Clinical Supervision Page 2



In this chapter, through vignettes, you will meet eight clinical supervisors with a variety of skill levels, a number of their supervisees, and an administrator. The supervisors face counselors with a variety of issues. One is unfamiliar with supervision, one has ethical issues, one is resistant to change, and another is a problem employee. The supervisors also have issues of their own. One grapples with the challenges of a new position, and another works to create a legacy. The vignettes, which incorporate these issues along with the principles outlined in Part 1, chapter 1, are designed to show how clinical supervisors might manage some fairly typical situations.

Each vignette provides an overview of the agency and of the backgrounds of the supervisor and other individuals in the dialog. A list of the learning objectives for each vignette is also included. Embedded in the dialog are additional features:

Master Supervisor Notes are comments from an experienced clinical supervisor about the strategies used, what the supervisor may be thinking, how supervisors with different levels of experience and competence might have managed the situation, and information supervisors should have.

“How-to” Notes contain information on how to implement a specific method or strategy.

The master supervisor represents the combined experience and wisdom of the TIP Consensus Panel and provides insights into the counselor’s relationships with clients and suggests possible approaches. The notes provide some indication of the breadth of the master supervisor’s clinical skills as well as the extent to which the supervisor moves effortlessly among clinical, supportive, evaluative, and administrative roles.
“How-to” notes reflect the collected experience of the TIP Consensus Panel along with information gleaned from a variety of textbooks, manuals, and workbooks on clinical supervision. Not all “how-tos” will apply in every situation, but this information can be adapted to meet the specific needs of your case.
This format was chosen to assist clinical supervisors at all levels of mastery, including those who are new in the position, those who have some experience but need more diversity and depth, and those with years of experience and training who are true master supervisors. The Consensus Panel has made significant efforts to present realistic scenes in supervision using clinical approaches that include motivational interviewing (MI), cognitive–behavioral therapy (CBT), supportive psychotherapy, crisis intervention methods, and a variety of supervisory methodologies including live observation, education, and ethical decisionmaking. In all of these efforts, basic dynamics of supervision, such as relationship building, managing rapport in stressful situations, giving feedback, assessing, and understanding and responding to the needs expressed by the counselor are demonstrated. The Panel does not intend to imply that the approach used by the supervisor is the “gold standard,” although the approach shown does represent competent supervision that can be performed in real settings.

Vignette 1—Establishing a New Approach for Clinical Supervision

This vignette illustrates the tasks of a clinical supervisor in describing a range of supervision methods to clinical staff, including establishing a consistent model of direct observation. The vignette begins with the supervisor describing to staff how he will implement a new method of supervision.


Walt has been assigned to redesign the supervision program for a community-based substance abuse treatment program, which includes an inpatient program, intensive outpatient program, family therapy, impaired driver treatment, drug court program, halfway house, and educational services. The decision was made to establish an integrated system of supervision. The agency’s staff, with ten full-time-equivalent counseling positions, has a broad range of professional training and experience, from entry-level certified addiction counselors to licensed social workers and licensed professional counselors. All staff, regardless of degrees and training, basically have the same duties.

Until now, staff received primarily administrative supervision with an emphasis on meeting job performance standards. Walt wants to make the supervision more clinical in nature, using direct methods of observation (videotape and live observation). He anticipates program growth in the next few years and wants to mentor key staff who can assume supervisory responsibilities in the future.

Walt has been meeting with clinical staff in small groups organized along work teams into dyads and triads to describe the changes and new opportunities. The vignette begins with Walt meeting with two staff members to discuss their learning needs and to present the new clinical supervision system. Al is in recovery, with 5 years of sobriety and 3 years of experience as a counselor. Carrie has an M.S.W. degree with 6 years of work experience.
Learning Goals

  1. To demonstrate a range of supervision methods, with an emphasis on direct observation through videotaping and live observation.
  2. To illustrate the mentoring, coaching, and educational functions of supervision.
  3. To demonstrate how these functions can be integrated into a consistent model of clinical supervision with fidelity to the methods and adaptability to the unique needs of each organization.

[After greetings, Walt begins the discussion about the new supervision approach.]

WALT : As you know, our CEO and senior staff have agreed that we need to establish a program of staff training and supervision that will help achieve the goals of the agency and, at the same time, help counselors improve their skills. We’ve done a good job developing other administrative systems, and the next step is to implement clinical supervision to address both agency goals and your individual goals for professional development. People are moving into new roles, so new skills will be required of us.
AL: I’m not sure what I need. How will supervision enhance my skills?

WALT: Al, I think that is a great place to start. We’ve had administrative supervision so far. As we continue to grow individually and together, we’ll need new skills. Perhaps a place for us to start is to discuss what will be asked of us in the future, what skills we’ll need. How would it be if we had that discussion now?

AL: That sounds a little frightening. We need to know and do more? How much more blood can they get out of us?
[Laughter in the group.]

Master Supervisor Note: A new supervisor might respond differently to Al’s comment, in a more mechanical or authoritarian manner, asserting authority, wanting to be the expert, creating an “us vs. them” scenario. Such an approach might discourage staff from embracing the new supervision system. An experienced supervisor would be less confrontive and authoritarian and would adopt a more consultative posture. He would be direct but not necessarily confrontational.

CARRIE: I remember the good supervision I had in my M.S.W. program. This sort of reminds me of that—that you’re suggesting we have more clinical supervision. Not to sound selfish, but what’s in it for me, to get more supervision?

WALT: That’s a great question, Carrie. We all want to know what’s in it for us. I’d like to hear about your experiences in supervision. How did you learn from that process? What direct observation did you have?

How To Provide a Rationale for Clinical Supervision

Clinical supervision has several benefits, which Walt can offer Carrie at this point:

  1. Administrative benefits: ensuring quality care, providing a tool to evaluate the staff’s strengths and learning needs
  2. Clinical benefits: improving counselors’ knowledge and skills and offering a forum to implement evidence-based practices within an organization
  3. Professional and workforce development: enhancing staff retention, improving morale, providing a benefit to enhance staff recruitment, and upgrading the qualifications and credentials of personnel
  4. Program evaluation and research: providing valuable information to determine program outcome and patient success

CARRIE: In school I found observation both frightening and helpful. At first I hated being observed and taped. Very quickly, though, I really saw the benefits of observation and learned a lot from the experience.

WALT: It’s been my experience that almost everybody has some initial reservations about direct observation, but at the same time nearly everyone finds it beneficial, too. I think one thing to keep in mind is that good direct observation doesn’t focus on the negative—on what somebody did wrong. The objective is to help us look at what we do well, give us new options, build a bigger tool box of skills, and help us to look at the larger process of our counseling, rather than just getting stuck in applying techniques with people. As we look at our goals and what we need to learn, I hope we can see how supervision, and particularly direct observation, will help all of us.

CARRIE: I’m told I’ll be doing more group counseling. I certainly need further training and feedback on my group skills. This is something we didn’t focus on much in grad school. There are other areas that I’d also like to be more proficient in, such as doing marriage and family counseling.

WALT: Okay. That would be one place for us to begin, Carrie. How about you, Al?

AL: I’m excited. I’ve wanted to do more counseling, moving out of running DWI groups and doing assessments. I need more training but I have concerns about being videotaped or observed. I’m going to make mistakes. I’ll be self-conscious about that. I think videotaping a session or having a supervisor sit in will make the clients nervous, too.

How To Help Counselors and Clients Become Comfortable With Live Observation

The following steps are recommended:

1. Acknowledge and understand the clients’ and/or counselors’ anxiety about observation or taping.
2. Listen reflectively to these concerns without being dismissive or ignoring the anxiety; noting that these feelings are common may help normalize the counselor’s concerns.
3. Clearly state the value of direct observation and reinforce the idea that such methods are “part of how we do business at this agency. We want to be respectful of your concerns. And we believe strongly that it is important for us to do so for quality assurance and improved client service.”
4. Keep the door open with the clients and counselors to continue to address their concerns and feelings as part of their normal clinical or supervisory process.
5. Help the counselor to allay clients’ anxiety or concerns by coaching the counselor through methods for presenting the direct observation methods to the client.

WALT: I can sure understand your sense of feeling self-conscious and your concerns that clients will, too. You’ve never been either videotaped or observed before?

AL: No, I haven’t. In the DWI program, my supervisor sat in a few times when I first started, but it was more a question of whether I was following the curriculum.

WALT: So, although you did have some observation before, this seems like it will be different for you. Perhaps we could look at your goals and how supervision with observation can assist us in meeting your goals.

[A discussion follows where Al and Carrie present their ideas for supervision needs. They then discuss what skills they need to develop in the next year.]

WALT: Perhaps we can discuss what the new supervision system will look like, how it will work, and what’s in it for you. First, we’re going to have regular observation of all clinical staff, through either one-way mirror (if we can get the audio working in the room), videotaping (my preferred method), or one of the supervisors will sit in and observe counselors with clients. We hope to observe each counselor at least once a month. We’ll meet as a group for supervision for an hour a week, and we’ll discuss the session that was videotaped or observed that week, with one of you leading the discussion. Each person will get a turn at bat over the course of 1 or 2 months.

