1. Describe the developmental stages that new clinicians go through.
2. Describe the different theoretical models of supervision.
3. Recognize and describe the need for a multicultural approach to supervision.
4. Identify barriers that can lead to impasse and resistance.
5. Describe transference and countertransference as they relate to the supervisor and trainee.
Models and theories are a set of principles that help us understand and process information. Working on an assumption or within a framework allows the clinician to work with purpose and direction.
Developmental models of supervision have been around for the last thirty years. Developmental models of clinical supervision suggest that supervisees pass through a series of developmental stages. There are two basic concepts of developmental supervision:
The first describes the counselor moving through a series of stages that are quite different from one another. The counselor is striving for competence.
Second, each stage must be qualitatively different if maximum growth is to occur.
Three different models of developmental supervision are presented below.
The four stages of the Littrell, Lee-Borden & Lorenz Model are summarized below:
Stoltenberg and Delworth described three developmental levels of the supervision process and eight dimensions. The Stoltenberg and Delworth model has three levels of development.
The first level occurs when counselors are new to the field of counseling psychology. Typically the counselor is in the process of learning the theories of psychotherapy. They are trying to account for the particular theory of psychology as it applies to their own lives as well as those of their clients. The beginning counselor is motivated to learn and improve their skill level. The experience of a low level of skills and the knowledge that their skills are being critiqued creates a high level of anxiety.
It is crucial for the supervisor to effectively evaluate the supervisee during the level one stage of development. Supervisees self reports are usually unreliable because of countertransference concerns. It is recommended that the supervisor rely on direct observation as the therapy sessions progress.
Level two counselors are typically in internships. They are post graduates and attend supervision on a regular basis. Level two counselors have moved beyond general theory and begun to explore different approaches at a deeper level. They have become more comfortable with their skill level and reporting of clinical material has taken on a more meaningful expression.
The level two counselor needs to be accountable for their interventions and the reasons for using them. It is the responsibility of the supervisor to question the supervisee about their intervention style, technique and desired outcome. The supervisor should be understanding and supportive of the supervisee and provide reliable and accurate feedback.
Level two counselors display a willingness to explore the concept of transference and countertransference. Counselors should be ready to address their own personal issues that arise during the course of treatment. It is important for the supervisor to promote counselor independence and confidence in their ability to perform psychotherapeutic techniques.
Level three counselors become self reliant. Their ability to empathize with their clients increases. Their relationship with the supervisor is more in balance.
The supervisees capacity to accept confrontation becomes more apparent. The supervisor provides support and caring when necessary.
1. intervention skills
6. theoretical orientation
The three structures proposed to trace the progress of trainees through the levels on each dimension are:
1. the trainee’s awareness of self and others
The Skovholt and Ronnestad Model of Supervision uses a life span model which includes eight stages to assess the growth of the supervisee. It is believed that the supervisee should assess one’s growth to determine which stage they are in. The same could be said about the supervisor.The Skovholt and Ronnestad Model of Supervision is grounded in research.
This is commonly thought of as the “common sense” stage of development. At this stage the new counselor uses the knowledge and experiences they already have.
Stage two counselors are in their first year of graduate school. They are likely enrolled in beginning counselor courses and are learning theories of psychotherapy. This may be combined with technique training. They are being presented with new ideas and thought processes.
Grad school counselors are mimicking their instructors and supervisor. They are typically open to new ideas and are beginning to become conceptual.
Counselors are now working as professionals. Their skill level is increasing, their techniques are becoming more refined and their conceptual world is expanding.
Counselors become analytic and think beyond traditional training. They cast aside previously introduced material.
During this stage, counselors work toward autonomy and independence. They develop theories and approaches that fit their personality and belief system.
During stage seven the counselor refines their concept of psychotherapy. They expand upon knowledge and become more authentic.
Integrated models of supervision are described as eclectic. This allows the clinician to integrated several models into a working paradigm. Some supervisors may choose to lecture, most typically, during group supervision. Others prefer the counselor approach, moving into areas of the supervisees psyche to uncover unconscious motives and desires. Other supervisors may find themselves in a co-therapist role with the supervisee. Regardless of the role, each integrated model serves a specific purpose. The purpose is to help identify obstacles that prevent the supervisee from learning, growing and ultimately helping the client sitting before them.
Communication is viewed as a process. The question that might be asked is did the supervisee correctly reflect the affect of the client. Was the process material in anyway reframed? Was the material presented out of context? What would help the supervisee help the client to more accurately reflect their true emotion.
Conceptualization describes the supervisees ability to apply theory to the counseling session. It also describes why and how the supervisee decided to use a particular technique, the desired result of that technique and the actual outcome.
Personalization refers to the unspoken aspects of the therapy session. The main theme of personalization is body language and what this information tells the client about the counselor.
Most supervisors adapt the same theoretical model that they use in their practice to the supervision hour.
The psychoanalytic supervisor would not only pay attention to the developmental stages of the client but also those of the supervisee. The supervisor would pay special attention to the defensive structure of the supervisee. During the middle stages of supervision you might expect the supervisee to avoid certain topics. This might have to do with the new found knowledge of working with the client or may be a result of the transferencial relationship that has developed between the supervisor and supervisee. The last and most important stage would be the working through stage. Upon successful completion of the working through stage is an independent, integrated professional counselor that is ready to venture out on their own.
Behavioral supervisors believe in problem solving. Two skills are required of the behavioral supervisor and supervisee: Identification of the problem, and selection of the appropriate learning technique (Leddick & Bernard, 1980). Role reversal is a common technique used by the behavioral supervision. The supervisor takes on the role of the supervisee while the supervisee plays the role of the client.
The role of the listener or helper is to allow such an individual to open the lock gates. When he does, the water gushes out. During this venting process, there is still too much pressure for a person to consider other perspectives. Only when the water level has leveled off between the two compartments, does the water begin to flow evenly back and forth. The role of the listener is to help empty the large reservoirs of emotion, anger, stress, frustration and other negative feelings until the individual can see more clearly. Not until then, can a party consider the needs of the other. Perhaps we can think of it as listening first aid.
Empathic listening skills require a different subset of proficiencies than conversing, and it is certainly an acquired skill. Many individuals, at first, find the process somewhat uncomfortable. Furthermore, people are often surprised at the exertion required to become a competent listener. Once the skill is attained, there is nothing automatic about it. In order to truly listen, we must set aside sufficient time to do so. Perhaps the root of the challenge lies here. People frequently lose patience when listening to another’s problem. Empathic listening is incompatible with being in a hurry, or with the fast paced world around us. Such careful listening requires that we, at least for the moment, place time on slow motion and suspend our own thoughts and needs. Clearly, there are no shortcuts to empathic listening.
There are advantages and disadvantages to integrated psychotherapy models. When the supervisor and supervisee have different theoretical orientations transference and countertransference issues are more likely to occur. When the two share the same theoretical orientation the training is more effective and the learning curve is minimized. The supervisee is more likely to benefit from the sharing of a theoretical orientation.
Parallel process originated from psychoanalytic theory. It’s derived from issues of transference and countertransference. When the supervisee, during a supervision session, recreates the feeling and presenting problem of their psychotherapy session with the supervisor, parallel process is active. Example: Clients presenting problem is being the victim of child abuse. The sessions are emotionally charged and often the feelings of dread, anger, fear, resentment and helplessness are directed toward the supervisee. The supervisee response back with empathy, understanding and concern. When the supervisee presents this case during supervision they recreate the feeling of dread, anger, fear, resentment and helplessness in the supervisor. This is the transference. When the supervisor responds back to the supervisee with feeling of empathy, understanding and concern the countertransference issues have taken hold. What took place in supervision is parallel with what took place in the counseling session.
Another example would be when a client shows up late for sessions and doesn't notify the supervisee. This behavior irritates the supervisee. The supervisee (who typically has no history of lateness) shows up late for the weekly supervision session, thus evoking the same irritation in the Supervisor.
To effectively resolve transference and countertransference issues the supervisor and supervisee need to develop a strong sense of self. They must be able to identify their strengths and weaknesses as well as develop an awareness of possible reactions to any given interaction.
Parallel process, when identified by the supervisor can be used to facilitate the understanding of the transference and countertransference issues between the supervisee and client. Supervisors can also model new strategies for the supervisees. If the client would benefit from an interpretation instead of empathy the supervisor can respond back with an interpretation. Example: The supervisee shows up late for a session. Instead of responding with irritation, the supervisor interprets the behavior. I noticed that you are normally on time. This last meeting you were late and didn't call. This helps to model the appropriate response toward the client. It also opens up the supervisory session to explore the feelings and thoughts of the supervisee regarding lateness.
Searles (1955) made the first reference to parallel process, labeling it a reflection process. He suggested that "processes at work currently in the relationship between patient and therapist are often reflected in the relationship between therapist and supervisor. Searles believed that the emotion or reflection experienced by the supervisor was the same emotion felt by the counselor in the therapeutic relationship. Although Searles recognized that the supervisor's reactions also might be colored by his/her past, this was not the focus of the reflection process.
As in the example above, the supervisee unconsciously recreates the feeling of irritation in the supervisor. This is the same feeling evoked in the counseling session. The supervisee may unconsciously be seeking answers to resolve the problems in the counseling session. Supervisors should be aware of this phenomenon.
Another reason for parallel process is the supervisee and the client may have similar issues. The supervisee may closely identify with the client as a way resolve their own inadequacies. Thus evoking a therapeutic response from the supervision.
Not everyone agrees with Searles reflective process theory. Doehrman (1976) believes that parallel process can be bi-directional. The supervisor may believe that the supervision hour is not a place for the supervisee to discuss their personal problem. They are referred to individual counseling to deal with their problems. The risk of bi-directional parallel process occurs when the supervisor responses unconsciously to the counselors feelings, the counselor in turn responses with the same feeling toward their client.
The supervisor may unconsciously display their own belief system. The supervisee in turn display and imposes the same believe system when working with the client, thereby creating parallel process.
With advanced supervisees, parallel process should be address as it occurs. Addressing the parallel process will help the supervisee to improve as a clinician. Responding to the parallel process helps the supervisee understand and respond to transference and countertransference issues. It helps the supervisee model appropriate interactions and interventions with the client. Addressing the parallel process helps to move the sessions for content oriented to process oriented.
When working with beginning counselors addressing parallel process can have a negative effect. New counselors are just beginning to understand theory, interpretation, techniques and interventions. Presenting parallel process as a concept that the counselor is currently participating in can produce unnecessary anxiety in the new counselor.
Supervisors should tell the supervisee what their theoretical orientation is. They should tell the supervisee what is expected of them. They should inform the supervisee regarding informed consent, standard of care, legal and ethical considerations, scope of practice, confidentiality, business practices and any other information pertinent to their work with their clients and within the supervisory relationship. Discussing the above at the beginning of supervision will help to alleviate problems in the future. It will also help to build a positive relationship between the supervisor and supervisee.
The supervisor should discuss with the supervisee their style of learning. The supervisor should make every attempt to accommodate the supervisee by providing information and instruction in a way that is conducive to the supervisees learning style. This may involve story telling, real time examples, theorizing, role playing, interpretation, conjecture, myths or inferences.
Confidentiality of supervisees. Material obtained in supervision is confidential unless specifically stated in the supervisory contract or by exceptions recognized by the profession and law. Supervisees must keep confidential all client information except for purposes of supervision.
When a patient enters our office and psychotherapy begins, everything which is said or done by that patient, with few exceptions, are confidential. The patient holds the privilege to release the confidential information in legal proceedings. While you may object to the patient using these records, you must have solid grounds for your objection. While these are quite variable, generally patients can request and use their records in any way they please. In some instances, a legal guardian or conservator may hold the privilege if the patient is unable to do so. If the patient dies, their privilege passes to the patient's personal representative who handles legal affairs.
The holder of the privilege also has the right to read all information in his or her file with the exception of your personal notes which belong solely to you. Some therapists find this requires them to keep separate files so their personal notes do not become part of the patient's legal record. Your patient can read all notes which have their identifying information, diagnosis, treatment plan, prognosis, and other information including billing and information from other sources which you have included in the file such as notes from other physicians and hospitals. Any spare notes in the patient's file also have information which must be passed to the patient. All information in HIPAA notes are the patient's property and must be released. The file is the property of the clinician so copies must be made if the patient requests a copy of their file.
It is your responsibility to maintain the confidentiality of the records. Patient records should be kept in locked containers except when in use. They should be shredded when they are discarded to avoid the potential of having the notes fall into the hands of others. Office staff and others who handle the files should be made aware of the importance of confidentiality. Handle these records as if they were notes made by your own therapist about you. Your patient feels the same need to have the notes be private. Office staff, filing clerks, billing agencies, and others do not have the same burden of confidentiality as does the therapist. However, it is the responsibility of the therapist to inform the staff about the importance of confidentiality and to take reasonable action to be certain that staff does not violate the patient's confidentiality. While this is a solid part of HIPAA, it seems to be regularly violated by clerks and other office staff. Often my patients who work for or with counselors in the community or in government report cases which are confidential which they have read with avid interest. Try to keep this sort of clerk off your staff.
In 1976, important case law was made in California which is now followed throughout the United States. A romantic young man, Prosinjit Podder, from India, fell madly in love with Tatiana Tarasoff who did not reciprocate his desire. He confessed his intention to cause her bodily harm to his psychologist at a clinic at UC Berkeley. He subsequently murdered her. The unfortunate psychologist had followed the law which until then required psychologists to keep all information from patients confidential and to disclose threats only to the intended victim. Luckily, the case came to be known by the name of the murdered young woman and the defendant was the Regents of U of C so he is never named. The California Supreme Court determined that confidentiality laws did not apply when the following rules are met.
1. The threat must be communicated to the psychotherapist directly by the patient.
2. Serious threat of physical harm is imminent.
3. The potential victim must be reasonably identifiable.
In this case, the psychotherapist must:
1. Warn any and all potential victims.
2. Notify authorities including the police, sheriff, or call 911.
3. Take steps of some sort to prevent the threatened danger.
Case law has continued to add to the confusion about when Tarasoff applies. One case found it applied when property was threatened, another found it applied when there was no overt threat but a history of violence, in another case Tarasoff was found to apply to communicating threat of suicide to subsequent caretakers.
A therapist is also required to breach confidentiality when a patient threatens to harm another person but there is no imminent danger or the victim's identity is unknown. In this case, however, the therapist is to take steps to prevent danger but is not to notify authorities or the potential victim.
Therapist are also required to breach confidentiality if the patient is in danger of committing suicide and is to take steps to prevent the danger from occurring. In most cases, this requires the therapist to hospitalize the patient.
The courts have required that therapists be able to predict when a patient will act on their impulses and cause bodily harm to themselves or others. Therapists, regardless of their experience are unable to predict when or if someone will be dangerous. Research has consistently borne out that therapists cannot predict violence above the level of chance (Stromberg et al., 1988; Bednar et al., 1991; Otto, 1992; Simon, 2001).
Some traits are more likely than others to predict violence, with the most robust being a history of violence (Simon, 2001), male gender (Simon, 2001), substance abuse (Stromberg et al., 1988). Peterson et al., 1983 has shown some positive results in identifying people who are likely to commit suicide. The scaling is simple and quick on the SAD PERSONS test and the results have been replicated (Campbell, 2003; Juhnke, 1994,1996).
Supervisors must make sure that the supervisee has informed the client of the parameters of informed consent. This must include, but is not limited to, disclosure that the supervisee is an intern and what exactly that means. They must inform the client of the supervisory relationship. They must disclose the laws surrounding confidentiality and exceptions to confidentiality. Supervisor can verify this information by using a disclosure statement that contain all of the information necessary. Have the supervisee and client sign the disclosure statement.
The supervisor should inform the supervisee of the evaluation process they will use to determine the supervisors progress. The evaluation criteria and standards that need to meet should be discussed.
It is important to note that regardless of your behavior a patient may decide to sue you for malpractice. This could include you as well as the supervisee. This is a frightening prospect, since the grounds for filing a lawsuit are so vague that even the finest, most ethical clinicians find themselves involved in litigation which threatens to take away their license, their means of livelihood, and substantial sums of money.
The development of an ethical practice, however, may help you to avoid some of the more important pitfalls. Regardless of how many times you read through the law, regardless of how many classes you take in ethics, regardless of how well you follow the rules of the profession, make no mistake, this is a path you will need to pursue consistently throughout your career.
To be sued successfully for malpractice in a civil court, the client must prove that you have breached the standard of care (Black, 1996). There are four parts which must be seen by the court to have been met for the malpractice suit to proceed.
(1) In some way as a supervisor you have established an agreement between yourself, your supervisee and the client that you will work together in a therapeutic relationship. The law does not define this in terms of the length of time the patient has been seen or whether or not the patient has paid you. It is entirely the responsibility of the court to determine whether you have established a Duty of Care with the patient.
(4)The client must also prove the supervisor and supervisee was directly responsible or the Proximate Cause for the harm which was done. So, the client must prove that the supervisee had an established relationship with the patient which would prove there was a duty to care, was working below the standard of care, which caused demonstrable harm to the client which could only have been a direct result of the supervisees actions.
Despite these levels of proof which sound difficult to attain, many therapist are sued successfully or have out-of-court settlements against them each year. Following a successful suit or settlement, one should expect an investigator from the licensing board to determine whether or not the actions taken by the counselor were egregious enough to sanction them by loss or suspension of their license, additional classes to educate the counselor and attempt to prevent further problems, or other measures.
First, it is important to take care of yourself. Supervisors who are having problems within their own families, use alcohol or drugs inappropriately, are having emotional problems, or simply need a vacation are the most likely people to make minor and major errors in judgment. This may occur from the distraction caused by the supervisor's own problems or from unconscious motives which are more likely to be enacted when one is not at one's best and inhibitions are lowered.
