This is an intermediate level course. After taking this course mental health professionals will be able to:
Supervision may well be the highest calling in psychology and other mental health professions. It entails the transmission of knowledge and art, mentoring, gatekeeping, monitoring and evaluating, and developing a relationship that serves as the foundation for the process. It is the way the profession is communicated and transmitted from generation to generation of practitioners. This process used to be informal and occurred essentially through osmosis. Now we realize the need for a formal process as the fields have evolved and supervision has become a core competency in mental health. Supervision requires the supervisor to assess and evaluate levels of supervisee readiness, competence, and affect, reflect upon these in the supervisor oneself, and to weave a tapestry of thought and feeling which translates into effective clinical intervention. These supervisory roles seem inherently inconsistent and require substantial articulation and attention. While the role of supervisor is weighty, it is also replete with potential for growth, development, inquiry, and excitement.
The purpose of this course is to provide a philosophy and a methodology for the practice of high quality supervision. Through competency-based supervision, and a strength-based orientation, many supervisee problems will be prevented. Emphasis upon strength, supplemented with encouragement in areas of lesser strength, provide for the sturdiest supervisory relationship and one that can easily sustain—and flourish with constructive feedback.
Competency-based supervision includes 1) identification of competencies site-specific; 2) initial assessment of supervisee’s level of competencies including knowledge, skills, and values; 3) ongoing evaluation and feedback and evaluation of supervisee competencies at completion of the training sequence.
Contextually, supervision consists of relationships among client (s), supervisee (therapist), supervisor, clinical setting of therapy, community, and the associated influences of culture/diversity in its broadest sense (ethnicity, religion, race, gender, SES, gender identity, educational level, etc.) and the discipline(s) in which one is practicing. To understand the complexity, one needs to consider the breadth of each domain, and then the interactions among them.
For the client/family, there is the reason for coming to therapy, often precipitated by a traumatic or painful event, revelation, or disclosure. There are fears or anger and reticence to enter therapy; anxiety about entry, process, and the therapist; paperwork that may be a barrier; cultural or diversity considerations that may make therapy a dystonic experience; lack of familiarity with the system; fears that secrets may be revealed; and hope for the future.
In the supervisee’s domain, there is the developmental status, uncertainty of role, feelings of inadequacy, feelings of dominance and knowing the family/client better than anyone else, eagerness to help the client, eagerness to please the supervisor, fear of failure, theories and ideas of conceptualization, dynamics and interventions, cultural-diversity identification, curiosity, or lack of information, identification with the family, client, and/or supervisor, and a desire to individuate and be a competent independent practitioner.
For the supervisor, there are the multiple roles, the feelings of optimism about the supervisory and therapy process, and perhaps some tentative anxiety about the competence of the supervisee (or the supervisor) to tackle this very difficult client/family. Add the primary supervisory roles of teacher, counselor, consultant (Ellis & Dell, 1986), facilitator, administrator (Bernard & Goodyear, 1998), and monitor/evaluator, instructor/advisor, model, supporter/sharer, and consultant (Holloway, 1999), and that supervision should also integrate supportive and affective components.
Contextual variables include all the community, social, socioeconomic, circumstances and associated attitudes and values. Each profession brings to supervision—and therapy—beliefs about how mental illness comes about, and how one can intervene most effectively.
Although clinical supervision is performed by a majority of psychologists, social workers, marriage and family therapists, psychiatrists, nurses, as well as other mental health professionals, and is the primary form of transmission of clinical skills, formal training and standards have lagged far behind. The Association of State and Provincial Psychology Boards concluded in their task force on supervision that, “Given the critical role of supervision in the protection of the public and in the training and practice of psychologists, it is surprising that organized psychology, with few exceptions, has failed to establish a requirement for graduate level training in supervision. Few supervisors report having had formal courses on supervision, and most rely on their own experience as a supervisee” (ASPPB, 2003, p. 1). Fewer than 20% of supervisors have had formal training in supervision (Peake, Nussbaum, & Tindell, 2002). Marriage and family therapy and counseling psychology have been exceptions however. Marriage and family therapists have a certification in supervision, which entails supervision of supervision. That supervision is a neglected area is clear, but it has now been recognized as a distinct practice area and is a central domain of training (Falender et al., 2004). Training in supervision in doctoral and graduate programs is variable, with greater occurrence in counseling programs than in clinical, but with a huge variety in value attached to such training and implementation strategies (Scott, Ingram, Vitanza, & Smith, 2000).
There are numerous definitions of supervision. Some of the critical components are protection of the client, gatekeeper for the profession, evaluator of the supervisee, provider of knowledge and skills, and transmitter of values.
In an intriguing definition, described by Bernard and Goodyear (1998) by Acker, the supervisory relationship is described as one between unequals, with the objective of equalization. Although seemingly an inherent contradiction, or a paradox, this is the challenge in supervision
Falender and Shafranske (2004) defined clinical supervision as “a distinct professional activity in which education and training aimed at developing science-informed practice is facilitated through a collaborative interpersonal process (mindful of the power differential). Supervision involves observation, evaluation, self-assessment and feedback, the acquisition of knowledge and skills by instruction, modeling and mutual problem solving, and encourages self-efficacy, building upon the recognition of the strengths and talents of the supervisee. Supervision insures that clinical consultation is conducted in a competent manner in which ethical standards, legal prescriptions, and professional practices are employed to promote and protect the welfare of the client, the profession, and society at large.” (p. 3) Particularly important in this definition are the concepts of collaboration—that the supervisee learns from the supervisor while the supervisor learns from the supervisee—which is a step away from the usual hierarchical supervision model in which the supervisor is on a pedestal. However, there is the power differential since it the supervisor who will sign off on the successful completion of the training and who will write the letters of recommendation.
Another definition of supervision, which comes from the counseling psychology perspective, is that of Bernard and Goodyear. Bernard and Goodyear (2004) defined supervision as “an intervention provided by a more senior member of a profession to a more junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s), monitoring the quality of professional services offered to the clients that she, he, or they see, and serving as a gatekeeper for those who are to enter the particular profession” (p. 8).
ASPPB defined supervision as “the relationship focused on the development, enhancement and evaluation of the supervisee’s skills, knowledge and behavior in the practice of psychology” (ASPPB, 2003, p. 2).
In fact, the term “supervision” is derived from the Latin for super (above or over) and vision or sight.
Each definition has a different focus. Falender and Shafranske place significant emphasis not simply on relationship, but also on self-assessment, processes of supervision, and the legal, ethical, and general context in which supervision occurs. They emphasize collaboration between supervisor and supervisee—a respectful interchange, remaining mindful of the power differential. Through collaboration and relationship, the supervisee grows. Bernard and Goodyear emphasize the transmission of knowledge from a senior member to another in the context of evaluation with regard for legal and ethical considerations.
Each supervisor must come to his/her own balance between a positive, facilitative supervisory relationship that embodies empathy, positive regard, and support, and the evaluative function that comes with the role. The greater the emphasis on informed consent—informing the supervisee of the evaluative realities of the relationship—the greater the success of the supervisory relationship.
In competency-based supervision, there are several major components. The supervisor must understand the competencies at entry of the supervisee. The supervisor must have a plan as to what competencies that supervisee must have upon completion of a time interval or training sequence. And the supervisor must him/her self have competencies of the supervisor including knowledge, skills, and values which have been established and will be described in Part IV – Competencies. Components of competency based supervision include the supervisory relationship, understanding of the level and competencies of the supervisee, being a competent supervisor, and engaging in role invocation, discussion of evaluation and the power differential, and providing ongoing feedback, positive and negative.
Think about which definition of supervision is most meaningful to you—what are the most important components of supervision? Also begin to think about which competencies are most important and relevant to your particular supervision context.
A critical first step in the supervisory process is establishing the supervisory alliance. A cardinal rule of supervision is to balance the power differential of the supervisor and the evaluative function, which is implicit in the supervisory role with the development of the supervisory alliance in which both develop shared goals, tasks to achieve these, and an emotional bond (Bordin, 1989). The clearer the expectations are for the supervisory relationship, the better. To establish the supervisory alliance, supervisor and supervisee must establish a relationship of trust. Through the interaction that ensues, the supervisor and supervisee develop a set of goals that are relevant to the developmental level of the supervisee and which are specific to the setting and context in which the supervision occurs. Once established, specific tasks to achieve these are formulated. The emotional bond is created and strengthened through this process in which supervisor and supervisee are focused on the specifics of the supervision process.
Examples of supervisory goals might be:
(These are simply intended as samples.)
Specific Tasks which could be developed for these
It is possible to develop goals and tasks using multiple theoretical orientations.
Develop supervisory goals and tasks with a particular supervisee. Or role-play this process with a colleague for practice.
As a way to orient the supervisee and the supervisor to the task of supervision, it is useful for the supervisor to use “role invocation,” or identification of the specific expectations the supervisor has regarding the supervision experience. Each of us has a sense of what comprises the “ideal supervisee” or the supervisee we prefer to work with. Through role invocation, the supervisor can specify particular behaviors either from Vesper et al.’s (2002) Supervisory Utilization Rating Form (SURF) or simply from making a list of behaviors most important to the individual supervisor or setting.
Types of areas to be covered in role invocation include the expectations and ground rules of supervision starting with such basics as format for supervision; what the supervisee should bring in terms of written, audio, or video materials; ethical, legal, and site regulations; and general expectations such as being interactive, and coming to supervision with a formulation or questions. Thorough role invocation is an excellent part of establishment of the supervisory relationship.
Make a list of the aspects of the supervisee role that are most important to you. Examples might be, being prepared for supervision with treatment notes and questions, accepting feedback, interest in theoretical perspectives, etc.
Another interesting aspect of role invocation is its possible contribution to dialogic reflexivity (Hawes, 1993). Dialogic reflexivity refers to “a process of explicitly turning one’s critical gaze back on oneself as well as the professional, historical, and cultural discourses that empower and constrain one’s capacities to think and act in the context of the relationship” (Hawes, 1993, p. 105-106). Two processes occur—the private thoughts of the participants and the dialogue between them, all considered in the broader context. Through role invocation, the supervisee could become acquainted with the expectation that all these variables are to be considered and of the substantial supervisee role in the process. In proposed collaborative forms of supervision, concern has been expressed that there is the reality of the power differential, which manifests itself in knowledge differentials, and in legal and ethical mandates, including protection of the client’s welfare as the supervisor’s highest duty. Through dialogic reflexivity, the supervisor and supervisee can develop a dialogue about the contextual factors and the particular manifestations of power, both through role invocation in setting the stage and in an ongoing manner. The supervisor can and should initiate this discussion.
Generally, it is most important to infuse supervision with informed consent so that supervisees are aware of the evaluation component, and so that feedback will be forthcoming and ongoing, and that it will NEVER be a surprise. This is directly addressed in the sections on feedback and informed consent.
Relationship is critical to effective clinical supervision. With relationship comes trust and the ability to disclose, receive difficult feedback, and confront difficult issues in therapy and supervision.
Several researchers provide empirical support for the importance of relationship. Holloway (1992) summarized that, in literature on supervisee characteristics across levels of experience, the only differences were between beginning practicum and intern-level supervisees, and that these involved relationship characteristics. Beginning supervisees appeared to require more support and encouragement while interns were striving for independence and wanting to explore personal issues like countertransference. Cook and Helms (1988) reported that the supervisor’s liking and positive feelings towards supervisees accounted for 69.4% of the variance predicting satisfaction in supervision. The stronger the emotional bond between supervisor and supervisee, the less role conflict was experienced by the supervisee (Ladany & Friedlander, 1995). The emotional bond was also positively related to satisfaction with supervision (Ladany, Ellis, & Friedlander, 1999). Efstation et al. (1990) defined three factors of the working alliance in the context of relationship: client focus, rapport, and identification. These were postulated to be pivotal in development, and provide a different approach to analysis of relationship.
Support should be a constant throughout the training process (Heppner & Roehlke, 1984; Worthen & McNeill, 1996; Worthington, 1984). Manifestation of support changes with personal characteristics and with experience level of the supervisee. The supervision progression seems to move from supportive through encouragement of growth to empowering and trusting enough to explore countertransference issues and to encourage creativity and innovation. For the supervisee, the relationship seems to evolve through dependency, growth of trust, and individuation or evolution of relationship to that of a colleague. Based on existent research, it is impossible to define empirically a quality relationship. Whiston and Emerson (1989) caution that the supervisor needs to ensure that “promoting insight, sensitivity, and personal growth in supervisees does not become counseling” (p. 321). Maintaining appropriate boundaries and not moving into the therapy domain is a central element of effective supervision.
In the conceptual framework to approach supervision, consider particular aspects of multiple theories. Hess (1987) in his discussion of Martin Buber’s concept of relationship describes how it relates to the conceptualization of the supervisory process. Hess (1987) encapsulates this as the “mode by which a humanizing, spiritual exchange occurs.” Worthington (1987) points out the neglect of relationship in the literature. That relationship is undervalued in the formulation and articulation of developmental theories is central in Ellis and Ladany’s (1997) critical review of developmental research in support of theory. They conclude, “The quality of the supervisory relationship is paramount to successful supervision.” (p. 495) Holloway (1987) suggests that the supervisory process can more parsimoniously be explained in the supervisor-supervisee relationship; and is “as a result of being in an intensive, evaluative, ongoing, and demanding relationship.” (p. 215)
Also important are attachment theory, personality, and intellectual variables powerful in the formulation of relationships. Attachment theory aids the supervisor in the understanding of the fragile process of attachment-individuation within supervisory relationships. Watkins (1995) suggests the use of attachment styles in understanding pathological relationships in supervision. His premise is that the majority of supervisees in fact develop secure attachments with their supervisors. This would provide a basis for trust and relating throughout the supervisory relationship, and would provide the stage for evaluative feedback, which is such a central part of development. Watkins (1995) suggests that the one-on-one supervisory relationship may be the first place in graduate school where such a “different focus, relationship, process, and demands” (p. 339) are experienced. Equally important is cognizance of the more normative attachment process in which the supervisor may serve as a secure base for exploration, and has the opportunity to shift onus and responsibility gradually to empower the supervisee. The secure base, a concept derived from Bowlby (1988), provides for reduction in feelings of isolation by supervisees, a sense of confidence in monitoring and supervision, and a constant resource—the supervisor, available anytime, without fail (Pistole & Watkins, 1995). The sense of awe, enthusiasm, wonder, and curiosity instilled in supervisees is akin to solution-focused therapists’ approach to both clients and supervision. Add to this respect for the values, learning, and thoughts of the supervisee, and one has the essential elements of quality supervision.
Another important theory is Erikson’s theory of development (Loganbill, Hardy, & Delworth, 1982), and more specifically, a focus on the positive, optimistic, and trusting aspects of supervisees and supervisors as adaptive human beings in their journey (Erikson, 1968). What has been misplaced in some of the theories is this basic optimism about development and Erikson’s focus on fostering “competence, identity, love, and wisdom.” By allowing cognitive theories to supersede these variables, some of the essential core of developmental theory has been lost.
As Seligman and Csikszentmihalyi (2000) described in their positive psychology, we have ignored our “hope, wisdom, creativity, future-mindedness, courage, spirituality, responsibility, and perseverance” (p. 5). This is evident in the process of supervision where the focus on pathology has seriously constricted the range of relationship and experience. The application of positive psychology to the entire supervisory process is powerful. Thinking preventively and positively are the hallmarks of successful supervision.
|Vignette: The supervisee comes for the first supervision session. You have met her one time before and felt very positively about her. How will you begin establishment of the supervisory alliance? What will you say? What forms of information and assessment are necessary? What aspects of role invocation will you use?|
The other element often shortchanged or ignored is the evaluative function, which provides a context and an ethical and professional structure to the relationship. It is also the sine qua non from the perspective of the universities, professional schools, and licensing bodies. That “evaluation is one of the most critical issues in establishing the supervisory relationship” (Holloway, 1995, p. 3) is a core concept. To varying degrees, at all levels of training, the supervisee, and supervisor are cognizant that the supervisor is a potent force in the supervisee’s future in terms of the evaluation of specific competencies. Although there is ample literature on supervisors’ aversion to evaluation (Robiner et al., 1993), this is not a justification for its omission. A limitation of some of the research has been failure to consider how the evaluative stance influences each step of the supervisee’s journey. Hansen (1965) described the limitations evaluation placed on supervisees’ expectations of supervisory relationships. Role ambiguity was defined by Olk and Friedlander (1992) as the supervisee’s uncertainty about how he/she would be evaluated and what the expectations were.
But how can a supervisor be an evaluator and have a strong supervisory alliance? The most highly rated supervisors are those who give evaluative feedback. Clarity and communication of expectations are a critical component underlying relationship, and therefore working alliance. Ellis and Ladany (1997) support the position that evaluation, being central and implicit in supervision, needs to be operationalized and incorporated into the research. Holloway (1999) describes the supervisory act of monitoring and evaluating performance as a “function of supervision” (p. 20), but warns of the reward and coercive power of the supervisor. Evaluation is the backdrop against which supervision is conducted as supervisors have a sense of standards to which they are comparing performance. Evaluation should also be viewed as constructive, with frequent, ongoing input on the direction of the intervention and therapy. It should not be a distant hallmark at the end of the training sequence.
It is important to lay groundwork for evaluation by letting supervisees know you will be giving feedback every session and that the “law of no surprises” is operative: the supervisee will be the first to know if you have performance concerns.