[Walt explains the “how-tos” of live observation and videotaping, including the concept of saliency, bringing to supervision the one issue the counselor wishes to address. Walt presents a step-by-step process to begin doing direct observation.]

How To Implement Direct Observation or Videotaping
1. Obtain written and verbal agreement from the clients and all concerned parties to be videotaped. Clients should be informed on admission that:

  1. Counselor–client contact may be observed by supervisors, and/or audio or videotaped.
  2. The conditions under which the tape will be used for training.
  3. How the taped material will be stored and destroyed after use.

2. Counselors should briefly explore client concerns about taping and observation, and respect their right not to be observed. If the client objects after the initial exploration, the counselor must respect that choice and ask another client.

3. On the visit before the observation occurs, remind the client that on their next visit, their session will be taped for quality assurance purposes. Ask them if they have any questions about that. If the client strongly objects to the taping, discuss those concerns. If the client repeatedly objects to any form of observation, the counselor should explore the client’s resistance, and attempt to understand the client’s concerns and point of view. Even though a client has signed an informed consent that discusses the possibility of direct observation by supervisors, a client always has the right to decline any aspect of treatment. Remember, no method of observation should ever exceed the client’s level of comfort so as to be detrimental to the therapeutic process.

4. At the beginning of the taping or observation, restate to the client the limits of confidentiality and how the videotape or observation notes will be used by the clinical supervisor and/or the counseling team. Clarify whether or how the supervisor will observe and/or cofacilitate the session or simply observe and intervene only as needed.

5. Be attentive to the counselor’s concerns about direct observation. It may be helpful to begin with the idea that “observation gives us a chance to learn from each other.” Then you can move into a discussion about the benefits and cost-effectiveness of certain observation methods.

6. Ask the counselor to cue the tape to the most salient points of the session and bring that section to their next supervisory session. In the beginning, counselors might be encouraged to choose the section of a session in which they thought they did well.

CARRIE: I’d like to hear more about why you prefer videotaping.

WALT: I prefer videotaping for several reasons: First, it is the most cost-effective way for us to observe a session. Second, videotaping helps us allocate staff time better; we don’t have to sit in on an entire session but can just look at the most salient points in the tape. It gives us all a chance to observe and learn from each other. Sometimes we get a tape where a counselor has done something really special, and we can use that tape again before destroying it, teaching a particularly powerful and effective technique. We can all learn from each other’s ex[Walt describes how direct observation works, including the legal requirements such as signed releases by clients, preparation and procedures for observation, and procedures for using tapes and observations and maintaining confidentiality.]

Master Supervisor Note: It is important for you to prepare the counselor for what will happen during the session. If you are sitting in the session to observe, you should explain if and/or when you might intervene in the session, seating arrangements for the session, nonverbal ways of communicating during the session, and how other interruptions, should they occur, might be handled.

AL: As I said before, I’ve never been observed or taped, and that makes me nervous.

CARRIE: Well Al, I think you’ll get comfortable with it, and you’ll find it to be very helpful when it comes to areas that you have concerns about. You said that you were concerned about mistakes, but it really won’t be about mistakes. My supervisor in grad school had a motto I liked; she always tried to “catch counselors doing something right.” I liked that. So, hopefully this is not about making mistakes but learning from each other. When you see yourself on the videotape and you have someone go over it with you, they can give you pointers about what worked and how you might have done other things differently. Over time you become comfortable with it. Observation was very helpful to me. I think your misgivings will go away after a couple of sessions with Walt. You’ll be surprised.

Master Supervisor Note: It may be helpful for you, as a supervisor, to find a “champion”—someone who’s experienced direct observation and found it helpful. Hearing positive statements about supervision from a colleague is often more acceptable than hearing it from superiors.

WALT: That’s been my experience, too, with videotaping and direct observation. Al, you said it would make the client nervous. Actually, we’re the ones who’re most nervous. We all want to know how we’re doing, but often we’re afraid to ask, to get feedback and be observed.

AL: Maybe it would be better if I saw tapes of others doing counseling first.

WALT: That’s a great idea. I can present a videotape of a session I conduct. Then we can all sit and discuss what I did. How would that work for you if we were to look at a videotape of one of my sessions for our next supervisory meeting? I’d benefit from your reflections. It might be a good place for us to start the process. periences.

How To Encourage Acceptance of Direct Observation

Since you should never ask a staff member to do something you are unwilling to do, it might be helpful for you to:
1. Be the first to be taped or observed.
2. Be open to feedback from staff, setting the tone of acceptance and vulnerability to feedback.
3. Solicit comments and suggestions from the counselors concerning what they might have done differently and why.
4. Model acceptance by committing to trying out these suggestions in future counseling sessions.

AL: Yeah, I like that idea.

CARRIE: That would be fine with me. I’ll volunteer to be second. It’s been a while since I was observed, but Idon’t have any problem with it. WALT: Thanks, Carrie. So, since I’m up to bat first, let’s talk about some of the processes of observation. [A discussion follows about what will happen in supervision when Walt presents his case.]

Master Supervisor Note: You will want to state clearly what is expected from counselors in supervision. A supervision contract forms the basis of this statement, and explains the ramifications of missing supervision sessions and what they can expect from you and each other. For example, if a supervisee repeatedly misses supervision sessions, this might be considered an administrative or disciplinary issue, much as if an employee was repeatedly late filling out paperwork or getting to work. Also, if the supervisee does not provide the required videotape of a counseling session for review by the supervisor, the supervisor might need to take action, following the organization’s policies for progressive discipline.

WALT: There are different methods that we can use, besides videotaping, that might work better for some clients or situations. We want to have an integrated supervision system, one that includes reviewing cases together; periodic review of our files, such as client progress notes and treatment plans; training that meets the needs of a variety of staff; and review of our client evaluation surveys. While I’m on that topic, we also want to receive more input from clients about how we’re doing. There’s a new tool we hope to incorporate that routinely asks for input from clients after each counseling session, and at the end of each day for our residential units.

AL: I have reservations about how useful information from clients might be. After all, for clients in early recovery, their brains are still foggy.

WALT: Good point Al. If we ask clients regularly, though, we should get useful information about our ability to address clients’ needs and the quality of our relationships with them. This is helpful information when we link it to our direct observation and supervision. Sort of like watching a TV program and getting the Nielsen Ratings about [Laughter.]

[In the discussion that follows, Walt acknowledges Al’s concerns, and Al, Carrie, and Walt talk about those concerns. Walt asks how they can get past those concerns, how they can work together to have further client input into the process.]

Master Supervisor Note: At times it is necessary for a supervisor to openly address staff resistance. The skill is in knowing when to address and when to deflect the resistance. Sometimes, it is useful to talk about staff resistance, to soothe people’s discomfort before launching into the specifics of how supervision will be accomplished. MI suggests that it is most helpful to “roll with resistance” by reflecting back to counselors both sides of their ambivalence about the new supervision format. Often it is best to return to the issue at a later time.

WALT: And that’s what we want to see happen with an integrated system of supervision. It will help us identify what we need to learn, the skills and competencies. To start the process, each of us will bring in a counselingsession that we think is going well, that we feel good about. How does that sound to each of you?

CARRIE: I like that: a chance for each of us to “show off” a bit.

AL: Well, if you go first, Walt, as you said. I’ll go the week after Carrie. I have all kinds of sessions where I’mdoing a good job. [Laughter.] CARRIE: I found it helpful in grad school for us to help each other, to avoid throwing anyone into the process alone. Will that be possible for us? WALT: That’s a great idea, Carrie. How did peer supervision work in grad school?[Carrie discusses how peer supervision and team coaching work.]

Master Supervisor Note: Peer supervision is an effective form of group supervision. Supervisees confer in the group, discuss key topics of their counseling, and suggest solutions for difficult situations. The participants learn better ways to manage clinical issues, thus increasing their professionalism. Peer supervision and team coaching have the following advantages and disadvantages:

1. The strengths and success of peer group supervision depend on the composition of the group, the individual members’ strengths, and the clarity of the peer group contract. Members must agree on the time, location, and frequency of meetings, as well as the organizational structure and goals of the meetings and limits of confidentiality. In these dimensions, peer supervision differs from occasional and unplanned peer consultation, a more informal process.

2. Peer group supervision decreases professional isolation, increases professional support and networking, normalizes the stress of clinical work, and offers multiple perspectives on any concern. Peer supervision has the added benefits of being of low or no cost, intellectually stimulating, and fun for supervisees. the show at the same time.

3. Vague, ambiguous, or ambivalent goals and structure often lead to difficulties in peer supervision. As with individual or clinical supervision, an interpersonal atmosphere of reasonable safety (including respect, warmth, honesty, and a collaborative openness) are critical.