Second, stay in touch with changes in laws through professional organizations. Maintain your memberships and attend meetings on a regular basis. This will also help you make and maintain friendships with other practicing clinicians. You are likely to find it is helpful to know someone you trust for a consultation if you do find yourself feeling that a patient may cause problems for you. Your friends may also tell you in a much nicer way than the licensing board that you need to take a break from work.
Third, take frequent breaks from work. You will have a better chance of staying on top of your cases and come to work with a smile.
Fourth, look at your mail at a time when you can do some reading. Instead of stacking the journal you just got, scan through the articles and read the ones that interest you. You could impress your colleagues at professional meetings by dropping names and you could even try out some of the new techniques you read about and develop some skill with timing.
Fifth, if you or the person you are supervising has a patient walk in who describes a history of lawsuits, suicide attempts, and has a gambling problem which might cost him/her more than one can afford and you feel the acid turn in your stomach and your headache begin, check on the client's current level of suicide risk then on your the level of expertise needed to manage this difficult client. Do not agree to let the supervisee see anyone who walks in the door. Do not let the supervisee take on more clients than they and you can reasonably manage. We all learn from the work we do with our clients and our toughest clients teach us the most, however, to provide the client with the best care and to take care of yourself, seek information from those around you, especially experts. Reading journals and books on the topic is also very useful but it can lead to a false sense that you understand the problems you face with that particular client when you only understand the issue in a broad sense. All clinicians are much better in some areas than others and it is incumbent on the practitioner to know where they stand in their ability to treat different sorts of difficult clients.
Sixth, and most importantly, do your paperwork. It gives you time to reflect on what you are doing with the supervisee. It is also illegal to fail to do it. Some people find they do this best when they complete a formal note in the 10 to 15 minutes between sessions while others find they need to lay out an hour several times weekly or a long afternoon to get it done. Do not underestimate how much time this takes. Completing HIPAA notes can become very quick and efficient if you have a system and do them regularly. On the other hand, trying to recreate the important points of a session from hastily sketched notes during an intense session at the end of the week is nearly impossible. You remember that it was an important session but often lose the crucial meaning which was derived from the work done that day. The main idea to remember is not to fail to do notes until you find yourself served a subpoena by a court or a disability claimant. The notes you create at those times are not beneficial to you or your supervisee because they lack credibility which comes from a case note which is written soon after the session. While all this seems self-evident, it is important to recognize that keeping notes for anything other than an aid to treatment in most cases was rare until HIPAA was imposed only a few years ago. Many of us had become quite comfortable with brief, non-HIPAA compliant notes and, although we plan to change that habit, have not yet done so. Do it now. You will sleep better.
Last, know your limitations. Refer the client when you have no experience or training in treating the presenting problem. Refer them if they scare you and you feel you will not be able to find a colleague or supervisor who can help you sort out whether or not your supervisee should give this patient a try and if you have someone to help if you find you have trouble. Refer the client to a physician when you have an odd feeling that the problem does not sound solely psychological. Always refer them if there is any question about whether medication would be helpful. If they refuse, note they refused and why. Refer patients who abuse other substances if that is not an area of expertise or one in which you want to develop expertise. Having a drug or alcohol problem may seem minor and secondary to the primary diagnosis but it is amazing how frequently a drug or alcohol problem becomes the main problem very quickly or the main reason why no progress is occurring in therapy. Many of us had the fortune to be trained by masters of the craft of psychotherapy either during or after graduate school. Many of us have become the new masters of the craft. Still, for each and every one of us there are people who walk through our doors as clients and walk out as potential plaintiffs. Even the grand old masters have this happen so it can certainly happen to you.
Try to avoid doing anything which will cause you to have problems with the Licensing Board. Keep up on your paperwork. The State Board can require you to produce case notes in a very short time. If the Licensing Board sends you any sort of inquiry, do not take it lightly. Make sure they have experience. Do not just dash off a letter which answers the questions asked by the board. If they have written you and asked for a response, it is a serious inquiry about your treatment practices. The Licensing Board takes your responses seriously and what may appear to be a simple misunderstanding between yourself and your client could result in having to defend yourself and your license before a member of the Licensing Board. Make sure you have Malpractice insurance to cover the fee for an attorney to defend you. Being sanctioned by the Licensing Board is a public process and even if you do not lose your license temporarily and have to take additional classes or other tasks to bring your standard of practice up to that of other clinicians, you may lose your referral base. You will also be likely to find yourself the subject of gossip. The Licensing Board also may determine that you should lose your license to practice psychology permanently. This does not preclude having criminal or civil charges brought against you or your supervisee by your client(s). All of this is quite public also.
Try to avoid actions by ethics committees by following the rules and guidelines for practice. Make it a habit to check in on the state web site and the Licensing Board Web site on a regular basis so you know when laws are changing. Unfortunately, some therapists were convicted of violating ethics of their profession when they were following what had been a typical pattern but was in the process of changing. When you are uncertain about the rules, ask. Get answers in writing if possible. Know the name of the person with whom you spoke regarding how to most appropriately do tasks or render treatment. Consult with other supervisors and inform them of the difficulties you face. Seek legal consultation. The fee you spend may save your livelihood. Be wary of dual relationships. Be wary of any sort of variation in billing and collecting fees. Be aware of what you put in writing and that the information can be passed on to others even without your knowledge or consent, leaving you in a legal limbo which will certainly require an attorney.
The Attorney General is involved in these proceedings. They are the most serious offenses, usually involving fraud, collusion in criminal activities, and a variety of criminal offenses. In your practice, you do many things totally on your own and you are aware that within your office what occurs is privileged information. This requires that you set the standard higher for yourself and supervisee because a small bit of cheating quickly spirals into greater corruption. Do not lie, cheat, steal or engage in any behavior which could appear to have involved illicit activities. Do not enter into relationships with your supervisee which involves felonious behavior. Make it clear to supervisees who wish to have you collude with them in illegal activities that you will not do that and you must report behavior which would cause harm to others. Although therapist are rarely involved in these activities, conviction results not only in the loss of your license, it also results in criminal prosecution and incarceration. Some of the most frequent offenses involve defrauding Medicare by claiming to have performed services which were either not performed or were not reasonable treatment for the patients involved. These have usually involved large numbers of patients.
Robert Walker, M.S.W., L.C.S.W. and James J. Clark, Ph.D., L.C.S.W.
The effective management of risk in clinical practice includes steps to limit harm to clients resulting from ethical violations or professional misconduct. Boundary problems constitute some of the most damaging ethical violations. The authors propose an active use of clinical supervision to anticipate and head off possible ethical violations by intervening when signs of boundary problems appear. The authors encourage a facilitative, Socratic method, rather than directive approaches, to help supervisees maximize their learning about ethical complexities. Building on the idea of a slippery slope, in which seemingly insignificant acts can lead to unethical patterns of behavior, the authors discuss ten cues to potential boundary problems, including strong feelings about a client; extended sessions with clients; gift giving between clinician and client; loans, barter, and sale of goods; clinician self-disclosures; and touching and sex. The authors outline supervisory interventions to be made when the cues are detected.
Mental health professionals deal with the intimate personal matters of their clients, and they enjoy the privilege to practice because their endeavors promote the common good. The benefits of prestige and a special role in society carry a duty to safeguard the welfare of the public. The pledge to protect the public good, reflected in the Hippocratic Oath, exists from antiquity, and it binds the professional to a purpose beyond personal gratification (1
Today the law recognizes this special role by defining a fiduciary relationship between the expert professional and the vulnerable client (3,4). The fiduciary responsibility puts the relationship in an ethical framework that bars the professional from self-dealing and from situations in which his or her personal interest conflicts with the client's (3,5). The professional is prohibited from exploiting a client and must refrain from actions that might be harmful to the client (6). This prohibition implies that minor harm can lead to serious harm (7).
Gutheil and Gabbard (8) have warned of the existence of a "slippery slope," on which unchecked seemingly insignificant acts can catalyze the development of unethical patterns of behavior. More recently, these authors have cautioned against simplistic, literal applications of their ethical warnings about boundary crossings and their relationship to violations (9). Noting the pendulum swing of policy and opinion, they call for a moderated application of boundary concepts to ethical practice, an idea that is consistent with earlier representations of ethical standards (10).
The complexities and varieties of contemporary mental health practice settings make a literal application of ethical standards impractical. Mental health professionals now work in settings ranging from formal institutions, such as psychiatric and general hospitals, outpatient clinics, nonprofit agencies, schools, private- and public-sector workplaces, and prisons, to clients' homes, which may include arrangements for assessment and treatment, intensive case management, family preservation, home health care, employee assistance programming, and hospice care. Because of the complexity of these settings and the nontraditional roles of service providers, the boundary rules governing traditional assessment and treatment are not easily applicable. Unfortunately, this situation results in the absence of clear rules or guidelines.
More important, many clients involved in these less structured treatment modalities are disenfranchised individuals who are at greatest risk for exploitation. Many are low-income minority clients with serious mental and physical disabilities that include deficits in cognition, judgment, self-care, and self-protection.
The promotion of cultural diversity in treatment environments often encourages expansion of traditional professional roles (11). The literature in this area calls for more flexible roles and more out-of-office services carried directly to the client in the client's own environment (12). However, these situations can create even greater power differentials between provider and client than are generally found in office-based psychotherapy practices. It can be argued that a higher fiduciary duty exists for mental health professionals who serve clients in less structured settings and that the relaxation of traditional roles carries with it an increased responsibility to define practice-specific ethical guidelines to protect the vulnerable client.
In this paper, we propose that agencies or practice directors and clinicians articulate practice-specific guidelines for ethical boundaries and establish supervisory processes to inhibit misconduct through careful scrutiny of early warning signs of boundary problems. We identify ten cues to possible boundary problems and suggest supervisory responses.
Clinical supervision to support ethical practice
Fundamental ethical principles can inform practice, but the complexities of the practice environment suggest that program directors might need to develop ethical guidelines adjusted to local culture, program aims, and the capabilities of providers (13). A clear and reasonably specific set of principles or ethical standards is recommended to guide local practice. The standards should be promulgated to all staff and should be signed by each provider, documenting proof of being informed.
However, developing and distributing ethical guidelines or standards does not go far enough. Clinical supervision can be used to apply general ethical guidelines to the complexities of practice settings and the uniqueness of a particular case (14,15).
Clinical supervision can support practice within ethical boundaries by following four major principles. First, the supervision should be proactive rather than reactive. The supervisor should not wait for calamity to review the supervisee's work. Supervision should be continuous and of varying intensity, based on the clinician's caseload and other characteristics of the practice setting, such as changes in funding, management, or contractual obligations.
Second, the supervision should be sensitive to the supervisee's personal situation. A supervisor should be aware of significant changes in the supervisee's life that might indicate increased vulnerabilities. Recent divorce, severe relationship problems, serious illness, or death of a loved one can leave a clinician emotionally vulnerable. A clinician who has previously practiced without distress can unexpectedly change the manner of relating with clients and create boundary concerns.
Third, the supervisor must pay attention to the details of the supervisee's cases and the interactions between clinician and client. For example, it is not helpful to simply rely on diagnostic labels to explain clinician-client problems. Instead, the supervisor should ask the supervisee to relate the full narrative sequences of clinical encounters. The patterns or themes found in the clinician-client interactions can capture meaningful content for further analysis and examination.
Fourth, the supervisory interaction should incorporate guided exploration rather than cross-examination (16). Although focused investigation can play a role during a crisis, the routine supervisory process will generally discover more useful content through less directive means. We recommend the use of the Socratic method, in which the supervisor asks a series of questions that guide the supervisee to reveal and understand his or her clinical judgments and behaviors and, optimally, develop more appropriate views (17).
Using these four principles, clinical supervision can be an effective process for detecting cues of potential boundary problems and exploring them. Based on the literature and practice, we identify ten cues that suggest possible boundary problems. Each is paired with a recommended supervisory response. Whether a boundary problem is serious or not depends less on what the clinician believes than on the regressive response or other harmful response it evokes from a client. It is also important to note that what might be helpful for one client can prove harmful for another; supervisory responses must be tailored to the specific clinician-client situation.
The cues and responses described below generally proceed from less serious to more serious. However, the order in which they are listed does not reflect an absolute ranking.
Strong feelings about a client.
Clinicians may confuse personal caring with professional caring (18). Although such confusion generally occurs with novice clinicians, experienced clinicians are not immune to it. Strong personal feelings about a client can indicate a developing personal relationship. Contemporary community-based programs sometimes encourage a more personal interest in the client as an alternative to institutional, regimented services. The supervisor can guide the clinician to develop warm but professional relationships.
Because strong feelings are not always a problem in themselves, the supervisor should first elicit the source and quality of the clinician's feelings about the client, with the goal of promoting greater insight. Second, the supervisor should survey the intensity of the feelings and contrast the case to others in the clinician's caseload. The supervisor should then ask the clinician to examine these feelings to encourage self-observation and professional discipline.
The practice of extended sessions often develops from strong feelings about a client. An occasional episode should be little cause for concern. A pattern, especially with particular clients, is a cue to potential boundary problems. Many community-based programs place a high premium on flexible care that prioritizes the client's needs. Supervisors can help determine whether it is the client's or clinician's needs that drive the clinician's actions. Supervisors should also monitor the equity of clinical services to avoid favoritism or neglect.
The supervisor can explore the clinician's reasons for longer sessions with a client as a way of discovering subtle favoritism or other personal bias toward the client. Simply exploring these issues may curb the practice. Explicit instruction to shorten sessions or reassignment of the case may become necessary when this approach fails.
Inappropriate communication during transportation of clients.
Contemporary case management programs often expect certain providers to transport clients to programs and services. In such cases, the case manager should be guided to avoid expressive psychotherapy that might explore deeply personal issues. Case managers bear considerable responsibility for drawing clients into services and for facilitating the client's access to care. When a case manager is spending considerable time with a client in the car, in the home, and in nonoffice settings, it is possible for the client and case manager to blur professional and personal roles.
A client who is enrolled in a welfare-to-work program and who has emotional problems might have difficulty understanding the professional limitations on companion-like case management services if the case manager, acting like a clinician, also delves into the client's emotional problems. The suggested intimacy arising from deeply personal conversation in the privacy of an automobile may tax the boundaries of both client and case manager. Vulnerable clients may be unable to adjust psychologically from the intensity of in-depth counseling sessions to more casual contact in the automobile. Emotionally vulnerable clinicians may experience the same problem when they step into a case manager role and have less structured engagements with clients. This practice is more worrisome when the clinician independently decides to transport a client without program approval.
When such a situation is noted, the supervisor should draw a clear line between case management and intensive psychotherapy practices. Performing both roles with the same client is a risk factor for boundary problems. The supervisor should help the case manager or clinician understand and avoid role confusion.
Off-hours telephone calls to and from clients.
Current clinical practices sometimes demand the clinician's ready availability to the client. Some new therapy approaches recommend the clinician's availability for even minor "emergencies," such as in treating patients with borderline personality disorder (19). However, four practices can indicate potential boundary problems in these cases: clinicians' giving clients their personal telephone numbers (rather than the number of an answering service or crisis line), a pattern of initiating calls to clients rather than receiving them (except in serious emergencies or to monitor client safety), frequent or lengthy calls, and a pattern of late-night or weekend calls. These practices involve the clinician's personal space and privacy. Unchecked, such access invites the possibility of increasing levels of intimacy.
When off-hours calls are an issue, the supervisor should explore the clinician's goals for such contacts. Likely areas for inquiry include the clinician's need to be needed or to be considered special by the client. The supervisor should help the clinician achieve more realistic expectations about the clinician's role and appropriate services (20).
Inappropriate gift giving between clinician and client.
Token gifts of appreciation from clients are not of great concern, and within certain cultures, gift giving is often expected. Supervisors need to be sensitive to the cultural dimensions of gift giving, but they should also pay attention to possible boundary problems.
Three concerns arise with client gift giving—the timing of the gift, such as a birthday or Valentine's Day gift; the gift's monetary value; and its personal specificity. Highly personal gifts, even of modest dollar value, should be cause for supervisory concern. A clinician's acceptance of gifts suggests that the clinician-client relationship has changed. Likewise, gifts from the clinician to the client, except when sanctioned by program guidelines, should prompt a supervisory response.
The supervisor should help the clinician explore the possible meanings of the client's gifts. The supervisor should explore how the clinician's and client's perceptions of their relationship might be changed by the gift, either positively or negatively. When gifts are very personal or expensive, the supervisor should help the clinician understand why accepting them could be harmful to the client. They should also explore ways to return items with minimal disturbance to the clinical relationship. In such situations agency rules should be helpful. The clinician can thank the client for being thoughtful but disclose that ethical codes prohibit accepting gifts. This response helps prevent the client from feeling a personal rejection.
Boundary problems in in-home therapy and home visits.
Many community-based programs, particularly for persons with serious mental illness and emotionally disturbed children, use in-home therapies to minimize risk of institutional care. Although many of these therapies focus on psychosocial skills training rather than expressive psychotherapy, they can create opportunities for boundary problems. Home visits that are outside sanctioned treatment should be examined very closely. Frequent visits combined with signs of personal interest in the client should prompt more focused supervisory review.
The supervisor should inquire about the clinician's feelings of special interest in the client. Inquiries may lead to exploration of the clinician's rescuer fantasies. Likewise, the clinician's anxiety or ambiguity should be examined in detail. The supervisor should take steps to reduce contact or transfer a case when there are signs of overinvolvement. The supervisor should immediately intervene if there is reason to believe that a client or a clinician is being exploited.
Overdoing, overprotecting, and overidentifying.
The clinician who overidentifies with a client might experience a need to do things for a client rather than help a client accomplish goals and learn to do things for himself or herself. At first, this behavior may appear relatively harmless or even admirable. However, such signs of enmeshment can suggest overinvolvement with a client and potential boundary problems. A clinician involved in this type of relationship might be unaware that the boundary has been crossed. For example, the clinician might believe that the actions truly benefit the client and that diminished involvement will result in the client's feeling abandoned.