Think of the following sequence and how you would give feedback:
In the fifth supervision session of a second year student, the supervisor became concerned that the supervisee seemed to be using a very directive approach, constantly telling the adult client what to do. It was not clear to the supervisor this was the best approach, but he wanted to discuss it with the supervisee. How would it be best to introduce the topic? Think of several ways to do so.
An issue is the supervisory alliance that has been established. Possible approaches are 1) reflection on how the therapy is going; 2) expression of curiosity about why that particular approach is being used, 3) wondering how the supervisee is feeling in the session with the client—and many others as well. Think of approaches you currently use and what is most effective. How do you vary your approach with different supervisees? What are some of the variables you take into consideration?
A significant portion of early supervision is socialization and patterning of the supervisee into the interactive mode of supervision, and honing the shared experience with a sense of humor and perspective. There is also the instillation of curiosity into the process so that the supervisee can approach each new client/ family with a spirit of openness and active, accepting curiosity. This approach is along the lines of the solution-focused therapy model. The relationship quality may have mediating or moderating effects. Hess (1987) observed, “because supervision is primarily growth oriented, deals with putatively healthy people, has skill and value inculcation as its goals, and is centered on the relationship, a theory specific to the supervisory relationship is central” (p. 187). In addition, we know that often what happens in supervision is replicated in the therapy process—in a “parallel process” or a reenactment of the process of supervision. Thus, if a supervisor is challenging and angry with a supervisee, that same process may be enacted between the supervisee/therapist and the client.
In cognitive-behavioral supervision, the contract can be constructed around requirements specific to setting, competencies to be attained—evaluation can focus on the competency document as can frequent and ongoing feedback and assessment.
It is critical to distinguish supervision from therapy – and also from consultation. Differentiating between supervision and therapy is a topic that will arise several times in this course. Studies of good and effective supervisors versus those who inflict harm show us that supervisors who cross the boundary and become therapists to their supervisees inflict substantial harm. Whiston and Emerson (1989) described the difficulty of switching from the empathic supervisor to the evaluator (and critiquer of the supervisee’s work), but emphasize the importance of remaining focused on the professional development of the supervisee in the context of his/her work with the client, rather than segueing to the development of action plans for the supervisee’s personal problems. A line must be drawn and maintained to keep the focus on the supervisee’s process and behavior with the client. This becomes an issue of informed consent, with it being extremely important for the supervisor to establish from the beginning of supervision that supervision is a distinct practice area separate from therapy or counseling. Whiston and Emerson (1989) proposed use of Egan’s (1986) model wherein using informed consent, the role of the supervisor when problems arise is elaborated upon, and clarified and explored to determine if the supervisee’s personal problems are interfering with client work. It is possible the process of supervision per se will be creating tensions or increasing personal issues of supervisees. Nevertheless, the supervisor should only explore and clarify problems of supervisees that are creating impasses in their clinical work. It is not the role of the supervisor to move beyond that exploration and clarification. In the second and third stages of Egan’s model, the line from supervision to counseling or therapy is crossed and thus, these stages should not be approached in supervision, but by an independent therapist. These stages entail establishing an action-oriented understanding of the personal problem of the supervisee, and determining through this exploration whether the personal problems are the reasons for difficulty with a particular client. Then, means are determined to accomplish goals to address the problems defined.
The rule of thumb then is that supervision keeps focus on the client and on the supervisory process. When the supervisor slides into exploration of the supervisee’s psyche, early childhood, etc., a boundary has been crossed.
Decide which of these are appropriate for supervision and which would require a referral for therapy or other external support:
Most supervisors would find 2 and 3 to be highly problematic and requiring additional steps. In 2, immediate attention should be given (probably even sooner than this) to the possibility that this client should be transferred to another therapist, as a cardinal rule of every profession is “do no harm”. Then the supervisor needs to discuss the pattern of response of the supervisee and plan with the supervisee specific steps to ensure that his/her needs are met outside of supervision. This process could even entail a leave of absence if deemed necessary.
In 3., the supervisee needs the supervisor to set boundaries and assist the supervisee in seeking appropriate supports for this major life event, and to explore the impact this might be having on clients being seen.
In 1 and 4, the supervisee can explore countertransference when the supervisee is in a less reactive state, and most likely, an exercise in differentiating the supervisor from the mother (in 1) or separating the client from other individuals with whom the supervisee might feel or have felt angry, have good results. If not, and a pattern emerges, then the additional steps taken in 2 and 3 could be implemented.
Supervision must also be distinguished from consultation. Differences are that in supervision, information is passed from a licensed person, who holds legal responsibility, to an unlicensed person. The unlicensed person is required to follow the directives of the licensed individual who is his/her supervisor. In consultation, both parties are licensed and insured, and the recipient of the consultation is not required to follow the directives or advice of the consultant. In both circumstances, individuals function with informed consent. In supervision, clients need to be informed that they are being seen by a supervisee who is not licensed and who is functioning under the licensure of a supervisor who is named and who will have access to their clinical records. In consultation, clients are informed that their therapist will be consulting with an individual regarding their case and that individual will be given information regarding the client.
What do you do if another supervisor’s supervisee comes to you for consultation?
It would be important to clarify roles and responsibilities—and to coordinate with the other supervisor, perhaps arranging a joint meeting to “consult” or for the other supervisor to obtain input from the second supervisor. Remember that the primary supervisor is legally responsible for the supervisee’s therapy with the clients.
Supervision always involves the evaluative component. In mentoring, the mentee typically chooses the mentor, the mentor does not evaluate the mentee, and the mentor assists the mentee in acquiring professional role development, contacts with relevant colleagues, research, and a multitude of professional activities including conferences, meetings, etc. Some supervisors do mentor but they use informed consent to think proactively about the possible conflicts that might arise when both roles are occurring with a given supervisee-mentee. Possible worst-case scenarios might include having to give negative, constructive feedback to the supervisee and then presenting a paper together later the same day! Or having to hold a supervisee back from going on internship and then introducing them in a prearranged way to colleagues at a meeting with whom they might collaborate in research.
The progression of becoming a supervisor is one of integrating theory (of supervision and of therapy), interpersonal skills, and focus. Specific competencies of the supervisor will be described in Part IV – Competencies. There needs to be a shift. Borders (1992) describes the cognitive shift from clinician to supervisor. Here are some examples of ways clinicians take their skills into the supervisory arena—the first two being problematic:
Falender and Shafranske (2004) posit that there is an even “higher” outcome in which supervisors see supervisees as active contributors to the process, and as collaborators in the supervision process, so that supervisee and supervisor both grow through the interaction.
Some of these developing supervisees in the categories above (#1 and #2) do not progress onward to become good supervisors. This is a very big problem for their supervisees.
There are other categories of problem supervisor (adapted from Liese & Beck, 1997 in Watkins, 1997). They include:
An excellent resource for beginning supervisors is Susan Neufeldt’s Supervision Strategies for the First Practicum (2007) in which the author provides a somewhat manualized approach to supervision through use of topical areas and targeted dialogues.
A more recent development in supervision is development of specific competencies that define it. In 2002, the Association of Psychology Postdoctoral and Internship Centers conducted a conference and the outcome was a series of papers on competencies comprising different aspects of practice. One was devoted to Supervision Competencies (Falender et al, 2004). A guiding definition was provided by Epstein & Hundert (2002) who defined competency as “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served (p. 227). Thus, supervision competencies were defined as knowledge, skills, and values associated with supervision. Supra-ordinate factors that were recognized were:
The framework for supervisor competencies is laid out in the areas of knowledge, skills, values, and social context. These are conceptualized as basic, entry-level competencies. A full description is available in Falender et al. (2004). Please note these were defined for the psychology supervisor and were a product of the Association of Psychology Postdoctoral and Internship Centers Competencies Conference (APPIC), which occurred in 2002.
Please self-assess your supervisory competencies—presently and what you aspire to. Think about your current practice and directions you would like to increase your knowledge, skills, values and attitudes, and contextual competence.
Supervision Competencies Framework*
(Rank present from 7 (superior) to 1 (absence of knowledge, skill, value); signify high priority to enhance competence items in column with “X”)
Of area being supervised
Of models, theories, modalities, and research on supervision
Of professional/supervisee development
Of evaluation, process/ outcome
Awareness of diversity in all forms
Sensitivity to multiple roles: Perform and balance
Provide effective formative and summative feedback
Promote growth and self-assessment in trainee
Conduct own self-assessment
Assess learning needs and developmental level of supervisee
Encourage and use evaluative feedback from trainee
Teaching and didactic skills
Set appropriate boundaries and seek consultation when supervisory issues are outside domain of supervisor competence
Scientific thinking and translation of scientific finding to practice throughout professional development
Responsibility for client and supervisee
Responsibility for sensitivity to diversity in all forms
Balance between support and challenging
Commitment to lifelong learning and professional growth
Balance between clinical and training needs
Value ethical principles
Commitment to knowing and utilizing available psychological science related to supervision
Commitment to knowing one’s own limitations
Social Context Overarching Issues
Ethical and legal issues
Knowledge of immediate system and expectations within which the supervision is conducted
Creation of climate in which honest feedback is the norm (supportive and challenging)
Training of Supervision Competencies
Coursework in supervision including knowledge and skill areas listed
Has received supervision of supervision including some form of observation (video or audiotape) with critical feedback
Assessment of Supervision Competencies
Successful completion of course on supervision
Verification of previous supervision of supervision document readiness to supervise independently
Evidence of direct observation (e.g., audio or videotape)
Documentation of supervisory experience reflecting diversity
Documented supervisee feedback
Self-assessment and awareness of need for consultation when necessary
Assessment of supervision outcomes—both individual and group
Other to be defined by supervisor/setting
*Derived from Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., Shafranske, E., & Sigman, S. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771-785, with permission of publisher and author.
After completing this self-assessment, highlight sections that are aspiration and describe how you plan to enhance your competency.
Considered together, these factors serve as a basis for understanding the competencies needed for a supervisor to be minimally competent. Because supervisory competence is a lifelong process, it is important to consider each of these factors as developmental and continuous, so that supervisory competencies are always evolving and developing.
As this self-assessment was designed for psychology supervisors, think about what other aspects should be added to reflect your particular discipline. Some ideas will be available in the competency assessments (for supervisees) that follow.
Use of competencies marks a significant change in procedures for assessment and evaluation. Defining and measuring competencies sets a standard against which development of the supervisee can be charted and tracked. Multiple disciplines have developed competencies. We will consider psychology, social work, and marriage and family therapy.
The ADPTC document defines competencies of readiness for practicum and those at completion of practicum experience, at the point of entry into internship. This document is in use by many practicum settings and in university and professional schools to track and assess competency development.
The Benchmarks conference (2006) focused on development of assessment techniques for each of the following transition points:
This document was based on the cube model, distinguishing between foundational and functional competencies.
Foundational competencies include
Supervision is a functional competency. (It will be referenced when it becomes available on the APA Education Directorate website.)
Social Work Competencies:
Significant effort has gone into the development of the CALSWECII documents. They are exemplary and are already adopted as evaluation and monitoring tools for many schools of social work and field placements.
Foundational Year: http://calswec.berkeley.edu/MH_Competencies_Fdn_Year.pdf
Specific Competencies: http://calswec.berkeley.edu/MH_Matrix_Competencies_Fdn.pdf
Advanced Specialization Year: http://calswec.berkeley.edu/MH_Competencies_Adv_Specializn_06.pdf
Specific Competencies: http://calswec.berkeley.edu/MH_Matrix_Competencies_Adv.pdf
Marriage and Family Therapy Competencies: A document is available for supervisee competencies:
An article explaining the development of core competencies is available:
Nelson, T.S., Chenail, R.J., Alexander, J.F., Crane, D.R., Johnson, S.M, & Schwallie, L. (2007). The development of core competencies for the practice of marriage and family therapy. Journal of Marital and Family Therapy, 33, 417-438.
Let’s consider some of the components of the Hatcher and Lassiter (2005) competencies document and the CalSwec II.
In Hatcher and Lassiter, baseline competencies are described: those which supervisees should possess and demonstrate prior to beginning their first practicum placement. Areas included are personality characteristics, intellectual and personal skills that include empathy, respect for and interest in other’s cultures, values, etc. Also included are integrity, honesty, valuing ethical behavior, affect tolerance, tolerance of ambiguity, openness to new ideas, personal organization, personal hygiene, and appropriate dress. It is important to review this document carefully as this is a standard of practice, establishing criteria for individuals entering the field of psychology.
In the CALSWEC II document, Foundational competencies relate to Culturally and Linguistically Competent Generalist Practice, including knowledge and understanding of all aspects of diversity, trauma, and legal and historical relationships, especially with the US government and the American Indian/Alaskan Native nations, values of traditional practices, issues facing immigrants and how these relate to mental health and services, assimilation and acculturation, and how social work values impact the individual and each of these, as well as how the student’s own diversity variables and status impacts each client including biases, prejudices, and awareness of disparities. The CALSWEC II document goes on to describe competencies for practice with individuals, families, groups, community, human behavior and the social environment, and workplace management. This is also a critical document to examine if you are training social workers. Many universities are using it or a derivative of this for evaluation purposes.
The AAMFT Competencies are organized around 6 primary domains and 5 secondary: admission to treatment (interactions leading to establishing the therapeutic contract), clinical assessment and diagnosis, treatment planning and case management, therapeutic interventions, legal issues, ethics, and standards, and research and program evaluation. Types of skill and knowledge are conceptual, perceptual, executive, evaluative, and professional. It is critical to review this document carefully if you are supervising MFT students or interns.
Please note that similar documents are available for nursing, psychiatry, and many other disciplines.
Each supervisor should keep with him/her a copy of the respective documents for the disciplines they supervise as well as the respective codes of ethics for the discipline—and refer to them frequently to model good practice to the supervisee.
Competency based supervision refers to consideration of the component knowledge, skills, and values or attitudes of each area of supervised practice, initial assessment, ongoing assessment and feedback, and final evaluation.
Increasingly, mental health professionals are turning towards identification of competencies, which can define performance of service. This is as significant an issue as the definition of the competencies that constitute supervision. APPIC sponsored a “Competencies Conference” in an effort to describe more thoroughly specific competencies of different aspects of professional functioning. As an outcome of the APPIC Competencies Conference, a number of papers were published. One of these papers, mentioned earlier, was on competencies of the supervisor by Falender, Cornish, Goodyear, Hatcher, Kaslow, Leventhal, Shafranske, Sigmon, Stoltenberg, and Grus (2004).
Also very important is a paper by Nadine Kaslow (2004) in the American Psychologist on competencies. She defined foundational competencies of diversity and ethical practice:
In addition, there are specialty competencies that require additional, specialized knowledge, skills, and attitudes.
Assessment of competence is complex and as defined by Kaslow (2004) takes into account developmental factors and self-assessment, and should be multi-trial, multi-method, and multi-informant. Kaslow (2004) advocates 360-degree feedback which is actually not conceptualized as evaluation but as developmental feedback, in which input is received from multiple constituencies including supervisors, peers, clients, and other parties and involve multiple skill, knowledge, attitudinal, and interpersonal, emotional factors. This process is derived from business and organizational psychology.
It is important for a training site or an individual supervisor to consider the existing documents on competencies and the particular site requirements to determine which competencies are relevant for supervisees in each particular setting. Supervisors who function in specialized settings should seek out supervision literature specific to the models they are using. For example, in Falender and Shafranske (2007) there are examples of cognitive behavioral supervision, psychodynamic, and family systems as well as other applied examples of supervisory experience. Neill (2006) provided approaches to particular child supervision derived from therapy models such as filial therapy, multisystemic, and dialectical behavioral therapy. Whatever the context or model, there should be a direct relationship between the competencies document and assessment of the supervisees and the training contract or agreement so that the expectations of the setting are clear-cut and laid out.
The greater the specificity of competency assessment, the more effective the evaluation and the contract can be.
The contract or supervisory agreement (which reaches beyond the basic structure of a supervisory agreement required in some states) is a means of articulating the roles, responsibilities, expectations, and requirements of the training period. Components of the contract include:
The contract or agreement is a critical part of the supervisory relationship. It is the set of expectations that is translated into the evaluation prototype, which is also presented to the supervisee at the onset of the training sequence. Please note that each setting will have its own criteria and competencies, although there may be more overlap in the specific performance expectation section. For this reason, each setting should tailor its competencies, agreement, and evaluation to meet its individual needs.
Before you begin this section, think about what models and theories of supervision influence your practice. List them. Then as you progress through this section, think about which of these relate most readily to your own practice.
Among the approaches to supervision are the psychotherapy-based approaches including psychodynamic, cognitive-behavioral, intersubjective or narrative, dialectical behavioral therapy, and systemic and family systems. Supervision mirrors the therapy process reflected in the theoretical orientation. Models also include process-oriented approaches, systems-oriented approaches, and developmental approaches (Falender & Shafranske, 2004).
Although there are multiple models that reflect the psychodynamic orientation, Eckstein and Wallerstein (1972) were very influential in describing the relationships among the three parties in supervision—client, therapist, and supervisor— and how the relationships reflect upon each other. Interest in transference, countertransference, and working alliance and parallel processes have all been exceptionally important to the understanding of supervision and will be discussed throughout the course.
Cognitive-behavioral models have provided for structured supervision protocols and even manualized supervision (Henggeler & Schoenwald, 1998). They provide an excellent structure for supervision of cognitive-behavioral therapy.