4. Effectiveness and supervisee enjoyment diminish when competitiveness, criticism, inconsistency of members, and absence of support are prevalent.

5. The success of peer group supervision is affected by supervisees’ varying commitment and irregular attendance.

WALT: So, we’ve identified how this works. This is a new role for me, too, so I can use your feedback and suggestions. Supervision involves a different set of skills than being a counselor.

CARRIE: Right. I took a course in school on clinical supervision and that’s exactly what the professor said.

How To Choose a Course on Clinical Supervision

Look for the following components:
1. The training should be approved by credentialing organizations to fulfill the requirements for certification as a clinical supervisor.
2. It should meet the minimum training requirements of 30 hours.
3. The training should be provided by a trainer with the following skills: Level 3 counselor, Level 3 supervisor, excellent training experience, and ability to provide information on both administrative and clinical supervisory issues.
4. The training should teach practical clinical supervisory skills through role-plays and demonstrations, video- and audiotapes of supervision sessions, and opportunities to practice clinical supervisory skills.
5. The training should be provided by a reputable training individual or organization.
6. Online courses are also available. However, an organization should first verify if online courses are approved by their State certification board.

WALT: Let’s summarize what we’ve said. We’re moving into new treatment program strategies. Each of us has an Individual Development Plan (IDP) stating our individual learning goals. Mentorship is an important aspect of helping us all meet our IDP goals.

[Walt describes the process of mentorship, that each staff member will have a mentor. Some staff will mentor each other. Walt discusses the relationship between the IDPs, clinical supervision, and the mentorship system. Walt also discusses the issue of stages of readiness and how that affects the form and extent of mentorship each person will receive.]

Master Supervisor Note: Mentorship is a formalized relationship between a skilled professional and a mentee and is established to enhance the mentee’s career by building skills and knowledge. In a series of structured sessions, a person of greater experience instructs, guides, advises, provides feedback, and coaches someone of lesser experience. Clinical Supervision and Professional DevelopmentWALT: One of my tasks is to ensure that all of us get training so that any one of you could take over for me if need be. I love to surround myself with people who can take over my job on a given day.

CARRIE: I’d be happy to both be mentored and serve as a mentor to others, if that’s what you wish. I’m feeling a lot better than when we began this discussion today.

[Walt starts a discussion on clinical issues that might be topics for discussion in supervision, such as caseload size and complexity, work with clients with co-occurring disorders, the impact of dual relationships with clients, and confidentiality. The session ends with the group establishing the times for their group supervision and the procedures for tape review and live observation.]

Vignette 2—Defining and Building the Supervisory Alliance


This vignette illustrates the tasks of defining and building a supervisory alliance, particularly when working with an entry-level counselor with an academic background different from that of the supervisor. The dialog is the initial supervisory session. It illustrates how to introduce direct observation and the establishment of an IDP.


Bill is a certified clinical supervisor who worked his way up through the ranks, starting as a substance abuse counselor 20 years ago, 3 years into his own sobriety. Ten years ago he enrolled in a part-time master’s degree program in counseling and completed the degree in 5 years. Since receiving his master’s degree, he has worked as a clinician and supervisor in a community-based substance abuse treatment program. In addition to his supervisory duties, he is director of the program’s intensive outpatient program (IOP).

Jan is in her first month at the agency, right out of graduate school. She is a Level 1 counselor, her first employment since receiving her M.S.W. She had limited substance abuse treatment experience in a field work placement and sees her current employment as a stepping stone to private practice after she receives her social work license. Her supervision in the field placement assignment focused on social work skills and integrating field work learning with her academic program. She averaged ten cases during her second year of field work.

The agency is a private, nonprofit organization providing comprehensive addiction treatment and education services. Jan has been assigned to the IOP and is expected to participate in a structured internship program of 3 months wherein she will receive training in the substance abuse treatment field. The agency has a well-established system for clinical supervision.
Learning Goals

  1. To illustrate how to initiate supervision with a new counselor.
  2. To demonstrate how to establish a supportive supervisory relationship and build rapport.
  3. To define goals and boundaries of supervision.
  4. To demonstrate how to identify supervision expectations and goals of the supervisee.
  5. To illustrate how to address the developmental needs of a new counselor.
  6. To show the start of a discussion on an IDP.

[After brief introductions, the discussion begins about what will occur in supervision.]

BILL: We’re excited to have you here, Jan. You may already know that supervision is an essential part of how we help counselors in the agency. Since this is our first session together, perhaps we can explore what you want from supervision and how I can help you. Building on your training and experience, maybe you can give me some ideas about the areas where you wish to grow professionally.

JAN: Well, I haven’t thought about that yet. I had excellent training and experience at the EAP [Employee Assistance Program] in the county health clinic. I’m not sure where to begin or even what I need. I recognize the need for supervision, certainly for orientation to the agency. I’d like to know about how much supervision I’ll get and the focus and style of supervision here. I also need supervision to meet the requirements for licensure as a social worker.

BILL: I can understand that you’re really excited about starting a new job and career. You had an excellent experience in your placement at the health clinic. I’d love to hear more about it, so perhaps you might tell me something about that placement, what you learned, and what treatment models they used there.

JAN: Wow, there is so much to tell you about that. I averaged ten clients on my caseload. Some were just assessments, but I did get to work longer term with several clients. I sat in on several counseling sessions, observed the senior counselor conduct the sessions, and co-led a group and several family sessions. I had weekly clinical supervision with my supervisor and the senior counselors. We used process recordings in school and that was really sufficient because I would write the verbatim, give it to my supervisor, she’d make comments, and we’d talk about it. So I didn’t really need to have her watch me work. I’ve heard from Margaret [another counselor in the agency] that in supervision you do direct observation of counselors here and that idea is new to me. Frankly, I’m not sure if I really need that. My model for counseling is eclectic, whatever is needed for the client. They used a lot of cognitive–behavioral counseling approaches at the EAP. I try to meet the clients where they are and focus my therapeutic approach to meet their needs.
[Discussion continues about Jan’s experience at her placement and academic training.]

BILL: So, we have a good sense of your background and experience. If it’s OK, I’d like to return to the earlier question about whether you have any thoughts about what you want from our supervision together.

JAN: I’m not sure. Do all counselors here get supervision and are they all observed? I’m not sure I need that observation, especially since the placement didn’t do that.

BILL: I appreciate your concerns about supervision. All our counselors here receive supervision. Some agencies don’t do much direct observation of staff, but we’ve found it very helpful for a number of reasons. Here, we see supervision as an essential aspect of all we do. We believe you have a right to supervision for your professional development. We have great respect for our counselors and their skills and also understand that we have a legal and ethical obligation to supervise, for the well-being of the clients.

Master Supervisor Note: Notice how Bill is laying the foundation and rationale for why clinical supervision is essential to this agency. Whereas every agency needs to develop its own, unique clinical supervision approach, there are models and standards of clinical supervision, as discussed in Part 1, chapter 1, which seem to be most effective. Agencies might benefit from adapting aspects of these models.

JAN: So, everyone must have supervision and observation?

BILL: We take our legal and ethical obligations seriously. We want all of our counselors—even the most experienced ones—to grow professionally, to be the best counselors they can be, for their own development and for the welfare of the clients. As you probably learned in your M.S.W. program, vicarious liability is an emerging issue for agencies. Counselors are legally liable for their actions. Vicariously, so are the agency and the supervisor. We need to make a “reasonable effort to supervise.”
JAN: OK, so what do you expect of me?

BILL: I’d like to explore that with you. I’m really interested in both what you expect of yourself and what you expect of us.

JAN: Again, I never really thought about that. I want to grow as a counselor and to develop skills that I can use in my future employment. I understood when I took this position that you do an excellent job of providing training opportunities for staff, something I really liked about the organization.

BILL: In our agency, clinical supervision is part of a larger package of staff development efforts. We try to help counselors improve their skills by offering the opportunity to work with a variety of different clients, using a variety of treatment modalities, such as individual, group, couples therapy, family therapy, and psychoeducation. Also, we want staff to be able to obtain their social work or substance abuse license or certification in the future. We want counselors to develop new skills by attending training both in-house and in workshops around the State. We encourage and support any efforts you might make toward professional development, such as getting your various levels of social work licensure. Our philosophy is that one of our greatest assets is our clinical staff and as they develop, the agency grows too. We believe clinical supervision is critically important in this mix. We both—you and the agency—benefit as a result.
[A discussion continues about Jan’s course work in school and her training in the field placement, and how she can continue that learning in the agency. She articulates her clinical strengths.]

BILL: That sounds good. Those are the skills we saw in you that we thought would be helpful to our agency. In what ways do you wish to grow professionally?

JAN: I could learn other counseling techniques beyond CBT. What do you think I need?