In response, the supervisor should explore how this case differs from others in the clinician's caseload. The clinician's perception of unique circumstances or characteristics should provide opportunity for further discussion and, if necessary, confrontation. Uniqueness is especially troubling when it presents in two forms—the clinician's perception of a unique client circumstance or the clinician's belief that he or she has qualities that are uniquely fitted to the client's needs. In either case, the supervisor should focus on the clinician's distorted thinking and consider whether overinvolvement is the clinician's characteristic way of dealing with other people or the response to a particular type of client. If the clinician cannot adequately respond to such redirection, vigorous supervisory intervention is indicated.
Loans, barter, and sale of goods.
Financial interaction between a clinician and client other than payment of fees is a boundary issue. Borrowing or loaning money is not always a profound ethical violation; nonetheless, it certainly warrants detailed evaluation. The use of agency funds available for client emergency needs are not a concern. The transfer of personal money or property to or from the clinician is entirely different. Bartering clinical services for goods or other services is ethically troubling and is certainly cause for supervisory exploration except in practice areas where cultural standards have made this practice more normative (21).
The supervisor should state the ethical limits regarding financial transactions with clients. Clear policies and procedures should be established to provide the clinician with unambiguous guidelines about financial issues with clients. The supervisory stance should be firm and generally inflexible. The risk of exploitation of a client in these matters is great.
Clinicians who disclose personal circumstances to clients open the door to boundary problems. Limited and clinically directed disclosures can be helpful, and in certain cultures, they are almost essential. However, disclosure of highly personal information is rarely welcome or justifiable. Clinicians who are vulnerable due to personal losses or substance use may make personal disclosures to remedy their own loneliness. Overly personal disclosures by the clinician can suggest mutuality in the relationship rather than collaboration for treatment purposes.
The supervisor should first explore the clinician's rationale for self-disclosure. Next, the supervisor should explore with the clinician the possible dynamics of such disclosures and their potential risks. The clinician should be coached on how to therapeutically redirect a client's requests for inappropriate personal information about the clinician. The supervisor should continue to monitor this issue very closely.
Touching, comforting the client, and sexual contact.
Some therapists use touch and hugs in their work. We consider this a high-risk practice for most mental health treatment environments. Although the occasional hug might be therapeutic, the risk of harm contradicts its use. Some children's therapists might hold a different opinion. Some young children may need physical reassurance in the course of clinical work. We recognize this need, but recommend careful monitoring of this practice with children.
In some cultures touch is an essential part of meaningful exchange, and its significance must be taken into consideration. Work with elderly persons represents another important exception—touch can be a critical part of therapeutic engagement with this population. However, as a general practice in most mental health settings, physical contact is high-risk behavior.
One might argue that seasoned clinicians could be granted greater license in this area than those less experienced. Unfortunately, experience does not immunize, and even seasoned clinicians can delude themselves into believing that sexual touching is therapeutic (22). Furthermore, despite the clinician's intentions, even "therapeutic" physical contact may be interpreted as sexual by the client (23,24).
The inequality of power and control in the clinician-client relationship also contributes to distorted perceptions of touch (25). Touch has a tendency to escalate physical response, particularly for clinicians who are as emotionally vulnerable as their clients. Sexual contact with clients is simply unethical and actionable (26,27,28,29,30,31). Psychiatry and social work have perhaps the clearest proscription against the behavior, including sexual contact with former clients. Although the major mental health professions have defined sexual behavior with current or former clients as unethical, less established professions with less clear licensure and certification standards have less clearly stated policies.
At the beginning of the relationship with a new supervisee, the supervisor should express clear rules or guidelines for physical contact with clients. The supervisor should coach the clinician on ways to show support or comfort that do not require hugging or other forms of touch. The prevalence of sexual abuse histories among mental health clients should be discussed along with the possible ramifications for clinical practice.
Gutheil and Gabbard (8,9) have now described a more gradual application of boundary guidelines than their earlier writings might suggest. We agree and suggest that the diversity in practice settings, cultures, and client populations calls for practice-specific ethical guidelines. Guidelines adjusted to the specific practice area can avoid both the rigid application of generic rules and purely subjective case-by-case decisions. Overly rigid rules can inhibit meaningful practice, while subjective decisions are not tested against the broader ethical consensus.
Not all clinicians are able to arrive at appropriate decisions without the benefit of dialogue with others. In fact, too much independence may be a risk factor. Strict adherence to rigid rules, on the other hand, is simply unrealistic. As an alternative to rigidity or idiosyncratic practices, we argue for the use of effective clinical supervision as a primary tool for managing the risk of boundary problems.
As administrative, educational, and monitoring resources become more scarce and as cases become more complex, the likelihood of boundary problems increases. Boundary crossings and violations may damage clients, clinicians' careers, agencies' reputations, and programs' credibility (32). Programs serving minorities, welfare recipients, persons with severe mental illness, and severely emotionally disturbed children face additional risks with already vulnerable populations. In-home services, case management, and other nontraditional services expose clients and clinicians to informal private settings. Without regular, proactive supervision, clinicians and other providers can easily lapse into boundary problems.
Clinical supervision can offer compassionate and cost-effective risk management by addressing clinical events higher up on the slippery slope. The supervisor who intervenes with a clinician's overuse of the telephone or too frequent use of home visits may prevent a lapse into sexual misconduct with a client. By using the four principles of proactivity, sensitivity, attention to narrative detail, and a commitment to Socratic methods, the supervisor is positioned to intervene successfully. The ten cues offer supervisory guideposts for discussion and inquiry.
Psychoanalytic Supervision and Vignettes
The practice of supervision of psychoanalytic trainees has gone through a series of changes as psychoanalysis matured. Beginning with the earliest Freudians, however, an important part of learning to do psychoanalysis is to be a patient of someone who is well trained in how to do psychoanalysis appropriately.
Since the beginning, there have been as many variations of psychoanalytic thought as there have been psychoanalysts. Each analyst adopts techniques which seem to work best with their particular set of patients as well as changing in minor or major ways while seeing different patients. In general, patients lie on the couch, free-associate, discuss their dreams, and are provided with interpretations from the analyst. The emphasis is on making the unconscious conscious as the primary means to achieving an understanding of oneself and alleviating symptoms.
Thus several of Freud’s patients followed his general technique while others, most notably Jung and Adler developed techniques which are quite distinct from their analyst. Even today, many analysts can trace their “family history” through their analyst in an unbroken chain back to Freud.
In the United States, the American Psychoanalytic Association controlled who would become supervisors or “training analysts” until about 1990. Before that time, only psychiatrists were admitted to institutes certified by “the American.” A long-term lawsuit brought by psychologists on the basis of restraint of trade, eventually led to the American Institutes accepting psychologists, doctoral-level social workers, and eventual marriage and family counselors as full students who were capable of not only becoming psychoanalysts but also training analysts or supervisors.
During this lengthy and acrimonious lawsuit, psychologists and other mental health professionals set up and developed training programs of their own; many of which were certified and affiliated with the International Psychoanalytic Association. Outside of the United States, other mental health professionals were welcome, even encouraged to attend psychoanalytic institutes and become training analysts. In the United States, the earliest and longest-lasting is the William Alanson White Institute, following the techniques elaborated on by Harry Stack Sullivan. Many other institutes have emerged and have solid reputations for training psychoanalysts in the United States in variants of Freudian, Jungian, Kleinian, and other schools of thought.
Traditionally, the beginning student of psychoanalysis takes four years of formal classes. Typically students who are admitted to institutes have experience in doing psychotherapy and have had their own practices for several years. This is important because the training can be expensive. During the years of training, the student is also expected to be in analysis from three to five times weekly with a training analyst who has been certified by the institute, and until recently, the American Psychoanalytic Association, as a training analyst. The classes focus initially on theory but quickly move into a blend of theory and technique. The student is expected to pay a reasonable fee for analysis.
There is an emphasis on case presentations so students can learn from the work of others including psychoanalysts about whom they have read, their own teachers, and their peers. The learning environment is a rich one and discussion about everything, including the foundations of psychoanalysis itself is encouraged. Classes are generally small and in many cases becoming smaller because of the expense and time required for training. Freud is read extensively as are commentaries on his work.
After the first year, students are encouraged to find a patient they can see several times weekly, preferably four or five, who is also committed to the process of psychoanalysis. Prior to beginning to do analysis on a patient, students must acquire a license which legally allows them to do psychotherapy. Some psychoanalytic institutes operate a clinic to serve patients who are unable to pay much for analysis. This also helps to provide a pool of patients for students. This “first patient” is expected to lie on the couch, free-associate, and be provided with interpretations as does the student with his or her own analyst.
Additionally, the student chooses a supervisor for the case. Because the psychoanalytic institutes in America follow their own rules and guidelines rather than being governed by state or federal laws, students are free to choose a supervisor who may have substantially different training. This supervisor does not provide “hours” for obtaining a license. Supervisors, like analysts, are paid privately by each individual student. The amount which is paid varies but is generally based on the fee the patient pays rather than on the supervisor’s regular fee. Psychologists may, for instance, choose a psychiatrist, marriage and family therapist, or social worker rather than another psychologist. There is generally a trial period to ascertain whether the supervisor and student will work well together. Either may decide that the relationship between them will not promote a solid learning experience. It is important that the supervisor trust the student to bring up important issues, particularly problems, encountered in treatment. The student must also be trusted to tell the truth about what occurred in the session and work toward understanding the transference and countertransference. Some supervisors also share their personal opinions and emotions while others retain a greater distance.
The supervisor is generally seen once weekly for an hour. During that time, the supervisor may ask how the case is proceeding in a manner which is unique to the supervisor or the student may bring up issues of interest. Generally notes are not brought to supervision sessions nor are notes taken during the treatment of the patient since they are seen as interfering with the analytic process. The supervision session may focus on the therapy as a whole or on specific issues which the student is finding difficult. The student is considered to be the expert on the patient since they are in the room with them. The role of the supervisor varies but it is usually to provide insight into developing issues between the student and patient which may not be noticed by the student due to transference, countertransference, and inexperience among other reasons. Generally a bond and trust develop between the supervisor and student which may last throughout the association of each with the institute.
The patient’s symptoms and history are presented before an open committee with both the student and supervisor present along with at least one other training analyst. Primarily, the task of this committee is to help the student recognize whether or not the patient is appropriate for analysis and to determine whether the student has enough expertise to work with the patient successfully. Technique and countertransference (or feelings and thoughts of the student about the patient) are discussed as well with an emphasis of pointing out possible difficulties before they begin to occur. While many students find these meetings intimidating, they are a necessary part of integrating the student and supervisor with the ongoing work of the Institute. Despite the findings of the committee regarding the suitability of the analysis, if the student and supervisor decide to continue with the analysis, they are free to do so without criticism.
In the second, third, and even fourth years, the students choose two additional patients and two other supervisors. This is considered to give the students a broader understanding of the process of psychoanalysis as well as to clarify that different analysts work from different premises, use different techniques, and provide supervision for their students in different ways. The student must see at least three patients for at least a year with the supervisor they have chosen to work with them.
In addition, the cases, appropriately disguised, are often discussed with other committees. At least one case is written in formal psychoanalytic style which recognizes the transference or feelings of the patient toward the student-analyst, the countertransference, the main interpretations which led to change and growth, and how termination of the case and the transference was done.
Students are also given an oral exam by two examiners chosen by the institute to ascertain that they have learned the material presented in their courses. Analytic students are expected to learn not only technique but also the deeper levels of theory which underlie the techniques. The oral exam is broad, covering all types of analysis taught by the institute.
Subsequent to graduation, some students are asked to teach courses along with other faculty members. This may continue throughout the member’s life with the institute. Others prefer not to teach at the institute and may do research, develop a psychoanalytic practice, teach at a university, or a variety of other activities which use the material they have learned.
A few students become training analysts or supervisors themselves. While this step has until quite recently been a part of the American Psychoanalytic Association who determined whether or not a faculty member who had written an additional case for the American and acquired certification as an analyst, Institutes which are part of the American are currently changing this process so they can choose their own training analysts from among their members. A committee is elected to choose members who show promise of being excellent supervisors. Usually these are people who have devoted time to teaching, serving on a variety of committees which run the Institute, written and presented original papers, and are well- respected and well-liked members of the analytic community.
It should be emphasized that there is no specific manner in which supervision is done in analytic training, instead, the student and supervisor create a unique relationship in which to discuss the patient. Both the opinion of the student and the supervisor are considered to be worthwhile in treating the patient. Both can also be incorrect in their understanding and change as the analysis progresses. The student is free to use the supervisor’s suggestions or not depending on how the relationship of the student with the patient develops.
Because of the confidentiality of the relationship as well as the openness of the student, supervisor, and patient, case studies are carefully guarded. The identity of the patient is consistently disguised by giving them different ages or occupations for example. The only time the patient is discussed in detail is with the supervisor, and even then, the patient’s real name is not used unless it is relevant to the analysis.
Therefore, unlike supervision which is usually primarily didactic, this analytic supervision involves the student and supervisor as a team with the supervisor as the senior member. They attempt through their insight, experience, and understanding to help the patient be freed from the unconscious thoughts, memories, and emotions which lead to unwanted symptoms.
Sample Case Discussion with a Supervisor: (1)
Student: My patient reported a dream to me yesterday. In the dream, he was dating a woman from work and had taken her to dinner. Everything was fine until he noticed that he did not have silverware. Then he tried to signal the waiter and discovered he had no arms or hands. He woke up in a panic. I waited but he didn’t say anything so I suggested that the dream created so much fear, he could not think about it long enough to have associations to it. He was still silent so I felt I had gotten it wrong.
Supervisor: Was there something about the dream which made you feel that you should say something?
Student: Well, after awhile, I started feeling like I wasn’t doing anything helpful. There was just silence and nothing was happening… I felt pretty useless…
Supervisor: Perhaps the content of the dream had an influence on you as well?
Student: I think anybody would react to finding they had no hands…You’re right, I was feeling helpless just like he probably was and some anxiety like a milder reaction rather than panic.
Supervisor: So the content of the dream conveyed helplessness and a fear about being helpless.
Student: Now that I’m thinking about it in this way, it seems that having the dream of a date makes him feel helpless and that leads to panic. I see why he doesn’t date very often…
Discussion: This is an excellent supervisor in that it is immediately understood that there is some part of the dream which has disturbed the student. Although the student attempts to dismiss the supervisor’s interpretations, the student continues to confirm in his responses that the supervisor is correct in his or her intuition that there is a problem which may be quite serious which the student is evading. The supervisor, despite the student’s attempts to change the subject or deny the problem, continues to return to it in a manner which is gentle and allows the student to begin to explore his reaction. While further work may continue in supervision, the student has become quite aware of issues which were likely unconscious and would be wise to discuss them in more depth with his analyst.
Sample Case Discussion with a Supervisor: (2)
Student: I really felt like my patient and I made progress today…She began to talk about the difficulties she has with men and then moved on to discuss her obesity and the way it protects her from sexuality with men
Supervisor: What was it about that interaction which made you feel she was making progress.
Student: Sometimes I don’t know if you are playing a game with me or if you’re just not listening.
Student: Like right now. I told you my patient made progress in understanding her obesity and its connection with her sexuality but you made me feel like nothing had happened.
Student: I don’t understand why you can’t sometimes tell me I did good work with my patient.
Supervisor: It seems important that you feel I approve of you but all you have told me is what your patient said, not about your role in her understanding.
Student: Her understanding obviously was a result of the work she and I have done.
Student: Maybe I’m falling back into needing support and praise. I sure feel like you should say something positive about my work but you’re right, I talked about work she had done as if I did not feel involved in it. I’m not sure I was involved in her being able to put the pieces together, maybe she was thinking about it on her own and they just began to make sense to her. I feel like I took her insight away from her and made it mine to impress you.
Supervisor: So she is able to do analysis on her own.
Student: No, I know I make useful interpretations but I also know that she is a good patient and continues to think about the sessions when I am not there.
Supervisor: Any thoughts about why it was so important to have my support and praise right now.
Student: …well, I feel like money is tight right now…actually, several patients have decided to quit lately and I felt it was because I was not doing a good enough job.
Supervisor: It’s painful to have that feeling.
Student: Yes. I think I had some sense that I could alleviate my concerns about making a living by being an analyst if my patients were making progress which you noticed. At the same time, I realize that my success or failure do not depend on your approval. I use to feel that so strongly as a kid with my dad.
Supervisor: Perhaps your patient has a similar need to please you by doing a good job at analysis.
Student: You may be right about that. Her parents did not give her much praise either. Maybe that’s more tied to her obesity than avoiding men.
Discussion: This supervisor is working very well with substantial difficulties which are being avoided by the student in his analysis of the patient because he has faced similar problems with his father and has not yet resolved them. The supervisor uses silence and a non-committal “Um” to allow the student to reach a deeper level of trust with the supervisor, almost as if the supervisor is temporarily in the role of the analyst. The gambit is effective in that the student becomes more ready to discuss personal problems he is having with the patient rather than glossing over the problems and pretending that the analysis is not at a turning point. Although there is some insight on the part of the student, he is expected to work out these issues in his own analysis rather than with his supervisor or his patients. It is the work of the supervisor to inform the student of problems in countertransference as they arise but the actual work of resolving the underlying problem is almost always that of the student’s own analysis.
Sample Case Discussion with a Supervisor (3)
Student: My patient has been having some problems making it in to sessions. She seems to have good reasons. Her car keeps breaking and she doesn’t have the money to fix it, her mom isn’t able to come over and watch her kids, or she’s out of money and can’t afford the gas.
Supervisor: Is it possible she is telling you that she wants to terminate analysis with you?
Student: I don’t think so. She pays me when she has the money and is concerned about paying me late. I don’t criticize her when she is unable to do that. I think she needs the help and I also think she wants to be in analysis very much.
Supervisor: Why would you think anything like that?
Student: She has made some significant gains in understanding herself and her relationship to her children and their father. She sees the money problem as temporary since she is working at changing jobs so she can make more money and not have to rely permanently on the children’s father.