Dialectical behavioral therapy supervision focuses on a type of parallel process with the therapist treating the client, and the supervisor “treating” the supervisee (Fruzzetti, Waltz, & Linehan, 1997). Intriguing aspects of this model are the assumptions that the dialectical agreement is negotiated such that there is no absolute truth, and that the therapist is fallible, not necessarily consistent, and consults with the client on interacting effectively with professionals.
Narrative or intersubjective models, or postmodern, deal heavily with context and social interaction. Supervision mirrors the therapy in which the clients present their story and the therapist is the editor and enhancer. The supervisor assists the supervisee in the client work and in developing a context in the experience of the supervisee, and constructing the reality around this (Bob, 1999).
Process-oriented approaches to supervision include those in which component tasks and roles are defined (Bernard, 1997). In their Discrimination Model, Bernard and Goodyear (1998) described “teacher,” “counselor,” and “consultant” roles with different foci (intervention, conceptualization, and personalization). Hess (1980) described roles (he described these as models) including lecturer, teacher, case reviewer, colleague-peer, monitor, and therapist. Bernard and Goodyear (1998) cited other models with expanded conceptions of supervisor roles including facilitator, evaluator, monitor, and administrator. Each of these models is useful to discuss with supervisees in order to determine what roles supervisors do, in fact, play during the supervisory session, whether these roles are balanced, and whether the supervisee would prefer more or less of one or another. It is also useful to determine whether the supervisee feels that the descriptors are adequate to encompass the entirety of the supervisory process, and if not, what could be added.
Other models include microcounseling (Daniels, Rigazio-Digilio, & Ivey, 1997) and Interpersonal Process Recall (Kagan & Kagan, 1997). Microcounseling is a technique for teaching skills, and is often used for beginning therapists. Skills are organized in sequence, and each skill is taught one at a time. Modeling, shaping, and social reinforcement are important tools. This framework has been expanded to a “Microskills Hierarchy” with steps for culturally effective interviewing. Attending behavior, or being sensitive to verbal and nonverbal cues, is at the base of the hierarchy followed by a basic listening sequence with particular skills for establishing rapport and drawing the client out. This is followed by skills of confronting, focusing, and reflecting, followed by influencing, skill integration, and personalizing the skills to the individual, culture, and particular theory.
Interpersonal Process Recall, or IPR, is based on the premise that individuals behave diplomatically. Thus, much of what supervisee thinks, intuits, and feels during therapy is disregarded automatically because allowing these perceptions to surface would confront the basic predisposition to be diplomatic. The purpose of IPR is to give the supervisee a safe place for internal reactions. The supervisor’s role is that of facilitator, stimulating awareness beyond that which occurred during the therapy session.
The actual IPR process entails the supervisor and supervisee viewing prerecorded video of the counseling session. At any point, when either perceives an important moment that was not being addressed, they stop the video and the supervisee reflects. The supervisee may indicate frustration, anger, impatience, or other emotional reactions. The supervisor does not adopt a teaching stance but allows the supervisee the space to explore internal processes of resolution. The supervisor may ask a series of questions that might include, “What do you wish you had said to her?” “How do you think she would have reacted had you said those things?” “What kept you from saying what you wanted to say?” and “If you had the opportunity now, how might you tell her what you are thinking and feeling?” The process continues with the tape advancing once again. This is an extremely slow process and puts interpersonal dynamics under a microscope that may be magnified so greatly as to be distorted. The role of the supervisor is to determine which interactions are important. This is a technique that should be used only after a significant supervisory alliance is established.
Another model of supervision was proposed by Hawkins & Shohet (2000) who suggested the “seven-eyed supervisor model” in two interlocking matrices useful as tools to direct the supervisory process. They advocated attention of supervisor and supervisee directed to therapy sessions themselves with the following foci:
This is a very interesting model as it integrates many of the aspects of supervision that will be addressed throughout this course.
Vignette: The supervisee is worried that the daughter in the family she is seeing is so remote and cut off from the parents that she is having significant difficulty deciding how to approach the situation. She is also finding it difficult to communicate her level of concern to her supervisor. She is grappling with her concerns about confidentiality of the adolescent, her role with the family, and her feelings of sympathy for the daughter. Considering the models described above, describe two alternate approaches to this situation.
Because developmental theory is a meta-theory and has been so influential in supervision thinking, substantial attention will be devoted to understanding the state of the art in this area.
Developmental theories of supervision have been at the forefront of theory and research for the past four decades, and have been referred to as the “zeitgeist of supervision thinking” (Holloway, 1987, p. 209). There has been such a profusion of models that Watkins (1995) joined Borders (1989) in urging that a halt to development of any further new models of supervision take place and that the focus turn to consolidating existing models. Developmental models have been central to training in counseling psychology but have been less dominant in clinical psychology training.
Premises of developmental models include:
Developmental models contain 3 to 5 stages of supervisee development.
Rather than levels or stages, it seems more useful to conceptualize a continuum of development in which movement may be forwards or backwards, with fluidity, after Hogan (1964) such that cycles and stages are not linear and may repeat themselves. This eliminates the critiqued issue of a time line in training and even the extreme time variability within discipline and across individuals (Holloway, 1987; Stoltenberg & Delworth, 1988). For example, some practicum or first year supervisees may be more sophisticated clinically than someone who has completed his or her degree program. It is useful to realize also that not all supervisees develop in all areas uniformly. Thus, one supervisee could be exceptionally sophisticated in cognitive behavioral interventions for depressed children but at a very beginning level in comments and reflection on the process in therapy or in structural or strategic family therapy.
An omission in the developmental models has been the absence of a set of skills or competencies towards which the supervisee aspires. Beutler and Kendall (1995) suggested that targeted goals in the context of skill acquisition are a key to professional psychology training. The necessity for a more explicit and empirically established set of competencies defined for supervisees at each level of training and for supervisors was advocated by Holloway (1992). Hess (1983) identified behaviors of supervisees critical from the perspective of supervisors:
Holloway asked a question which is very important to this discussion (Holloway 1997, 1998)—Is developmental theory, or a derivative of such a theory, of value in the determination of the structure of the supervisory situation, the behavior of the supervisee and/or supervisor, or the prediction of performance issues?
A large amount of research and theory regarding developmental conceptualizations of supervision has been advanced over the past four decades. Numerous conceptual frameworks and developmental paths have been put forth and then revised, leading to researchers’ lamenting the lack of progress to provide support for developmental theory in research that occurred between Holloway’s (1992) review to Ellis and Ladany’s (1997) and Goodyear and Guzzardo’s (2000) reviews.
A predominant developmental theory of supervision was advanced by Stoltenberg (1981), Stoltenberg and Delworth (1987) and refined in Stoltenberg, McNeill, and Delworth (1998). This theory provides a framework for clinical supervision including the stages through which the supervisee progresses and the environment the supervisor should provide.
The most recent revision of the Stoltenberg et al. theory, IDM (or Integrated Developmental Model (Stoltenberg, McNeill, and Delworth, 1998)) is the most comprehensive and complex. The three structures underlying the theory are self- and other-awareness relating to cognitive and affective aspects of awareness of the client and of the self; motivation relating to perceived efforts, enthusiasm, and investment across time; and autonomy defining individuation and independence as it evolves. Some of the concepts the authors postulate as most central to the development of the supervisee are carefully described in auxiliary chapters but are not integrated into the theory per se. These include the relationship of supervisee to supervisor, the supervision environment, and the development of the supervisor. Around these three central structures, the authors weave a sequence of development of increasing autonomy, shifting awareness from self to client, and independent functioning.
Thus, for example, the Level 1, or beginning, therapist is highly anxious, highly motivated, and highly dependent on the supervisor. Focus in therapeutic interventions is primarily on his/her own behavior and performance. Supervisory interventions are structured, containing, prescriptive, and supportive. These authors suggest that theory be put on the back burner with emphasis placed on case conceptualization.
For Level 2 supervisees, who have progressed through some beginning experience and solidified some skills, there is fluctuation of motivation with self-doubt about skills as cases and conceptualizations increase in complexity. There is the possibility of dependence-independence conflicts as the supervisee strives to be more independent while at the same time realistically unsure of his/her skills. Stoltenberg suggested that at Level 2, supervisees may even have an unrealistic sense of their abilities and may need feedback to provide a more accurate assessment. Supervisory interventions should be balanced so that autonomy and independence are fostered while support and structure are still available. Countertransference considerations are important to introduce into the supervision at this level.
For Level 3 supervisees, motivation is more stable, and they are secure with their level of autonomy. They are focused on all aspects of the therapy including the client, the process, and their own contribution. They are cognizant of their strengths and weaknesses, addressing them directly and moving toward a flexible approach. Supervisory interventions should include continuing to monitor carefully, placing emphasis on increasing independent functioning and conceptualization, being supportive of growth and development of the supervisee, and generally attending to the parallel process and transference-countertransference. Stoltenberg continues to elaborate levels within the stages with development more finely scaled within each.
Although the Stoltenberg et al. (1998) model ends with the Level 3i, or integrated, development, in which the therapist integrates the highest level of proficiency and skill across all levels of practice, it is clear that development never stops—lifelong learning is essential.
More autonomy for supervisee
Exception in crisis cases
Supervisor provides structure
Less supervisor-imposed structure
Supervisee imposed structure
Focus on personal/professional integration
Exception in crisis cases
Interpretive of dynamics*
Balance of ambiguity/conflict
Address strengths, then weaknesses
Closely monitor clients
Interpret dynamics, parallel process
Strive for integration
Empathic, understanding Affirmation through self-disclosure
Interpersonal processing better left until transition to L2
Respect, Understanding of expectations, Definition of supervisory relationship
Processing personal issues
Supportive, safe environment
Encouragement to experiment and explore
Use relationship to increase insight, use of parallel process
Mutual respect and collegial exploration
Evaluative Function +
Interface with Agency
* derived from Stoltenberg
This arrangement of the information presented by Stoltenberg, et al. (1998) is a synthesis of some of the most intriguing portions of the model. Encircling relationship and evaluation around this structure seems to be a very effective way of presenting developmental theory. Development is conceptualized as one factor, albeit a very potent one. You may ask what catalytic interventions are. They are interventions that result in a catalytic outcome—similar to a chemistry experiment in which a chemical reaction occurs. An example might be the supervisor watching a video of the therapy session and seeing the dynamics of the session or some part of it in a very different light, or the supervisor focusing on a parallel process observed in supervision that corresponds to what is going on in the therapy session. The supervisee might be passive and accepting of the child’s behavior, just as the mother is in the therapy session.
Another group of developmental theories is of supervisor development. With recent changes in state regulations, the experience level of the beginning supervisor is lowered. A supervisor may be a Level 2 supervisee. As supervision practicum occurs very early in the training sequence in graduate curricula, one could imagine even less sophisticated therapists assuming a supervisory role. Supervisors with no clinical experience are less effective than those with significant experience (Russell & Petrie, 1994). We share the concerns expressed by Bernard and Goodyear (1998) regarding potential parallel tendencies of novice supervisees paired with novice supervisees to intervene in a rigid and overstated manner. There is concern as well for lack of support, insight, humor, perspective, and flexibility.
The theories of supervisor development share many of the characteristics of the supervisee development models: meta-theoretical, sequential, and progressing to a fixed endpoint. Supervisory developmental models have been articulated by Stoltenberg et al. (1998), Watkins (1993), Rodenhauser (1994), and Hess (1986, 1987).
Vignette: A supervisor requested a first year practicum supervisee to make an audio tape of his third session with a family. On the tape, the client’s mother entered the session describing a huge fight that had taken place between her two children the previous week at a restaurant. The supervisee responded by asking questions, “ A taco restaurant? Where is it located? It sounds really good. What kind of tacos did they have? Did they have different colored salsas? What kinds? Do they have fish? What kind?” The mother and children responded to the questions but eventually the mother said she really needed help with managing the children and preventing another episode like that because she was really afraid she might hit them, and she does not want to do that.
Think about how you would approach the next supervisory session. What would you say and how would you approach discussion of the session on the audio tape? How much assessment should occur. Was that anxiety on the part of the supervisee or accurate assessment of lack of competence or an inadequate therapeutic alliance potentially enhanced through talk of a mutual interest in food? A competency-based approach assists in systematically assessing strengths and determining a course for proceeding.
Take a strength-based approach and develop three possible reasons or rationales for how the practicum student proceeded in the session up to this point.
Vignette: A supervisee enters her first supervisory hour with a new case, a chaotic family. The mother and younger sibling are being treated for chronic pain secondary to severe physical abuse by a father who is no longer with the family. The identified patient is depressed, withdrawn, and not eating, but is a straight A student. Mother describes her as an “overachiever.” The supervisee expresses worry to the supervisor about the severity of pathology. The supervisor immediately says she will be a CO-therapist to the supervisee.
Conceptualization: A session should have occurred before the case assignments in which levels and previous training and experience are discussed, and a supervision plan is developed. Great specificity should be used to understand the supervisee’s level of competence with different diagnoses, developmental levels (of children and adolescents), and modalities. Also at that time, the evaluation measures and criteria would be introduced and discussed as well as particular parameters and contractual requirements of the supervision (use of video/audio tapes, timing of turning in progress notes, procedures for emergency contact, what comprises an emergency, etc.). Having the supervisor jump in might undermine the supervisee’s confidence, or might be justified given the severity of the presenting problem and the level of supervisee.
What are the developmental considerations that would dictate an approach to this situation? What are the assessment steps that could be taken to determine supervisory approach?
Analysis of Level of the Supervisee
Analysis of Level of the Supervisor
A preliminary analysis would be to consider the anxiety level of the supervisee and the supervisor. This was an initial supervisory session, and neither engaged in the usual introductory behavior, including evaluating the level of the other. Most critical is that the supervisor has a clear sense of the experience, conceptual, and clinical level of the supervisee:
What steps could be taken in such a supervisory scenario to prevent premature closure or inappropriate interventions? It is critical to approach the anxiety of the supervisee and to consider the impact of alternative approaches:
Depending on the response to this, the supervisor needs to outline the treatment issues, and integrate information from the supervisee’s description into a formulation and hypotheses about proceeding clinically. The amount of input from the supervisee should be supplemented and framed by the supervisor. If the supervisor suspects the supervisee is not describing all that she actually could, some gentle prompting is indicated. The supervisor could say, “I noticed you worked with abused children last year. How would that experience contribute to your understanding of this case?”
Form a visual mental image of your best supervisor: imagine that person in as much detail as you can, remembering appearance, style, interactions, and all the dimensions you can recall. Then think of words describing him/her. You will probably find that the words you generate correspond very closely to the literature on best supervisors, but may not be comprehensive. This process is especially meaningful because as Guest and Beutler (1988) found, the valued and prestigious supervisor’s theoretical orientation exerts a substantial influence on supervisees’ theoretical orientations for three to five years following the conclusion of the training experience.
Descriptions of best supervisor have included:
(Summarized in Falender & Shafranske, 2004)
(Henderson, Cawyer, & Watkins, 1999; Worthen & McNeill, 1996)
The last two points are especially important as they highlight the importance of two-way feedback: supervisor to supervisee AND supervisee to supervisor.
Putney, Worthington & McCullough (1992) reported that theoretical orientation might mediate relationship in that cognitive-behavioral supervisors were perceived to be in a consultant role and to focus on skills and strategies more than humanistic, psychodynamic, or existential supervisors were. Those latter were perceived as using a relationship model with a focus on conceptualization. However, they found no differences in use of growth and skill development models or focus on the supervisee as a function of theory.
Nelson (1978) concluded that interest in supervision appeared to override experience and knowledge as an essential component. Other factors in “best” supervision included theoretical grounding or working within a cohesive theory (Allen et al., 1986), a shared theoretical framework (Kennard et al., 1987; Putney, Worthington, & McCullough, 1992), and comments focused on the client (Shanfield, 1992).
There has been some research to support developmental theory, leading Ellis and Ladany (1997) to conclude that:
Continuities Supervisees Prefer Across Developmental Level
Skill Acquisition Different skills
Heppner & Roehlke, 1984
Worthington, 1984; Russell & Petrie, 1994; Heppner & Handley, 1982; Kennard et al., 1987
Heppner & Roehlke, 1984
Although the sample was very small, Nelson (1978) reported supervisee discipline differences in supervisor characteristics preferred. Social work supervisees preferred genuineness and ability to provide feedback above interest and experience in supervision. Advanced psychiatry supervisees preferred research and academic pursuits by their supervisors rather than applied work. Psychiatric residents did not favor the supervisor functioning as a CO-therapist
Social work supervisees and supervisors both reported strengths in supervisors related to knowledge skills, experience in the work being supervised, and the ability to develop positive supportive relationships with supervisees (Kadushin, 1992). A specific theoretical orientation, a structured, directive style, and clear, unambiguous directives were preferred (Lazar & Eisikovits, 1997). Among marriage and family therapy supervisees, results (Anderson, Schlossberg, & Rigazio-Digilio, 2000) bore some similarity to Allen et al.’s (1986) results with psychology supervisees. Variables associated with best supervisory experiences included longer duration, more frequent contacts per week, and a balance of personal growth with development of technical skills. Best supervision was in a facilitative environment of openness, respect, support, and an appreciation of individual differences. Better experiences were associated with viewing the supervisor as more interpersonally attractive, trustworthy, and expert. Wetchler’s (1989) results with marriage and family therapists highlighted the importance of interpersonal skills including respect, helping the supervisee assess his/her own strengths and growth areas, and encouraging the development of personal style.