BILL: That’s what we can explore in supervision. I’ll need to have a sense of what you’ve learned and where you see your skills. In addition to talking about your skills, we find it helpful to learn through observation of our staff in action, by either sitting in with you on a session or by viewing videotapes of counseling sessions. That way, we can explore your specific learning objectives. We all learn from watching each other work, finding new ways of dealing with clinical issues. What do you think of that process?

JAN: As I said, I wasn’t observed in my placement and find it anxiety provoking. I don’t really like the idea of your taping my session. It feels a bit demeaning. After all, I do have my M.S.W. I don’t recall anyone saying anything in my interview about being videotaped. Now, that’s intimidating, to me and the clients.

BILL: Being anxious about being taped is a fairly common experience. Most counselors question how clients will accept it. You might speak with Margaret and some of your other coworkers about their early experiences with taping, what it was like for them, and how they feel about it now.

JAN: How often do we have to meet for supervision?

BILL: Generally I meet each counselor individually for an hour each week. Then we do weekly group supervision where each counselor, on a regular basis, gets a chance to present a case and videotape, and we, as a group, discuss the case, and talk about what the counselor did well and how other things might have been handled differently. When you present a case, we all grow and benefit.

JAN: I want to be a proficient therapist, ultimately, to work as a private practitioner. If supervision can help me professionally, that’s good. Master Supervisor Note: It is important for Bill to be aware of what feelings are arising within him, particularly concerning Jan’s seeming desire to pass through and use the agency as a route to private practice. This has happened to Bill and the agency before. Bill acknowledges to himself his feelings of being used by these clinicians in the past. Bill’s self-awareness of these feelings is critical and he does not respond out of anger or resentment but makes a conscious effort to remain present to what the issues are with Jan.

BILL: I’m glad you see the value of supervision. And I admire your professional goals of wanting to be in private practice although I must say that I have difficulties with people just “passing through our agency” on theway to something else. But, that’s my issue, and I’ll address those concerns if they come up in our relationship.

Master Supervisor Note: In his own supervision, Bill might explore his feelings about people passing through the agency, his anger or resentment, and how he can effectively address those feelings. For example, Bill’s supervisor might wish to explore with Bill the following questions:

1. What feelings does Jan bring out in you? When have you had these similar feelings in the past?
2. How do you deal with negative feelings about a supervisee?
3. How do you keep from being drawn into a defensive posture where you are justifying the agency’s use of direct methods?

JAN: Will I be criticized by others, perhaps those without as much formal training as I have? I understand you have several nondegreed counselors here—certified addictions professionals, with lots of life experience but without advanced degrees.

Master Supervisor Note: A Level 1 supervisor might respond angrily here. A Level 2 supervisor might get into an argument about the quality of counselors at the agency. Bill, as a Level 3 supervisor, does not react to Jan’s seeming criticism of the nondegreed counselors. He responds in a supportive but direct manner, as you will see. But perhaps Jan is making this comment in response to Bill’s previous statement that he has “difficulties with people just passing through” and this is another reason for Bill to address this in his own supervision.

As discussed in Part 1, chapter 1, just as there are levels of counselor development, there are also levels of supervisor development. Level 1 supervisors might have a tendency to be somewhat mechanical in their methods, perhaps needing to assert their leadership and position, and approaching situations somewhat anxiously. This is especially so for supervisors who have been promoted from within the organization. Their peers, with whom they have worked side-by-side before, know they do not know their strengths and limitations, and hence the new Level 1 supervisor may feel that she has to assert her authority (see vignette 6). A Level 2 supervisor is much like the Level 2 counselor, who is driven by alternating anxiety and self-confidence and who feels the need to be independent, even though she might not as yet be able to act independently. Finally, Master Supervisor Note: It is important for Bill to be aware of what feelings are arising within him, particularly concerning Jan’s seeming desire to pass through and use the agency as a route to private practice. This has happened to Bill and the agency before. Bill acknowledges to himself his feelings of being used by these clinicians in the past. Bill’s self-awareness of these feelings is critical and he does not respond out of anger or resentment but makes a conscious effort to remain present to what the issues are with Jan.

BILL: I’m glad you see the value of supervision. And I admire your professional goals of wanting to be in private practice although I must say that I have difficulties with people just “passing through our agency” on theway to something else. But, that’s my issue, and I’ll address those concerns if they come up in our relationship.

Master Supervisor Note: In his own supervision, Bill might explore his feelings about people passing through the agency, his anger or resentment, and how he can effectively address those feelings. For example, Bill’s supervisor might wish to explore with Bill the following questions:

1. What feelings does Jan bring out in you? When have you had these similar feelings in the past?
2. How do you deal with negative feelings about a supervisee?
3. How do you keep from being drawn into a defensive posture where you are justifying the agency’s use of direct methods?

JAN: Will I be criticized by others, perhaps those without as much formal training as I have? I understand you have several nondegreed counselors here—certified addictions professionals, with lots of life experience but without advanced degrees.

Master Supervisor Note: A Level 1 supervisor might respond angrily here. A Level 2 supervisor might get into an argument about the quality of counselors at the agency. Bill, as a Level 3 supervisor, does not react to Jan’s seeming criticism of the nondegreed counselors. He responds in a supportive but direct manner, as you will see. But perhaps Jan is making this comment in response to Bill’s previous statement that he has “difficulties with people just passing through” and this is another reason for Bill to address this in his own supervision.

As discussed in Part 1, chapter 1, just as there are levels of counselor development, there are also levels of supervisor development. Level 1 supervisors might have a tendency to be somewhat mechanical in their methods, perhaps needing to assert their leadership and position, and approaching situations somewhat anxiously. This is especially so for supervisors who have been promoted from within the organization. Their peers, with whom they have worked side-by-side before, know they do not know their strengths and limitations, and hence the new Level 1 supervisor may feel that she has to assert her authority (see vignette 6). A Level 2 supervisor is much like the Level 2 counselor, who is driven by alternating anxiety and self-confidence and who feels the need to be independent, even though she might not as yet be able to act independently. Finally, BILL: We do individual observation and group supervision where we find common issues in our counseling, using videotape and case presentation to trigger discussion of related issues. Everyone learns from the presenter’s experience. Each counselor takes a turn presenting a case, including a videotape. We can cue the tape to the session segment you want us to discuss. After your brief introduction of the case, we discuss how the session went, what skills were effective, and what areas might be further developed. How does that sound?

JAN: That sounds great. Can I come to you at other times to review cases, especially while I am learning the ropes of how things are done here?

BILL: Yes. I appreciate your wanting immediate feedback. I have an open-door policy. Although I may look busy, I’ll try to find time when we can discuss whatever you want. You can also meet with others if you feel comfortable doing so. We encourage teamwork. Does that seem reasonable?

JAN: Yeah. I’m pretty autonomous at this point. I think it’s great that there are other counselors and social workers I can collaborate with. It will be really helpful for me especially since I’m new at the job, and it’s good to be able to work together. I’m OK with supervision, and I like the fact that we’re both going to have an agenda, so that’s fine.

BILL: So, let’s go back to your experience. I’d love to hear more details about your internship and what you learned there.

[Jan explains her work experience in her internship.]

JAN: In my second year I was at an EAP clinic. I had a great supervisor, Jackie. Several of my clients were alcoholics, my first introduction to substance abuse. There was something that attracted me, to understand more about the disorder and to contribute what I was learning in social work. Jackie was a social worker and a really good role model. I need to understand more about substance abuse treatment, and try to marry the social work and substance abuse fields.

[Bill and Jan continue to discuss her experience with supervision, what worked best, what she found most useful and supportive.]

JAN: I’m a little worried about how I’ll meet my licensure requirements about being supervised by a social worker. Will that be a problem for me?

BILL: Not at all. Margaret is an LCSW and we can ask her to provide the supervision you need for social work licensure. This will allow Margaret to develop her supervision skills. I also think that an important part of developing a professional identity is receiving coaching from an experienced person, and perhaps Margaret can assist in that area too.

JAN: That sounds fair and helpful.

BILL: You mentioned that Jackie was a good supervisor. Can you tell me what she was like and what she did that made her a good supervisor?

JAN: She was really smart. I could learn from her. When I went to talk to her she always gave me good advice. She trusted that I knew what I was doing and didn’t micromanage me. She was open about her theories and made linkages to issues. She trusted me to just go ahead and implement what I learned. She was easy to talk to. If I had a problem, I could say so.

BILL: It sounds like Jackie and I have a similar orientation as supervisors, and that should make the transition easier. I hope you’ll observe from your perspective how the supervision is developing, and give me feedback on the relationship, the process, and the outcomes from your point of view. Our first step will be to expand your training by introducing you to a broad range of substance abuse issues. Perhaps at our next session we can start developing a learning plan to apply your studies to clinical work. What do you think of that? How To Write a Supervision Contract The following elements might be included:

1. The purpose, goals, and objectives of supervision.
2. The context of services to be provided.
3. The criteria and methods of evaluation and outcome measures.
4. The duties and responsibilities of the supervisor and supervisee.
5. Procedural considerations.
6. The supervisees’ scope of practice and competence.
7. The rewards for fulfillment of the contract (such as clinical privileging or increased compensation).
8. The frequency and method of observation and length of supervision sessions.
9. The legal and ethical contexts of supervision as well as sanctions for noncompliance by either the supervisee or supervisor.