Supervisor: I notice you call her ex-husband “the children’s father” which implies she has no real relationship to him. Might you be attracted to her and negating his influence on her life.
Student: She and I have discussed her relationship with him extensively, as you know. She calls him “the children’s father” and I find that I think of him in that way as well.
Supervisor: Do you feel you are being pulled down into this woman’s abyss? You seem to be unconcerned when she can’t pay you, you excuse her absences as having a basis in reality, and you see her as someone who can change enough to be truly independent of her ex-husband.
Student: Perhaps you and I see this differently because of our own experiences.
Supervisor: Perhaps we see it differently because you lack experience and are far too forgiving of her lackadaisical manner rather than confronting them directly.
Discussion: It is clear that this supervisor and student do not have similar ideas about the patient. It is also clear that the supervisor has little respect for the work the student is doing. In a case such as this, if it is near the beginning of the analysis, the student may decide to seek a different supervisor who has a similar view. The supervisor also appears angry in that he consistently confronts the student in a manner which is disrespectful of the student’s relationship with the patient and the feelings and thoughts the student has about the analysis. This type of critique makes it difficult for the student to learn to do analysis because, unlike the previous two cases, he cannot openly discuss issues he actually has with the patient because the supervisor is consistently putting him in a position which is defensive. This supervisor may be seen as someone who should not be in that role since he actively attacks the student rather than promoting growth.
At times in supervision, it is necessary for the therapist to confront the student on flagrant errors and failures to deal effectively with the transference and countertransference. However, a good supervisor is likely to confront the issue early in the process and help the student work through different problems as they come along rather than having a session such as this in which the student appears barraged by criticism for many different types of issues on different levels.
The student has recourse. He can discuss the problem with his analyst to clarify his own part in the supervisory relationship. He can also change supervisors even though it would mean beginning the year of a supervised case over again. While some students feel the supervisor is always correct, because they are exposed to the work of at least three supervisors, it provides the student with the opportunity to understand how some supervisors fail to teach students, to establish trust, and to allow the student to grow into the type of analyst he will eventually become.
Sample Case Discussion with a Supervisor (4)
Student: Sorry I’m late today, the traffic was unusually bad…My patient had a dream that I would like to discuss. He is at a restaurant with his boss and other people from work. He is talking comfortably which he usually is unable to do in that sort of situation. He notices as he is talking his teeth begin to feel loose. As he is eating his teeth come out and he has to pick them from his mouth. The other people at the table notice and become silent. Then they all begin to laugh at him and make fun of him. He feels humiliated by the experience and tries to leave the table but finds he is unable to move his chair.
Supervisor: What associations did the patient have to the dream?
Student: He was very reluctant to tell me the dream or discuss it at all. When I inquired about why he was having so much trouble, he said the dream continued to make him feel humiliated and if I knew about it he was afraid I would see him as having such severe problems that I would terminate the analysis.
Supervisor: Has there been any problems between the two of you in the analysis which might make him feel that way?
Student: I feel I have not been able to make much progress, I guess. I don’t seem to have much insight into his dreams or the other information he discusses. It seems to stay at a superficial level.
Supervisor: Any ideas about why that might be happening? You had been doing very well with him prior to a few weeks ago.
Student: The only thing I can think of was that I was late several times. I seem to get on the road early enough but the traffic seems worse lately.
Supervisor: Perhaps the patient feels you are not very interested in seeing him.
Student: I can see him thinking that. He has a lot of trouble with interactions with his peers at work. He feels anxious while talking to them and then gets angry when they do not include him. He expects to be asked to go out to lunch rather than simply going when everyone else does.
Supervisor: So in his transference to you, you have become just like everyone else. You tolerate him but don’t really want him around.
Student: Yes, that feels right. He’s very servile with me but I feel he is also angry. When I interpret the anger he denies it and becomes even more servile. His history is pretty bad. He had parents who expected more from him in school and in his mind, they were constantly critical of him.
Supervisor: So what do you think of the dream?
Student: I think he sees himself as an object of ridicule who no one really likes even when he is functioning well. Having the teeth come out makes me think that he feels there is nothing he can do to save himself from inevitable humiliation.
Supervisor: Why do you think it is his teeth which are his problem?
Student: Well, it seems like his teeth would be connected to biting, like anger or even rage. When they come out it seems like he becomes helpless since he cannot attack people verbally anymore without showing them he has lost his teeth…I guess I also connect the loss of teeth with poverty since people lose teeth when they can’t afford to see a dentist.
Supervisor: So the teeth seem connected to an impotent anger which he hides under his servile manner. It also sounds like he continues to feel a deep sense of shame about himself from the manner in which his parents treated him. Perhaps it would be a good idea to focus more on interpreting his anger.
Student: I think so too. I think I have been avoiding really confronting him on it because I worry he will blow up and leave.
Supervisor: Perhaps if you were to interpret that concern prior to the interpretation it would enable him to have enough understanding of himself that he would be able to stay. It would also convey to him that you are not so critical of his anger that you will want him to leave if he shows it to you.
Discussion: In this vignette, the student and supervisor are working well as a team to open up and discuss various aspects of the analysis. The supervisor gives some direct suggestions but continues to respect the student’s opinion. The supervisor also makes some comments on technique which may be useful in helping the student through what is clearly a rough time for both himself and the patient. The student is open and trusting with the supervisor including being able to admit to errors he is aware he is making. His errors are not criticized by the supervisor but instead become part of the reason why the analysis has stalled. The supervisor does not directly interpret the dream since that is the job of the student and patient but gives the student some means by which he can open up the dream and the patient’s neurosis which will hopefully lead to more trust by the patient and a deeper level of analysis.
Counselor educators and field supervisors often feel uncomfortable about assessing trainee skills and struggle to find an appropriate vehicle for delivering essential constructive feedback regarding performance. Most have received little or no training in evaluation or assessment practices. However, current and proposed accreditation, certification, and licensure regulations place an increasing emphasis on the evaluation and assessment of counselor performance. Clearly, evaluation practices will need to be augmented by theoretical and conceptual knowledge, as well as programmatic research.The purpose of this digest is to suggest that there exist some fairly basic premises from educational psychology (Gage & Berliner, 1984), educational evaluation (Isaacs & Michaels, 1981), and counselor supervision literature (Bernard & Goodyear, 1992) that can improve supervision evaluation practices, and thus reduce the ambiguity and uncertainty about evaluation in supervision. Although this digest does not specifically address program evaluation, it should be clear that this is also an important component of any comprehensive evaluation endeavor.
Professional competence evaluation is made in a series of formal and informal measurements that result in a judgment that an “individual is fit to practice a profession autonomously” (McGaghie, 1991). Summative evaluation describes “how effective or ineffective, how adequate or inadequate, how good or bad, how valuable or invaluable, and how appropriate or inappropriate” the trainee is “in terms of the perceptions of the individual who makes use of the information provided by the evaluator” (Isaac & Mitchell, 1981, p. 2). Counselor supervisors are responsible for summative evaluations and assessments of supervisee competence to university departments, state licensing boards, and agency administrators. Summative evaluation is described by Bernard and Goodyear (1992) as “the moment of truth when the supervisor steps back, takes stock, and decides how the trainee measures up” (p. 105). Effective summative evaluation requires clearly delineated performance objectives that can be assessed in both quantitative and qualitative terms and that have been made explicit to the trainee during initial supervision contacts.
The heart of counselor evaluation, however, is an on-going formative process which uses feedback and leads to trainee skills improvement and positive client outcome. In this case the trainee is the person using the information. Bernard and Goodyear (1992) refer to this kind of evaluation as “a constant variable in supervision.” As a result, every supervision session will contain either an overt or covert formative evaluation component.
When supervisors measure behavioral therapeutic skills they find several difficult areas. First, they find that measurement and subsequent evaluation of therapeutic skill is a complex process in a field where many skills inventories and behavioral checklists abound, and research findings suggest that these may lack adequate reliability and validity. Second, university supervisors recognize the tension between providing a supportive facilitative environment within which counselors-in-training can feel free to stretch and learn counseling skills and the anxiety that results from academic grades. Third, lacking a theory of supervision, supervisors are unable to articulate desired outcomes for their supervisees and may revert to the evaluation of administrative detail and case management. As a result of these difficulties, numerous areas of competency may be neglected, anxiety may persist, and supervisors may resort to summative evaluation practices in global and poorly measured terms.
There are resources which outline requisite skills and knowledge for effective evaluation practices. The Curriculum Guide for Training Counselor Supervisors (Borders et al., 1991) provides specific learning objectives for supervisors-in-training. Other current publications (Bernard & Goodyear, 1992; Borders & Leddick, 1987; McGaghie, 1991; Stoltenberg & Delworth, 1987) further develop the Guide's “three curriculum threads” (p.60) of self awareness, theoretical and conceptual knowledge, and skills and techniques. The guidelines and suggestions from these resources are summarized in the following list of effective evaluation practices:
1. Clearly communicate evaluation criteria to supervisees and develop a mutually agreed upon written contract reflecting these criteria.
2. Identify and communicate supervisee strengths and weaknesses. The Ethical Guidelines for Counselor Supervisors (ACES, 1993) recommend that supervisors “provide supervisees with ongoing feedback on their performance.” This performance feedback establishes for supervisees a clear sense of what they do well and which skills need to be developed. Supervisee strengths and weaknesses can be evaluated in terms of process, conceptual, personal, and professional skills (Bernard & Goodyear, 1992, p. 42).
3. Use constructive feedback techniques during evaluations. Supervisees are more likely to “hear” corrective feedback messages when these are preceded by positive feedback, focused on observable behaviors, and are delayed until a positive relationship has been established.
4. Utilize specific, behavioral, observable feedback dealing with counseling skills and techniques; avoid terms such as “understanding,” “knowing and appreciating,” and “being aware of.” Successful evaluation practices should include behaviorally-based learning objectives (Gage & Berliner, 1984).
5. Use Interpersonal Process Recall (IPR) to raise supervisees' awareness about their personal developmental issues. The unobtrusive and non-threatening nature of IPR is particularly helpful as supervisees retrospectively explore their thoughts, feelings, and a variety of client stimuli during counseling sessions. This process can assist supervisees in contributing to, and benefiting from, formative evaluation.
6. Employ multiple measures of supervisee counseling skills. These can include a variety of standardized rating scales including measures completed by both supervisor and supervisee, client ratings, and behavioral scales (Stoltenberg & Delworth, 1987). Additional measures such as work samples from audio/videos, critiques of counseling sessions, and conceptual case studies (both brief and detailed) can provide a comprehensive picture of a supervisee's competency, expectations, needs and professional development, as well as an understanding of the context within which both the counseling and the supervision take place.
7. Maintain a series of work samples in a portfolio for summative evaluation. Since the evaluation of only one session provides an inadequate assessment of supervisee competency, and the selective nature of work samples may prove to be an overly negative reflection of current competency level, the portfolio provides both the supervisor and the supervisee with a more comprehensive and useful basis for a summative evaluation.
8. Use a developmental approach which emphasizes both progressive growth toward desired goals and the learning readiness of the trainee (Nance, 1990). The Nance model emphasizes a learning readiness based on the supervisee's ability, confidence, and willingness--the assessment of which directs the roles and practices of the supervisor. As a result, supervisors can “match” their supervisee's level and “move” them toward independent functioning one step at a time. Although Nance does not specify evaluation practices, he clearly describes effective supervisory styles, interventions, role, contracts, and agendas for each developmental stage. These variables can guide the evaluation process indirectly by enabling the supervisor to understand the characteristics and appropriate expectations for supervisees at each developmental level.
A structured approach to supervisee assessment and evaluation produces several beneficial outcomes. First, supervisors can reduce their own, as well as their supervisee's, anxiety about the process. The meanings associated with assessment can be altered to suggest a positive experience from which both partners can grow and learn. Second, supervisors who articulate their adopted “supervision theory” to their supervisees will also clarify their evaluation criteria as well as their supervision practices. Third, when evaluation is viewed as a process of formative and summative “assessment” of the skills, techniques, and developmental stage of the supervisee, both supervisees and their clients benefit. Fourth, as supervisors deal successfully with the process of supervisee evaluation, they also bring similar skills to the evaluation of their training programs, an area in search of an appropriate evaluation paradigm. Finally, just as training is most successful when multiple methods (didactic, modeling, and experiential) of skills acquisition are employed, so too the use of multiple methods for evaluation contributes to the supervisee's sense of self-worth and success.
Skills in Counseling Supervision
The administrator of a supervision program is the person ultimately responsible for the quality of supervision provided and the effectiveness of supervisory staff. Conceptually, the supervision "program" includes not only the staff of supervisors, but also the activities they do, outcomes they strive to help their supervisees achieve, materials and resources they use, and means by which the activities, outcomes, and staff performance are evaluated. Administrators of supervision programs include school system, central office-based guidance directors who administer the supervision activities of campus-based counseling department heads; counselor-owners of private practices with multiple counselor supervisors; heads of counselor education departments with multiple faculty members supervising intern and practicum students; and counselor educators responsible for field-site practicum and internship supervisors of their students.
Administrators provide leadership and direction to supervision programs by developing and upholding the program mission and the goals of supervision. To ensure effective implementation of the program (and the related counseling activities), administrators must know and be able to articulate for the staff and others the purpose, value, and goals of supervision, including its contribution to the quality of the counseling program. Essential here are knowledge of and commitment to the professional standards of counseling performance, ethics (American Counseling Association, 1988), and supervision (Dye & Borders, 1990), as well as the relevant legal standards. Administrators must be able to articulate how supervision relates to performance evaluation and to other professional development activities. They need to be able to facilitate the establishment of program priorities and to assist counselors and/or supervisors in establishing relevant objectives which not only will maintain the program, but also cause its improvement.
Administrators need to help supervisors be clear about the priority of supervision in relation to other aspects of their jobs. Supervisors of school or agency counseling departments with multiple counselors often have counseling caseloads in addition to supervision responsibilities. Counselor educators often carry teaching or advisement responsibilities in addition to supervising practicum and internship students.
Administrators not only are accountable for the provision of high quality supervision, they also are accountable for resultant improvement in the performance of supervisees/counselors, and ultimately for assuring effective treatment for clients. Based on their evaluations of supervisors' competence, administrators have a responsibility to match supervisors and counselors for optimum professional development, and for establishing efficient systems for matching counselors and clients for optimum personal development. They also must be able to develop, with supervisors, the system for monitoring client progress. Establishing systems that are not burdensome to the staff is often a challenge to the administrator. Writing skills are needed for documentation and for reporting.
In a "business manager" role, the administrator needs skills in acquiring and allocating resources needed for effective and efficient program implementation. Specifically, administrators pursue sufficient budgets, adequate materials, appropriate facilities, and equipment. Managing the supervision program entails handling logistics, such as scheduling to match clients and counselors, counselors and supervisors, making good use of facilities and equipment, and efficiently using time. Administrative skill requisites include being able to develop plans for supervision activities on a yearly, a semester, or perhaps a weekly basis.
Administrators must have the political and communication skills necessary to establish or collaborate with those who establish the policies that support the program and enhance the supervision efforts. They also are responsible for setting workable procedures and rules. They must know how to conduct effective and efficient meetings. Administrators help others in and out of the department to know the value of and best practices within counseling supervision.
Administrators of supervision should have the knowledge and skills needed to provide leadership to the supervision program staff, as well as the counseling program staff members. "Personnel" within the responsibility of the supervision administrator may include supervisors, supervisees, support staff, and clients. Ideally, supervision administrators are or have been exemplary supervisors (and counselors) and are well-grounded in the knowledge, skills, and experiences of effective counseling supervision. They have developed their own models of supervision and know its steps, procedures, and a wide repertoire of techniques. It is beneficial if administrators model these and other basic skills to better assure such skills in the supervisors and counselors within their responsibility.
Supervisors and their administrators are involved in relationships with a myriad of dynamics. Prerequisite to skilled administration is having the interpersonal skills necessary to counsel, supervise, and administer such a relationship-based program. Relationships develop and interactions occur between clients and counselors, between counselors and supervisors, and between supervisors and their administrator. These relationships should be characterized by mutual respect, two-way interactions, and a collaborative spirit.
Administrators establish the climates within which their programs operate. Their values are reflected in the program and by the supervisory staff. If they value ethical practice, the worth and dignity of each individual, such are the values of the department, agency, or business. If their personal interactions are characterized by trust and respect, those become hallmarks of the interpersonal climate of the staff. A collaborative leadership style sets a different climate than an authoritarian one.
Usually, program administrators are protectors of the rights of the supervisors, supervisees, other staff members, and clients. They need skills to intervene if needed. Dissatisfied clients, having first discussed their issues with their counselors and then the supervisors, may bring their appeals to administrators. Thus, administrators must listen well and evaluate cases and disputes fairly.
Supervision administrators typically have traditional personnel responsibilities for the supervisors. They need skills in recruitment, hiring, placement, orientation, and induction of new supervisors. They need to be able to write and to clarify job descriptions of the supervisors. Given the dearth of supervisor training, today's supervision administrator needs to be able to train new supervisors as well as provide inservice training for those with experience (Borders et al., 1991; Henderson & Lampe, 1992). They assist supervisors in choosing appropriate supervision methodology when they are faced with problematic supervisees (e.g., those in burn-out, stress, conflict, or who are incompetent). As with the other supervision skills outlined in the Standards (Dye & Borders, 1990), administrators must be able to match their own administrative behaviors to the needs of their "administratees."
Supervision administrators both supervise and evaluate supervisor performance and suggest goals for supervisors' professional development. As is often true with supervisors and supervisees, these responsibilities may appear to the supervisor ("administratee") to overlap or even be in conflict. Administrators need to be clear as to which role they are fulfilling in any given situation. They need to be able to distinguish between formative supervision and summative performance evaluation. They need to be able to evaluate fairly and to provide constructive criticism.
