EBP Times
EARLY JANUARY 2006 NEWSLETTER

In September’s issue of the EBP Times, we mentioned that staff participating in the Strengths Model Case Management Project at Pawnee Mental Health Center listed four factors they thought most contributed to improvement of outcomes for clients:

1)      Having a supported employment worker on the team

2)      The group supervision format as outlined by the Strengths Model

3)      Proactive use of the strengths assessment

4)      Field mentoring with staff

In this month’s issue, we want to focus on one of these factors, group supervision, which seems to be integral to getting the most out of the other three factors mentioned. In many ways the group supervision model seems to be a simple process to implement, but very few centers have been able to continue using the group supervision process with any fidelity for any prolonged length of time. This is despite the fact that it is one of the most well-received methods of the Strengths Model. With a well done group supervision process, staff leave the meeting with more ideas and experience more support and direction in working with specific client than through any other form of supervision.

Here we describe the group supervision process and offer guidelines on why each step is important to the process. We also detail some common barriers experienced in the process and how these might be overcome.

Group supervision consists of six steps; each is distinct and critical to the success of the process.  KEEP IN MIND: At Pawnee, it took two full months of deliberately following each of the steps in order before it finally took hold. Prior to this there was a tendency for staff to want to skip a step here and there or make some modifications and combine steps, but this only led to the entire process unraveling and returning them gradually back to the way they had done supervision in the past.

So our first key point here is that if an agency wants to adhere to this model, the agency (and specifically the supervisor) must make a commitment to follow the process as outlined for all group supervision meetings.

Each discussion of a client situation should take no more than 20-30 minutes so that four to five clients can be covered during a typical two hour supervision.

Step 1: Hand out Strengths Assessments - The presenting staff person makes copies of a strengths assessment for every team member and hands them out.  The process will NOT work unless each team member has his or her own copy of the strengths assessment for the person being presented.

At Pawnee, staff were not allowed to discuss a client at group supervision unless they brought that person’s strengths assessment. A few times staff tried to do this anyway, but the supervisor (Dennis Webb) gently reminded them of the purpose of group supervision. Staff bring up people in supervision because they are stuck and need ideas. Without the strengths assessment, typically the same old ideas get thrown around or people get stuck in discussing the presenting problem. The strengths assessment allows people to step back a little from the presenting problem and get a more holistic view of the person being discussed (i.e. what is important to them in their life, what are their intrinsic motivators, what strengths they currently possess or have access to, etc.). In group supervision, we want staff to get creative and generate ideas that might be most meaningful to the client or create opportunities that might open a window of recovery for the person. The strengths assessment keeps staff client-centered and strengths-centered.

Key point number two: The supervisor must ensure that staff keep strengths assessments current on client. Having a strengths assessment that is a year old, while better than no strengths assessment, doesn’t give the best picture of where the person is now. Supervisors can help prep staff for the presentations at group supervision by having them update a strengths assessment prior to make copies. If the client is not available or unwilling to contribute to updating the strengths assessment, the staff person can update it their own by reflecting on what strengths they have discovered about the person since the last time they worked on the strengths assessment.

Step 2: What do I need? -  The presenting staff person states very precisely what he or she needs from the team (i.e., I need ideas on how to engage with Mary; I need help on how to assist Joe to reach his goal, etc.).  This keeps the provider and team focused on what is to be accomplished in this meeting.

At Pawnee, we found that this step worked best if the supervisor had time prior to supervision to help case managers think about what they wanted help with and narrowing this question for the group. Through this process, sometimes case managers came up with a better question that allowed for a much more fruitful brainstorming discussion. For example, a case manager started with the question of “How do to I motivate this person to attend groups?” In discussing this more, it was clear that attending groups was not the person’s goal. When asking the case manager why they thought going to groups was important, the answer was that the person did better when they had some structure in their day. With that information, the question for group supervision changed to “Can the group help me come up with ideas for meaningful activities that will help provide more structure for this person and help them with their goal of recovery?” The ideas generated now, extended beyond groups and included ideas (based on the strengths assessment) such as work, volunteer opportunities, greater involvement with church, going back to school, and getting involved with some structured community activities with friends and family.

Key point number three: The supervisor must help staff focus in on specifically what they want help with and keep other staff centered on answering this question to make the supervision time productive. If a staff person has absolute no idea of what they want help with, it is okay to have the question be, “I have no idea where to go next with _____, could the group give me some ideas on where I could take the next step to help this person in their recovery.” What is important is that there is a targeted question for staff to answer through their brainstorming. When brainstorming gets away from the presenting question (and this will happen frequently), the supervisor needs to remind the group what the presenting case manager initially wanted help with and refocus brainstorming ideas towards answering this.

Step 3: Thumbnail sketch - The presenting staff person gives a brief description of the situation and a few things that have already been tried. Brief is the key word here. Within many centers, other staff are already familiar with clients who are brought up for group supervision. Unless this is a new client or someone most people don’t know, there is no need to recount the client’s entire history with the center. Typically when this does happen, it saps the energy of the group because what is usually brought up is a litany of all the things that the client has done wrong. What is needed here is just a brief update of the situation and what has been recently tried by the case manager. If staff need more detail, they can ask these questions during the next step.

Step 4: Questions only - For five to ten minutes the team asks questions of the staff person to further clarify things written on the strengths assessment.  For example, “It says here that the grandmother is supportive.  Tell me more about her role in the person’s life.”  No advice can be given in this section, only questions based on the material in the strengths assessment.

This is one of the first areas that gets abandoned from the group supervision process, because once staff hear the presenting questions they are usually ready to give advice. This step is important because it has staff ground their brainstorming ideas in things that are on the strengths assessments. If there are areas that are vague, incomplete, or unclear on the strengths assessment, we want staff to help flush this out so that the group has the most complete picture of the client as possible.

