developing the clinical skills or competency of the supervisee or counselor, but it also facilitates his or her spiritual growth or spiritual formation (Wicker & Moore, 2005), and develops his or her integration skills. Just as there can be implicit (covert, quiet) and explicit (overt, open, more direct) integration of Christian faith in clinical practice (Tan, 1996), there can also be relatively more implicit or explicit integration of Christian faith in clinical supervision, as a parallel process (Tan, 2007b; see also Campbell, 2007). Similarly, just as informed consent from the client is necessary before explicit integration including the use of religious and spiritual resources or interventions (e.g., prayer and Scripture) is employed in clinical practice, so informed consent also needs to be obtained from the supervisee or counselor before explicit integration is used in Christian clinical supervision (Tan, 2007b).

THREE MAJOR MODELS OF CHRISTIAN CLINICAL SUPERVISION

Three major models for effectively conducting Christian clinical supervision in ways that facilitate the development of integration skills in students and trainees, will now be reviewed: (1) Aten, Boyer, &C Tucker (2007); (2) Campbell (2007); (3) Gingrich & Worthington (2007).

(1) Aten, Boyer, & Tucker (2007)

A conceptual framework or model for Christian integration in clinical supervision has been described by Aten, Boyer, and Tucker (2007), based on a qualitative study conducted with eight peer-nominated supervisors and psychologists, using in-depth semi-structured interviews with them. The conceptual framework that emerged for Christian clinical supervision consisted of the following four core constructs (see pp. 314-318): supervisor indicators (supervisor clinical competence, supervisee conceptualizations, client religiosity, and client presenting problems), supervisor conceptualizations (faithbased, consistent with psychotherapy orientation, and integrates approach), supervisor roles and supervisor actions (teaching role and actions, facilitator role and actions, model role and actions, and inward focused role and actions).

Aten et al. (2007) also provide a helpful list of twenty-two representative supervisor actions in four major categories with the following as some examples (see p. 317): (a) teacher actions (e.g., supervisors assess supervisee's religiosity/spirituality, provide Christian integrative resources for supervisees, teach and give supervisees feedback on how to use spiritually oriented interventions, offer instruction on Christian integration models for supervisees); (b) facilitator actions (e.g., supervisors encourage supervisees to include spirituality in case conceptualizations, initiate discussions with supervisees about religious/spiritual experiences, use Socratic questioning to deepen supervisees' awareness of the sacred, identify religious/spiritual transference and countertransference, encourage supervisees' spiritual development); (c) model actions (e.g., supervisors share spiritual self-disclosures with supervisees, use role-playing to provide examples of Christian integrative approaches); and (d) inward focused actions (e.g., supervisors engage in spiritual introspection, examination, and reflection, practice spiritual disciplines such as prayer, worship, Bible study, pray silently for guidance while in clinical supervision, pray outside of supervision for supervisees and their clients). These are helpful ways in which Christian supervisors can use clinical supervision in an effective and crucial way to help students and trainees learn and develop integration skills as well as clinical skills, and to grow personally and spiritually.

It is interesting to note that Aten et al. (2007) found, in their sample of eight Christian supervisors and psychologists, that these participants used implicit religious techniques such as praying silently for guidance during the supervision session, and psychological techniques such as Socratic questioning more often then explicit religious techniques such as quoting Scripture in their Christian clinical supervision with supervisees. More research is needed with larger and more diverse samples of Christian clinical supervisors before more definitive conclusions can be made about the use of implicit and explicit religious interventions by Christian supervisors in clinical supervision. Hypothetical verbatim transcripts of the explicit use of spiritual disciplines such as prayer and Scripture in Christian clinical supervision (e.g., see Tan, 2007b) as well as in Christian cognitive-behavioral therapy (e.g., see Tan, 2007a) are available in the literature.

(2) Campbell (2007)

Campbell (2007) has also proposed a model for conceptualizing Christian aspects of clinical supervision. He emphasizes that the following relationships are all important and meaningful ones to be explored and discussed in clinical supervision from a Christian perspective: the supervisee's relationship with the client, the supervisee's relationship with the supervisor, the supervisee's relationship with God, the client's relationship with God, and the supervisor's relationship with God. These relationships within Christian clinical supervision can be implicit and/or explicit in nature.