Finally, supervision administrators need to pursue their own meaningful professional development. Administrators are professional models to their staff members, and should exemplify excellence in counseling and supervisory as well as administrative professional knowledge and skills.
As both counseling and counseling supervision are developing disciplines, so too is the administration of counseling supervision. Appropriate training, based on the ACES-developed Curriculum Guide (Borders et al., 1991), needs to be provided for counseling supervisors and extended for administrators of counseling supervision programs. When training is accessible, appropriate certification and licensing requirements need to be established. Perhaps before all of that can happen, more discussion of the topic needs to occur in the profession.
Gender Issues in Supervision
Gender as a concept encompasses "culturally-determined cognitions, attitudes, and belief systems about females and males ; [it] varies across cultures, changes through historical time, and differs in terms of who makes the observations and judgments" (Worell & Remer, 1992, p.9). Using this definition, discussion of the effects of gender on supervision must be built upon an examination of the present status regarding gender within this culture.
Currently, there appear to be three basic perspectives concerning gender differences. These perspectives are focused in areas of unequal distribution of power, socialization, and inherent differences. Combining information from these bodies of literature, we can construct an explanation of what it means to be male or female in our society.
First, men as a group within American society have more economic, political, social, and physical power than most women. Males and females also, however, are socialized to become different beings as well. Messages received from family, school, and media continue to be heavily laden with sex-role messages representing very different sets of acceptable behaviors for boys and girls. These social rules and expectations create remarkably disparate psychological environments for development based on gender. Finally, in terms of inherent differences, those characteristics stereotypically identified with women historically have been dismissed as of little value. Even within psychology, the model of the healthy adult has traditionally been described through masculine characteristics. Only in rather recent history have we begun, at any level, to hear and value "the other voice" (Gilligan, 1982).
This societal framework indicates the existence of a power differential and suggests the potential for bias in expectations and/or actions. With gender as such a significant social variable, it is unlikely that the effects also would not be apparent in counseling and supervision. These parallel processes must continually be examined within the larger context of society.
Two remaining factors are worth mentioning. Minimizing the importance of the differences between the genders discounts the importance of meaningful within-group experience while exaggerating this importance reduces the potential for individual difference. Additionally, it is important to remember that while much that we have come to understand about gender differences has been motivated by the women's movement, the potential for bias and discrimination affects both men and women.
As supervision involves the oversight of counseling, several gender issues related to therapy are worth restatement. Using the societal context as a framework, Bernard and Goodyear (1992) suggested three areas be considered and evaluated for gender impact and/or bias: (1) the issues which the client brings to counseling, (2) the perspective of the counselor, and (3) the choice of interventions. Complaints by female clients concerning therapy have tended to focus on counselor encouragement of traditional sex roles, bias in expectations, devaluation of female characteristics, use of sexist theoretical concepts, and continuation of the view of women as sex objects (APA, 1975). Counseling supervisors have a responsibility to help the supervisee evaluate gender as a factor of concern in case conceptualization, self-evaluation of assumptions and biases, and in selection of approaches.
The supervisory relationship, itself, is taking place within the same societal context as other gender issues. Bernard and Goodyear (1992) noted gender interactions in supervision related to response to initiation of structure, style used in handling conflict, personalization of supervisee feedback, satisfaction with supervision, comfort with closure and initiation, and sources of power used by supervisors. An additional significant research study found gender-related differences associated with the amount of reinforcement given to trainees' powerful, more assertive messages (Nelson & Holloway, 1990).
While, as in the counseling profession generally, much more research is needed to understand the effects of gender on supervision, these sample findings clearly indicate the potential importance of this variable on the supervisory relationship and process. Supervisors, in addition to assisting trainees with the associated counseling issues, must be aware--in fact, vigilant--in identifying any ways in which bias in expectations or actions might be occurring within supervision.
Implicit in both counseling and supervision are two areas of legal and ethical concern related to the overarching issue of sexuality. These are sexual harassment and sexual involvement. These issues are gender-related, though they may manifest themselves in same or cross gender interactions.
Sexual harassment refers to unwanted sexual advances and/or contacts while sexual involvement between supervisors and supervisees may seemingly occur by mutual consent (Bartell & Rubin, 1990). Although subtle forms are more difficult to recognize and eliminate, most personally and professionally aware supervisors avoid the most blatant types of behaviors associated with sexual harassment. Through efforts at many institutions and agencies, individuals are being educated concerning the defining characteristics of harassment and the legal and ethical implications.
Unfortunately, incidents of sexual involvement continue and in some cases seem to be increasing. While the degree of coercion or consent may seem to separate these two issues, they have two factors in common. Both sets of behaviors are clearly unethical and both work to the detriment of supervision. Mutuality does not excuse abuse of power, and there is an inherent power differential in supervision--a factor which always provides a degree of question concerning true consent (Bartell & Rubin, 1990). Even the most egalitarian of supervisors must acknowledge a greater responsibility and accountability in this area. Additionally, as a word of self-protective warning to supervisors beyond the need to behave ethically, research indicates that supervisees' perceptions of the amount of coercion tend to increase with the passage of time (Glaser & Thorpe, 1986).
An additional disturbing finding in this area of sexual contact (beyond damage done to individual supervisees and supervisory relationships) is that the behaviors perpetuate themselves. Students or trainees who become involved with supervisors are more likely to accept this as a norm and repeat the pattern themselves (Pope, Levenson, & Schover, 1979). The power of modeling in all areas related to gender should never be minimized. Even when contact is initiated by a supervisee, the moment can be a teachable one where ethical standards can be explained not as efforts to monitor thoughts and feelings but to regulate behaviors in order to protect certain types of significant relationships.
The supervisory relationship is an incredibly important one in the personal and professional development of counselors. In relation to gender, it is crucial that supervisors use the relationship as an opportunity to educate, confront, and model. This requires a special level of awareness of self and society. Challenging our own biases, prejudices, and issues is one of the most critical parts of the process. Because gender is one of our most powerful and descriptive characteristics, it tends to be one of the most sensitive areas of personal exploration. The sensitive nature of the topic as well as the potential for crossing lines associated with sexual discrimination, harassment, and involvement make it imperative that supervision take place within the clearest ethical parameters. Such parameters provide a safe and established environment for growth and development while modeling appropriate professional behavior for the next generation.
Within the larger social context, supervisors and counselors are also in a position to work effectively as advocates to address injustices implied in the previously mentioned perspectives on gender differences. Professionals can, perhaps, have the greatest effect in this area by promoting equity in institutions and systems, gender-fair practices in socialization processes, and a genuine appreciation for and celebration of both masculine and feminine characteristics.
Supervision is often treated as a "univocal" term meaning the same in whatever context it exists. Unfortunately, such is not the case, and even in instances where there is conceptual agreement on what it means, there are still differences on how it is operationalized. Although there is little data to show in which countries supervision exists and to what extent it is influential, there are some indicators about its breadth. The International Conference on Supervision held in London in 1991 drew participants from the United States, Britain, Ireland, Holland, Belgium, Austria, Russia, and South Africa with the opportunity to share how supervision was viewed in different countries. In 1993, I was privileged to spend time in four countries other than Britain (Colombia, Denmark, the United States, and South Africa), providing a further chance to compare and contrast supervision in these contexts. Writings on supervision have emerged from a number of countries other than those mentioned above, including Norway and Australia. This Digest is an attempt to summarize some of these ideas on paper, realizing the limitation of how few and how impressionistic rather than experimental are the conclusions.
There seem to be two strands in the history and understanding of supervision, one emerging from the United States and the other from Britain. What distinguishes them is the location of counseling training. In the United States counseling training has largely taken place in and been controlled by the universities, whereas in Britain counseling training has existed almost exclusively within the private domain and only in the past 10 years have universities become involved. As a result, the United States has concentrated on the conceptual and intellectual pursuit of supervision, while Britain has stressed the practice, the training of supervisors, and the supervision of supervision.
The bulk of supervision writing and research comes from the United States. A number of reviews have summarized the research, models, and components of supervision (Bernard & Goodyear, 1992; Holloway, 1992). More recently, an ethical code for supervisors has been published (ACES, 1993) and there are moves to set up training standards for supervisors and training courses for beginning and experienced supervisors. Within the writings on supervision there is some movement away from what are called "counseling-bound" models of supervision (where supervision is conducted along the lines of the counseling model) to a more generic understanding which emphasizes supervision as an educational process in its own right, not tied specifically to counseling orientations. A good example of this integrative, educational approach can be seen in Holloway's (in press) forthcoming book.
In Britain, on the other hand, the focus on training and practice has resulted in a number of supervision training courses (see below), a Code of Ethics and Practice for the Supervision of Counselors (1988), and an accreditation scheme. The theory/research side however, is not entirely missing. A key text written by Hawkins and Shohet (1989) contains a "Process Model of Supervision" and the authors of two new books on supervision (Carroll, in preparation; Wokset & Page, in preparation) hope to make contributions to model-building in supervision. In addition, a number of research projects at masters' and doctoral level on counseling supervision have been completed within the past few years.
The British Association for Counseling has outlined an accreditation scheme for supervisors which has been running for approximately five years and to date has about 40 accredited supervisors. Applicants for these awards are required to write their philosophy of supervision, submit a tape of a supervision session with comments by supervisee and supervisor, and take part in a full day evaluation where they are asked to supervise and be supervised before two assessors and are interviewed on their theory of supervision and how congruent it is with their practice. An interesting new development has occurred with the arrival of the European Association of Psychotherapy (E. A. P.), which is in the process of forming a Committee on Supervision. this Committee will consider standards of training in supervision leading to individual accreditation. Obviously, this venture will have wide-ranging implications for both counseling and counseling supervision throughout Europe.
More recently a number of training courses in supervision have appeared in Britain, some within particular counseling orientations and others viewing themselves as integrative. The curriculum of these courses stresses experiential learning as a key factor in supervisor training but without neglecting the conceptual frameworks. By and large, these trainings are for experienced counselors who are beginning to supervise or see themselves as supervisors in the near future. Training lasts for either one or two years, resulting in a certificate or diploma. There are approximately 10 to 12 such courses in Britain at the moment. Every year there is a one-day British conference on supervision organized by the British Association for Supervision Research and Practice (BASRP).
Unlike the United States, where supervision is a requirement for counselors in training but not for credentialed counselors, supervision in Britain is seen as a life-long commitment (BAC Code of Ethics and Practice for Counselors, 1990). Counselors, both those in training and those qualified, are expected to be in supervision, although consultation is the term often used to designate supervision with a qualified counselor.
The United States and British approaches to counseling supervision exemplify the two strands that seem to characterize supervision in most countries: the conceptual influencing practice as in the United States and practice moving towards theory as in Britain.
What is not known is how well supervision "travels" and how culturally "friendly" are either the conceptual ideas or the specific activities when transferred from one country to another. There is some evidence for caution, however. An attempt to introduce Rogerian counseling and supervision to Taiwan resulted in frustration simply because the culture there expects more direct approaches (P. P. Heppner, University of Missouri, Columbia, private communication). In addition, countries are at various stages in the development of supervision. In some countries counseling is still without formal professional standards, while others have progressed to devising ethical codes and formal training programs.
There seem to be a number of steps through which supervision develops, and internationally countries may be seen at different stages:
1. Counseling and counseling psychology become more professionalized.
2. Supervision is seen as an important part of counselor training and on-going counseling work.
3. Experienced counselors take on the roles, tasks, and functions of supervisors.
4. Models, theories, approaches, and research in supervision begin to be set up and/or are imported from other countries.
5. Codes of ethics for supervisors are outlined.
6. Formal training in supervision is set up and required.
7. Supervision training, practice, and research are viewed as an essential component in counseling work.
There is an increasing amount of contact between counseling supervisors throughout the world. Workshops have been put on in Britain by counseling supervisors from the United States. A small group of black South African students are studying counseling and counseling supervision in London before returning to set up counseling training within the black communities in their home country. International conferences are being held in places such as Hanover, Germany (September, 1994) and St. Petersburg, Russia (International Conference on Supervision, Institute for Psychotherapy and Counselling, September, 1995). These efforts will result in dialogue, correspondence, and personnel exchanges allowing supervision ideas and practice to be disseminated throughout the world. What we need at this stage is more awareness, and indeed more study, on the cultural aspects of supervision so that it can be integrated into different countries with culturally-sensitive adaptations.
Supervision of Marriage and Family Counselors
The adage "training shapes practice" describes the work of most marriage and family supervisors. Taking this metaphor one step backward, most marriage and family supervisors also believe that "theory shapes training." In terms of theory, the defining hallmark of marriage and family supervision during its brief history has been a systemic orientation (Smith, 1993). Other distinguishing features include a reliance on live forms of supervision, and the viewing of ethical issues within larger familial, cultural, and societal contexts (Smith, 1993).
A family system is often described as constantly evolving and self-regulating. During counseling, systemic change occurs via interactions among family members and via interactions with other systems (e.g., the supervisor, the counseling team, social service agencies, legal systems, and others) (Pirrotta & Cecchin, 1988). Furthermore, each client family can be understood as a special group of people sharing a unique history, and featuring unique operating rules and social behaviors.
For these reasons, marriage and family supervisees face a particularly complex and powerfully dynamic counseling situation in which they may experience a high level of anxiety (Pirrotta & Cecchin, 1988). Commonly used supervisory approaches, described below, may be thought of as avenues to effectively manage both the complexity and power of the family system, and any resulting supervisee anxiety (Pirrotta & Cecchin, 1988).
Anxiety also may occur when supervisees face counseling situations that parallel their own family backgrounds. Typically, rather than helping supervisees resolve family of origin concerns, marriage and family supervisors focus on helping supervisees develop clinical skills (AAMFT, 1993). Accepted practice among marriage and family supervisors is to provide competency-based supervision that is "clearly distinguishable from personal psychotherapy" (AAMFT, 1993, p. 17). This practice speaks to the general belief that with a solid repertoire of clinical goals and skills, supervisees can manage both their own emotions and issues and those of the families they counsel.
Marriage and family supervisors regard live supervision as particularly effective, because the supervisor can assist both the supervisee and the family by altering the course of counseling as it occurs. Modalities include telephone interventions, consultation breaks with trainees, and supervisor-as-co-counselor. Other conventional supervisory methods include delayed video or audiotape review, and verbal reports.
One goal of videotape review is to help trainees improve what Tomm and Wright (1979) described as perceptual and conceptual skills. After watching part of a videotaped session, supervisees might be asked, for example, to describe family members' common themes or behavioral interactions, to reflect on interventions that might work in similar future situations with client families, or to describe what they have learned about marriage and family counseling from the session. Using the supervisee's verbal reports also encourages clinical growth. Verbal reporting allows a mutual questioning process between supervisor and supervisee that helps the supervisee organize information about client families into useful frameworks for consideration (West, Bubenzer, Pinsoneault, & Holeman, 1993).
As societal perspectives change, so do marriage and family counseling and supervision. Because marriage and family supervisors view families within the larger social context, the field of marriage and family supervision may be more immediately influenced by changes in the social fabric than other related disciplines. Emerging forces affecting marriage and family counseling and supervision include the evolution of social constructionist ideas, the challenge of the feminist critique, a growing awareness and recognition of cultural diversity, and the assimilation of current research into training (Smith, 1993).
Many ideas changing marriage and family supervision arose from a social constructionist perspective. This is the perspective that "realities are created and formed by our views of the world" (West et al., 1993, p. 136). Imbedded in this view is the assumption that there is no one "correct" reality; that there may exist a multiplicity of useful opinions concerning how to live life, and how to view the world. Counseling interventions informed by social constructionism often involve questioning sequences that illuminate new perspectives on life and new possibilities for living. Still, despite these more collaborative supervisory approaches, it continues to be true that supervisors oversee the work of supervisees, and "should recognize their legal responsibilities for cases seen by their supervisees" (AAMFT, 1993, p. 12).
One constructionist supervision method uses a reflecting team of peers. The process often begins with an interview in which one person questions a supervisee about a counseling-related case or dilemma while the team silently observes. Afterwards, team members share a variety of observations and thoughts they believe may help the supervisee in working with families. Some purposes of reflecting teams include a) having supervisees actively engage in co-constructing realities through the isomorphic form-follows-function reflecting process, b) creating a collaborative and supportive training atmosphere, and c) encouraging the sharing of alternative perspectives that may help supervisees solve counseling impasses or dilemmas (Davidson & Lussardi, 1991). Team members' thoughts are shared with the supervisee in a speculative manner, and are often posed using question stems such as "I wonder what would happen if..." "Could it be that..." or "How would things be different if...."
Another constructionist perspective increasingly used in marriage and family supervision emphasizes the self-defining nature of narratives. This perspective has been most fully developed by White (1992), who believes that the narratives we construct reflect and shape our reality and the way we live our lives. During supervision, White highlights supervisees' useful narratives about their "life as a therapist" (White, 1992, p. 86). The supervisor (or a reflecting team) helps the trainee in identifying and expanding "unique outcomes" (White, 1992) in counseling sessions, those breakthrough times when the trainee did something pivotal that helped the client family. The supervisor helps the supervisee weave these unique outcomes into an evolving narrative about the trainee's "preferred way of being a counselor." Examples of possible questions are "What does this [unique outcome] say about you as a counselor?" "What do you think the family members might tell me about how you helped them?" "What does this suggest about the future direction of your work?" (White, 1992).
Throughout its history, the field of marriage and family supervision has been shaped by the systemic orientation of its practitioners. Some prominent features of this orientation are a reliance on live forms of supervision, a contextual view of client families, and an educational supervisory role that emphasizes supervisee skill-building. Promising additions to the field of marriage and family supervision involve questioning and collaborative team approaches that aid trainees in exploring and living out their ideal ways of being counselors.