Key point number four: The presenting staff person should be updating the strengths assessment as they answer questions about the person’s strengths assessment. Even with the best strengths assessments, we have found that the presenting case manager always has more useful information about the person’s strengths than they have written on the strengths assessment. In many cases, it was information that they had forgotten until asked about it or had not really given an areas much thought. If the case manager writes this information on their copy of the strengths assessment, they will now have a more updated strengths assessment that they can put in the person’s chart.

Key point number five: Do not allow staff to mix the brainstorming and questions steps. We have found that when staff go right to brainstorming, they typically start pulling ideas out of the air and many of these ideas can be incongruent with what the person wants or might find meaningful to their recovery. Especially be aware to what we call “quasi-question/solutions”. They will sound like this “Have you ever tried ________?” While it sounds like a question, it is really an idea that’s best left for brainstorming. When you hear this, have the staff person hold that thought and proceed along with more questions from the strengths assessment.

The time for questions can sometimes drag out if allowed, so the supervisor needs to be alert for when questions being asked start to stray from the strengths assessment. Ten minutes of focused questions should be enough to get the information needed for productive information, though can be extended if questions are still being drawn specifically from the strengths assessment.

Step 5: Brainstorming - For ten to fifteen minutes the team brainstorms ideas.  The presenting staff person MUST write down every idea without speaking (i.e., no evaluation of the ideas or “yes, buts”).  For example, “The client could ask the grandmother to call her every Saturday to see how she is doing.” The list should include 20 to 40 ideas.

Key point number six: It is important that the presenting case manager focus on listening and writing rather than speaking during the brainstorming step. Nothing kills good brainstorming than people debating the ideas that are presenting. We have found that many of the initial ideas that come out during brainstorming are typically the obvious ones and hence typically ones that the presenting case manager has already tried. The presenting case manager just needs to be patient as the group builds upon these ideas and increasing becomes more creative with their suggestions. At Pawnee, it was fairly common that ideas brought up during the last five minutes of brainstorming ended up being the ones that actually made a difference.

Key point number seven: The supervisor should be comfortable with periodic silence during the brainstorming phase and not be tempted to end this phase too early. Sometime silence can be mistaken for there being no new ideas, but we have often found that this is just when creativity just starts beginning. Sometimes the supervisor can prompt the group again by restating the presenting question again or having staff refocus on the strengths assessment for any possible creative ideas that might help answer the presenting question.

Step 6: Top Three Ideas - The presenting staff person reviews the ideas and identifies the three that are the most useful and asks for clarification on any ideas if necessary.  Depending on the nature of the goal being reviewed, the provider may present the list to the client (at their next meeting) as possible strategies to help him or her reach the goal, or may choose two or three strategies he or she will try in order to make progress toward the goal.

This step is to ensure that the presenting case manager has received some new ideas on how to work with the person they presented. If they don’t have any ideas that they find useful, the supervisor can open up brainstorming again or agree to meet with the case manager separately to re-look at the ideas that were generated and see how they could be used.

Key point number eight: To ensure that the presenting staff person has taken something useful away from group supervision, the supervisor should always follow-up with the presenting case manager after supervision. Unfortunately, we have had the experience where a group supervision generated some exciting new ideas (even the case manager left excited), only to find that none of the ideas were actually tired or a few were tried and since it didn’t get a favorable response, the case manager gave up on the others.

Below are some factors that commonly get in the way of case managers being able to implement ideas following group supervision:

1)      Case manager didn’t know how to present the ideas to the client.

2)      The case manager didn’t know what to do once an idea was responded to negatively by the client.

3)      The case manager got stuck on trying to get the client to do one of the ideas they liked, but which really didn’t fit well with the client’s preferences or interests.

4)      The case manager incorrectly presented an idea to a client (e.g. presented it as something they needed to do, rather than as a possible option)

By the supervisor meeting with a case manager following supervision, they can make sure they got the help they needed and help them think through how they would use these ideas with the client. Some helpful things a supervisor can do with a case manager are: 1) agreeing to go with them to meet the client (field mentoring); role playing how they might present ideas to client; 3) model for them some of the possible ways of implementing ideas; and 4) brainstorming with the case manager further some specific ideas they would like to try and how to go about it.

A final point is that when the full process of group supervision is used it is a valuable tool for teaching and reinforcing strengths-based practice. By requiring that the strengths assessment is present for any client being discussed, it reinforces that the focus is to be on the client’s goals and his or her journey of recovery, not just the presenting problem that the client or case manager is faced with. This requires that supervisors ensure that high quality strengths assessments are being completed in the field. At Pawnee, we found that when case managers saw that their strengths assessments were actually being used as a tool in group supervision, they tended to spend more time in the field gather important information about the person’s strengths that might help in their recovery.

The supervisor should also use group supervision to help other case managers at the meeting apply what is learned when discussing a specific client to other people they are working with. For example, at Pawnee we sometimes took a few minutes after discussing one client to discuss a key point that came up (e.g. using motivational interviewing techniques to help a client that was ambivalent about something, the importance of keeping the client as the director of the helping process when setting goals, ways to introduce the concept of recovery to a person, how to use the personal plan to further break down a person’s goal, etc.).

As mentioned earlier, group supervision is one of the most well-received methods of the strengths model, but one that many centers have difficulty sustaining for any prolonged period of time. If you have any questions about the group supervision process, contact Rick Goscha at (785) 864-0149.

Please feel free to contact the Case Management consultant/trainer at KU: Rick Goscha, rgoscha@ku.edu or call (785) 864-4720 for further information.

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