Campbell (2007) conceptualizes Christian or integrative clinical supervision as having three major domains: therapeutic relationship issues, technical competence issues, and issues related to God's presence (p. 323). In the first domain of therapeutic relationship issues, he suggests several supervisor queries that can be used to focus on Christian integrative aspects including: "In what way is the ease or difficulty of establishing and maintaining the therapeutic frame a reflection of the client's experience of relationship with God?" and "What is God doing in the client's life and how may you participate?" (p. 324).

In the second domain of technical competence issues, eight competency areas are listed and described by Aten and Hernandez (2004) for addressing religion and spirituality in clinical supervision: intervention skills, assessment approaches and techniques, individual and cultural differences, interpersonal assessment, theoretical orientation, problem conceptualization, selecting treatment goals and plans, and professional ethics (see pp. 154-158). Campbell (2007) suggests a few supervision queries in this domain that can be used to focus on Christian integrative aspects, including: "How does the client's faith promote a healthy or dysfunctional perspective on their problems and desire for treatment?" and "How do the treatment goals and plans promote both healthy spiritual and psychological functioning?" (p. 325).

In the third and final domain of supervisory issues related to God's presence, Campbell (2007) encourages open dialogue between the supervisor and supervisee as appropriate, about how God is working within them and through them. He points out in particular how the thoughts of the therapist may be silent prayers or silents dialogues with Jesus about the client and therapy, especially asking for guidance, patience, and wisdom. The supervisee can be encouraged to engage in such thoughtful silent prayer during a therapy session with a client. The supervisor can also use spiritual disciplines such as prayer and scripture discussion with a supervisee during a clinical supervision session in order to acknowledge and experience God's presence (see also Tan, 2007b). Informed consent from the supervisee is, of course, needed for the explicit use of spiritual disciplines by the supervisor and supervisee during clinical supervision. Campbell suggests a few supervision queries that can be used to focus on Christian integrative aspects in this final domain, including: "What thoughts do you have while you are seeing this client, and do any of these thoughts pertain to your relationship with God?" and "How is God's presence manifested in your work with this client?" (p. 326).

Campbell (2007) points out that his integrative approach to Christian clinical supervision is similar to what Johnson (2007) has called transformational supervision that goes beyond focusing on developing technical clinical competence in the supervisee, to include mentoring and more collaborative dimensions in the supervisory relationship, so that the personal and spiritual growth of the supervisee are also addressed (see also Butman & Kruse, 2007). Transformational supervision that includes mentoring is not without the inevitable tension between the supervisor's evaluative (and gatekeping) and mentoring roles (Johnson, 2007; see also Palmer, White, & Chung, 2008). However, supervisors can learn to deal with such tensions and potential conflicts wisely and effectively (see Nelson, Barnes, Evans, & Triggiano, 2008).

(3) Gingrich & Worthington (2007)

Gingrich and Worthington (2007) have briefly described how integration skills or competencies can be developed across three major stages of clinical supervision (beginning, advanced practicum, and internship and beyond), and in five aspects or areas of integration (see p. 346). The first aspect or area of integration is the presuppositional, including worldview, beliefs, assumptions, and values (see also Bufford, 2007). The beginning supervisee or counselor has very limited awareness of this area but with the supervisor's help, the supervisee grows to more fully appreciate and understand how spiritual and religious worldviews impact therapy as he or she moves on to more advanced stages of supervision.

The second aspect or area of integration is the theoretical, including models of personality, pathology, therapy, and health (Gingrih & Worthington, 2007). The beginning supervisee has a basic under standing of the major models or schools of therapy and how they each view spirituality. With the help of the supervisor, the supervisee grows to develop his or her own uniqre personal theroretical orientation that integrates spirituality and religion with the process of therapeutic change as he or she moves on to more advanced stages of supervision.

The third aspect of integration is in the area of intervention, including case conceptualization, assessment, skills and techniques (Gingrich & Worthington, 2007). The beginning supervisee usually has some awareness of a few techniques and how spirituality can be considered in case conceptualization, but he or she may not have the skills needed to more directly deal with spiritual and religious dimensions. With the help of the supervisor, the supervisee grows to develop the integration skills needed to deal with spiritual and religious issues with more ease and facility, both conceptually as well as practically, as he or she moves on to more advanced stages of supervision.