Clinical Supervision in Addictions Counseling
Since the early 1970's addictions counseling has experienced significant growth and change. Addictions treatment has become "big business" and as a result, there is a new consciousness for cost management and containment. Top priorities now include reducing staff turnover, preventing employee burnout, and maintaining credentialing to meet insurance reimbursement requirements (Powell, 1993). As the field matures, continued professional training becomes increasingly important. Declining budgets within many agencies, however, often prohibit participation in costly seminars designed to promote advanced clinical skills. A solution to this dilemma is ongoing, in-house clinical supervision (Powell, 1991).
In the addictions profession's infancy, supervision was often little more than a more senior level helper telling another what to do. In addition, directions to the junior level treatment provider were primarily based upon the supervisor's personal recovery experience. Today, a more professional and systematic approach to clinical supervision is warranted. A good counselor won't necessarily be a good supervisor (Machell, 1987). Therefore, addictions supervisors need to be well versed in both advanced supervision techniques and addictions counseling.
Despite increased numbers of addictions treatment programs over the past twenty years, addictions supervision has been virtually neglected. Evidence of this is demonstrated through the limited number of journal articles written on the topic of addictions supervision. For example, a recent search for articles written on the topic resulted in only ten citations; of these, only four specifically addressed the topic of providing clinical addictions supervision.
One conspicuous exception has been the work of David Powell, who has written consistently about addictions supervision since the mid 1970s. His seminal writings have resulted in descriptive and databased articles, culminating in the recent publication of his second book on supervision in addictions counseling. Powell (1993) has developed a model of clinical supervision which blends aspects of several supervision theories. His model is developmental in nature and addresses nine descriptive dimensions of clinical supervision issues (e.g., influence, therapeutic strategy, counselor in treatment, etc.). Powell also outlines issues specific to addictions counseling and supervision. It is because of these unique aspects of addictions counseling that attention is greatly needed in the area of supervision.
Although a great number of issues related to the supervision process are similar across different types of counseling (e.g., school, mental health, family, career, etc.), at least three supervision issues are idiosyncratic to substance abuse counseling and deserve special attention (Powell, 1993). First, a significant number of addictions treatment providers are paraprofessionals. Unlike professional counselors, paraprofessionals have not fulfilled the educational requirements for a master's degree in counseling or an allied human service field. Paraprofessionals in some states are required to have little more than a high school diploma or equivalent and pass a state certification examination. They, therefore, lack formal graduate school instruction pertinent to the eight common core areas considered rudimentary to the counseling profession (i.e., human growth and development, social and cultural foundations, helping relationships, group, lifestyle and career development, appraisal, research and evaluation, and professional orientation). Paraprofessionals also may lack the fundamental counseling skills typically developed through participation in an organized sequence of practica and field-practica experiences (e.g., counseling internships) common to counselor education program graduates. The implication for supervision is clear. Supervisors must be continually aware that paraprofessionals lack fundamental counselor training. Therefore, the supervision milieu must contain a strong educational component to ensure a minimal level of skill and knowledge-based competencies. Supervisors may find that informal lectures related to counseling theories and practice of counseling techniques enhance clinical sophistication and promote greater treatment effectiveness. Undoubtedly, clinical supervisors working with paraprofessionals who lack adequate training may need to assume a greater proportion of the responsibility for treatment planning and can help paraprofessionals learn how to apply their existing skills with diverse clients.
A second complicating factor related to addictions supervision is that many professional counselors and paraprofessionals facilitating addictions treatment strongly believe that one must be in recovery to provide effective treatment (Powell, 1993). Treatment providers espousing such a "recovery-only" position may be highly resistant to supervision from non-recovering persons. Direct inquiry by the supervisor can be helpful in understanding the counselor's position on this matter. For example, the supervisor may find it helpful to ask the supervisee, "How will my not being in recovery effect our supervision relationship?" Whatever the response indicated by the supervisee, the supervisor will need to follow-up by asking, "How can we effectively work together so our clients receive the best possible treatment?" Such directness is typically prized within the substance abuse community and encourages supervisee honesty. Failure to address this important topic can result in pseudo-supervision, which wastes valuable time and inevitably impedes client progress. Even the most adamant helper who believes one needs to be in recovery to facilitate effective addictions treatment, will typically recognize the benefits of supervision when the emphasis is placed upon working together for the sake of the client.
Finally, it should be noted that to some degree all treatment providers are influenced by personal issues. In an attempt to be helpful, however, recovering helpers may be particularly vulnerable to imposing their personal experiences and unconscious beliefs on a client (e.g., what worked for me will work for you). A client's relapse also may provoke unconscious responses in the recovering helper (i.e., loss of empathy, reduction in patience, etc.) which may negatively effect the counseling relationship. Therefore, the supervisor's attentiveness to these possible issues is critical. Encouraging recovering helpers to embark on a "recovery expedition" can be helpful. Here, helpers ask others how they initiated their recovery experience and what things they find helpful to maintain chemical abstinence. Participation in the recovery expedition teaches helpers that there exists no single method in which people initiate or maintain the recovery process. Helper behaviors, cognitions and feelings resulting from a client's relapse or a client's unwillingness to commit to the abstinence process can be discussed within small group experiences. Such small group experiences can promote effective ways of dealing with anger, frustration, and fear related to the helper's own recovery.
Because supervision has been neglected within many addictions agencies, basic supervision practices are often foreign to addictions helpers. Therefore, it is critically important for addictions supervisors, as it is for all supervisors, to establish supervision practices in a nondemeaning manner which emphasizes client benefits. To secure such practices, it is imperative that addictions supervisors: 1) establish a solid working relationship with the supervisee, 2) assess the supervisee's counseling skills, 3) agree to contract for the conduct of supervisory sessions, and 4) establish learning goals with the supervisee (Borders & Leddick, 1987). Mutually agreed upon goals for supervision need to be concrete, attainable, and specific. Together, both the supervisor and the supervisee need to determine methods for attaining these goals and ways to evaluate progress in each area (Bradley & Boyd, 1989).
Effective supervision principles include consistent meeting times and a collegial atmosphere, both of which contribute to a working relationship vis-a-vis a structured hierarchy in which the supervisor dictates counseling interventions. This promotes the supervisee's "ownership" of the case. As both supervisor and supervisee become more familiar with the working relationship, professionalism grows and clients benefit. This typically leads to increased supervisee effectiveness and satisfaction.
A number of factors endemic to the addictions field make supervision within this community both challenging and rewarding. Effective supervision requires developing the skills of front-line staff at all levels and addressing possible supervisee concerns related to non-recovering treatment providers. When these issues are adequately addressed within the supervision process, the promotion of professionalism and professional identity will occur.
Strategies and Methods of Effective Supervision
A variety of strategies and methods are available to supervisors for use with counselors whom they supervise. This summary is designed to acquaint supervisors with techniques for enhancing the counseling behavior of their supervisees while also considering individual learning characteristics as depicted by the supervisee's developmental level.
To improve a supervisee's skills in working with clients, some form of assessment must be done while counseling is taking place (rather than with clients who have terminated). Using strategies that examine a supervisee's counseling behavior with current clients allows a supervisor to correct any error in assessment, diagnosis, or treatment of the client, and thus increases the probability of a successful outcome.
Whether the supervisor's purpose is to improve a supervisee's skills or to ensure accuracy, actual counselor-client interaction must be examined (Hart, 1982). Although the traditional method of counselor self-report is often used, this form of data-gathering is notoriously inaccurate. The more reliable forms of data-gathering are review of a client's case history; review of results of current psychodiagnostic testing, including a structured interview (such as a mental status exam); and, particularly, examination of the counselor-client sessions via methods such as audiotape, videotape, and observation through a one-way mirror or sitting in the sessions (Borders & Leddick, 1987).
Of the methods for reviewing counselor-client sessions, the use of live supervision (observation via television or one-way mirror) provides an opportunity to give a supervisee immediate corrective feedback about a particular counseling technique and to see how well the counselor can carry out a suggested strategy. Live supervision is effective for learning new techniques, learning new modalities (e.g., family counseling), and gaining skills with types of clients with whom the counselor is unfamiliar (West, Bubenzer, Pinsoneault, & Holeman, 1993). A live supervision strategy can be supplemented by review of a session immediately following the session or delayed a day or more.
Supervision conducted immediately following a counseling session or delayed a day or two could use an audiotape or videotape of the counseling session or use non-recorded observation through a one-way mirror or television system. Supervisors are advised to review audio or videotapes of a supervisee's counseling session prior to the supervision session in order to plan a strategy of intervention. The supervisee also should review the tape to prepare questions and discussion topics.
In immediate and delayed supervision sessions, the supervisor should focus on what the supervisee wanted to do with the client, what he/she said or did, and what he/she would like to do in future counseling sessions. Regardless of when the review of the counseling session is conducted (live, immediate, or delayed), the supervisor will have examined an actual work sample of the supervisee and no longer must rely solely on self-report. This examination is likely to aid in the supervisor's credibility in reporting on a supervisee's competence to school or agency administrators regarding retention or promotion, to state licensing officials, or to courts, should that be necessary.
Although group and peer supervision are powerful approaches (Hart, 1982), individual supervision is likely to be the main form of reviewing supervisee performance (Bernard & Goodyear, 1992). When using individual supervision, a supervisor must consider most carefully the developmental level of the supervisee (Stoltenberg & Delworth, 1987). Specifically, how skilled is the supervisee in general and specifically with the type of client in question, how anxious is the supervisee when reviewing his/her work, and what is the supervisee's learning style? Although these factors may vary somewhat independently, it is likely that less skilled counselors will be somewhat anxious. Additionally, developmental level has been conceptualized as cognitive or conceptual level and has been associated with challenging a supervisee to grasp increasingly more sophisticated concepts.
With novice supervisees, a high degree of support and a low amount of challenge or confrontation is advisable (Howard, Nance, & Myers, 1986). When learning style is considered, a micro-training approach focusing on specific skills might be used, demonstrated by the supervisor, and then practiced in the supervision session by the supervisee in a role-play. However, some novice or anxious supervisees learn best by a macro approach; that is, having a clear overview of the goals of the session, expected role of the counselor, client typology, and specific client characteristics such as race, gender, culture, socioeconomic status, family background, and personality characteristics. For these supervisees, use of written case study materials or an IPR (Interpersonal Process Recall) approach (Kagan 1980) might be better than a micro-training approach.
With more competent supervisees, the focus may be placed on more advanced skills or on more complex client issues. Either a micro or macro approach may be used. Using videotape is suggested for these supervisees, as they are more likely to be able to assimilate the larger amount of data provided by videotape compared to that provided by audiotapes, which are suggested for use with less competent supervisees.
With more skilled and more confident supervisees, exploration of issues usually found to be threatening also may be examined. Such issues include relationship of theoretical orientation to technique employed, personal style, counselor feelings about the client, and learning new and innovative techniques or modalities (individual, group, or family counseling).
Developmentally, a supervisor should expect that supervisees progress to more independent functioning whereby supervisees pick the clients and client issues which they wish to review as well as the personal issues or client dynamics they wish to examine. Audio or videotape segments can be selected for review rather than listening to entire tapes. At this more advanced stage of supervision, the supervisor may feel more like a colleague or a consultant than a teacher, which allows the supervisor to share more examples of his/her own counseling experience conveyed either through self report or via audiotapes (Hart, 1982). With more skilled and confident supervisees, collaboration such as co-leading a group or co-counseling with a family can be conducted. Although such collaboration strategies have been advocated for novice counselors, maximum benefit more likely may be achieved by supervisees who are more confident in their skills and who have developed basic skills sufficiently to be able to perceive and learn the complex skills that a supervisor is likely to use when working with a group or family.
Supervision for the clinical/counseling functions of counselors in schools and agencies should focus on actual work samples. Using a micro-training versus a more macro approach should depend on what works best for a particular supervisee, along with the supervisee's level of skill and confidence.
A counselor's learning and continued development typically is fostered through concurrent use of individual and group supervision. Group supervision is unique in that growth is aided by the interactions occurring among group members. Counselors do not function in isolation, so the group becomes a natural format to accomplish professional socialization and to increase learning in a setting that allows an experience to touch many. Supervision in groups provides an opportunity for counselors to experience mutual support, share common experiences, solve complex tasks, learn new behaviors, participate in skills training, increase interpersonal competencies, and increase insight (MacKenzie, 1990). The core of group supervision is the interaction of the supervisees.
Collaborative learning is a pivotal benefit, with the supervisees having opportunities to be exposed to a variety of cases, interventions, and approaches to problem solving in the group (Hillerband, 1989). By viewing and being viewed, actively giving and receiving feedback, the supervisee's opportunities for experimental learning are expanded; this characterizes group supervision as a social modeling experience. From a relationship perspective, group supervision provides an atmosphere in which the supervisee learns to interact with peers in a way that encourages self-responsibility and increases mutuality between supervisor and supervisee.
Groups allow members to be exposed to the cognitive process of other counselors at various levels of development (Hillerband, 1989). This exposure is important for the supervisee who learns by observing as well as speaking. Finally, hearing the success and the frustrations of other counselors gives the supervisee a more realistic model by which they can critique themselves and build confidence.
Bernard and Goodyear (1992) summarized the typical foci of group supervision: didactic presentations, case conceptualization, individual development, group development, organization issues, and supervisor/supervisee issues. Models for conducting group supervision detail experiential affective approaches designed to increase the supervisees' self-concept and ability to relate to others, and/or cognitively focused activities, such as presenting cases which broaden the counselor's ability to conceptualize and problem-solve. While the literature provides information on how to conduct these activities, less obvious are the reasons why certain activities are selected and when the activities are most appropriate to use.
Borders (1991) offered a model that details reasons with the suggested activities. Groups may be used to increase feedback among peers through a structured format and assignment of roles (e.g., client, counselor, and other significant persons in client's life) while reviewing tapes of counseling sessions. "Role-taking" encourages supervisees to assume more responsibility in the group as feedback is offered from several viewpoints.
Models provide almost no attention to how the supervisor is to make judgments about the use of "group process." The supervisor has little guidance about how to use the collective nature of the group to foster counselor development.
Similarly, the development of the group has not been the focus of researchers--only a few empirical studies have been conducted to examine group supervision. Holloway and Johnston (1985), in a review of group supervision literature from 1967 to 1983, suggested that peer review, peer feedback, and personal insight are all possible to achieve while doing supervision in groups. Focus on the development of the group is not apparent in these studies, yet the term "group supervision" is defined with an emphasis on the use of group process to enhance learning.
As above indicates, the group supervision format requires that supervisors be prepared to use their knowledge of group process, although how this is to be done is very unclear. A recent naturalistic study of four groups across one semester provided some initial insights. Werstlein (1994) found that guidance and self-understanding were cited by supervisor and supervisees as the most important "therapeutic factors" (Yalom, 1985) present in their group. In addition, the initial stages of group development were apparent. Less noticeable were the later stages of group development which are characterized by higher risk behaviors that increase learning (Werstlein, 1994). Clearly, additional work is needed to clarify the process variables of group supervision and the role of the group leader (supervisor).
Based on existing group supervision literature and small group literature, the following guidelines are offered to supervisors who wish to address process in group supervision:
1. Five to eight supervisees meeting weekly for at least one and one half hours over a designated period of time (i.e., semester) provides an opportunity for the group to develop.
2. Composition of the supervision group needs to be an intentional decision made to include some commonalities and diversities among the supervisees (i.e., supervisee developmental level, experience level, or interpersonal compatibility).
3. A pre-planned structure is needed to detail a procedure for how time will be used and provide an intentional focus on content and process issues. This structure can be modified later in accordance with group's climate.
4. A pre-group session with supervisees can be used to "spell-out" expectations and detail the degree of structure. This session sets the stage for forming a group norm of self-responsibility and does not interfere with group development.
5. Supervisors may use "perceptual checks" to summarize and reflect what appear to be occurring in the here-and-now in the group. Validating observations with the supervisees is using process. Be active, monitor the number of issues, use acknowledgements, and involve all members.
6. Supervisees' significant experiences may be the result of peer interaction that involves feedback, support, and encouragement (Benshoff, 1992). Exploring struggles supports learning and problem-solving.
7. Bernard and Goodyear (1992) provided an excellent overview of the group supervision literature. Many ideas are available for structuring case presentations and the entire group sessions. Also, reviewing materials on group facilitation with a particular focus on dealing with process is essential.
8. Competition is a natural part of the group experience. Acknowledge its existence and frame the energy in a positive manner that fosters creativity and spontaneity.
In preparation for group supervision, communicate the following to the supervisees about how to use group process:
1. Learning increases as your listening and verbal involvement increases. Take risks and reveal your responses and thoughts.
2. Decrease your personalization of frustration by sharing with your peers. You will be surprised how often other supervisees are experiencing the same thoughts and feelings.
3. Intentionally look for similarities as you contemplate the relationships you have with your peers in the group with the relationships you are having with clients. Discuss similarities and differences.
4. Progress from client dynamics to counselor dynamics as you present your case. Know ahead of time what you want as a focus for feedback and ask directly.
Integration of knowledge and experience is greatly enhanced by group supervision. Existing literature emphasizes the importance of a structure that outlines procedures for case presentation and supervisee participation; less obvious are approaches to address group development. It is essential the we fill in these gaps in the literature by systematically gathering data that establishes the unique aspects of using groups for supervision.
The Supervisory Relationship
All conversation about supervision contains messages, implicit if not explicit, about the supervisory relationship. Those who perform supervision are necessarily in contact with those whom they supervise; some sort of relationship exists. In its broadest sense the term "relationship" refers merely to the manner in which the supervisor and counselor are connected as they work together to meet their goals, some of which are common and some of which are idiosyncratic. Within the context of particular supervisory orientations, however, the nature and function of the relationship must be defined in specific terms.
This Digest reviews perspectives on the supervisory relationship which have been described in the recent supervision literature. For purposes of organizational clarity, three dimensions will be addressed: the relative importance of the relationship within the total supervision process; variables which influence the relationship; and how the relationship differs when working with experienced versus inexperienced counselors.