JAN: That’d be good. I like that you’re interested in my experience, about who I am. I’d like to know a bit about you. Jackie would talk about who she was, her model of supervision, and why this work was important to her. I felt I could trust her because I knew where she was coming from. Would you tell me more about yourself?

Bill: I’d be happy to.

[Bill provides an overview of his work, academic experiences, and primary model of counseling and supervision.]

JAN: I have a beginning understanding of the type of supervisor you are. I like that you’re direct so I don’t have to guess at the agenda. So, we’ll work on a training plan and I’ll suggest times for you to observe a session and videotape. Is that correct?

BILL: That seems fair and clear. Any other concerns we should talk about today?

[Further discussion follows about Jan’s anxiety about supervision. They discuss how supervision would work to help reduce her anxiety about being scrutinized and critiqued.]

BILL: So, although you’re a bit nervous about the process, you’re ready to begin. We’ll start with your observation of me to give you an opportunity to get your feet wet. Then you can tell me when you’re ready for me to come in and observe, maybe in the next 6 or 8 weeks.

JAN [jokingly] I think sometime in the next 6 months.

Master Supervisor Note: As a Level 3 supervisor, Bill doesn’t react to this comment. A Level 1 supervisor might respond by saying “The timeframe is not negotiable. You’ll begin the observation in 6 weeks.” Another response might be to avoid the issue without affirming her. When she is noncompliant after 6–8 weeks, he’d blame her for her lack of follow through. Such responses might negatively affect the relationship. A supervision of supervision issue might be to explore what was happening for Bill and his possible ambivalence about Jan. BILL: Thanks for your willingness to begin and try the process.

JAN: OK. So, I can pick the client?

BILL: Yes. You can pick the client or group. We’ll meet every week for about an hour.

[Bill and Jan set the time for the next supervision session and discuss what is expected for the next session and end the discussion with both excited about the process.]

Vignette 3—Addressing Ethical Standards

This vignette illustrates the role of the supervisor as a monitor of ethical and professional standards for clinicians, with the goal of protecting the welfare of the client. The vignette begins with a discussion about a potential ethical boundary violation and illustrates how to address this issue in clinical supervision.


Stan has provided clinical supervision for Eloise for 2 years. He’s watched her grow professionally in her skills and in her professional identity. Lately, Stan’s been concerned about Eloise’s relationship with a younger female client, Alicia, who completed the 10-week IOP 2 months ago and participates weekly in a continuing care group. Alicia comes to the agency weekly to visit with her continuing care counselor. She also stops by Eloise’s office to chat. Stan became aware of her visits after noticing her in the waiting room on numerous occasions. Earlier in the day, Stan saw Eloise greet Alicia with a hug in the hall and commented that she will see Alicia “at the barbecue.” Stan is aware that Alicia and Eloise see each other at 12-Step meetings, as both are in recovery. Eloise feels she is offering a role model to Alicia who never had a mother figure in her life. Eloise expresses no reservations about the relationship. Stan sees the relationship between Eloise and Alicia as a potential boundary violation.

Learning Goals

  1. To illustrate monitoring professional boundary issues of counselors in clinical supervision.
  2. To demonstrate supervisory interventions to help the counselor find appropriate professional boundaries with clients.
  3. To help counselors learn and integrate a process of ethical decisionmaking into their clinical practice.
  4. To demonstrate skills in addressing transference and countertransference issues as they arise in clinical supervision.

[After brief introductory comments, the discussion begins with how Alicia is progressing in her recovery.]

STAN: If it’s OK, I’d like to share some concerns I have about Alicia.

ELOISE: Sure, I’m always ready for feedback.

STAN: When I walked through the lobby a few minutes ago I heard you say something to Alicia about seeing her at a barbecue.

ELOISE: Right. Sarah is one of my sponsees in AA, and we’re having a barbeque at her house for some people in recovery. She and Alicia have gotten really close, so Alicia will probably go, too. STAN: And that’s a barbecue you might be attending?

ELOISE: Yeah. I’m fairly active with all my 12-Step friends and sponsees.

STAN: I would like to raise a concern I have about your relationship with Alicia. You take great pride in working with recovering people, helping them, and doing everything you possibly can to ensure their recovery.

ELOISE: Yes, it means the world to me. Alicia reminds me of myself when I was in early recovery. When I see her and how hard she’s working, it inspires me because I know that struggle.

STAN: I’m pleased that you care so much about your clients and that you can identify with their struggles. I do have concerns though, when I hear you are going to see her at a barbeque. It seems like a possible dual relationship issue for you, and I would like to know what you think about this?

ELOISE: Well, I certainly know not to sleep with my clients, or borrow money from them, or hire them to mow my lawn, or take them on trips. But seeing Alicia at a barbecue? Come on, Stan.

Master Supervisor Note: At this point Stan might be feeling somewhat defensive and may need to restrain his urge to begin disciplinary action against Eloise for her attitude. A Level 1 supervisor might react angrily to Eloise’s tone of voice, seeing this as a clear disciplinary issue. A Level 2 supervisor might get caught up in an argument with Eloise about the extent of the violation. The skill of a Level 3 supervisor is to be clear with Eloise about what a dual relationship is without responding out of anger. As shown below, Stan needs to help her identify what a boundary violation is, how to make ethical decisions, and how to have this discussion in the context of a supportive supervisory relationship. It is important for Stan to help her be more aware in future situations with similar clients and dynamics.

STAN: I’m glad we agree on those kinds of extremes because dual relationships are a big concern of our agency and staff. A dual relationship occurs when a counselor has two relationships with a client, one personal, one professional. Our mission is to provide professional clinical services to clients. Within those services there is a scope of practice. When a personal relationship with a client or former client intrudes on that professional clinical service, then we may have a relationship that is considered outside the parameters of what’s considered solely professional.

ELOISE: What I understand about dual relationships is that it . well, help me here. For example, I know I’m not supposed to hire anybody for any personal services or any form of exchange of money or buy anything from a client. If they’ve been a client here, I can’t contract with them for private practice or anything like that.

STAN: Let’s talk about your relationship with Alicia and what the intent is now. You want to do everything you can to build a safety net for her recovery. I appreciate your concern for her recovery. One goal of recovery is for the client to achieve a sense of autonomy and make decisions on her own, to take care of herself. You play a role. So, if we can, let’s discuss what that professional role is, and what it isn’t. When I walked through the lobby and heard you say “I’ll see you at the barbecue,” I had some concerns.

ELOISE: You mean I shouldn’t say that in a public place?

STAN: My concern is whether going to a barbecue with a client is appropriate behavior, to have a relationship with her outside your professional relationship as defined by our agency. When I heard your remark, I thought, “I wonder what Eloise’s intent was and where that’s going or what might that lead to? Let me check it out to see if I am being clear.” ELOISE: Are you saying I shouldn’t see clients in other contexts? How reasonable is that? We live in a small town here and run into clients all the time in the supermarket and at 12-Step meetings. So what are you saying?

Master Supervisor Note: There is a difference between a dual quality to a relationship and a dual professional and personal relationship. Dual qualities are inevitable in certain communities. A dual relationship has the potential for the abusive use of power, where harm might be done to the client through manipulation or inappropriate self-disclosure. Actions in one context might be acceptable, whereas in another they might be harmful. A skillful supervisor would help Eloise see this distinction and help her be better able to make sound ethical decisions concerning the line between dual qualities and dual relationships.

STAN: Great observation. Yes, we find ourselves in situations that potentially have a dual quality to them. The difference between running into clients in the supermarket and going to social activities together involves the potential impact that action might have on the client and our use of the power we have in the relationship. You were her counselor.

ELOISE: Yes, but I’m not her counselor anymore. She’s in continuing care now.

STAN: Okay, but she’s still a client of the agency. The ethical question is how long is a client a client? According to our substance abuse counselor’s code of ethics, once a client, always a client in terms of our professional responsibilities.

ELOISE: Yes, but she just stops by when she’s here. She pops in just to say hi, for not more than 5 minutes. I don’t counsel her anymore.

STAN: Okay, that might be reasonable. Perhaps we can discuss that relationship and the impact of seeing her outside the agency at functions.

ELOISE: Well, she goes to the women’s AA meeting that I go to. And she knows some of my sponsees. What should we do, leave our home group because clients attend the meetings also?

STAN: It is inevitable that we will run into clients at meetings. When does that cross over the ethical boundary and become a dual relationship? I’d like to hear your ideas about where you see that line for you.

ELOISE: I don’t want to do the wrong thing, Stan, to hurt her. My intent is to be helpful.