In family therapy supervision, Liddle, Davidson, and Barrett (1988) described criteria for supervisor competence correlated with supervisee satisfaction. These included supervisor’s relationship skills (humor, sensitivity, communication, respect, challenge, support, and enthusiasm); supervisory feedback; supervisor’s conceptualization ability; supervisor as role model; and a supervisor who can provide:
There is some suggestion that what was viewed as best at the time of supervision may not persist over time, but may in fact be replaced by alternate supervisors. Close to the time of supervision, those rated best might be those who were warm, supportive, and congenial. However, in retrospect, if the same individuals were interviewed years later, they might view as best those supervisors who were more strict, demanding, and challenging, even though at the time of supervision, they were more difficult and seemed perhaps unduly rigorous or demanding.
What emerges is that supervisees view as “best” a supervisor who focuses on supervisee personal development and enhanced self-understanding, while creating a safe environment for risk-taking.
Many supervisees can remember more “worst” than “best” supervision situations. Some of the worst seem to be very memorable.
Worst experiences were more diffuse and difficult to define—no single characteristic was identified as critically important in a majority of worst experiences. It seems to be characterized by what the supervisor failed to provide rather than by what actually occurred. Exceptions are authoritarian or sexist behaviors by supervisors. Other behaviors include disrespect; distance; disinterest; preoccupation with the supervisor’s own process, cases, insights, or personal dilemmas; failure to assess supervisee developmental level and act appropriately; and insensitivity to the supervisee.
Communication is central to best and worst supervision.
(Neufeldt, Beutler, and Banchero, 1997)
When conflict arose, the worst-case scenario was when supervisors did not initiate discussion of the conflict or move towards some type of resolution so that supervisees engaged in “spurious compliance” or essentially not telling supervisors what they were actually doing, but pretending to be following supervisory directives (Moskowitz & Rupert, 1983). This is the worst-case outcome of supervision as the supervisor is legally and ethically responsible. This will be discussed further in the legal and ethical section, respondeat superior— the ultimate legal responsibility of the supervisor.
Worthen and McNeill (1996) investigated “good” supervision events. There is a fragile and fluctuating level of confidence and a generalized state of disillusionment and demoralization with the efficacy of providing therapeutic interventions—supervisees may be anxious and sensitive to supervisor evaluation.
Anxiety level actually decreased when supervisors helped to normalize struggles as part of the ongoing developmental progression. This is especially powerful as a supervisor self-disclosure. (Example: “I remember the first time I had to give a family a diagnosis of autism for their child whom they thought was gifted.”) These authors characterized the good supervisory relationship as empathic, nonjudgmental, validating, and with encouragement to explore and experiment. This set the stage for nondefensive analysis by the dyad, as confidence in the relationship was strengthened. In addition, supervisees reported an increased perception of therapeutic complexity, expanded ability for therapeutic conceptualizing and intervening, positive anticipation to reengage in previous difficulties and issues with which they had struggled, and a strengthening of the supervisory alliance.
(McNeill and Worthen, 1989)
Social work supervisees and supervisors concurred that low priority given to supervision, interruptions in the supervision, and ineptness in exercising administrative authority are what is wrong in social work supervision (Kadushin, 1992). In a social work supervisee study, Rosenblatt & Mayer (1975) described objectionable supervisors as those who limited supervisee’s autonomy; failed to provide adequate direction or clarity; were cold, aloof, and/or hostile; and contributed to student stress. They identified styles of supervision including constrictive, amorphous, unsupportive, and therapeutic, all found to be objectionable. For marriage and family therapy supervisees, worst experiences were marked by an emphasis on weaknesses and shortcomings of the students, encouraging unthinking conformity, and intolerance for divergent viewpoints (Anderson, Schlossberg, & Rigazio-Digilio, 2000).
Before you begin this section, think about your preferred supervisory format. Do you meet one-to-one with your supervisee? Observe behind a one-way mirror? Conduct group supervision? The majority of supervision occurs in the case consultation model: a supervisor meeting individually with a supervisee, and the supervisee reporting a synopsis or some data from the clinical session. Whether this is the most effective modality is unclear as there is to date no research linking client outcomes to supervision modality. However, research on supervisee preferences for modality reveal that most preferred supervision types include (in order of preference):
(Goodyear & Nelson, 1997)
This data should lead us to evaluate supervisory formats and seek input from supervisees—and perhaps experiment with alternative strategies such as video or audio review of session, group supervision, or live supervision. Ironically, many supervisors believe it is too anxiety producing for supervisees to be observed—in vivo or via video tape or audio tape. In fact, after a very brief beginning time, most supervisees who have been studied forget about the observation—and report on the incredible usefulness of modalities that involve direct observation and feedback.
For excellent supervision to occur it is important to have:
(Falender & Shafranske, 2004)
In a pilot study (1994), Fukuyama elicited critical incidents from racial minority interns who had completed APA internship. They were asked to offer positive and negative incidents and to describe organizational or environmental conditions that contributed to their professional development. Responses included:
Negative incidents were few but were categorized as
But they also cautioned supervisors not to overestimate cultural diversity issues in an attempt to be “politically correct.”
In another study, supervisors did not view exposure to cultural differences as influential in supervisee’s development while supervisees do. Relationship is pivotal to diversity consideration —negative interactions, conflict in communication, impede relationships—and discussion cannot occur without a good supervisory alliance (Toporek, Ortega-Villalobos, & Pope-Davis, 2004).
A critical part of supervision is the communication that occurs between supervisor and supervisee. There are a number of different frameworks to view the patterns of communication and supervisor behaviors.
Depending upon the supervision model and theory, supervision may be either horizontal or vertical. Horizontal refers to patterns in which there is a collaborative supervisory approach with some power sharing within a defined framework. Vertical refers to a hierarchical model in which the power is held by the supervisor, and information flow is from supervisor to supervisee.
A useful approach to enhancing communication within supervision is to use one of a number of techniques or structural approaches geared to description of the supervision process. These techniques are a form of feedback as well that is less intrusive than formal feedback from supervisee to supervisor.
It is very useful to analyze the process of supervision either formally or informally. One strategy is to review with the supervisee the roles that were adopted by the supervisor during the preceding supervision hour. Bernard (1997), in her Discrimination Model, defines foci and roles. Foci refer to intervention skills, or observable supervisee behavior that occurs within session; conceptualization skills, or the supervisee’s formulation of what is happening including covert processes; and personalization skills, or the overlap of personal style with the therapy and attempts to not “contaminate” the therapy with personal factors or their manifestation.
Bernard’s roles include teacher, counselor, and consultant. In the role of teacher, there is didactic interchange with the supervisee that may entail elucidation, introduction to techniques, analysis, or reading assignments. As counselor, the supervisor may deal with personal factors that may be affecting the therapy process or particular aspects of it. This might entail identification of parallel processes, or of areas unrealized by the supervisee that are influencing the therapy process. As consultant, the supervisor suggests alternative approaches, interpretations, or takes more of a meta-approach to view context of the therapy interaction. To use this strategy of analysis, near the end of a supervision session, both supervisor and supervisee could discuss their perceptions of what portion of the supervision hour was spent by the supervisor in each of the roles of teacher, counselor, and consultant.
In contrast to this, an approach by Holloway (1995) is the Systems Model. In this model, the supervisory process is considered in terms of the relationship: phase, contract, and structure. The tasks of supervision are monitoring-evaluating, instructing-advising, modeling, consulting, and supporting-sharing. The functions of supervision are counseling skill, case conceptualization, professional role, emotional awareness, and self-evaluation. Holloway conceptualizes her systems model as a 5 (task) by 5 (functions) cube, with functions relating to tasks depending on a variety of assessments the supervisor makes of the supervisee’s level and needs. Bernard and Goodyear (1998) clarified that Holloway uses the word “functions” to refer to what others including Bernard have called “foci”, and labels as “tasks” what others call “supervisor roles”.
Kadushin (1968) wrote extensively about the games supervisors and supervisees play in the supervision process. In these, communication leads off the supervision track into areas that will be discussed more extensively in the section on legal and ethical considerations. In one situation, the supervisee praises the supervisor’s extensive knowledge and skill, discloses the reverence with which he/she holds the supervisor, and as a result has elevated the supervisor to a position in which he/she is infallible, thus interfering with supervision. In another, the supervisee tells the supervisor that he/she views the supervisor as a wise parent, and would like to get some of that parental advice on a pressing issue he/she is now facing. This would cross the boundary of supervision. In another, the supervisee or supervisor tells the other that he is hungry as supervision is so close to the lunch hour, and wouldn’t it be great to walk down to the coffee shop to get a snack. It is impossible to discuss cases on the walk, at the café, or on the way back, so personal issues are discussed, and the supervisory relationship morphs to one of friendship—and no supervision occurs as the hour is over by the time they return. There are numerous combinations and permutations of these dances, some supervisee-initiated and some supervisor-initiated, albeit not intentionally.
Developmental variables are important—the stages of the intern and supervisor’s development, personal and personality factors, theoretical dimensions, perceived competence and expertise, clinical approach and technique, degree of structure, communication style, and the supervisor’s attitude towards the supervisee. What is necessary for adequate supervision, and what dimensions are associated with the most highly rated supervision? What is the role of the supervisee in the process of achieving optimal supervision? To address aspects of supervisor competence for adequate supervision, the following are some characteristics marking such performance:
Attributes of the supervisor, relationship aspects, behavior of supervisor towards supervisee, clinical competence, and facilitative factors are categories of variables associated with “better supervision.”
Shanfield et al, (1989) devised an inventory for use with supervisees to assess the supervisory session. They urged analysis of the following qualities of the supervisory hour and reflection on these with the supervisee.
Another framework for analysis is provided by Milne, Pilkington, Gracie, & James (2003). The following are some of the categories they used in the analysis of effectiveness:
Although these researchers were looking for transfers from supervisory interventions to the therapy setting, this type of analysis or frame would also be useful for application to the actual supervisor-supervisee interaction. For example, one could ask the supervisee which behaviors he/she would prefer in the supervisory process, and then either through videotaping the supervisory session, or through both supervisor and supervisee giving their impressions after the supervisory session, assess what the session actually looked like and how each might like it to change. This might lead to a discussion of the types of presentation or material useful to ensure that the supervision moved in that direction.
Beginning supervisors use an abundance of listening, and beginning supervisees use abundant reflection. With experience and training, there is movement towards use of a broader range of behaviors, including those that are more constructive.
Think about critical incidents that have occurred for you in supervision—times in which things have happened that stand out in your memory as being very problematic. Think about any times when there might have been conflict between you and the supervisee.
In supervision, there are times when there is covert conflict between supervisor and supervisee. In many instances, one or the other is not aware of the conflict and—because of the power differential—it is extremely difficult for the supervisee to raise it in supervision. Supervisors have varying degrees of comfort with power differential and discuss it accordingly. If supervision is structured to be unidirectional, from supervisor to supervisee, there is clarity in the tradition of top-down supervision. However, supervision is increasingly envisioned as, at least to some extent, bi-directional, with the supervisee and supervisor mutually influencing the other and creating a dialogue. It is very important to insert discussion of the nature of the power differential, as it has not vanished. The supervisor still is the legally responsible entity for all supervision and for the welfare of the client. As such, establishing parameters of legal and ethical responsibility, as well as the significant gatekeeping responsibility to the field, must be discussed. Gatekeeping refers to the supervisor’s responsibility to ensure that particular competencies have been met to responsibly allow the supervisee to progress to the next level of training or practice. Within the gatekeeping function is the evaluative one—that the supervisor must systematically evaluate the supervisee according to a format previously disclosed to the supervisee (See 7.06 in the Ethical Principles of Psychologists and Code of Conduct (2002)).
There is some evidence that sheer role conflict is a major source of discomfort amongst supervisees. Moskowitz and Rupert (1983) surveyed practicum students and found that over 1/3 reported they had experienced a major conflict with their supervisor. Although many of the supervisees in the study did initiate discussion with the supervisor, less than half of those who experienced conflict ultimately experienced improvement.
The power differential is such that supervisees may be fearful that such discussions would be reflected in their evaluations, be personalized to the interaction, or simply would be hopeless.
Moskowitz and Rupert (1983), supporting results by Rosenblatt and Mayer (1975), found that some of the students engaged in spurious compliance, or pretending to follow supervisory directives while in fact doing whatever they thought to be correct. They concealed relevant information, especially their personal feelings. This might be manifested in distortion of progress notes. This is a terrible outcome for supervisors as they hold legal responsibility for the actions of the supervisee. Spurious compliance is something to be avoided through enhanced communication and sensitivity to the supervisee. It is also important for the supervisor to take the initiative in identifying and exploring the conflict, and to be receptive to discussion should a supervisee raise the subject. This is one of many areas in which the supervisor bears responsibility. In cases where conflicts were addressed, there was good resolution in many cases and a positive learning experience that strengthened the supervisory alliance.
Another responsibility relating to conflict for the supervisor is to disclose possible conflicting roles that the supervisor may carry out in the training setting, or outside, and anticipate what conflicts might arise as a function of these. Thus, for example, if the supervisor were in a very small rural area, and had the potential for multiple relationships with clients of the supervisee, it would be important to discuss these, to direct the supervisee to current literature on the subject, and to devise strategies or general guidelines of how this would be approached if it were to arise.
Ladany and Melincoff (1999) studied supervisor nondisclosure. They reported that 98% of supervisors withheld some information from supervisees—just as supervisees withhold information from supervisors, which will be discussed below. In some cases, of course, it is positive to withhold information from supervisees, especially in cases in which the information is private and does not relate to the supervisory situation. However, Ladany and Melincoff reported that supervisors did not disclose negative reactions to supervisee’s therapy and professional performance, which may occur because the supervisor may be considering the supervisee’s developmental trajectory, and possibly end up placing it above that of client welfare. Another rationale for nondisclosure was that it was addressed nondirectively.
Another area where supervisors did not disclose was their negative reactions to supervisee’s supervision performance. This was a less frequent type of nondisclosure. Ladany and Melincoff (1999) suggested that nonconfrontation of supervisee problematic supervision performance may impede supervisee growth. It may also be associated with supervisees who are later identified as having significantly problematic behavior.
A third category of nondisclosure was the supervisee’s personal issues. It would be critical to be respectful of the supervisee’s privacy, and of not crossing the line to convert supervision into therapy, while at the same time being mindful of supervisory responsibility for addressing how supervisee issues may be adversely, or otherwise, affecting the therapy.
The fourth category of supervisor nondisclosure was negative supervisor self-efficacy. This includes all of the doubts supervisors might have about their own effectiveness or the goodness of fit with the supervisee. Rationale for not disclosing included that the supervisee need not be privy to supervisor insecurity, however it was highly recommended that supervisors seek consultation to distinguish his/her issues from those related to the supervisee.
The fifth category was dynamics of the training site. These nondisclosures were viewed as appropriate boundary setting. Next were supervisors’ clinical and professional issues. The authors indicated that it would be important to balance keeping professional boundaries and professional mentoring in this category. Supervisee appearance was another category, and should be addressed if it is affecting the supervisory alliance or the therapeutic relationship with the client. Positive reactions to the supervisee’s therapeutic and professional performance were not disclosed for reasons not understood to the authors (or to this one), as it would seem this is a critical part of the feedback that needs to be communicated to the supervisee. Attraction to the supervisee was not disclosed and this seemed reasonable, as it is a supervisor issue, not a supervisee issue. However, there was concern expressed that it is important for supervisors to model appropriate working through of sexual attraction, an area seldom discussed or processed in training.
There is also a significant literature on supervisee nondisclosures. Supervisees have significant power over what they disclose in supervision, especially when sessions are not videotaped or audiotaped. The most frequent type of supervision practiced is individual case consultation in which the supervisee describes his/her impressions of the therapy session. Supervisees may disclose certain aspects of the session to the exclusion of others.
Yourman and Farber (1996) reported that 60% of their (small) sample never or rarely failed to tell supervisors of what they perceived to be clinical errors, but about 40% said they distorted reports. Forty-seven percent of the sample said they told supervisors what they wanted to hear fairly frequently, and nearly 60% said they generally felt uncomfortable disclosing negative feelings toward their supervisor. Yourman and Farber summarized that, in instances with high potential for shame, such as acknowledging they made an error or not agreeing with the supervisor, over one-third of their sample affirmed they would tend to withhold information or tell the supervisor what he/she seemed to want to hear (back to spurious compliance).
In another study of supervisee nondisclosure, Ladany, Hill, Corbett, and Nutt (1996), categories were developed. Categories not disclosed to the supervisor were:
Supervisees reported a mean of eight nondisclosures of moderate importance during the course of supervision to date, and that almost all (97% of this sample) of supervisees withhold some information from their supervisors.
Many reasons were given for not disclosing including not thinking the information was important, it was too personal, negative feelings about the nondisclosure, alliance difficulty with the supervisor, worry about the impression it would make on the supervisor, or deference to the supervisor.
Generally, it is important for supervisors to be aware of the categories of behavior supervisees AND supervisors do not disclose and to be thoughtful and proactive in interactions about this. A useful technique is to introduce this information during supervision and process it with supervisees to increase openness and potential for discussion.
Red flags and warning signs of conflict or other difficulty in supervision:
The supervisor is responsible for identification of warning signs and initiating discussion. Garrett, Borders, Crutchfield, Torres-Rivera, Brotherton, and Curtis (2001) suggested the use of supervisory statements like “I’m sensing some tension right now between us. I’m wondering if you are experiencing it too, and what sense you make out of it” (p. 153).
A counterproductive event takes place when a supervisee perceives the supervisor to be less than helpful, hindering, or even harmful (Gray, Ladany, Walker, and Ancis, 2001). Categories that Gray et al. described included the supervisor dismissing supervisee’s feelings or ideas, or being unempathic.