The fourth aspect of integration is in the area of therapeutic relationship, including setting of practice, joining, responding to resistance and growth, and termination (Gingrich & Worthington, 2007). The beginning supervisee usually has great hesitancy in introducing or responding to spiritual and religious issues that may arise in therapy, or in directly discussing spiritual and religious practices and affiliations, especially in particular practice settings that are more secular. With the help of the supervisor, the supervisee grows to be more et ease in introducing and discussing spiritual and religious issues in therapy, and sees spirituality not only as a positive resource in therapy but also as a crucial part of the therapeutic relationship between the supervisee (counselor) and the client, even if spirituality is not explicitly dealt with, as the supervisee moves on to more advanced stages of supervision.

The fifth and final aspect of integration described by Gingrich and Worthington (2007) is the personal area, including one's functioning as a spiritually integrated person. The beginning supervisee has limited awareness of how his or her own spirituality and religious beliefs may impact the process of therapy. With the supervisor's help, the supervisee grows in his or her awareness and knowledge about how his or her own spiritual life and religious values and beliefs can impact therapy, in his or her ability to self reflect on hisor her own spirituality, and in how a spiritually-integrates sense of self can facilitate the work of therapy, as he or she moves on to more advanced stages of supervision. Tan (1987, 2001) has emphasized that this personal or intrapersonal area of integration, including the spirituality and the spiritual formation or growth of the integrator is the most foundational or fundamental, without which the other areas of integration cannot be substantially achieved. He has also affirmed the crucial role of the Holy Spirit in all areas of integration, including intervention (see also Tan 1999).

Gingrich and Worthington (2007) noted however, that while their model suggests a linear growth trajectory in spiritual awareness, empirical research may not support such a view. In fact, they pointed out that preliminary research findings actually do not support the view that spiritual development proceeds smoothly and continuously across stages of supervision over time (e.g., see Sandage, 2007). Nevertheless, Ripley, Jacson, Tatum, and Davis (2007) have proposed a developmental model for the clinical supervision of religious and spiritual issues that takes into consideration the clinical and religious/spiritual developmental level or status of the supervisee, based on the work of Kohlberg (1981) and Fowler (1981). Their key informant survey of 22 clinical supervisors showed that these supervisors work differently with supervisees depending on the religious/spiritual developmental level of the supervisee, thus providing some support for their model.

TRAINING CHRISTIAN CLINICAL SUPERVISORS

Students or trainees in Christian graduate clinical programs or schools also need to be trained in how to conduct Christian or integrative clinical supervision after they graduate, since many of them will end up doing some clinical supervision as part of their jobs or work. They can then do a more effective and competent job at supervision other students and trainees so that integration skills are also developed in addition to clinical skills, and personal and spiritual growth are also facilitated.

Jones (2007) has provided nine helpful recommendations for training clinical supervisors to integrate psychology and Christianity. These recommendations can be used in the teaching of supervision courses in the curriculum, in individual or group clinical supervision, and in mentoring relationships. Her nine recommendations for Christian clinical trainers are that they:

(1) mind the spirituality of supervisors-in-training; (2) are cognizant of attachment issues that may affect the ability of supervisors-in-training to integrate psychology and Christianity; (3) facilitate the understanding of supervisors-in-training about humankind and the Christian faith; (4) model christian integration through an interpersonal relationship with supervisors-in-training; (5) utilize and model spiritual practices and interventions with supervisors-in-training when appropriate; (6) incorporate religious and spiritual assessment and evaluation tools when preparing supervisors-in-training; (7) inform supervisors-in-training about ethical and legal issues; (8) promote multicultural competence in supervisors-in-training; and (9) teach supervisors-in-training key supervision models, modalities, and issues. (Jones, 2007, pp. 337-339)