Members of the Association for Counselor Education and Supervision (ACES) rated supervisor personal traits and qualities and facilitating skills as more important than conceptual skills, intervention skills, management skills, and knowledge of program management and supervision. Respondents rejected the notion that these traits and qualities cannot be taught, that they are the products of life-long socialization (Dye, 1987). These results suggest that the ability to form and sustain relationships is more important than certain knowledge and skill factors, and that effective supervisory behaviors can be learned.
Current descriptions of counseling supervision invariably include discussion of the supervisor-counselor relationship, and the means by which the individuals communicate, manage the process of reciprocal influence, affiliate, make decisions, and accomplish their respective tasks. However, the relative importance of the relationship and the role it plays varies according to supervisory orientation. For some, the relationship is the sine qua non of supervision (Freeman, 1992) while for others it is a necessary but less-than-defining variable (Linehan, Ch. 13, and Wessler & Ellis, Ch. 14, both in Hess, 1980). Thus, while the nature and function of the relationship differ according to several variables, which are discussed below, recent supervision literature usually includes explicit attention to this vital process.
The supervisory relationship is subject to influence by personal characteristics of the participants and by a great many demographic variables. Several major sources of influence, some static and others dynamic in nature, have been identified and discussed in reviews of the supervision literature. Among static factors receiving prominent attention are gender and sex role attitudes, supervisor's style, age, race and ethnicity, and personality characteristics (Borders & Leddick, 1987; Leddick & Dye, 1987). Dynamic sources are those which may exist at only certain stages of the relationship or which are always present but in varying degrees or forms, such as process variables (stages: beginning vs. advanced; long term vs. time limited); and relationship dynamics (resistance, power, intimacy, parallel process, and the like) (Borders et al., 1991).
Conflict, the nature and magnitude of which is likely to change across time, can have a significant influence upon the relationship. Bernard and Goodyear (1992) pointed out that conflict occurs in all relationships, and in the supervisory relationship, specifically, some common origins are the power differential between the parties, differences relative to the appropriateness of technique, the amount of direction and praise, and willingness to resolve differences. These influences can be moderated to some extent by mutual respect. Because of the greater power inherent in the role, the supervisor should take the lead in modeling this attitude if it is to be attained by both parties (Bernard & Goodyear, 1992).
Citing their own and others' research, Ronnestad and Skovholt (1993) presented an extensive description of effective supervision of the beginning and advanced graduate students. They concluded that "There is reasonable validity to the perspective that what is good supervision depends on the developmental level of the candidate" (1993, p. 396). Supervisors of beginning students should provide high levels of encouragement, support, feedback, and structure. They explained carefully that the relationship with advanced students is typically more complex because students at this stage tend to vacillate between feeling professionally insecure and professionally competent. The supervisor should take responsibility for creating, maintaining, and monitoring the relationship which serves to provide structure and a mediating role while students are in turmoil (Ronnestad & Skovholt, 1993). Thus, supervisors of inexperienced counselors serve in a well-defined role as patient teachers; there is an emphasis upon structure and instruction. As students acquire experience, the need for instruction diminishes, and it is the supervisory relationship which provides a supportive context as advanced students assess and reassess their professional competencies and personal qualifications.
Two additional sources of dynamic influence on the supervisory relationship have been identified by Olk and Friedlander as role ambiguity and role conflict (1993). Role ambiguity is defined as uncertainty about supervisory expectations and methods of evaluation, while role conflict refers to expectations associated with the role of student in contrast with the role of counselor and colleague. Olk and Friedlander found that role ambiguity was more prevalent across training levels than role conflict, but that the effects diminished as the student gained counseling experience. Role conflict, however, seems to be more prevalent among those with more experience. They suggested that supervisors remain alert for signs of such conflict, and that teaching explicitly about roles and expectations may minimize threats to the supervisory relationship (Olk & Friedlander, 1993). These results relative to implications for the relationship as a consequence of learning stage are consistent with those of Ronnestad and Skovholt (1993), described above.
1. The body of literature on the subject of counseling supervision, including the supervisory relationship, has grown rapidly during recent years.
2. Instructional materials for teaching supervision methods and processes are available.
3. Knowledge of the supervisory relationship and competencies in establishing and maintaining effective relationships can be acquired through a combination of didactic, laboratory, and practical experience.
4. The supervisory relationship is an integral component in virtually all supervision orientations, though important differences exist in quality and function.
5. The definition of an appropriate and effective supervisory relationship varies according to several identifiable fixed (static) and changeable (dynamic) variables. The relationship should be structured accordingly with the knowledge and consent of both supervisor and counselor.
Ethical and Legal Dimensions of Supervision
In recent years, it has become generally accepted that supervision draws upon knowledge and skills that are different than, and go beyond, those of psychotherapy. Similarly, the ethics and legal imperatives regarding supervision both encompass psychotherapy issues and go beyond them. Furthermore, because supervision is a triadic rather than a dyadic relationship, the supervisor must always attend to the need for balance between the counseling needs of clients and the training needs of the counselor.
With the increase of litigation in American society over the past generation, ethics and law have become intermingled (Bernard & Goodyear, 1992). It is important for the supervisor to remember, however, that ethics call the supervisor to a standard of practice sanctioned by the profession while legal statutes define a point beyond which a supervisor may be liable. For our purposes here, the functional interconnectedness between ethics and the law will be accepted.
Competence is an increasingly complex issue as mental health and supervision have become more sophisticated enterprises. Implications of both counselor competence and supervisor competence will be described here briefly.
By definition, a supervisee is a person who is not yet ready to practice independently. It is for this reason that supervisors are held responsible for what happens with clients being seen by the supervisee (Harrar, VandeCreek, & Knapp, 1990). At the same time, counselors must be challenged in order to become more expert. This, then, is the supervisor's tightrope: providing experiences that will stretch the counselor's ability without putting the client in danger or offering substandard care. Whenever a close call must be made, supervisors must remember that their obligation is to the client, the public, the profession, and the supervisee -- in that order (Sherry, 1991). Therefore, the supervisor continually decides if the supervisee is good enough on a consistent basis to work with any particular client (ACES, 1993).
First, the supervisor needs to know everything, and more, than is expected of the supervisee. Secondly, the supervisor must be expert in the process of supervision. It is not enough that clients are protected as a result of supervision; the contract between supervisor and supervisee dictates that supervision must ultimately result in better counseling skills for the supervisee. In order to accomplish this, it is generally accepted that the supervisor receive training in performance of supervision as well as supervision of supervision.
For both counselors and supervisors, any dual relationship is problematic if it increases the potential for exploitation or impairs professional objectivity (Kitchener, 1988). There has been greater divergence of opinion about what constitutes an inappropriate dual relationship between supervisor and counselor than between counselor and client. Ryder and Hepworth (1991), for example, stated that dual relationships between supervisors and supervisees are endemic to many educational and work contexts. Most supervisors will, in fact, have more than one relationship with their supervisees (e.g., graduate assistant, co-author, co-facilitator). The key concepts remain "exploitation" and "objectivity." Supervisors must be diligent about avoiding any situation which puts a supervisee at risk for exploitation or increases the possibility that the supervisor will be less objective. It is crucial, however, that supervisors not be intimidated into hiding dual relationships because of rigid interpretations of ethical standards. The most dangerous of scenarios is the hidden relationship. Usually, a situation can be adjusted to protect all concerned parties if consultation is sought and there is an openness to making adjustments in supervisory relationships to benefit supervisee, supervisor and, most importantly, clients.
As part of the mandate of competence, the supervisor must determine not only if the supervisee has the knowledge and skill to be a good counselor, but if he or she is personally ready to take on clinical responsibility (Kurpius, Gibson, Lewis, & Corbet, 1991). The issue of personal readiness can lead the supervisor to blur the roles of supervisor and therapist in an attempt to keep the supervisee functional as a counselor. This is problematic for two reasons: (1) it compromises the objectivity of the supervisor, especially in terms of evaluation; (2) it may allow an impaired counselor to continue to practice at the risk of present and future clients.
Informed consent is key to protecting the counselor and/or supervisor from a malpractice lawsuit (Woody, 1984). Simply, informed consent requires that the recipient of any service or intervention is sufficiently educated about what is to transpire, the potential risks, and alternative services or interventions, so that he or she can make an intelligent decision about his or her participation. Supervisors must be diligent regarding three levels of informed consent (Bernard & Goodyear, 1992): (1) the supervisor must be confident that the counselor has informed the client regarding the parameters of counseling; (2) the supervisor must be sure that the client is aware of the parameters of supervision (e.g., that audiotapes will be heard by a supervision group); and (3) the supervisor must inform the supervisee about the process of supervision, evaluation criteria, and other expectations of supervision (e.g., that supervisees will be required to conduct all intake interviews for a counseling center in order to increase interview and writing skills).
Due process is a legal term that insures one's rights and liberties. While informed consent focuses on the entry into counseling supervision, due process revolves around the idea that one's rights must be protected from start to finish. Again, supervisors must protect the rights of both clients and supervisees. An abrupt termination of a client could be a due process violation. Similarly, a negative final evaluation of a supervisee, without warning and with no opportunity to improve one's functioning, is a violation of the supervisee's due process rights.
Confidentiality is an often-discussed concept in supervision because of some important limits of confidentiality both within the therapeutic situation and within supervision. It is imperative that the supervisee understands both the mandate of honoring information as confidential (including records kept on the client) as well as understanding when confidentiality must be broken (including the duty to warn potential victims of violence) and how this should be done. Equally important is a frank discussion about confidentiality within supervision and its limits. The supervisee should be able to trust the supervisor with personal information, yet at the same time, be informed about exceptions to the assumption of privacy. For example, supervisees should be apprised that at some future time, their supervisors may be asked to share relevant information to State licensure boards regarding their readiness for independent practice; or supervisors may include supervision information during annual reviews of students in a graduate program.
Supervisors should not shun opportunities to supervise because of fears of liability. Rather, the informed, conscientious supervisor is protected by knowledge of ethical standards and a process that allows standards to be met consistently. There are three safeguards for the supervisor regarding liability: (1) continuing education, especially in terms of current professional opinion regarding ethical and legal dilemmas; (2) consultation with trusted and credentialed colleagues when questions arise; and (3) documentation of both counseling and supervision, remembering that courts often follow the principle "What has not been written has not been done" (Harrar, Vandecreek, & Knapp, 1990).
As gatekeepers of the profession, supervisors must be diligent about their own and their supervisees' ethics. Ethical practice includes both knowledge of codes and legal statutes, and practice that is both respectful and competent. "In this case, perhaps more than in any other, supervisors' primary responsibility is to model what they hope to teach" (Bernard & Goodyear, 1992, p. 150).
At the practicum stage of supervision (when students work with actual clients under direct supervision), technological aids are rapidly opening up new windows of opportunity for both live and delayed supervision.
The telephone and the "bug-in-the-ear" are probably the two best known traditional methods of live supervision. A supervisor, observing a session from an adjacent room through a one-way mirror, sends and receives messages to the counseling students as the session progresses. One limitation of these approaches, however, has been its disruptive intrusion on the counseling process.
More recently, two networked computers have been employed to accomplish the same interchange (Neukrug, 1991). The supervisor observing behind the mirror transmits messages by keyboard entry to the supervisee, who reads the messages and can respond similarly with keyboard entry to the supervisor.
Two networked computers offer additional opportunities. A client completing a standardized instrument online, such as the Diagnostic Interview for Children and Adolescents-Revised(TM) (Reich et al., 1990), could receive the results during the same session. Persons in the observation room could send additional interpretative hypotheses, aided by access to databases either on CD-ROM locally or through modem and telephone link to a remote location, to the supervisee.
Whether networked computers offer less disruptive intrusion than the telephone or "bug-in-the-ear" is an open question. New advances in personal digital assistants (PDA's), such as the Apple Newton(TM), may provide less intrusive alternatives. The PDA is a small, pocketsized device that recognizes handwritten communication. PDA's will ultimately be capable of simplifying a variety of tasks in supervision with less intrusion upon the counseling process. These could include:
*two-way, wireless communication
*access to remote locations for database searches or journal inquiry, e.g. ERIC
*phone calls and faxes
*retrieval and printing of forms and documents
*test scoring and interpretation.
After a session is completed, students frequently replay audio and videotapes for supervision purposes. Increased availability and affordability of VCR's has allowed students to review tapes and prepare selected segments for later process in supervision meetings. Dual track recording has allowed supervisors to record comments on one track while the session's original soundtrack is preserved on the alternate track. Dual track recording has also been used to accommodate bilingual translations.
The use of technology in delayed supervision has also been reported to review psychophysiological data where emotional states of the supervisee were inferred from electromyograph (EMG), skin conductance levels (SCL), and skin temperature monitoring. Froehle (1984) described videotaping a split screen, with one camera fixed on the counseling session and a second concurrently filming the psychophysiological readings.
"Disk swapping" between supervisor and supervisee could allow for paperless submission and evaluation of such practicum paperwork as case notes and case studies. These case notes and case studies, combined with segments of videotaped counseling sessions transferred to disc, could lead to an "electronic portfolio" to demonstrate attainment of specific counseling skills competencies.
When the supervisee leaves the campus for internship, communication with the supervisor is often limited to phone calls or voice mail messages, periodic supervision meetings held weekly or monthly, and anxiety-filled onsite visits. It can be hours, days, or even weeks before a message is returned.
Advances in electronic connectivity present several innovative possibilities for more efficient internship communication utilizing a computer, modem, phone jack, communications software, and an account on an electronic network. The most well known current examples of electronic connectivity are through services such as the Internet, America On-Line(TM), CompuServ(TM), and Prodigy(TM).
Advantages of electronic connectivity might best be observed by examining TeacherNet (Casey, 1990). TeacherNet, begun in 1989 at California State University, Long Beach, links through electronic conferencing and e-mail, 15 student teachers, 7 classroom teachers, and 11 university based resource people (the direct supervisor plus experts in related fields). Members of TeacherNet sign in with their password through their computer and modem to a local phone number. They then check the "teacher's lounge" for public notices that may be of interest and enter reactions or new postings for others to read. They may choose to send or review private communications exchanged with one or several other network participants. Any written communication can be saved on the members' own computer for future reference. Student teachers are given free loan by the university of the hardware and software for the year, in exchange for a commitment to log on daily to the TeacherNet. A 1990 evaluation of the project indicated participants experienced:
*a widespread sense of connectedness over isolation,
*more frequent and more thoughtful contact between supervisor and supervisee,
*expanded opportunities for collaboration and input from a wider spectrum of consultants,
*enthusiasm for the expanded range of topics the network triggered, including job frustrations and satisfactions, classroom management strategies, and career opportunities, and
*satisfaction with efficient exchange of paperless communication that is easily stored, edited, and retrieved.
The International Counselor Network (ICN) is another model of electronic connectivity that can provide supervision opportunities. Accessible through Internet (and America OnLine(TM) to those without direct Internet connectivity), the ICN operates through Vanderbilt University and offers nonconfidential supervision through hundreds of counseling practitioners and graduate students around the world. Initial public communication through the ICN can lead to direct e-mail communication between individuals. As of January 1994, over 200 counselors subscribed to the ICN. A cursory review of the hundreds of messages posted in 1993 shows discussions on such topics as AIDS/HIV, learning styles inventories, early intervention programs, consultation, child abduction, and suicide prevention. A large, public network like the ICN appears to offer informational resources while a smaller network like TeacherNet seems to emphasize interpersonal process. Other "mailserv's" and "listserv's" of interest to counselors continue to grow through the Internet and elsewhere.
Compressed video is another form of supervision among remote locations. The University of Wyoming coordinates a video telephone conference call among Wyoming counselors at a scheduled, periodic meeting time. Unlike the ICN, the compressed video conference operates in "real time," with all participants on the telephone lines simultaneously.
A wide range of limitations and ethical considerations must be considered when using making appropriate use of technology. Confidentiality, for example, is nearly impossible to guarantee when using wireless communication over airwaves or sending messages through the INTERNET. For a more detailed discussion on limitations and ethical considerations, the reader is encouraged to reference Engels et al. (1984) and Phillips (1984).
Technological advances have created a multitude of challenges and opportunities for counselors in supervision. From practicum to internship, strategies for improving the supervision experience can be utilized with the appropriate ethical integration of technology.
It has been my very good fortune to have been supervised by several good supervisors. These supervisors were quite different from each other in personality and their supervision style, focus, and goals. One insisted that the person of the counselor is of greatest importance, and then struggled with me to discover who that person was for me and how to use it in my relationships with clients. Another focused on more concrete behaviors and cognitions, forcing me to learn how to articulate what I was doing and why. A third introduced me to a new theoretical perspective on counseling, broadening my conceptualizations of clients and my interactions with them. With each, I felt tremendous challenge to stretch and grow, buffered by an implied belief that I could achieve their goals for me. Each seemed to have been assigned to me at just the right time in my professional development, and/or they recognized my needs at that time and were able to provide what I needed. The influence of each of these supervisors can been seen in my counseling and supervision work today. Only one of these supervisors had received any supervision training.
Like other counselors, I also have had less memorable supervision, and have heard numerous colleagues' and students' horror stories about their unpleasant experiences as supervisees. Some describe busy supervisors or those who lacked interest in their supervisees and the supervision process. Some cite supervisors who seemed most interested in putting in the minimum required time with as little work and as few hassles as possible. Others remember mismatches in theoretical orientation to counseling or critical personality traits.
All of these experiences, and my own professional work in the area, have convinced me that potentially good supervisors are born, but all benefit from training experiences in which they focus on supervision knowledge and skills, reflect on their role and responsibilities, and receive input from others about their work as supervisors. These experiences also have led me to ask questions about what distinguishes "good" supervisors from "bad" supervisors and how counselors become effective supervisors.
Thus far, there are too few answers to my questions. The supervisor by far has received the least attention of any variable in the supervision enterprise. To date, only a few researchers have focused on supervisor qualities and skills, and only three very brief models of supervisor development have been proposed. What we do know is summarized below, drawing from reviews by Worthington (1987), Carifio and Hess (1987), Dye and Borders (1990), Borders et al. (1991), and Borders (in press).