An example that comes to mind was that of a supervisee who was terminating a case management case, and was calling the family to schedule the last session after the family had cancelled. She reached the father on the phone. He commenced to tell her how attractive she was, and said that now that therapy would be ending, he wanted to take her out to a play or to dance, and would like to have a date after the last session with his child. The supervisee was shocked and quickly said, “no,” but was unsure how to proceed beyond telling him that would not be appropriate at all. She told him she needed to talk to her supervisor and would get back to him, but that she definitely could not go out with him—that that is strictly prohibited. The supervisee called her supervisor to let her know of the incident; the supervisor responded very unempathically to the supervisee’s sense of overwhelm, stating that she could not understand what the supervisee was so shocked about, that that is predictable behavior, she should have expected it to happen sometime, and that he was even more shocked at how the supervisee had handled it. This left the supervisee feeling lost, alone, and completely overwhelmed as well as uncertain what it was she had done wrong besides disclosing to her supervisor her feelings.
A response that would not have led to a counterproductive interaction would have been for the supervisor to empathize with the surprise of the supervisee, to discuss the fact that client sexual attraction to therapists is in fact a common phenomenon, to praise the supervisee for setting a clear limit, and to advise her on the next steps to finish the case and complete the transfer or closing, including how to deal with the father in the final session if he was present. A big part of this would be processing the supervisee’s feelings and, while keeping it in the context of the client interaction, problem-solve about what made the interaction so shocking, and how the supervisee could move ahead to feel more prepared to see this father and others in the future when this could happen. It would also be important to analyze the interaction in terms of what transpired and what the supervisee wished she had done, if there was anything she so wished.
Other analyses of critical issues in supervision highlight that relationship issues and personal issues may not be adequately addressed in some models of supervision. Ellis (1991) found that issues of relationship, competence, emotional awareness, autonomy, and personal issues were all identified as critical issues. In contrast, issues of identity, individual differences, ethics, and personal motivation were only infrequently identified as critical issues. It would appear that these findings are supportive of developmental models in that self-esteem, and general competence and individuation considerations are central to development of the supervisee.
Critical incidents may arise from a wide variety of events, but there are predictable areas for which to be vigilant and sensitive.
Many of the instances referred to as counterproductive or critical incidents reflect supervisee or supervisor countertransference. We now know that personal and professional sources influence the course of behavior, treatment, and supervision—and become intertwined. Our conscious beliefs, cultural- and diversity-embedded values, and unresolved conflicts are all interwoven (Falender & Shafranske, 2004). Supervision as well as therapy is subject to these influences. In discussing countertransference, we must understand that the supervisor and the supervisee’s understanding is perspectival—influenced by personal interests, commitments, and cultures from which we construct personal meanings (Falender & Shafranske, 2004). Countertransference is inevitable and discussion of it is highly desirable.
Some supervisees come to us thinking that countertransference is indicative of their own psychological problems. To the contrary, it is very desirable for supervisees to identify and address countertransference in supervision—in the context of the client and supervisor, and reactions to the client and to supervision.
Before countertransference can be addressed, there must be a relationship between supervisor and supervisee. Depending on the developmental level of the supervisee, the discussion will vary. One must always be mindful of maintaining a boundary between supervision and psychotherapy as discussed earlier in this course. The guiding principle is that all discussion relates to the client. If the supervisor or supervisee sees a drift towards exploration of factors relating to the supervisee’s relationships and life apart from reactions to and feelings about the client, the supervisor should stop, rethink, and consider alternatives. This would definitely be the case should the supervisee present a pattern of countertransference (angry with the father in every family case, for example), should the supervisee have reactions which interfere with his/her ability to conduct therapy, or have reactions to which it would be inappropriate to expose the client (crying whenever child abuse is mentioned, for example).
Discussion of countertransference is an incredibly useful tool, but always within the boundaries of supervision. In order to approach the countertransference issue, it is important to help the supervisee return to a reflective stance from a more reactive one. Once in the more reflective position, it will be more possible to proceed to assess and consider the countertransference.
Counterproductive events may result in strains or ruptures in the supervisory alliance. Strains may be brought about by challenges inherent in training, conflicts in how goals or tasks of supervision are seen, inadequate attention by one or the other to superordinate values, inadequate technical competence by supervisor or supervisee, boundary crossings or violations, supervisee behavior viewed as problematic, or countertransference and parallel process phenomena (Falender & Shafranske, 2004). Indicators of strains in the alliance include supervisee behavior changes such as withdrawal, decrease in disclosure or supervisory interaction, display of hostility or criticism, or passivity or noncompliance (Falender & Shafranske, 2004). Often in the course of the strain, one or both parties become increasingly rigid, controlling or critical, placing additional strain on the supervisory relationship. Thus, the relationship cycles downward in a negative spiral, resulting in a supervisory alliance rupture.
Safran and Muran (2000) described a process of metacommunication in which the supervisor and supervisee attend to the rupture marker, explore the rupture experience, and explore the avoidance. Then the supervisee asserts and the supervisor validates the assertion. Both may step back from the process and approach it more objectively in order to return to a reflective state. It is critical to address strains and ruptures as quickly as possible. Due to the power differential, it is the responsibility of the supervisor to do so whenever possible. Depending on the severity of the rupture, it may be very difficult to adopt the stance of inquiry—stepping back from a defensive mode and gaining insight into the process—in the context of client process. However, it is essential to bear in mind that spurious compliance and other negative outcomes may ensue from not addressing the conflict, rupture, or strain.
Vignette: The supervisor is concerned that his supervisee, who was excellent in all her clinical work for the first four months of the training sequence, suddenly is experiencing significant problems with one case, and seems very insecure and unsure about her other clinical work. He had tried being supportive but she was increasingly withdrawn and unwilling to discuss case material. He is beginning to be angry with her for being withholding. And the angrier he becomes, the more withdrawn she becomes. Thinking back, the supervisor begins to think that the difficulties started after he had been very hard on her for an intervention she had tried in the case with which she now seems to have great difficulty. He wonders if there is a connection.
Using the concepts described above, think about hypotheses about what could have happened and what steps should be taken at this point.
What was the rupture marker? How could you explore this? How would you approach avoidance?
An area of training that has been much neglected is that of diversity competence. It is an ethical standard.
Ethical Principles of Psychologists and Code of Conduct (APA, 2002):
Principle D: “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices” (APA, 2002)
Principle E: “…Psychologists are aware of and respect cultural, individual, and role differences including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices” (APA, 2002)
2.01b: “Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals…” (APA, 2002).
In addition, there are the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003), containing prescriptive statements regarding the necessity for cultural competence.
It is important to be knowledgeable about the American Psychological Association guidelines: Guidelines for Psychological Practice with Older Adults (APA, 2003), and Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual clients (APA, 2000).
For social workers from the NASW Code of Ethics:
1.05 Cultural Competence and Social Diversity
(a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.
(b) Social workers should have a knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' cultures and to differences among people and cultural groups.
(c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or physical disability.
3.01 Supervision and Consultation
(b) Social workers who provide supervision or consultation are responsible for setting clear, appropriate, and culturally sensitive boundaries.
Ethical standards and multicultural guidelines notwithstanding, there is some evidence that therapists are continuing to provide services to some clients they do not feel competent to treat (Allison, Echemendia, Crawford, & Robinson, 1996, surveying 90% Caucasian respondents) and that supervisors’ knowledge, skills, and values relating to diversity may not be as sophisticated as is that of their supervisees (Falender & Shafranske, 2004), and that supervisors’ perceptions of their efforts to integrate diversity into supervision may not be in total agreement with the supervisees’ perceptions of the same. Hansen, Randazzo, Schwart, Marshall, Kalis, Frazier et al., 2006 suggested that we do not necessarily practice what we preach. In a sample of practitioners, they found that even though the majority self-assessed as culturally competent, they often did not follow the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003). For example, they did not necessarily seek out consultation when they felt they did not have adequate cultural knowledge or expertise. Duan and Roehlke (2001) showed how the competence differential between supervisor and supervisee might play out: 93% of the supervisors in their sample reported they had acknowledged their lack of cross-racial supervision experience to their supervisees but only 50% of the supervisees reported receiving the acknowledgment. A smaller differential in the same direction was reported between supervisor and supervisee perceptions of initiating discussion of cultural differences in general.
Then it is important to consider 7.04 Student Disclosure of Personal Information from the Ethical Principles of Psychologists and Code of Conduct (APA, 2002).
Psychologists do not require students or supervisees to disclose personal information in course- or program-related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peer, and spouses or significant others except if:
(1) the program or training facility has clearly identified this requirement in its admissions and program materials, or
(2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professional-related activities in a competent manner, or to be posing a threat to the students or others.
This is a critical area of concern for any supervisor who uses consideration of personal factors or countertransference in their supervisory process. Using option (1) is highly recommended to provide informed consent to incoming supervisees of the expectation that discussion of such material is encouraged in the context of case discussion. The following is a statement recommended to be included in program/setting descriptions that supervisees receive prior to selecting their training site:
“While as trainers it does not seem wise to require supervisees to disclose such information, there was concern among the APPIC Board, that this statement could be interpreted as discouraging voluntary disclosure of personal information in the course of clinical supervision. It is our experience that such disclosure in the course of supervision can be quite useful as it relates to the clinical work being discussed. It seems clear that one of the implications of the new ethical guidelines as written is that it will be essential for training programs that place value on such personal exploration in the course of supervision to state this value clearly in their internship and post-doc materials” (Illfelder-Kaye, APPIC Newsletter, 2002).
Brown and Landrum-Brown (1995) suggested, “A supervisor’s cultural frame of reference, or worldview, is likely to influence, for example, the therapeutic choices made by supervisees and their supervisors. Furthermore, we argue that worldview conflicts between supervisees and supervisors may be reflected in the evaluation of the supervisee, in the quality of the supervisory relationship, and in each party’s therapeutic approach” (p. 263-4).
That pervasive quality, supervisor worldview—with biases, assumptions, and belief structures—is an incredibly important component of supervision but one that is often neglected or at least not given a central place in supervision practice.
The supervisory question becomes how to increase diversity competence and multicultural competence in supervision. In addition to the ethical standard, there is the reality that ethnic and social diversity is increasing dramatically and that mental health training is based on Eurocentric perspectives (Daniel, Roysircar, Abeles, & Boyd, 2004). Increasingly, it appears that we need to move from culture as an “add-on” to culture as a driving force in practice models. This entails a shift from cultural content to context, moving focus from the client to the interaction between client and therapist and the process of that (Vargas, 2004). This may result in shifting conceptualization of the problem exclusively from the individual to recognition of social justice and contextual factors. Further, infusion of diversity into training, rather than placing consideration into a specific seminar on the topic, is more useful and communicates a message of integration and inclusion, assisting supervisees in broadening their perspectives, investigating their own feelings and assumptions, and applying these to clinical cases.
A primary issue is self-awareness. Most of the multicultural frameworks (Sue, Arredondo, and McDavis, 1992) consider self-awareness to be an essential first step in the process of becoming more culturally competent. There are multiple deterrents to enhanced self-awareness including the fact that white therapists may not consider themselves to have a culture or if they do, they question whether it is relevant. There is also disregard of white privilege—and as long as it is disregarded, the multiple power differentials in the therapy equation are disregarded. Self-awareness has not traditionally been a part of training programs. As if therapy were value-free—a premise long discounted—training programs have not attended to what values, assumptions, and belief structures each of us brings to our practice of therapy and supervision.
A second key deterrent is resistance to content, i.e., believing there are no differences among ethnic groups, or feeling a lack of safety in discussing diversity or culture.
A third deterrent is neglecting the concept of ecological niches or diversity as an important part of the equation. What are ecological niches? Think of all the descriptors that go into your identity.
For example, gender, religion, profession, sexual identity, culture, ethnicity, SES, race, and so forth. It has been speculated that each individual could develop an “equation” to describe which of one’s niche characteristics are most impactful, and how they interact. This whole area of discussion requires openness to discussion and self-awareness of culture and diversity status.
Beyond lack of comfort with the discussion or self-disclosure, deterrents to multicultural competence also include differing developmental levels of supervisor and supervisee in:
The following are some scales of multicultural competence that are useful for assessment.
Scale Name and Authors
Sample Item and/or scales
Multicultural Counseling Knowledge and Awareness Scale (Ponterotto et al, 2002) or Multicultural Counseling Awareness Scale-Form B (Ponterotto et al., 1996)
Measures general knowledge and Eurocentric worldview bias
Multicultural Counseling Inventory
(Sodowsky, Taffe, Gutkin, and Wise, 1994)
“When working with minority clients I am able to quickly recognize and recover from cultural mistakes or misunderstandings:”
“My life experiences with minority individuals are extensive (e.g., lack of bilingual staff, multiculturally skilled counselors, and outpatient counseling facilities.”
“When working with minority clients I find that differences between my worldviews and those of the clients impede the counseling process.”
Multicultural Counseling Skills, Multicultural Awareness, Multicultural Counseling Knowledge, and Multicultural Counseling Relationship. (Sodowsky, Taffe, Gutkin, & Wise, 1994)
Multicultural Awareness/ Knowledge/ and Skills Survey (D’Andrea et al., 1991)
“Psychological problems vary with the culture of the client”
Assesses awareness of personal attitudes towards people of color; knowledge about populations, and communication skills,
Cross-cultural Counseling Inventory Revised (LaFromboise et al., 1991)
“Counselor is willing to suggest referral when cultural differences are extensive”
Subscales: Cross-cultural counseling skill, sociopolitical awareness, cultural sensitivity.
Also useful is self-assessment such as a scale developed by Gargi Roysircar (2004). With this scale, both supervisor and supervisee can identify beliefs and attitudes, knowledge, skills, privilege, internal and external feedback, interethnic countertransference, multicultural awareness, and multicultural counseling relationship.
An important aspect of diversity competent supervision is to draw from positive psychology and take a strength-based approach. In this situation, supervisor and supervisee determine individual and collaborative strengths upon which to build. Similarly, the client is approached from a strength-based perspective. Much of community mental health and mental health in general is focused primarily upon deficits or problems, which must be documented to justify services, while attention to strengths and individual factors in each party are ignored or neglected.
Gonzales (1997) has proposed conceptualizing the supervisor as “partial learner”, which places supervisor and supervisee in a collaborative stance. This is similar to the DBT stance described earlier, in which the supervisor is viewed as fallible. Both of these remove some of the distance between supervisor and supervisee, and allow for a more direct cultural and clinical discussion and mutual problem solving.
It is important to maintain a balance between knowledge leading to stereotypes versus openness to learning and acquisition of knowledge and skills that are sensitive to individual cultural niches. Cultural niche refers to consideration of an individual as multiply determined culturally; for example, I am a female, Caucasian, heterosexual, psychologist, mother—to isolate one of these factors would not be an accurate portrayal of me in my entirety. Increasingly, mental health professionals are considering multiple factors in proceeding with treatment and supervision rather than simply pulling out one, “African-American” for example, and proceeding on stereotyped knowledge acquired about that group which may or may not be relevant to the individual being treated. It might be more relevant that the individual is gay, single, Buddhist, or visually impaired.
There is the danger of over-attention to diversity to the exclusion of good clinical practice. Excellent practice leads to a balance among the factors, and an understanding of how each factor contributes to an individual’s sense of self. Underlying trust in the relationship will lead to cultural understanding.
Writing about working with gay, lesbian and bisexual clients, Bruss, Brack, Brack, Glickauf-Hughes, and O’Leary (1997) suggested the supervisor assess the supervisee’s level of functioning, being particularly vigilant for inadequate information, anti-gay attitudes, attribution of all problems to sexual identity, and considering family/intimacy issues in heterosexual terms (from Buhrke & Douce, 1991). Supervisor self-awareness is key as well as is willingness to explore countertransference. When gay and lesbian clients were asked about what they wished their therapist understood, they responded that they wished therapists had greater knowledge of how gay and lesbian relationships are invisible, about the coming-out process and how it is not linear, effects of homophobia, and generally the history of gay rights and social action (Biaggio, Orchard, Larson, Petrino, & Mihara, 2003). In addition, therapists should have knowledge of the “Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients” (APA, 2000). Understanding one’s own feelings towards gay, lesbian, transsexual, and bisexual clients is an important first step.
If a supervisee self-identifies it is important for the supervisor not to view him/her as an exemplar of that particular group or as an expert. Instead, this should be considered in the equation of client, supervisee, and supervisor characteristics that may influence assumptions, biases, and directions in therapy.
Framing language to begin supervision is an excellent step. It is recommended that the supervisor take responsibility for the initiation of discussion of multicultural issues in supervision. This includes taking responsibility for having awareness and knowledge of one’s own multiple cultural/diversity identities—and having addressed the emotional components. This also entails discovering values, beliefs, biases, and prejudices present in our assumptions about the world, our perceptions, and our actions.
Page and Wosket (2001, p. 212) suggested questions like, “What would you like me to know that would help me to work most effectively with you?” and “What differences between us might we need to address as our relationship develops?”
Other options include general statements about how important differences in background and culture might be to the supervision, and how critical it is to discuss these. One way of highlighting this is expression of interest in understanding and knowing values, traditions, and worldviews (Daniels et al., 1999).