STAN: Again, I know you don’t want to hurt her, and I know you’re trying to help her in her recovery. We have to be mindful of not being drawn into relationships that hurt the client or that could be perceived as dual relationships.

ELOISE: She doesn’t call me or come see me. I want you to know I’m not sponsoring her. But I didn’t know that going to the barbecue was wrong. So, I won’t go.

Master Supervisor Note: Stan really wants to keep the focus on the larger issue of dual relationships. Once Stan and Eloise have clarified this larger perspective, then it might be more appropriate to come back to the specific issue of the barbecue. A more inexperienced supervisor might be tempted to just establish the boundary about socializing with clients with a comment like “That would be a wise decision (not to attend the barbecue)” but would possibly lose the potential of helping Eloise develop more effective ethical decisionmaking skills in the process. It would, in effect, run the risk of making the decision for Eloise, rather than helping her come to an ethical decision on her own.

STAN: With your permission, perhaps we can talk about how we make ethical decisions about the nature of a relationship with a client or a former client, and what’s not professionally appropriate. If it’s okay, let’s use the conversation with Alicia in the agency lobby. How do you think that conversation might be perceived by anyone who is walking by who hears you say you’ll meet at the barbecue?

ELOISE: I’ve never really thought about it. Well, I guess if it was someone who didn’t know me, they might think that I was personal friends with her. That’s not a perception I want others to have.

STAN: So, you want others to see you as a professional, upholding boundaries and your code of ethics?

ELOISE: Yes, of course.

STAN: I reread the code of ethics to help evaluate whether or not there might be an issue. I was reminded of the power differential in all counseling relationships and that as professionals in our field we need to be careful to not engage in social relationships (or relationships that might be seen by others as social relationships) with clients or former clients. You may recall we recently had a lawsuit over dual relationships that put the agency in jeopardy. It got resolved in our favor but we’re particularly sensitive about our liability. It was a wake-up call to all of us. So how can we clarify this boundary issue with your relationship with Alicia?

ELOISE: Wow, I never saw going to the barbecue as pursuing a friendship, and I certainly would not want to jeopardize our agency’s relationship with her. I certainly don’t seek any personal gain from our time together. Although I must admit, she does remind me of myself when I was in early recovery. Besides, she has never had a strong, positive, maternal figure in her life. That’s something I think I can help her with. What do you think?

STAN: I admire your concern for her and it sounds like you are becoming aware of some maternal feelings for her that might be coming close to stepping over that professional boundary. When our relationships with others, and particularly with clients or former clients, begin to even have the possibility of affecting their recovery in a potentially negative way, then we might be edging close to an ethical boundary violation.

ELOISE: I understand, but part of my recovery program is being in touch with other people in recovery, other people from meetings, like Alicia.

STAN: I agree. It’s important for your own recovery that you stay connected to other people in recovery. So, the question is: What’s the difference between seeing people in recovery at meetings, such as your sponsees or your sponsor, and relating to clients active in treatment at our agency whom you encounter at a meeting?

ELOISE: Do I have to cut off all my recovery relationships and not go for coffee after meetings?

Master Supervisor Note: It is important for supervisors to take into account cultural variables that might affect clinical relationships, such as differences in ethnic, religious, and geographic factors and their impact on the counselor–client relationship. This is not to condone unethical behavior but to be mindful of cultural issues as they affect the context of counseling. For example, in some Latino cultures some form of socializing may be expected. In Asian cultures, it is not uncommon for a client to ask the counselor personal questions as a means of establishing trust. Skillful supervisors assist counselors in understanding cultural variables while continuing to make sound ethical decisions. STAN: I understand the dilemma we find ourselves in as counselors. We have to go on living our lives in our small rural community. So, how do we reconcile our daily lives with the Federal laws, agency policies, and our code of ethics? We need to be mindful of those boundaries just because of the closeness of our community. The interesting thing is that the clients are not bound by the same rules as we are. So, they might not see it as a boundary violation. In fact, as often as not, clients and former clients are flattered by contact with their current or former counselor and invite such relationships. How will we reconcile these differences? How do we know what the ethical wall looks like before we hit it?

ELOISE: Well, I guess we need to be careful about what contexts we see clients in, whether they are actively being counseled by us or not. Is that what you’re saying?

STAN: Yes, we do need to be mindful of the various relationships we develop with clients. I’d like to use the barbeque as an example to discuss. Okay?

ELOISE: Sure. First, I have six sponsees. They’ve all been in recovery for different lengths of time, and they like to get together every 3 months, all six of them, and do some kind of activity. And they invite over a bunch of people from the 12-Step group. Sarah was having this barbecue and asked me because we go to the same home group. She also invited Alicia. I’m not sponsoring Alicia. Does that mean I can’t go?

How To Perform Ethical Decisionmaking

Stan’s task here is to help Eloise identify potential boundary issues in a broader context and aid her in her ethical decisionmaking. The following are steps to ethical decisionmaking:

1. Recognize the ethical issues by asking whether there is potentially something harmful personally, professionally, or clinically. In what way might this go beyond a personal issue to the agency, the profession?
2. Get the facts. What are the relevant facts? What facts are unknown to us at this time? Who has a stake in the decisionmaking? What are the options for action? Have all of the affected parties been consulted?
3. Evaluate alternative actions through an ethics lens. Which options will produce the most good and least harm? What action most respects the rights of all parties? What action treats everyone fairly?
4. Make a decision and test it. If you told someone you respected what you did, how would they react?
5. Act, then reflect again later on the decision. If you had to do it all over again, how would you react differently?

STAN: It might help to ask yourself what happens for you when you find yourself in such a dilemma, to be your own problemsolver.

ELOISE: Well, it’s hard to not go to social activities in this small community when I’m invited. But I can see how some might see me in a different light because I’m a counselor. At one party, someone came up to me and started to ask questions about problems in their marriage. I guess she figured that since I’m a counselor, she could get some free assistance. I was really uncomfortable in that situation.

STAN: What did you do? Master Supervisor Note: At this point Stan might:

1. Have Eloise consider her own solution.
2. Use her solution in a dialog to expand the context so she can generalize the solution to other situations she may encounter.
3. Conclude with Eloise’s restatement of what she has learned for the future from this discussion.

ELOISE: I told her I could not be her counselor and was there at the activity in my “civilian” clothes. [Chuckling.] Ah, I see what you’re getting at. It’s hard to be in two relationships, a professional and a personal one, with the same person. And I can see what you mean by how a reasonable uninvolved person might view this situation. At the party, when that woman wanted free counseling, it was clear that that was not the context or the relationship for that. That’s unprofessional. But Alicia is different.

STAN: So, you see that it is unprofessional to counsel someone outside of a professionally defined relationship. I’d like to hear how it is different with Alicia.

ELOISE: Well, I really care for her. She reminds me of myself when I was younger. I am the mother she never had. I feel bad for her that she’s never had a positive female, maternal role model in her life.
[Eloise cries as she expresses her concern for Alicia.]

STAN: This is difficult for you. You care very deeply for her. I can understand that in some ways she reminds you of yourself at that point in your recovery.

ELOISE: Yes, she does.
[Her crying continues, and Eloise speaks of her concern for Alicia. After a few minutes, the two sit quietly.]

ELOISE: The last thing I want to do is to hurt her or to act in an unprofessional manner.

STAN: I value your concern for Alicia and your desire to be professional. It is difficult when we care so deeply for our clients. We’re asked to show empathy and caring for clients, and sometimes it can be confusing if we care too deeply. It’s like, as caring professionals, we’re always living close to that ethical slippery slope. We can retreat into “professional white coats” and separate ourselves emotionally from clients. But that turns counseling into a sterile activity, and we’re detached and removed from their pain. But, when we care deeply, we are drawn into the emotional world of our clients. And the boundaries can become fuzzy for us.

ELOISE: I see what you mean. I guess we can rationalize a lot of our behavior when we care so deeply. We call that enabling behavior, don’t we, when family members do that with the person in substance abuse treatment? So, how do we walk close to that ethical slippery slope without falling over the edge?

STAN: That’s an excellent question. Ethical decisionmaking can be difficult at times. Intent is an important part of ethical decisionmaking. How To Ask Questions in Ethical Decisionmaking

The following are key questions to ask at this point:

  1. What would a reasonable person, counselor, or colleague do in a similar situation?
  2. What are the relevant issues regarding justice, fairness, self-advocacy, non-malfeasance?
  3. How would a person discern his or her intentions? How do you keep yourself from self-deception about your motives, remembering that the best test for your motives is time?

ELOISE: What do you mean by “intent?” It was my intent with Alicia to be helpful, certainly not to hurt her in any way or to be disrespectful of our agency or of me as a professional.

STAN: When we commit to a professional relationship with a client, there is always a power differential. When someone like Alicia comes with her need for a maternal figure, as you well described, we need to be careful of our role in offering to fulfill that need. The power differential alone can create some opportunities for people to misperceive what’s going on. What do you think?