Good supervisors seem to have many of the same qualities of good teachers and good counselors. They are empathic, genuine, open, and flexible. They respect their supervisees as persons and as developing professionals, and are sensitive to individual differences (e.g., gender, race, ethnicity) of supervisees. They also are comfortable with the authority and evaluative functions inherent in the supervisor role, giving clear and frequent indications of their evaluation of the counselor's performance. Even more, good supervisors really enjoy supervision, are committed to helping the counselor grow, and evidence commitment to the supervision enterprise by their preparation for and involvement in supervision sessions. These supervisors evidence high levels of conceptual functioning, have a clear sense of their own strengths and limitations as a supervisor, and can identify how their personal traits and interpersonal style may affect the conduct of supervision. Finally, good supervisors have a sense of humor which helps both the supervisor and supervisee get through rough spots in their work together and achieve a healthy perspective on their work. Such personal traits and relationship factors are considered as significant as technical prowess in supervision.
In terms of professional characteristics (roles and skills), good supervisors are knowledgeable and competent counselors and supervisors. They have extensive training and wide experience in counseling, which have helped them achieve a broad perspective of the field. They can effectively employ a variety of supervision interventions, and deliberately choose from these interventions based on their assessment of a supervisee's learning needs, learning style, and personal characteristics. They seek ongoing growth in counseling and supervision through continuing education activities, self-evaluation, and feedback from supervisees, clients, other supervisors, and colleagues.
Good supervisors also have the professional skills of good teachers (e.g., applying learning theory, developing sequential short-term goals, evaluating interventions and supervisee learning) and good consultants (e.g., objectively assessing problem situation, providing alternative interventions and/or conceptualizations of problem or client, facilitating supervisee brainstorming of alternatives, collaboratively developing strategies for supervisee and client growth). In fact, good supervisors are able to function effectively in the roles of teacher, counselor, and consultant, making informed choices about which role to employ at any given time with a particular supervisee.
Existing models of supervisor development (Alonso, 1983; Hess, 1986; Stoltenberg & Delworth, 1987) give brief descriptions of supervisor stages of growth, and are quite different in their theoretical perspectives. Two assume that supervisors receive no training for their role, but change with experience and age. Only a few researchers have investigated novice supervisors; even fewer have conducted comparison studies of novice and experienced supervisors. These writings provide a fairly consistent profile of novices, but little information is available about how novices learn about supervision and develop a supervisor identity, how they think and behave at various stages of development, and what factors encourage (and discourage) their development.
In general, novices are characterized as self-doubtful, leery of being evaluative or confrontive, tending to be highly supportive and/or didactic, concrete, structured, and task-oriented. There is little flexibility in approach, with novices relying on their more familiar counseling skills and focusing more on the client and client and counseling dynamics than on counselor development. Novice supervisors also seem to have personalized supervision styles that remain stable across supervisees.
Perhaps surprisingly, comparison studies have yielded few differences between novices and experienced supervisors. In general, more experienced supervisors seem to use more teaching and sharing behaviors, and they and their supervisees are more active. Ratings of effectiveness, however, find novices to be equally effective as experienced supervisors.
There are several plausible explanations for these results. First, novices typically supervise beginning counselors, which may be the pairing that allows novices to be and/or to be seen as most effective by their supervisees. Second, "experienced" supervisors in these studies often are relatively inexperienced and, most importantly, typically have received no training in supervision. In other words, comparisons of inexperienced and experienced are not representative of comparisons of novice and expert. In fact, the expert supervisor has yet to be described empirically, particularly in terms of their actual behaviors and conceptual skills.
One joy and challenge of being a supervisor is the necessity of using skills from a variety of professional roles and knowing when to use each one. I must draw on my teaching, counseling, and consultation background, but integrate them in a unique way. During one supervision hour I may be highly structured; at the next, I may deliberately avoid giving suggestions. With each I am operating on today's goals within a larger context of long-term development.
A second challenge is the necessity of attending to several different levels at the same time. I am responsible for what happens to the client and to the counselor. I must be aware of counselor-client dynamics, supervisor-supervisee dynamics, and any similarities between them. I must think about what the client needs, then determine how I can help the counselor provide that for the client. I must consider the impact of the client on the counselor, client on supervisor, counselor on client, and counselor on supervisor, in addition to the supervisor's impact on counselor and client. I must assess the counselor's readiness for my intervention, taking into account a myriad of factors (e.g., developmental level, skill level, anxiety and typical ways of handling anxiety, motivation, learning style, response to authority figures, etc.). I must be cognizant of maintaining an optimum balance of challenge and support during the supervision session and across time. I have to be aware of all of these dynamics and then, almost instantaneously, create an elegant response.
As a novice supervisor, these were the exhilarating aspects of my new professional role, and they are the aspects that my students repeatedly cite as the great fun in doing supervision. When I think back to time spent with my own good supervisors, this is, gratefully, what I received. Today, as an experienced supervisor, these are the standards I set for myself--and sometimes achieve. And, as a supervisor educator, these are the measures I offer supervisor trainees so that they, too, can become "good supervisors."
Some recent models of counseling supervision have tended to be task oriented, emphasizing such competencies as case conceptualization and the attending skills of the counselor. However, attention is also needed to increase counselor self-awareness regarding the therapeutic relationship. Interpersonal Process Recall (IPR) is a supervision strategy developed by Norman Kagan and colleagues that empowers counselors to understand and act upon perceptions to which they may otherwise not attend. The goals of IPR are to increase counselor awareness of covert thoughts and feelings of client and self, practice expressing covert thoughts and feelings in the here and now without negative consequences, and, consequently, to deepen the counselor/client relationship.
IPR is built around the notion that counselors' selective perceptions of surface issues block their therapeutic efforts more than any other variable (Bernard, 1989). IPR is based on two elements of human behavior: that people need each other and that people learn to fear each other. Kagan (1980) proposed that people can be the greatest source of joy for one another. However, because a person's earliest imprinted experiences are as a small being in a large person's world, inexplicit feelings of fear and helplessness may persist throughout one's life. These fears are most often unlabeled and uncommunicated. This combination of needing but fearing others results in an approach-avoidance syndrome as persons search for a "safe" psychological distance from others. As a result, people often behave diplomatically.
Kagan (1980) believed the "diplomatic" behavior of counselors is expressed in two ways: "feigning of clinical naivete" and tuning out client messages. Feigning clinical naivete, most often an indication that counselors are unwilling to become involved with clients at a certain level, occurs when counselors act as if they did not understand the meaning behind client statements. Tuning out occurs most often among inexperienced counselors who are engrossed in their own thought process, trying to decide what to do next. The result is that the counselor misses messages from the client, some of which may seem obvious to the supervisor. Thus, a wealth of material in counseling sessions is acknowledged by neither the client nor the counselor. Interactions occur on many levels, but clients and counselors label only a limited range of these interactions (Kagan, 1980). IPR is designed to help counselors become more attuned to dynamics of the counselor/client relationship that they may be missing due to their tendency toward diplomatic behavior.
In IPR, counselors (and sometimes clients) reexperience the counseling session via videotape or audiotape in a supervision session that can be characterized by a supportive and nonthreatening environment. The supervisor functions as a consultant, taking on the role of inquirer during the IPR session. Because the supervisee is considered to be the highest authority about the experiences in the counseling session, the inquirer does not attempt to teach the counselor or ask leading questions (Bernard, 1989), but rather adopts a learning-by-discovery philosophy and functions in an assertive and even confrontive, but nonjudgemental, capacity (Kagan, 1980).
IPR is most often conducted with the counselor alone, but in some instances the inquirer may meet with the counselor and his/her client or with the client alone. Mutual recall sessions often help counselors learn to communicate with clients about the here-and-now of their interaction for future counseling sessions.
The following steps are intended as a guideline for conducting a recall session:
1. Review the tape (audio or video) prior to the supervision session. As it is not typically possible to review the entire tape during the recall session, it is important to preselect sections of tape that are the most interpersonally weighted (Bernard & Goodyear, 1992). If it is not possible to preview the tape, ask the supervisee to preselect a section of tape for the recall session.
2. Introduce the recall session to the supervisee and create a nonthreatening environment, emphasizing that there is more material in any counseling session than a counselor can possibly attend to, and that the purpose of the session is to reflect on thoughts and feelings of the client and the counselor during the session that will be reviewed.
3. Begin playing the tape; at appropriate points, either person stops the tape and asks a relevant lead (see below) to influence the discovery process. If the supervisee stops the tape, he/she will speak first about thoughts or feelings that were occurring AT THAT TIME in the counseling session. The supervisor facilitates the discovery process by asking relevant open-ended questions (see below). During this period of inquiry, attend to supervisee's nonverbal responses and process any incongruence between nonverbal and verbal responses.
4. During the recall session, do not adopt a teaching style and teach the supervisee about what they could have done differently. Rather, allow the supervisee to explore thoughts and feelings to some resolution (Bernard & Goodyear, 1992). This is often more difficult than it seems.
Questions can be worded to enhance supervisees' awareness of their blind spots at their own level of readiness and capability (Borders & Leddick, 1987)(e.g., focus on client nonverbals versus counselor's internal reaction to the client). To further an understanding of the inquirer role, the following inquirer leads are provided from various sources (Bernard & Goodyear, 1992; Borders & Leddick, 1987; Kagan, 1980):
1. What do you wish you had said to him/her?
2. How do you think he/she would have reacted if you had said that?
3. What would have been the risk in saying what you wanted to say?
4. If you had the chance now, how might you tell him/her what you are thinking and feeling?
5. Were there any other thoughts going through your mind?
6. How did you want the other person to perceive you?
7. Were those feelings located physically in some part of your body?
8. Were you aware of any feelings? Does that feeling have any special meaning for you?
9. What did you want him/her to tell you?
10. What do you think he/she wanted from you?
11. Did he/she remind you of anyone in your life?
IPR, then, provides supervisees with a safe place to examine internal reactions through reexperiencing the encounter with the client in a process recall supervision session. IPR also has been shown to be useful in supervisor-supervisee relationships (Bernard, 1989), group supervision (Gimmestad and Greenwood, 1974), and peer supervision (Kagan, 1980).
Research has consistently supported the use of IPR as an effective medium for supervision. For example, Kagan and Krathwohl (1967) and Kingdon (1975) found that clients of counselors being supervised with an IPR format fared better than clients of counselors supervised by other methods. The model has been demonstrated to be effective with experienced counselors, entry-level counselors and paraprofessionals (Bernard, 1989). It is possible, however, to magnify the interpersonal dynamics between the counselor and client to the point of distortion (Bernard and Goodyear, 1992). Thus, IPR is not recommended as the sole approach to supervision. Used effectively and in conjunction with other supervision approaches, IPR provides counselors with the opportunity to confront their interpersonal fears, understand complex counselor/client dynamics, and maximize the interpersonal encounter with their clients (Kagan, 1980).
Certification of professional counselors is presently viewed in two realms, that of state regulation and of national voluntary credentialing. Many states use the term certification in two contexts, school counselor certification and certification to practice counseling privately for a fee. In this digest, we will consider national voluntary certification only.
The first national certification began in 1972 with the incorporation of the Commission for Certification of Rehabilitation Counselors. In 1979, the National Academy for Certified Clinical Mental Health Counselors began certifying counselors trained in the specialty of clinical mental health counseling. Soon after, in 1984, the National Vocational Guidance Association (now the National Career Development Association) began certifying career counselors. The International Association of Marriage and Family Counselors has begun a certification process. Clinical mental health counselors and career counselors have merged with the National Board for Certified Counselors to become a specialty certification of the general practice of counseling.
Across the realm of certifications in the counseling profession is the common thread of assessing individual counselors, training, supervision, experience, and knowledge; the similarities across the processes are remarkable.
Counselor certification begins with individuals providing certification boards with a portfolio of data pertaining to their training, supervision, experience, and knowledge. All are areas of difficulty in quantifying or qualifying.
Training is perhaps the easiest certification area to assess but even in evaluation of coursework, a variety of factors are evident. Most academic training reviews require determination of term (semester, trimester, quarter) hours awarded for graduate study in regionally accredited institutions. Course titles of counseling and related disciplines number in the thousands. Certification boards must categorize courses by reviewing catalogue course descriptions or syllabi. While quantifying transcript review appears to be a simple task, it consumes a great proportion of portfolio review time.
A further complication in determining appropriate training appears when certifying boards accept nontraditional education. Processes must be developed that compare home study and other methods of delivery with traditional campus experiences. This may be done by designating which areas of study must be delivered by traditional professor/student/classroom methods and which courses may safely use nontraditional techniques such as distance learning. In counseling, the most important training dynamic is the demonstration of theory-to-practice transference. Topics requiring application of skills to counselees, such as group, individual, or family counseling and assessment of individuals or groups indicate the need for close supervision by a professor.
Supervision duration is easily assessed if certification boards can define supervision and supervisors clearly. Then accurate reporting of supervision by supervisors establishes an hour total to judge against a standard number of hours. As the concept of certification has matured the qualification and definition of supervision has advanced. Defining and assessing supervision, however, is probably the least sophisticated and standardized certification area assessed at present. Bernard and Goodyear (1992) point out that as models of supervision grow the research and practice will bring forth clearer definitions.
Experience is easily quantified for assessment once standards and permutations are set. For example, certification boards may set a year or hour experience requirement and also set ways to accumulate hours of supervised experience at less than full time employment. Again, as certification evolves the ways of achieving experience have become more strict. In counseling, this is probably a result of the maturation of the profession.
Knowledge is relatively simple to assess if the universe of the information to be assessed is small. Counseling information included in the eight core areas of the Council for Accreditation of Counseling and Related Educational Programs are as follows: (1) Human growth and development; (2) Social/cultural and family foundations; (3) The helping relationship (including counseling theories); (4) Group dynamics, processes, and counseling; (5) Lifestyle and career development; (6) Appraisal of individuals; (7) Research and evaluation; and (8) Professional orientation. These core areas are an example of the discipline producing more and more information as the research and literature base of counseling grows. Therefore, sampling the relevant knowledge base becomes an increasingly difficult task. All counselor certification examinations employ multiple-choice, single-answer formats and range from 100 to 250 items per form.
Because the practice of counseling involves application of information to action, examination constructors face the task of applying knowledge data to cases or situations. The standard beginning point for this application is the job analysis or study of behaviors used in a profession. Most counselor certification exams are based upon comprehensive job analyses of practicing counselors. The National Organization for Competency Assurance requires state-of-the-art job analyses as a prerequisite for accreditation of certification programs (National Organization for Competency Assurance, 1993). Professional examinations which are not based upon comprehensive study of the necessary behaviors needed for professional practice are suspect even before reliability and validity statistics are gathered.
Shimberg and Rosenfield (1980) identify the general purpose of job analyses as: a process that seeks information from a large number of incumbent practitioners regarding the most important aspects of the job; and the knowledge and skills needed to perform the job in a safe and effective manner (p.14).
Fine (1986) continues that job analyses can also provide definition of the behaviors needed to practice, knowledge and abilities needed in training curricula, and relevant assessments of performance (p.55). Loesch and Vacc (1993) describe job analyses as having multiple facets to obtain a picture of a profession. Three major categories of decisions must be considered in conducting a job analysis: a) conceptual; b) procedural; and c) analytical. Conceptual decisions as a basis for a credentialing examination is intended to allow for development of a "test blueprint." Procedural decisions include research methodology, type of examination format, and item generation technique. Analytical decisions involve the statistical and methodological treatment of the list of professional behaviors generated (pp.5-6). So, job analysis is not directly applied to the individual applicant for certification, but to a large group of practicing professionals. It is the precursor to assessment of certificants and, indeed, essential for logical application of certification criteria.
Continuing training is an ongoing assessment process that begins, for certification purposes, after credentialing is achieved. Most certifying boards require continuing education as a part of recertification. Some require both continuing education and re-examination periodically. The boards requires different amounts of continuing education per year over each five year certification period. All certificants must attest to continuing their training and submit to random inspection.
Every national program certifying counselors uses multiple-choice examinations as part of the application requirement. While this method can assess information retention readily, it does not lend itself to measuring counseling skills and application of theory to skills. Recent revisions of the National Counselor Examination for Licensure and Certification (NCE) have included more applied items. Future modifications should include methodologies that assess skills better. Tape simulations, computer applications, branching answer format, in vivo review, and case scenario models all may be included in future revision. These modifications, of course, have expense implications, which has been the major force in retention of multiple choice formats in counselor certification.
In an emerging profession such as counseling, an examination which is not undergoing change will soon be obsolete. Monitoring professional practice, research, and literature, as well as advances in examination development and theory are essential to a good assessment program.
This method requires extraordinary time expenditure by applicants for certification as well as tape reviewers. Each tape is reviewed by clinical counselors to assure clinical counseling skills. Ongoing reliability checks of tape review processes are a must. More research will no doubt help delineate better methods of judging tape samples.
Since gathering data on counselor behavior and examination statistics for over twelve years, the time has come to begin releasing these assessment data for use by those with interest in the profession. Such a process is now occurring beginning with the release of all data regarding the most recent and comprehensive job analysis performed within the counseling profession.
Requiring supervision for certification continues to generate a need for better definitions of supervision and qualification of supervisors. In a profession depending upon performance, supervision of pre-service and in-service counseling is essential. Not only will standards need to be developed further but some more quantifiable measures of supervision must emerge.
While counseling is an emerging profession, the boards have kept pace with national mandates for state-of-the-art assessment techniques. Present methods are constantly being modified in light of assessment advancements. Use of presently unreported data my lead to further positive steps in selecting certificants.
Author: Eric Digest, K. Gates, PhD
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Mr. Walker is assistant professor in the department of psychiatry at the University of Kentucky College of Medicine and the Center on Drug and Alcohol Research at the university, 643 Maxwelton Court, Lexington, Kentucky 40506-0350. Dr. Clark is associate professor in the College of Social Work at the university.