For individuals in a formal training program, describing a training sequence in materials that supervisees receive before selecting the setting (providing informed consent), one can have a seminar or several orientation sessions relating to culture and diversity set the tone. One model was described by Wisnia and Falender (1999) in which supervisors model describing one aspect of their cultural/diversity experience, using a framework derived from Falicov (1998):
Worldview refers to the entire set of an individual’s guiding beliefs, values, logic, concepts of reality, and even concept of self.
Falender and Shafranske (2004) urged consideration of the culture and diversity variables of all parties including client(s), supervisee, and supervisor, and to consider how each of these are consonant and dissonant—all of which casts significant light on the supervision process and direction of therapy.
Using the Wisnia and Falender (1999) framework, each participant chooses one aspect of his/her diversity niche from the above eight possibilities and presents this to the group. The presentation can be an oral presentation, story, objects, video, food, or a combination. Through this sharing, a tone of appropriate self-disclosure and sharing is set, which is then tied to case material. Self-disclosure does carry with it risks, especially as the supervisor is also the evaluator, and information disclosed may end up being used for evaluative purposes.
Vignette: The client is a 37-year-old African-American woman whose parents moved to California from the South. She is in therapy because she is depressed and she is feeling that she is not being promoted at work because her boss is racist. Her therapist, the supervisee, is a 25-year-old intern who was born in Puerto Rico and has lived in Southern California since high school. The supervisor is a 58-year-old Anglo woman.
Consider the cultural complexity by comparing each dimension of client-supervisee-supervisor in terms of worldview, migration, place in the family life cycle, ethnicity, and hypotheses about how different belief structures or perspectives, and privilege and oppression, may affect a therapeutic approach.
There is no separate supervision code of ethics that has been adopted by the APA, NASW, or AAMFT. There is, however, a code of ethics for supervision available through the Association for Counselor Education and Supervision, the founding division of the American Counseling Association (ACA) (https://www.accta.net/default.asp?OPID=90). It is the responsibility of the supervisor to know and keep updated on regulations, laws, ethics codes, and all developments that impact client care and supervision. In this section, there will be references to the ethics codes listed below when each of the codes has relevant standards. You may use these links to review your own code in further detail.
In the contract or supervisory agreement, the supervisee should agree to abide by the ethics of his/her profession, and the laws and regulations. An important part of beginning supervision is to provide the supervisee with specifics of legal decisions relevant to the geographical location. For example, in California, the supervisee needs to be introduced to Tarasoff and its extensions. If the supervisee was trained in another state, the duty to warn provisions may not have been in effect or it may have been illegal to warn. Many regulations and practices are state specific as well.
For example, in California:
Recent changes to California Laws and Regulations Relating to the Practice of Psychology and to Statutes and Regulations Relating to the Practice of Marriage and Family Therapy
Ethical prescriptions are integrally yoked to legal requirements. Ethical codes and principles can often form the basis for legal liability. Even when there is no direct connection, the lack of adherence to ethical norms of behavior can color decision-makers’ actions.
To differentiate ethical from legal decision-making, Stromberg et al. (1988) distinguished ethical categories from legal decision-making categories. These categories are important for general understanding and need to be communicated to supervisees:
In instances when ethics and law conflict, “the degree of the psychologist’s understanding of and ability to evaluate professional principles and practice guidelines as well as the laws governing practice, concern for the client, and the circumstances must be examined in resolving to his or her satisfaction what must be done” (Bennett et al., 1990).
The APA Ethical Principles and Code of Ethics (2002) states,
“If psychologists’ ethical responsibilities conflict with law, regulations or other governing legal authority, psychologists make known their commitment to the Ethics Code and take steps to resolve the conflict. If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority.” (1.02)
There are also issues of differing burden of proof across contexts. For example, it must be established that harm was done to the plaintiff for damages to be awarded in a malpractice suit. However, a licensing board can discipline professionals for improper conduct without harm having been inflicted. Licensing boards have a much broader range of admissible evidence (e.g., hearsay, prior acts) than does the court (Hansen and Goldberg, 1999).
Respondeat Superior refers to Vicarious Liability. This is a very important term for supervisors to understand as it applies to responsibility for supervisee actions. It is the legal term that refers to one individual holding a position of authority or direct control over another—a subordinate—and as such can be held legally liable for the damages a third individual suffered as a result of the negligence of the subordinate. Generally, clinical supervisors are legally liable for injury caused by the supervisee. Supervisory liability only typically occurs if the negligent acts of the supervisee occurred in the course and scope of the supervisory relationship. Relevant factors include:
(Disney & Stephens, 1994)
Bennett et al. (1990) described four criteria to be met for malpractice:
Keep in mind that there are two forms of supervisory liability:
Sometimes it is not so clear-cut between these two.
The supervisor is gatekeeper in that the supervisor holds power to pass or fail the supervisee by signing off on hours or completion certification, and the supervisor holds the power to protect the client. Supervisors must remember that their highest priority is duty to the client. They must balance responsibility to the training of the supervisee, but always maintain clarity about duty to the client’s safety and well being, with “doing no harm” the highest priority. Generally, supervisors should practice carefully, and be actively involved in supervision. If one makes an error in judgment under those circumstances, the risk is substantially less than for someone who has a history of negligent supervision.
Do supervisors always behave ethically? In one study (Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999), 51% of supervisees reported at least one ethical violation by their supervisor.
The following were the categories of perceived ethical violations:
Ladany et al. (1999) reported that about 35% of supervisees discussed their perceived ethical violations by the supervisor with the offending supervisor. Fifty-four percent discussed it with someone other than the supervisor—a peer, friend, significant other, another supervisor, therapist, professor, or relative.
A supervisor’s unethical behavior was associated with less satisfaction on the part of the supervisee with supervision. Greater supervisory unethical behavior was associated with lower goal and task agreement, and a lower emotional bond between supervisee and supervisor (Ladany et al., 1999).
In this context, with respect to the first category of perceived ethical violations, refer to Ethical Standards for Psychologists and Code of Conduct (2002):
7.06 Assessing Student and Supervisee Performance
(a) In academic and supervisory relationships, psychologists establish a timely and specific process for providing feedback to students and supervisees. Information regarding the process is provided to the student at the beginning of supervision.
(b) Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements.
NASW Code of Ethics
3.03 Performance Evaluation
Social workers who have responsibility for evaluating the performance of others should fulfill such responsibility in a fair and considerate manner and on the basis of clearly stated criteria. It is incumbent upon the supervisor to inform the supervisee of the measures and process of evaluation and assessment of performance, that feedback be ongoing, and that informed consent be honored by providing the supervisees with the tools (and not changing them midway through the training) that will be used for supervisee evaluation. Also it is important to inform the supervisees exactly what the criteria are for successful completion of the superviseeship and what the consequences will be if one or more of these criteria are not attained.
Remember that the same standard of care for services provided by supervisees pertains as that for licensed professionals (Harrer, VandeCreek, & Knapp, 1990).
For psychologists, be guided as well by the APA’s Ethical Principles for Psychologists and Code of Conduct: LCSW’s should be guided by their NASW Code of Ethics: MFT’s by the AAMFT Code of Ethics.
2.05 Delegation of Work to Others
Psychologists who delegate work to employees, supervisees, or research or teaching assistants or who use the services of others, such as interpreters, take reasonable steps to (1) avoid delegating such work to persons who have a multiple relationship with those being served that would likely lead to exploitation or loss of objectivity; (2) authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training, or experience, either independently or with the level of supervision being provided; and [italics added] (3) see that such persons perform these services competently. (See also Standards 2.02, Providing Services in Emergencies; 3.05, Multiple Relationships; 4.01, Maintaining Confidentiality; 9.01, Bases for Assessments; 9.02, Use of Assessments; 9.03, Informed Consent in Assessments; and 9.07, Assessment by Unqualified Persons.) (APA, 2002)
There is the same duty to warn and adherence to all ethical and legal codes for the supervisee as for the supervisor as therapist.
Association of State and Provincial Psychology Boards (ASPPB) Supervision Task Force (2003):
Supervisors shall not permit supervisees to engage in psychological practice they cannot perform competently
Supervisor has the responsibility to interrupt or terminate supervisee activities whenever necessary to protect the public and insure adequate skill development
APA Ethical Principles of Psychologists and Code of Conduct:
2.01 Boundaries of Competence
(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.
(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.
(c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.
(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.
(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.” (APA, 2002)
NASW Code of Ethics:
3.02 Education and Training
(a) Social workers who function as educators, field instructors for students, or trainers should provide instruction only within their areas of knowledge and competence and should provide instruction based on the most current information and knowledge available in the profession.
AAMFT Code of Ethics:
Principle IV. Responsibility to Students and Supervisees
4.4 Marriage and family therapists do not permit students or supervisees to perform or to hold themselves out as competent to perform professional services beyond their training, level of experience, and competence.
Supervisors should carefully ascertain at what level their supervisees are performing, and determine what cases are within their competence with what corresponding level of supervisory support.
Supervisors must have knowledge and skills regarding diversity and multiple niches of diversity. If supervisors self assess and determine they do not have the competencies needed, they take immediate action to gain education, training, supervised experience, etc., or they identify a more appropriate supervisor and transfer the supervision to that individual
In “emerging areas” of practice, if generally recognized standards do not exist, supervisors must take responsibility for ensuring safe and competent practice and protect their clients from harm. Supervisors of all disciplines must take care to supervise only in areas in which they have established competence and in compliance with their respective code of ethics.
Now that increasingly elaborate competency-based measures are available for determining supervisor competence and practicum student competence, supervisors have the responsibility of ensuring that those competency levels are met.
Supervisor competence refers to the body of knowledge, skills, and values regarding clients, modalities of treatment, theories of treatment AND supervisees, modalities of supervision, and theories of supervision.
From the Ethical Principles for Psychologists and Code of Conduct (APA, 2002):
4.02 Discussing the Limits of Confidentiality
(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent.)
(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.
(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.
NASW Code of Ethics:
1.02 Privacy and Confidentiality
(e) Social workers should discuss with clients and other interested parties the nature of confidentiality and limitations of clients' right to confidentiality. Social workers should review with client’s circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the social worker-client relationship and as needed throughout the course of the relationship.
AAMFT Code of Ethics:
Principle II. Confidentiality
2.1 Marriage and family therapists disclose to clients and other interested parties, as early as feasible in their professional contacts, the nature of confidentiality and possible limitations of the clients’ right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.
Supervisors have responsibility to ensure confidentiality of their supervisee’s clients’ information.
Supervisors have responsibility to ensure that their supervisees understand fully the limits of confidentially (or lack of such) of their communications to their supervisors
Supervisors have responsibility to ensure that if electronic communication occurs (between client and supervisor, supervisee and supervisor, or client and therapist), clients and supervisees are informed in advance of the limits of confidentiality and the possibility that such communications are not private.
Ethical Principles of Psychologists and Code of Conduct (APA, 2002):
10.01 (c) When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor. (APA, 2002)
This addresses informed consent as it relates to supervision.
Another relevant section, discussed earlier is:
7.04 Student Disclosure of Personal Information
Psychologists do not require students or supervisees to disclose personal information in course- or program-related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peers, and spouses or significant others except if (1) the program or training facility has clearly identified this requirement in its admissions and program materials or (2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professionally related activities in a competent manner or posing a threat to the students or others.
The supervisor should disclose supervisory experience, training, theoretical orientation, limits of confidentiality of supervision, expectations for the training period including all logistics, required behavior and productivity, services to be performed, what constitutes successful completion, and consequences if one does not complete adequately one or more of the parts plus due process steps.
There should be prior agreement regarding expectations for professional functioning, evaluation procedures, criteria, and timing; communication to be expected through formative and summative feedback to remediate perceived performance deficits; communication with the graduate program including progress reports, concerns about development or other issues; development of an action plan for remediation; time lines and consequences of time line not being met; due process procedures for appeal; and time and procedure for responses to feedback.
One of the biggest mistakes supervisors make is not providing for due process—and not telling supervisees what will happen if they do not meet performance criteria—and what recourse they have.
This is the area of supervision relationships that has been most written about and addressed. It has been referred to as dual relationships or multiple relationships. Again, it is useful to review the ethics codes below:
Ethical Principles of Psychologists and Code of Conduct (APA, 2002):
3.05 Multiple Relationships
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.
(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)
3.06 Conflict of Interest
Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploit.
NASW Code of Ethics:
1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client.
(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.
3.02 Education and Training
(d) Social workers who function as educators or field instructors for students should not engage in any dual or multiple relationships with students in which there is a risk of exploitation or potential harm to the student. Social work educators and field instructors are responsible for setting clear, appropriate, and culturally sensitive boundaries.
AAMFT Code of Ethics:
Principle IV. Responsibility to Students and Supervisees
4.1 Marriage and family therapists are aware of their influential positions with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships that could impair professional objectivity or increase the risk of exploitation. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists take appropriate precautions.
Critical aspects of supervisor behavior include the avoidance of (1) exploitation, (2) impaired objectivity, and (3) exposing an individual to harm.
Regarding the specific category of sexual boundary violation, each ethics code has a separate standard.
APA Ethical Principles for Psychologists and Code of Conduct:
7.07 Sexual Relationships With Students and Supervisees
Psychologists do not engage in sexual relationships with students or supervisees who are in their department, agency, or training center or over whom psychologists have or are likely to have evaluative authority.
NASW Code of Ethics:
2.07 Sexual Relationships
(a) Social workers who function as supervisors or educators should not engage in sexual activities or contact with supervisees, students, supervisees, or other colleagues over whom they exercise professional authority.
AAMFT Code of Ethics:
Principle IV. Responsibility to Students and Supervisees
4.3 Marriage and family therapists do not engage in sexual intimacy with students or supervisees during the evaluative or training relationship between the therapist and student or supervisee. Should a supervisor engage in sexual activity with a former supervisee, the burden of proof shifts to the supervisor to demonstrate that there has been no exploitation or injury to the supervisee.
Boundary crossings have been distinguished from boundary violations. Boundary crossings refer to those actions which depart from commonly accepted clinical practice and that may or may not benefit the client. Boundary violations refer to departures from accepted practice that place the client or the process of therapy at significant risk.
Examples of boundary crossings include accepting a gift from a client, going to lunch with a client, or in the case of supervision, accepting a gift from a supervisee or engaging in social activities with a supervisee.
An example of a boundary violation is having sex with a client or having sex with a supervisee.
An example of supervisor touch (a supervisor hugging or massaging a supervisee) or requiring the supervisee to go to lunch with him weekly. What is your response to these examples? It is so important for a supervisor to keep in mind several factors: the power differential may prevent the supervisee from telling the supervisor that the boundary crossing is a violation of the supervisee’s space, or is otherwise intrusive or potentially hurtful. Take for example the supervisor who requires the supervisee to go to lunch during supervision, and requires him to pay for lunch. The supervisee has tried not eating (supervisor will not accept this), ordering inexpensive foods (supervisor splits the bill with the supervisee and orders more expensive foods), and asking if the supervisory hour could be changed (supervisor refused citing lack of other available times.) The supervisee feels violated as he cannot afford expensive lunches, feels he is sacrificing adequate supervision as he cannot discuss his cases (ethically) in a public place, and feels totally trapped and if he protests too much it may impact his evaluation or even the supervisor’s signing off on the hours he has accrued. If this is a mixed gender dyad, there could be additional complexity, inferences, and pressures. On the walk back to the office, the supervisor starts putting his arm around the supervisee’s shoulder making the supervisee increasingly uncomfortable but unclear what he/she can do.
Supervisors have the responsibility to behave ethically and to minimize boundary crossings. If boundary crossings occur, supervisors should consider the impact upon the supervisee and use problem solving frames below.
What, if any, multiple relationships are appropriate between supervisor and supervisee?
Using boundary crossings versus violations as a guideline, it is important to note that individuals who engage in boundary crossing are at greater risk when later accused of a boundary violation (Gutheil & Gabbard, 1993). That is, engaging in behaviors that in of themselves are only crossings, such as hugging clients, going to dinner with an individual intern, or accepting presents from supervisees can be viewed in retrospect as a loosening of boundaries. The minor boundary violations, then, are part of a pattern of escalating violations along a slippery slope. Gutheil and Gabbard (1993) suggested consideration of:
Supervisors in rural areas have expressed concern about the impossibility of avoiding multiple relationships. The rule that has been proposed is for the relationships to be focused on informed consent and a thoughtful analysis of potential risks or exploitation of the client, and to involve the client in thinking through the relationships.
Lazarus and Zur (2002) presented a thoughtful analysis of when dual relationships and boundary crossings are therapeutically indicated, and how, in this era of risk management, we have been unduly influenced by attorneys to be risk avoidant—in ways that may not be in the best interests of the client. They urge us not to let risk management considerations take precedence over providing the best possible clinical care to our clients. They argue that some multiple relationships are healthy and promote healing, and that demonizing them has harmed psychologists and the profession. It would seem that there should be some balance in this as in most areas of practice, with adherence to a thorough informed consent process and thoughtful analysis. Please note that these authors denounce sex with the client. They are referring to other categories of multiple relationships such as lending books, sending birthday cards, accepting invitations to attend special events, accepting small gifts, playing tennis or having lunch with a client, and the like.
It is useful to consider Bennett et al’s (1990) caution that one must always consider what the therapist’s (or, in this case, supervisor’s) behavior means to the client (or supervisee). That is, a hug may be intended as a sign of support and empathy by the therapist (or supervisor), but may be interpreted as a sexual gesture by the client (or supervisee). In fact, when groups of supervisors are asked about their worst supervision experiences, they often refer to boundary issues of touching, back rubs, hugs, or kisses by supervisors who have no idea that the supervisee is feeling that these are boundary crossings or violations.