ELOISE: Can it be that I took advantage of her because of my own need to be a mother figure in someone’s life?

STAN: That is always a risk we have. It could be perceived that way.

ELOISE: I feel bad that I wasn’t being very professional with her and my own needs came out.

Master Supervisor Note: It is important to remember the power differential between supervisor and supervisee. How might key audiences (colleagues, the community, board of directors, the press, peers) see or experience the counselor’s behavior? What is the risk? There are many stakeholders involved who each view the situation from their own perspective. For example, stakeholders (such as the board of directors) might be concerned about the risks of legal liability for the agency, the media and community with the public image of the organization, and peers with the clinical implications of a possible boundary violation.

STAN: That’s a key insight. It’s great that you could step back from the situation and see how your caring deeply for her spilled over in other ways.

ELOISE: You think I had power over Alicia?

STAN: As I said, when you’re a counselor to a client, there is always a power differential that we have to be very cautious and very aware of. It may not be something we do so much as the power that the client gives us. Now, if it is okay with you, I’d like to summarize a little.

[Stan and Eloise review what has been discussed and what actions might be appropriate for Eloise to take at this point. They express their concerns about Alicia and how she might be hurt if Eloise abruptly cuts off the relationship with Alicia. They strategize on how to best handle the situation in a way that would be clinically supportive of Alicia.] STAN: I want to talk a little about ethical decisionmaking and how we can keep within certain guidelines. There are some questions to be asked, such as how that behavior is experienced by someone else. How would your actions be perceived by colleagues, the community, a supervisor, and clients?

ELOISE: I appreciate your saying that; I need to think about it. It makes sense.

STAN: I’d like to review what we’ve discussed and your understanding of the issues.

ELOISE: I have a clearer understanding of how my relationship with clients after they’re discharged is as important as when they are my active clients. I need to think and give more consideration to how that’s perceived, to consider my role with clients from their perspective. In my relationship with Alicia, I’ve thought of myself primarily as a recovering person, but I need to remember that she may perceive me primarily as her counselor. In other words, I am wearing two hats—a counselor and a person in recovery—and I need to be clear which hat I am wearing and when those hats are on.

STAN: So you have a sense of the potential conflict of interest depending on what hat you’re wearing and how that might be perceived.

ELOISE: Yes. I need to think about how that reflects on the agency and how the community sees it.
[The supervision session ends with Eloise making a commitment to rethink the relationship with Alicia and strategies for making ethical decisions in the future.]

Vignette 4—Implementing an Evidence-Based Practice


This vignette portrays supervision of two counselors at different levels of experience and orientation to implement an evidence-based practice (EBP) into their clinical work. Both counselors have reservations about adapting the way they practice and have some resistance to undertaking the new EBP. The clinical supervisor has to address their resistance while achieving the mandate of the agency.


The executive director (ED) of a mid-sized substance abuse treatment program has issued a statement to all staff that, according to State requirements, the agency must incorporate EBPs, now a necessity for State funding. Therefore, the ED has directed the three clinical supervisors to begin the implementation of MI as a primary treatment method for treatment staff, first on a pilot basis then agency-wide. Gloria, one of the supervisiors, is meeting with Larry and Jaime, two program counselors, to discuss implementation of MI with their clients. Both Larry and Jaime are aware of the mandate but have not had an opportunity to discuss the change with Gloria until their regularly scheduled supervisory session this morning. Both have, in the last year, expressed some resistance to undertaking a new treatment approach when they were required to attend MI basic training.

Learning Goals

1. To demonstrate leadership by a clinical supervisor toward meeting agency goals and mission.
2. To demonstrate leadership in the face of staff who are resistant and reluctant to incorporate EBPs into their counseling. 3. To model MI in the supervisor/supervisee relationship.


  1. To illustrate fostering a spirit of learning and professional development among counselors.
  2. To illustrate how a clinical supervisor can help counselors build new clinical skills, especially those that are science-based practices.
  3. To understand the resistance and impediments in the field to the implementation of EBPs.

GLORIA: I know you have some reservations about the MI implementation program. Today I want to spend time discussing your reservations and how MI can be good for our clients and for the agency. You have both done a tremendous service for our programs. We want to be responsive to your needs, not just impose something on you. When you’ve been doing a good job and you know that what you’re doing works, it’s hard to take on something new that you’re uncomfortable with. I know that you’re concerned that taking on something new could, at least initially, potentially interrupt the normal flow you have with clients.

So, there are several things that I think are important for us to consider today. First, let’s review why we are implementing MI for staff as a tool in their counseling. Perhaps we can explore any concerns you might have, then review why it is important to implement MI.

Second, let’s look at your concerns about how those changes might affect client care.

Third, let’s focus on how we can keep the strengths you have with your clients and be sure they don’t get lost in the transition process. One of the beauties of MI is that it integrates well with what good counselors do naturally: active listening, respect for others’ views, an appreciation of the role of resistance, good goal setting practices, and the like. Most important, MI aids in establishing and enhancing the therapeutic alliance between the counselor and the client.

Finally, I want to spend a little time talking about where we go from here and how we are going to make the implementation process as smooth as possible.

How To Introduce Changes in Clinical Practices

Changes in counseling methods are difficult for staff who are attached to their model of counseling and know that it is working for them. When presenting new policies and directions to staff, it is important that you follow these guidelines:

1. Be respectful of staff’s resistance. Instead of exhorting, arguing with, or threatening the counselor if they do not “play ball,” seek to understand the counselor’s concerns with words such as “Yes, this is difficult. So how can we resolve the issue?”
2. Show respect for counselors and for the experience each brings.
3. Depending on the individual counselor, you may need to be flexible yet firm in your approach with staff who are expressing resistance to or ambivalence about change, being clear that the change is needed yet allowing time for the person to adjust and providing the resources needed to aid the counselor in making that change.
4. Recall when you were in the counselor’s role and perhaps how you experienced resistance to change in supervision. 5. Consider using self-disclosure to address defensiveness with supervisees. You can either give an example from your own training or experience, such as, “I know it was difficult for me too when I was a supervisee,” or by describing your own ambivalence in the present, such as, “I also have concerns about the change we have to undertake and want to ensure that it works in the best way for clients, now—what can I do?” These self-involving statements can engage supervisees in the discussion and problemsolving.

LARRY: Well, Gloria, we’ve had the MI training, and I like its focus on active listening, the attention it gives to the relationship and respect for the client’s perspective. But, you know, I’m basically a 12-Step facilitation guy. That works for me and for my clients. I don’t see changing horses in the middle of the stream to achieve political correctness.

GLORIA: Your 12-Step approach works for you, and we heartily endorse it, too. 12-Step facilitation is an essential part of everything we do at the agency. And I definitely don’t want to see us throw out the baby with the bathwater. As you know, counseling is an ever-evolving process, and I think our task is to be able to take what we do well and build on it with new approaches. I think MI can add to your repertoire. I think your concerns are realistic, and we need to consider that as we move into adopting new methods. What about you, Jaime?

Master Supervisor Note: At times a supervisor might feel caught in the middle, representing policies and procedures coming down from funding sources, yet posing implementation difficulties. An effective supervisor plays this dual role of advocating for both administrators and leadership and the line worker and client. Whether working on a factory floor or in a clinical setting, it is difficult being in the middle. To aid you in this position, it is helpful to:

1. Understand the rationale of both administrators and line staff.
2. Never lose sight of where you came from. At some point in your career, you were a supervisee. It is useful to remember what it felt like being in that position.
3. In the example of MI, practice reflective and active listening to understand the concerns of those above and below, and to empathize with each group’s concerns.

JAIME: All of this discussion is really above me. I just want my Latino clients to get good care and for their treatment needs to be respected. My clients need decent jobs and to be accepted as Latino men being sober in their community. That’s what’s important to me. I just want to serve my clients. I know that may not be what you want to hear, but that’s how I feel.

Master Supervisor Note: A Level 1 supervisor might respond either in a defensive or overly directive fashion here, telling Jaime that this is something he must do. A Level 2 supervisor might get into a struggle over what really matters, defending MI as good for Jaime’s clients, or disrespecting his statement about what matters most to him, his clients. A Level 3 supervisor listens to Jaime’s statement, affirms and supports him in that, and tries to engage Jaime in the discussion. Further, Gloria is working with two counselors at different lev-els of proficiency, so she has different expectations for their contributions and recognizes that they have different learning needs. An effective supervisor understands the stages of counselor development and varies the approach depending on the stage of each staff member.

GLORIA: Jaime, I respect your commitment to the Latino clients. Larry is clear about one of the things he knows works, 12-Step facilitation. In your experience, what works with Latino men?

JAIME: I’d agree with Larry, 12-Steps, because I go to AA myself, and I know AA works. But what’s also important is jobs, not feeling discriminated against, not being asked for ID papers if you’ve lived here all your life. What helps is to be with a group of sober men. That’s what helps my clients.