HOW STUDENTS LEARN INTEGRATION

Sorenson, Derflinger, Bufford, and McMinn (2004) published the final report of a national collaborative research study on how students learn integration that was groundbreaking. It took 10 years of collaborative research, with more than 5,000 data points based on students' perceptions of more than 80 faculty members from four evangelical schools with the longest APA accreditation for their doctoral programs in clinical psychology: Fuller, Rosemead, George Fox University, and Wheaton College (Illinois). Sorenson, et al. (2004) concluded from the 10 year collaborative research:

The way students learn integration is through relational attachments with mentors who model that integration for students personally. These mentors may be professors, but they don't have to be. They may also be student's therapists ... or other figures. Whoever tey are, what counts is that the mentor is affectively and personally present for the student. (p. 363)

They further state:

Instead, students want personal access to someone who is modeling integration before them as a living, breathing, flesh-and-blood manifestation of integration-in-process. Students want broad and candid access to integrators so that they can see how their mentors think, weigh choices, make clinical judgments, pursue courses of research, and most importantly, how they interact with themselves and others, including Gode. (p. 364)

In an earlier, previous report, Staton, Sorenson, and Vande Kemp (1998) already came to a similar conclusion, regarding how students learn integration from their professors:

From the students' point of view, the most salient dimension to contribute to their own integration was how well they could determine that a given professor had an authentic, lively, and growing relationship with God, coupled with the professor's nondefensive, emotionally unguarded, and even vulnerable relationship with students, (p. 348)

Integration skills are therefore more often caught than taught, through a personal mentoring relationship. More recent research with 595 graduate and undergraduate students in different disciplines from four evangelical Christian institutions of higher learning has essentially affirmed these earlier conclusions from Sorenson and colleagues, but also indicated the importance of institutional or environmental support for integration in learning integration (see Hall, Ripley, Garzon & Mangis, 2009, this issue, and Ripley, garzon, Hall, Mangis, & Murphy, 2009, this issue).

CONCLUSION

It is clear from the groundbreaking research done with clinical psychology doctoral students and how they best learn integration, that an authentic, open, caring and meaningful mentoring or personal relationship with a professor, a therapist, or some other significant person in the student's life and training, is the most important and crucial factor in learning and developing integration skills. The clinical supervisor is also an example of a person who can be a significant mentor to students in such a way that they learn integration (see Stevenson, Eck, & Hill, 2007) and integration skills (see Aten, Boyer, & Tucker, 2007; Campbell, 2007; Gingrich & "Worthington, 2007; Tan, 2007b). The research supervisor or mentor is another example in Christian doctoral training programs (see special issue of the Journal of Psychology and Christianity, 23, 2004, 243-365, on research in Christian doctoral training) but research supervision is beyond the scope of the present article.

Clinical supervision therefore has a crucial and essential role in the learning and developing of integration skills in students and trainees. The present article has provided several examples and models with regard to how clinical supervisors can conduct Christian clinical supervision in ways that facilitate the learning and developing of integration skills (and clinical skills) in students and supervisees, as well as their personal growth and spiritual formation, with an emphasis on personal mentoring and transformational supervision (Johnson, 2007) that is Christ-centered, Bible-based, and Spirit-filled (Tan, 2007b). However, a key research question that remains has been well put by Gingrich and Worthington (2007): "Ultimately, one of the most important questions will be, does integrating spirituality into supervision result in better therapists, and in better treatment outcomes for clients?" (p. 353). "Another question is whether such integration will lead to preferred treatment processes or culturally and spiritually more congruent treatment for Christian clients.

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SIANG-YANG TAN

Graduate school of Psychology

Fuller Theological Seminary

AUTHOR

TAN, SIANG-YANG. Address: Graduate School of Psychology Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101. Title: Professor of Psychology. Degrees: B. A. (Honors), Ph.D., McGill University. Specializations: Clinical psychology; cognitive-behavioral therapy; religious psychotherapy; intrapersonal integration and spirituality; integration of psychology and Christian faith; lay counseling; and cross-cultural counseling, especially with Asian Americans.

Correspondence regarding this article should be addressed to Siang-Yang Tan, Ph.D., Professor of psychology, Graduate School of psychology, Fuller Theological Seminary, 1180N. Oakland Avenue, pasadena, CA91101 I would like to express my appreciation to two anonymous reviewers for their helpful comments on an earlier version of this article.