In fact, there has been a decrease in reported incidence of sexual behavior between clients and therapists, and low reported levels between supervisors and their supervisees (from 1.4-4%). The supervisees report the incidence as between 5 to 6% (Lamb, Catanzaro, & Moorman, 2003; summarized in Falender & Shafranske, 2004). Thus, there is a slightly higher report of sex between supervisor and supervisee by supervisees than by supervisors. Lamb, Catanzaro, and Moorman (2003) reported in their survey that only 3.5% of the 368 individuals who responded to the survey, or 13 individuals, had had one sexual boundary violation as a professional psychologist. In the case of the very small number of individuals who had a sexual boundary violation with a supervisee, all of them occurred after supervision had ended. Although a small sample, it is noteworthy that 40% of those surveyed did not view their involvement as harmful to the other individual.
Sexual advances, seductions, and/or harassment have reportedly been experienced by 3.6 to 48% of psychology and mental health-related students. Although most mental health educators believe it is unethical and/or poor practice to engage in sexual contact with a supervisee or student, especially during the working relationship, it appeared that such practices do occur. Many students (53% – n of 223) would not feel safe to pursue action if they had firsthand knowledge of a sexual contact occurring—due to fear of loss of anonymity and fear of repercussions (Zakrzewski, 2006).
Having sexual feelings or attraction toward a client at some point in one’s professional career is normative, and approximately 80-88% of psychologists report they have experienced those kinds of feelings (Blanchard & Lichtenberg, 1998). Over half of all psychologists reported that their training was not adequate in these matters (Pope Keith-Spiegel, & Tabachnick, 1986).
In fact, it appears that many supervisees do not self-disclose or process sexual attraction unless the attraction is from the client directed towards the therapist. That type of disclosure is much more common and discussed. Reflect back on your supervisory experience and how many times a supervisee has ever disclosed sexual attraction to a client.
A good way to increase such discussions—as it is very important to process such information rather than allow for the possibility of it being acted upon—would be to provide the supervisee with some normative data or an article about sexual attraction. A book by Pope, Sonne, and Holroyd (1993), Sexual feelings in psychotherapy: Explorations for therapists and therapists in training, is an excellent resource.
Hamilton and Spruill (1999) conducted a retrospective analysis of two students who did engage in sex with their clients. They identified a number of commonalities and risk factors that are useful to consider. The students had been paraprofessionals before returning for graduate training and had had quasi-friendship relationships with their “clients” in those roles. They had moved from different parts of the country and were feeling isolated. Because of limited experience with therapy, they interpreted their clients’ statements of needing them, caring so much for them, etcetera very literally, rather than considering them as transference phenomena and bringing them to supervision (another reason to actively encourage discussion of sexual attraction in supervision). Hamilton and Spruill developed a checklist for risk management purposes of behaviors that are potentially problematic. They included therapists who extended the session regularly, scheduled sessions up to clinic closing time, dressed specially for the client, appeared very preoccupied with the client, failed to document phone calls or contacts or could not remember them.
Younggren & Gottlieb (2004) developed questions to ask to make decisions about whether to engage in a multiple relationship. These are useful as a framework in supervision as well:
(Adapted from Younggren & Gottlieb, 2004)
Consider the example of a supervisee who wants to carpool, having discovered that the supervisor lives one block away, and the drive to the setting is 45 minutes. What parameters would one consider? Try the questions from the Younggren and Gottlieb (2004) framework first. Here is one individual’s analysis:
This relationship is not necessary most likely, and although it might save money for gas, it might be very inconvenient in terms of hours. It could potentially cause harm to the supervisee if the supervisee disclosed personal information or data unknown to the supervisor or if the relationship evolved out of supervision. There is a risk the dual relationship could disrupt the supervisory relationship, and there would be a possibility the supervisor could not evaluate the matter objectively, if he/she developed a friendship with the supervisee making evaluation difficult or impossible, or if the supervisor became financially dependent on the supervisee’s provision of gasoline.
Then consider Burian and Slimp (2000). They developed a decision tree and Likert scales specific to decision-making in the internship.
(Burian & Slimp, 2000)
Considering the carpool scenario in the Burian and Slimp framework, the same supervisor provided this analysis:
There is no apparent professional benefit to this; personal benefit could be to both. The present professional role is supervisor-supervisee (so it is a definite “No”). The location of the relationship is in the car, not in the office (a “no”). The intern might not be able to leave the activity without repercussion. This might have impact on the uninvolved interns feeling that one was receiving preferential treatment or developing a closer relationship and similar concerns with uninvolved staff members.
These are examples of the types of thought that should go into decisions about multiple relationships with supervisees.
Excellent general frameworks for decision-making are other tools for supervision. One developed by Barrett et al. (2003) has a first step of considering one’s own (add, one’s supervisor’s own) personal (emotional) reaction to the ethical issue. Another added step should be consideration of the role of diversity/cultural considerations in the decision. Koocher and Keith-Spiegel (1998) derived an ethical decision-making model from work by Tymchuk and Haas-Malouf.
Steps after the personal reaction and consideration of cultural/diversity factors are:
(Adapted from Koocher & Keith-Spiegel, 1998, 12-15)
Other relevant ethical standards
There is a supervision code of ethics, not adopted by the American Psychological Association, but proposed by the Association for Counselor Education and Supervision (ACES), 1993. https://www.accta.net/default.asp?OPID=90
It is a code of supervisory ethics, and it has been suggested that, should a suit be brought against a supervisor, it is likely it would be used as a standard of care, even though it is not adopted by the APA.
Other ethical standards include section 7 of the Ethical Principles and Code of Ethics of the American Psychological Association that addresses Education and Training.
There are some legal issues specific to training. One of those is “Borrowed Servant”; it relates to vicarious liability for acts of an individual who is sent to work for another organization. In the case of students, it has been applied to the relationship between graduate school and placement. The placement bears the benefit of the student placement, and the expectation is that the student will return to the graduate school to complete training. Articulation of who is responsible for what part of the training is central to this. It should be clear who is the supervisor of record, who holds the malpractice insurance, and, generally, what is the arrangement for the supervisee in the setting.
Other legal issues relate to Duty to Warn.
Prosenjit Poddar, who was born in Bengal, India, was a student at the University of California at Berkeley. At folk-dancing classes, he met Tatiana Tarasoff, with whom he fell in love. Although Tarasoff was friendly to him, she was not receptive to his overtures except for giving him a New Year’s Eve kiss. Eventually she told him she was not interested in a relationship with him. He was devastated by the rejection, and all areas of his functioning were impacted including school, personal appearance, and mental health. Eventually, after Tarasoff had left the country for a trip, Poddar began mental health treatment as per a friend’s suggestion. He was interviewed by a psychiatrist, and eventually began treatment with a psychologist. When he disclosed to his therapist his intent to kill Tarasoff upon her return from her trip, his psychologist consulted with superiors in the department, and they agreed Poddar should be involuntarily committed to a psychiatric hospital. The psychologist informed the campus police and asked them to begin commitment proceedings. However, when they picked him up, Poddar did not appear disoriented or dangerous, and he promised to avoid contact with Tarasoff. Subsequently, Poddar discontinued therapy. When the head of the Department of Psychiatry learned of the police referral, he asked that the psychologist destroy his therapy notes and not attempt to contact Poddar. When Tarasoff returned from her trip, she was unaware of the danger posed by Poddar. In fact, Poddar had convinced Tarasoff’s brother to share an apartment with him. When Poddar went to Tarasoff’s house, she refused to see him, but he shot her with a pellet gun, pursued her, and fatally stabbed her with a knife. Poddar was convicted of second-degree murder, but later the ruling was reversed and Poddar returned to India.
Tarasoff’s parents filed a wrongful-death suit against the Regents of the University of California, which, in the second decision, resulted in a duty to warn by a therapist out of the “special relationship” that exists between therapist and client. The duty to protect arises only when the victim has been identified, or could be identified, “upon a moment’s reflection.” Further, as part of the discharge of their duty, therapists may need to take multiple steps including warning the intended victim, initiating involuntary commitment, notifying the police, modifying treatment, or other steps to deter the violence.
It requires supervisors to be knowledgeable and alert to the latest legal status of Tarasoff and its extensions. This varies state by state. For example, in California presently, the duty to warn has been expanded through decisions in Ewing v. Goldstein, Ewing v. Northridge (2004), and Calderon v. Glick (2005) (all described in an article by Caudill in California Psychologist, 2006). Essentially, supervisors need to ensure that the extension of Tarasoff is reflected in informed consent, letting clients know that if a family member communicates to the therapist a threat the client has made, that may give rise to therapist duty to warn. Supervisors bear responsibility for following the most recent updates on such laws.
This law requires supervisors to have procedures in place for when this or any other emergency or crisis situation arises so the supervisee knows exactly what steps to take to contact a supervisor and to systematically arrange to protect the client, the potential victim, and to appropriately fulfill the duty to warn.
Supervisors must assess supervisee skills in emergency situations. Kleespies (1993) has suggested that supervisees are inadequately trained in such assessments and in follow-up steps.
Foreseeability is a critical piece of Tarasoff—and those who are forseeably at risk have been extended by subsequent legal decisions to those who are in close proximity to individuals who have been threatened.
Because of the imminent danger, it may be necessary for the supervisor to be physically present with the supervisee or to arrange for another supervisor to do so to ensure complete coverage.
It is interesting that Slovenko (1980) stated that had the director of the clinic in the Tarasoff case interviewed the patient himself, and came to the determination he was not dangerous to self or others, there would have been no cause of action under foreseeability. This has specific implications for supervisors in this type of high-risk situation.
Ultimate responsibility for execution of Tarasoff lies with the supervisor—to ensure that identification, assessment, and appropriate action plans have been completed. This is part of Respondeat Superior.
In addition to a thorough understanding of Tarasoff, and the “duty to warn, protect, and predict” (Behnke et al., 1998) (which includes reasonable attempts to communicate the threat that was expressed to the victim and the police, and developing action plans to manage and contain the client), supervisees should be trained in all aspects of risk and danger assessment. They should know how to conduct suicide risk assessments; have protocols for management of potentially violent clients, child abuse and elder abuse; and the knowledge about psychologists possibility of being harassed or threatened by clients. It is critical to have written protocols for supervisees on procedures for any type of emergency in terms of assessment, supervision and procedures to reach supervisors; steps to take; expectations; reporting to agencies; and follow-up. Training in graduate school is limited or nonexistent in most of these areas, even though supervisors in internship and practicum settings assume their incoming students have had the training. This creates a risk situation unless the actual level of competence of each student is assessed in these areas.
It is clearly highly traumatic for a supervisee to have a client suicide or make a significant attempt. This is traumatic for even the most experienced professional, and we know that supervisees are more vulnerable and that the effects of such a trauma are long-standing. Care should be taken in how the supervisee is informed of the fact, and of the type of processing and debriefing that occurs (Knox, Burkard, Jackson, Schaack, & Hess, 2006). Discussion of the impact and the therapeutic and legal issues is also available (Weiner, 2005)
Documentation is an important part of the supervisory process. It is important to keep some type of supervisory log so that the supervisor can record which cases were covered in the supervision session
There are legal issues associated with use of client names in supervisory records. It might be desirable to code numerically the names of the clients as the log is actually not about the client, but about the progress of supervision.
The supervisory log should include:
The importance of the log is to document that supervision did occur, that issues were addressed, and that the supervisor is maintaining a reasonable level of scrutiny and responsibility over the supervisee who is functioning under his/her license.
It is important to keep such a log. Some supervisors encourage supervisees to keep their own logs, but it seems important for supervisors to make note of particular issues that arise that are of concern to them. And, ideally, share these with the supervisee.
Every supervisor at some point is asked to write a letter of recommendation. This is a very difficult issue as it intersects with Human Resources Department guidelines, legal liability, and general issues about how the supervisor viewed the supervisee. In addition, there is a huge inflation in letters of recommendation, with most writers making statements like, “This supervisee was in the 99th percentile of any supervisee I supervised in my 30+ years of supervision.” When supervisors write multiple letters like this, besides defying statistical realities, it creates an environment in which—if a supervisor has legitimate concerns about an area of functioning of a supervisee (which is good, as everyone should be still developing and learning)—mentioning that concern could result in the supervisee’s not obtaining a placement or job. Such is the incredible inflation of letters.
Canada adopted a procedure that a standardized form had to be used for letters of recommendation with a section that was compulsory to complete on areas in which the supervisee could continue to grow or develop—essentially, areas of relative weakness. Although training councils in the United States have not agreed on use of such a standardized form, some training directors are moving in that direction with a cover letter explaining that in the interests of supervisee growth and development, they are giving the strengths AND the areas still in development.
Supervisors may be concerned about the legal liability associated with, on the one hand, disclosing supervisee weaknesses, and on the other hand, NOT disclosing such weaknesses. If one were to disclose, one might fear the supervisee would blame the supervisor for not obtaining a job or training position. If one were not to disclose, one could worry that the next training or job site could blame the supervisor should the same problems arise in their setting, as most likely they would.
In a study that was done on this topic, Grote et al. (2001) reported that more than half of the respondents in their study either would refuse to write a letter or would exclude all mention of alcohol or drug abuse problems from a letter of recommendation on the supervisee. Less than half said they would mention the supervisee’s depression or anxiety in such a letter.
Some supervisors are discussing frankly with their supervisees exactly what they are and are not willing to write. This is an example of informed consent. Thus, in the case of a supervisee with specific difficulties, the supervisor might agree only to a standard letter stating that the supervisee was in a superviseeship between certain dates, listing the activities completed, and stating that the superviseeship was completed, or even just the first of these. The supervisee has the choice of whether he/she wants such a letter written. If the supervisor feels duty-bound to reveal some aspects of the supervisee’s performance that are problematic, he/she could then inform the supervisee of this, and again give the supervisee the choice of whether the letter is to be sent.
Another example of informed consent is the discussion of power in the supervisory relationship. It should be clearly articulated that the power remains constant throughout the relationship with respect to duty to the client, legal issues, and evaluation issues. This encompasses Respondeat Superior. However, power shifts in the developmental aspect of the relationship as the supervisee gains increased competencies, knowledge, and skills, and is increasingly autonomous in practice. The culmination of the progression is when the supervisee becomes licensed to practice independently.
The other element that has been shortchanged or ignored is the evaluative function, which provides a context and an ethical and professional structure to the relationship. It is also the sine qua non from the perspective of the universities, professional schools, and licensing bodies. To varying degrees, at all levels of training, the supervisee and supervisor are cognizant that the supervisor is a potent force in the supervisee’s future, in evaluation of specific competencies. Although there is ample literature on the supervisor’s aversion to evaluation (Robiner et al., 1993), this is not a justification for its omission from consideration as a factor. A limitation of some of the research in this area has been the failure to consider how the evaluative stance affects each step of the supervisee’s journey. Hansen (1965) described the limitations evaluation placed on supervisees’ expectations of supervisory relationships. Role ambiguity was defined by Olk and Friedlander (1992) as the supervisee’s uncertainty about how he/she would be evaluated and what the expectations were. Omission of consideration of the evaluation component was suggested as a possible explanation for poor predictive validity of the working alliance as a predictor of supervisory satisfaction (Ladany, Ellis & Friedlander, 1999). Clarity and communication of expectations are critical components underlying the relationship, and therefore the working alliance. Ellis and Ladany (1997) support the position that evaluation—being central and implicit to supervision—needs to be operationalized and incorporated into the research.
It is so interesting that psychologists, whose profession rests on assessment and methodology, have been so lax in the development of reliable and valid assessment devices for supervisee progress. Also interesting is that it is frequently reported that supervisees get no evaluation until the last day of their training sequence, and then get some negative feedback which had never been mentioned in the course of training. Also, remember that performance evaluation—actually lack of such—is the most common ethical violation reported by supervisees in supervision (Ladany et al., 1999).
What are some of the reasons supervisors do not evaluate or, more specifically, do not give negative feedback? Robiner, Fuhrman, and Ristvedt (1993) described several categories of why supervisors are lenient in evaluation. First is the definition and measurement issue. Supervisors say that they are very concerned about the methodology, reliability, and validity of the scales or measures they use, or they are concerned that anecdotal feedback does not meet criteria for accurate assessment. Thus, for example, since many of the assessment forms in use simply ask the supervisor to list supervisee strengths, areas needing improvement, and several other general questions, there is no way to determine levels, to consider validity or reliability, or to conduct an adequate assessment. Second, supervisors are concerned with legal and administrative issues such as legal liability should the supervisee dispute the feedback (especially in light of the first concern, as they fear the feedback may not be defensible), or should their administrators be concerned or prohibit such feedback. For example, in some settings, for any employee to receive any type of merit increase, the feedback must be all exemplary. If a supervisee were to receive less than exemplary feedback, it might interfere with his/her limited stipend or merit increases. Supervisors also might fear that administrators would decide training is just too much trouble, and discontinue the whole training program, or choose another discipline of student to train, citing difficulties with the particular training program as evidenced by the negative feedback given. They might also be fearful of gaining a negative reputation in the training community for being too “tough” on students.
Third, supervisors may be concerned about interpersonal issues. This might include fears that the evaluation might be turned back upon the supervisor such that he/she might come under unwelcome scrutiny. The supervisor might like the supervisee, and although there are areas that need to be addressed, the supervisor might not want to risk jeopardizing the interpersonal relationship or supervisory alliance established with the supervisee. Furthermore, the supervisor may not want the personal hassles, time, and stress associated with documenting and pursuing supervisee problematic behavior. Fourth, the supervisor may feel that he/she has issues that he/she would prefer not be brought to light. The supervisor may not feel particularly competent, may feel that he/she has made supervisory errors, or otherwise not want to be under scrutiny. He/she may be fearful of reactions by other staff members or supervisees to a supervisee’s negative evaluation.