GLORIA: You both seem to be clear on what you see works for you and your clients. That’s a good start for us. As you know from the recent ED’s memo to staff, the State has required all agencies to implement an EBP to continue to receive State funds. There has been a lot of discussion at all levels about this. We’ve talked before about our desire to move from being a good agency to a great one, being one of the best in the State. Over the past year we’ve made incredible progress toward this goal, thanks to all the staff’s efforts. And all through this process, we’ve been able to stay true to our 12-Step philosophy. Honestly, when I first heard about the new State policy, I, too, was skeptical, saying to myself, “Here we go again.” But then I was reminded of the agency’s mission to keep improving our skills for the well-being of the clients. So, discussing this together now is helpful. I’d like to hear more from you about your concerns regarding MI.

LARRY: I don’t really give a darn about MI versus CBT versus 12-Step facilitation versus the next thing to come down the pike. I’ve been in the field for a long time, and I know what works is my relationship with people. I know 12-Step works, and I have to be convinced that this doesn’t interfere with having a strong relationship with my clients. I think that’s the most important thing. I’m not sure I need a new way to do this. I don’t want to have to be worried about whether I have to use this science-based thing.

GLORIA: Wow, Larry! I really hear that the most important thing to you is building strong relationships with your clients, and it’s not so important what method you use to build strong relationships, but that the method helps you accomplish that goal. Perhaps we can look at how MI’s approach to active listening with clients and reflection enhances that relationship. If it builds the therapeutic alliance with the clients, that’s good. I’m curious how you feel about that.

LARRY: What I want to be sure of is that we’re not moving away from our roots: that this is not taking us away from 12-Step. That’s what this agency is founded on, and that’s what we stood for all these years. I need to hear that from you.

GLORIA: That’s a really excellent point. How do MI and other approaches keep us close to our roots of 12-Step work? What do you think?

LARRY: If an approach builds the relationship with the client, I’m all for it. I know that 12-Step facilitation does that. And I know from the course I took on MI that it also emphasizes the counselor–client relationship. But it is also a new way of thinking and a whole new vocabulary and I don’t want to get so bogged down in catchy phrases that I lose contact with my client.

GLORIA: Larry, I clearly hear your concerns about interfering with your relationship with your clients and about us losing our roots.

LARRY: Maybe Jaime can do the MI stuff and I can do my 12-Step facilitation.

JAIME: What?

GLORIA: There are several different ways we can approach the implementation. We may decide that MI works better with some client populations than others. A place to begin would be for us to learn more about how MI  can be implemented in the program. I know you’ve been to the MI training. That’s a great start. MI has some good strategies that are congruent with a variety of client populations.

LARRY: What I heard you just say is that it doesn’t matter whether we’re on board or not.

GLORIA: That’s a dilemma. The State’s said, “You have to do it.” What they haven’t said is how you have to do it. They said we have to do “something.” We have something to say about how we’re planning this, how we’ll implement an EBP. I want to be sure that we hear and use your experience.

Master Supervisor Note: It is helpful to watch how Gloria handles the polarizing confrontation. A Level 1 supervisor might either come down hard on Larry for his suggestion, saying “No, we’re not doing that.” A Level 2 might argue about it. Note the Level 3 approach, not to confront the statement by Larry but to find a working alternative.

A master supervisor is able to manage staff confrontation and avoid becoming defensive. To do this, it is important for the supervisor to understand that struggle is a sign of staff ambivalence to change. Resistance and ambivalence are normal in any situation involving change. A master supervisor works with the resistance, using its energy to promote change, not taking it “head-on.”

LARRY: I like the idea that we can implement the strategies that work best for our agency because that allows us to stay close to our roots of 12 Steps.

GLORIA: So you see the value of implementing an EBP approach such as MI as long as it stays close to our 12Step roots. Moving ahead, I recognize that this is going to change some of our approaches, how we think about treatment, how clients experience us.

LARRY: How are we going to do this implementation anyway? Who’s going to do the implementation, train us in MI?

GLORIA: Perhaps I can show a videotape of a counseling session I conduct when I think I am doing effective MI. What do you think of that idea? Would that help us all feel more comfortable with an EBP? I’m willing to stick my neck out if you’re willing to give me feedback on what you see on the videotape.

Master Supervisor Note: A basic rule of supervision is “do not ask a supervisee to do something you’re not willing to do first.” A second rule is that “leaders bear pain, they don’t inflict it.” Master supervisors are willing to take a risk by demonstrating their skills first before asking staff to do so. Effective supervisors are able to establish trust by serving as a team leader, inspiring staff by encouragement and motivation, communicating enthusiasm and capability, and taking appropriate risks to initiate change. Leaders also demonstrate vision, drive, poise under pressure, and maturity of character. They inspire rather than command staff. Since leadership entails teaching, mentoring, and coaching, having the title “supervisor” does not necessarily make a person a leader. To earn respect, the supervisor should display qualities of honesty, responsibility, fairness, and understanding. In this vignette, Gloria provides direction and leadership by showing staff how they can implement MI together and how the training will work. She also gives them a say in the process and allows them to keep to their roots, learn new tools, and do so over time. GLORIA: That’s a good question about implementation. Any approach we use needs to be respectful and build on the counselor–client relationship. So let’s start there. First, we want to implement MI over time. It’s not something that we’ll become instant experts at. I want to make sure that we’re well prepared and understand what we’re doing.
[Larry and Jaime nod in agreement.]

GLORIA: Again, let’s be clear. We need to implement EBP for State funding. Remember when the agency went smoke free: How difficult that was, how much resistance some staff expressed? But, it was something we just needed to do, and in the end, being smoke free has had significant health benefits to staff and clients, and has reduced the health care premiums for all personnel. I’m interested whether you see the similarity to such changes.

LARRY: Yes, I do. The smoke-free campus has been a real benefit to all. I hope implementing an EBP is also.

GLORIA: I agree. Maybe we can return to the training issue you raised earlier. Larry and Jaime, with your help and support, I’d like to establish a year-long training plan. First, I’d like to have an advanced trainer come in and provide several days more of training that particularly addresses the needs and concerns of the staff. We’d also like to contract with the trainer to establish an MI coding system that will be part of what we do in our clinical supervision. Over the year, we’d continue our direct observation for supervision. Only now we’d look at the interactions through the MI lens. The coding system will help us in doing so.

JAIME: I remember hearing about coding in the basic MI course I attended. Can you tell me more about that?

GLORIA: Here is a coding sheet that the trainer of that course recommended. I like the form and find it simple and easy to use. I also think it’s consistent with what we do as counselors, and it reinforces our efforts to listen better to clients. As in 12-Step facilitation, it helps to build an alliance with the client.

LARRY: So you’re convinced this is a good thing? You’re not just doing this to get State money?

GLORIA: From what I know about MI and have read about it, I think MI is a very useful tool for us. We’re concerned about our funding, of course. But, client welfare always comes first. No, we would not be doing this simply for money. I believe this will help our clients, and that’s the bottom line, isn’t it? So, perhaps we can discuss the skills we have as a team and how to proceed.

JAIME: I think we work well together and we seem to have good stable funding that allows us to maintain the quality of care we offer to our clients.

LARRY: Yes, we have good teamwork and support each other. Jaime and I work well together. We’ve got a lot of respect for each other. We’ve had the basic MI training. That’s a good start.

GLORIA: Teamwork is important.

LARRY: We do good treatment. Our clients respect us. We have good credibility out there. That’s a plus.

GLORIA: I’d also add that we have experience at successfully implementing changes.

JAIME: Three years ago we had few Latino clients and no Latino program.

GLORIA: Implementing a Latino program was a major positive step forward. The other thing I like is that we have a good supervision system which helps us assess how we’re doing when we implement any new practice or program, like the Latino program. It gives us a way of assessing quality.

LARRY: So, what’s going to change here?

GLORIA: We do have time for more training. It’s difficult jumping into a new approach if we don’t feel like we’re adequately prepared for the change. One solution would be for us to devote more time in our normal clinical supervision sessions (individually and in group) to MI practices, to use videotapes and role plays to continueour learning and practice our skills. We can phase in MI over time. I’m committed to supporting you in whatever you need to do your job effectively. More than 150 studies have shown that MI is effective; this will enhance our skills and give us better client outcomes. It might be helpful for us to talk to an agency that uses MI and ask how they did it. We need to do training, as I said earlier, so we can be consistent with our core approach. I want to integrate this in a way that makes sense for all of us. Perhaps between now and our next meeting you’d think about two things you can do to help us write the implementation plan that will show how we’re going to do this. We have an excellent team and do good work. I value and trust the work that we do. Learning a new strategy requires training, mentoring, and coaching. Our relationships with the clients and each other are the most important because that’s how we serve the clients.

[A discussion follows when they discuss the training system, who might serve as a consultant for the advanced training, and how the coding system works and can be incorporated into the clinical supervision system. The session ends with a mutual commitment to move to the next stage of implementation.]



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