For all these reasons and others, supervisors often do not provide accurate evaluation to supervisees. Ironically, supervisees report that their best supervisors are those who give abundant constructive feedback and evaluation, a generalized finding that should alleviate some of the apprehensions of supervisors.
Vignette: Andrew is a personable, kind individual and Dr. Stone has been working with him for several weeks. The approach is based on assessing Andrew’s strengths and areas needing improvement, and Dr. Stone has been very impressed with Andrew’s empathy and warmth. The only problem is that Andrew appears to be so focused on support with the clients that he is avoiding the hard issues that come up. Dr. Stone is hesitant to raise this issue, as he doesn’t want to hurt Andrew’s feelings.
How would you approach assisting Dr. Stone in this situation?
It is useful to think behaviorally when giving feedback. Dr. Stone could use a competency-based approach and discuss areas of strength and areas needing improvement more specifically. It appears that there may be a parallel process between the interaction between Dr. Stone and Andrew and that between Andrew as therapist and his client. In other words, in both situations, difficult issues are being avoided. Dr. Stone could make an observation about that parallel process to open the discussion.
Summative evaluation, or the type of evaluation given to supervisees in written form during the training year, relates to a summary of progress and a type of grading. ASPPB (2003) has suggested summative evaluation be given four times during the training year, raising the bar for programs. Summative evaluation is typically a one-way process with the supervisor or supervisors imparting the evaluation to the supervisee.
Formative evaluation refers to feedback given on an ongoing basis to supervisees. It could take the form of praise or support (ironically, a process which appears to occur infrequently in much of supervision), or constructive feedback focused on analysis or suggestions. This would include, for example, thinking about what other options might have been helpful, wondering about the rationale for particular interventions, thinking more about process than content, affect rather than content, or generally refocusing the therapy process. Depending on the developmental level of the supervisee, the feedback may take different forms. For the beginning (Level 1) supervisee, the feedback could be very specific and directive, while for a more advanced supervisee, it could be more thoughtful and open-ended, resulting in a discussion of options.
An important innovation is introducing frequent feedback to the supervisor on the process of evaluation. This introduction of two-way feedback enhances the interactive process, and allows feedback to pass in both directions. Although supervisees may be wary of summative feedback to supervisors, fearing that it may negatively influence their own evaluations, ongoing structured feedback about process or supervisee needs tends to be less stressful and more easily integrated into supervision, especially if the supervisor is truly open to and accepting of the feedback. In supervision trainings, supervisees often complain that their supervisors urge them to give feedback and say they are open to it, but when the supervisee tries, he/she is met with resistance, dismissive behavior, or anger. It is most important to be open to feedback and to discuss it fully with the supervisee, attempting to introduce modifications or structures to deal with the supervisee’s concerns.
In addition to outcomes of supervision, it is excellent to introduce a tracking for outcomes in client progress. Lambert’s Outcome Questionnaire is an excellent tool to use for this, but there are other treatment progress or symptom checklists that would work as well. Some supervisors advocate creating their own scales of client presenting problems and having clients rate themselves on those. Whichever technique is used, the important piece is to bring the data to supervision and for the supervisee to monitor or graph the client’s self-report on progress.
As Belar et al. (2001) have suggested, self-assessment is an essential part of supervision and of professional practice. Modeling attention to lifelong learning, the supervisor can construct self-assessments such as the one described in Belar et al. (2001) in order to assess and expand one’s practice areas, or to simply see how current one’s skills and knowledge are. Self-assessment can be woven into every aspect of the supervisee’s training, instilling in him/her a sense of urgency to be self-aware about competencies.
First, one can use a competency-based approach for evaluation. The template developed by Hatcher and Lassiter can be found at http://www.adptc.org/public_files/CCTCPracticumCompetenciesChartRevFeb2005.doc
Using this template, or one like it, the supervisor could have the supervisee self-assess upon entry into the superviseeship. Then the supervisor could add his/her initial impressions in a second column, and reflect on any differences in impressions between supervisee self-assessment and supervisor assessment. This process could be repeated at intervals throughout the training sequence, to chart progress and to address areas that are still developing.
Second, one could conduct “360-degree” feedback that should NOT be considered evaluation in the sense of making decisions for merit increases or graduation, but is highly useful for developmental feedback. 360-degree feedback, or multi-source feedback, refers to identifying a set of core competencies and asking multiple sources to rate them. Ideally, supervisors would first conduct this process on themselves. Thus, for example, the supervisor would self-assess, and then be rated by peers, administrators, clients, supervisees, clerical staff, and others in the setting. Then the same process is done for each supervisee, with the coordinating supervisor integrating the resulting information to provide a comprehensive feedback mechanism. This should create excellent developmental data to ensure the supervisee understands his/her impact upon multiple constituents.
The supervisor should be sure that every area that is important to performance in his/her particular setting is included in the evaluation documents, as it is not acceptable to evaluate areas that were not included in the forms supervisees receive at the onset. This is a matter of informed consent.
Areas most neglected in evaluation are those of interpersonal competencies; the impact of personal factors such as biases, assumptions, and countertransference upon the therapy process and supervision; interpersonal skill sets such as congeniality, relationship skills, emotional awareness, autonomy, and diversity competence; and attitude towards training and the profession.
Other options for evaluation include using measures such as those included in appendices of the supervision books written by Bernard and Goodyear (2004) or Falender and Shafranske (2004) which include supervision outcomes, alliance measures, and multicultural and diversity competence assessments, among others.
It is most important for the evaluation to be yoked with the goals and tasks for completion of the training year, and that these all be related to the training agreement.
Summative evaluation is not enough. Formative evaluation should be a part of every supervision session. One strategy is for the supervisor and supervisee to rate the process at the end of supervision to determine whether particular components, such as formative evaluation, occurred during the session.
Most supervisees have a productive, developing training experience from which they proceed onward in their placements with enhanced skills and confidence. However, sometimes supervisees exhibit behavior that is problematic to the site or the supervisors. Supervisees with problematic behavior are infrequent in their occurrence. Some estimate that there is one such supervisee every 4-5 years in a setting. Certain settings report a higher prevalence (summarized in Falender and Shafranske, 2004).
Some red flags for supervisee problematic behavior include supervisee delinquent paperwork, chronic lateness, client cancellations (by client or by supervisee), changes in interaction style or behavior, and inconsistencies between notes and descriptions of cases in supervision.
Previously, “impairment” was a term used to denote the supervisee not meeting performance standards. “Impairment” has a specific meaning now within the Americans with Disabilities Act (ADA). It refers to medical or mental health disability. There will be supervisees who apply or enter your training program who qualify under ADA, but in order to invoke ADA, the supervisee must notify you or the agency of their ADA qualifying diagnosis, provide documentation, and work out reasonable accommodations. It is critical to gain knowledge of ADA and understand fully its implications and all its aspects. An excellent reference is http://www.eeoc.gov/policy/docs/accommodation.html.
According to these guidelines:
Under the ADA, the term "disability" means: "(a) A physical or mental impairment that substantially limits one or more of the major life activities of [an] individual; (b) a record of such an impairment; or (c) being regarded as having such an impairment." - (EEOC Addendum, 2005)
“During the hiring process and before a conditional offer is made, an employer generally may not ask an applicant whether s/he needs a reasonable accommodation for the job, except when the employer knows that an applicant has a disability – either because it is obvious or the applicant has voluntarily disclosed the information – and could reasonably believe that the applicant will need a reasonable accommodation to perform specific job functions. If the applicant replies that s/he needs a reasonable accommodation, the employer may inquire as to what type.” - (EEOC, 2005)
Supervisors who use “impairment” to refer to supervisees who do not meet performance criteria or who manifest other problematic behavior place themselves at risk and also risk inflicting harm on the supervisee. There are court cases in which supervisors used this label with a supervisee, and the supervisee was therefore “regarded” as being “impaired,” which was judged to be as injurious as being disabled. For additional information, see http://www.appic.org/NewsOnLine/Articles/SuperImpairment12-8-04.html for an article by Falender, Collins, and Shafranske on Use of the Term "Impairment" in Psychology Supervision —or really why NOT to use the term.
Ideally, the supervisor will identify particular behaviors that are not being done or are not meeting the performance standard and will work with the supervisee to improve performance on these. This approach decreases stigmatization, increases the supervisee’s sense of optimism that there can be a positive outcome, and is chartable or accountable.
Problematic Supervisee Behavior Defined
Lamb et al. (1987) defined problematic behavior (previously “impairment”) as interference in professional functioning reflected in one or more of the following ways:
(Lamb et al., 1987, pp. 291-292)
Supervisees with problematic behavior
(Lamb et al., 1986, p. 599)
Lamb and others outlined plans for proceeding once a supervisor has identified a supervisee with problematic behavior. These steps, which are adapted from others but elaborated and expanded upon, are suggested as an outline, but it may be necessary to implement them in a different order or supplement them depending on the situation, setting, and seriousness of the problem.
First is a behavioral description of the problematic behavior. It is most important to use behavioral terms. Do NOT diagnose supervisees. Stick to the behavior and link it to behavioral expectations/requirements in the training agreement, or in the evaluation measure, or ideally, both. Be as specific as possible as to context, frequency, and other variables. Have documentation including a record of instances in which the problem has occurred. If, for example, the problem is delinquent notes, have a list of the missing case notes and dates for each client.
Determine whether the problematic behavior is occurring with only one supervisor or whether it is occurring more frequently. This calls for consultation with the multiple supervisors who work with the supervisee.
At each step, determine your feelings as supervisor. If you begin to personalize the situation or feel you cannot be objective, get consultation and support from colleagues and peers.
Discuss the behavior(s) that are not meeting performance criteria with the supervisee. If you are the only supervisor working with the supervisee, explore whether this is something that he/she has been told before. Try to understand any circumstances, life changes, cultural or diversity aspects, or other contributing factors that may be influencing the behavior.
For example, it would be a very different course of action for each of the following scenarios:
It would also be a different course of action if the supervisee was always late to appointments, and explained that at her previous settings, time considerations were not important, and that she did not realize how seriously time was taken here—versus a supervisee who said that she did not see the problem.
Next, develop with the supervisee a plan based upon any additional data that can be obtained regarding successful completion of the behaviors in the past, facilitating factors, and a plan for completion or change. Document this meeting. A time line should be constructed with intermediate points for check-in, spaced relatively close together.
Be sure to follow up within a few days of the meeting with the initial check-in to see if significant progress has been made.
If the supervisee begins to improve, do not stop monitoring. Be sure to follow up with each scheduled check-in and continue to monitor to completion of the tasks or until behavior changes, and continue to monitor beyond that point as well.
If the problem behaviors do not subside, or if the problem is viewed as somewhat more serious, take appropriate steps. Possible steps include:
Continue monitoring and check-ins with the supervisee to see how he/she is doing, feeling, and progressing.
If there is no change with all the increased supports and monitoring, the supervisor may begin to think about termination. This would need to have been clearly spelled out as a possible consequence of not meeting specific performance criteria and a specific due process procedure would have to have been given as part of informed consent at the onset of training. Movement towards termination or dismissal would move through steps with chances for the supervisee to dispute the documentation.
The other supervisees at the site are definitely affected by this entire procedure. Some may have been aware of the problem for some time and may have wondered why it took so long. For others, there may be concerns as to whether they would be next, whether the setting is safe, and what safeguards there are for their peer and for themselves.
It is critical that the supervisors NOT discuss the procedures occurring with the identified student with the other students to protect the supervisee’s confidentiality. However, once it is determined that the individual will be leaving, it would be important to process feelings of the others about the loss, and that discussion might touch on the process that occurred. Supervisors should be very thoughtful about this, protective of the student who is leaving, and respectful and forthright about the importance of preserving the student’s confidentiality and rights.
All of the steps must be documented.
Mental health professionals are not known to be good at self-care, even though we espouse its importance. Thus, we do not model good self-care to our supervisees. What is the relevance of this to supervision? It is a multilevel problem. If we are not protective of ourselves, we may supervise when we are not at our best. If we do not have strategies for stress reduction, relaxation, and activities in which we let off the stress and anxiety of the day, having listened to incredible problems and crises others have suffered, we place ourselves at risk. We are vulnerable to vicarious traumatization from our clients, and our supervisees are even more vulnerable as they have had less experience with the types of situations and disclosures that prompt it. Examples are neighborhood violence, drive-by shootings, child abuse including sexual abuse and incest, suicide, death, loss, and all the other situations in which clients experience significant pain. There is evidence to suggest that our supervisees and we may be even more vulnerable as a substantial number of therapists and supervisees are children of alcoholics or survivors of abuse. As a result, the vicarious traumatization is on top of existing trauma, and has a cumulative impact. There is evidence that supervisees exposed to community violence and to suicide or suicide attempts of clients find that the impact is long-standing and pervasive, sometimes manifesting itself in PTSD symptoms. The role of the supervisor is to be sensitive to the potential for supervisee burnout or vicarious traumatization, and to process with care events with the supervisee. Supervisees report that this is infrequently done, and that supervisees carry feelings with them literally for years after the incidents.
In a study by Stevanovic and Rupert (2004), respondents who had higher job satisfaction reported various strategies for maintaining this. They included varying work responsibility, using positive self-talk, maintaining a balance between their personal and professional lives, spending time with their partner/family, taking regular vacations, maintaining their professional identity, turning to spiritual beliefs, participating in continuing education, reading literature to keep up to date, and generally maintaining a sense of control over work activities. This study is important for supervisors as it gives possible strategies for the supervisor to adopt, to model, and to communicate to supervisees.
The end of a training sequence can bring with it many feelings. For the supervisor, there may be a feeling of pride in all that has been accomplished, happiness in the effectiveness of the relationship and the supervisee’s growth and development, and a general satisfaction of a job well done. However, there may be lingering worries about whether the supervisor taught the supervisee everything possible, and whether there are areas that were not covered which will be particularly critical to the supervisee’s subsequent placement or practice. The supervisor may worry that for some reason he/she did not have the best year, and as a result may not have given the supervisee the best possible training.
For the supervisee, there is the parallel sense of accomplishment and excitement about moving on into an increasingly autonomous role. There is the excitement of the next placement, if known, and the challenges ahead. However, there is also the parallel fear of whether one is as competent as supervisors are saying, and whether the supervisee is truly ready for the next step. The artificial nature of client termination may cast a pall on some aspects of the termination process, as may the clients’ reactions, which could include anger, sadness, or ceasing to attend sessions. Clients may disclose pivotal information in the last session, increasing the supervisee’s sense that they are abandoning the client or leaving them at the time they are most needed.
A useful approach is to review the contract or agreement and to think about the goals, achievements, and expectations that were not met. Personally, the relationship of supervisor to supervisee will transform towards colleague, but there will still always be some residuals of the old relationship and the power differential, especially since supervisors may be called upon to write letters of recommendation or provide other forms of support.
Attending to the parallel processes with respect to client and supervisor reactions is a useful process and provides another modeling experience for the supervisee.
Vignette: A supervisee’s client disclosed in their very last session that she was sexually abused as a child, presenting the supervisee with information that would be pivotal to future treatment. The supervisee was devastated, not understanding that perhaps the reason the disclosure was made was in fact that it was the last session. The supervisee was so guilt-ridden that she was leaving that prior to supervision, she considered telling her post-doc placement she would have to defer several months to continue with the client.
Vignette: A past supervisee continues to receive calls from his/her supervisor requesting resources, translations, and other materials that take significant amounts of time for the past supervisee to produce. The supervisee is not comfortable setting limits with the previous supervisor, but is becoming increasingly stressed by the number of demands on time and resources. However, the past supervisee has loyalty to the past supervisor and is concerned that she/her may need a letter of recommendation sometime in the future. Therefore, he/she feels compelled to continue to respond and supply everything that is requested.
For each of these vignettes, consider what the ethical and legal aspects are, how the contract may be a factor, and what types of responses could be given by supervisee and supervisor.
Vignette: A supervisee is told by her supervisor during the first week of placement that he is not sure she is skilled enough for the practicum placement. She is taken aback, having applied, been interviewed, and having turned down several other placements to come to this one. She talks to her school, which urges her to continue in the placement, and to talk with the supervisor to get a better sense of what is needed. The supervisor agrees to keep her once he learns she refused other placement. However, once she begins seeing cases, he is constantly reminding her that her skills are not up to par, but is not providing much guidance as to what that means. He favors a highly unstructured, play therapy approach and her two clients are elementary school children who have severe aggressive behaviors that have been injurious to other children.
An issue in this vignette is the powerlessness of the supervisee. However, should a competency-based approach be adopted, both supervisor and supervisee could be “on the same page” about what the supervisee’s areas of strength and areas needing development are—and could devise plans. An underlying issue here is the lack of a supervisory alliance—a sine qua non of supervision. It is extremely difficult for a supervisee to be in a position of having to provide structure…so it is incumbent upon all supervisors to take responsibility and to confront, head on, difficult situations…and to get consultation on issues that are problematic, such as when a supervisor does not like his/her supervisee or has negative associations to him/her. Also, in the two-way process, supervisees may present with more information about evidence-based treatments than supervisors. It is critical for supervisors to engage in lifelong learning to update skills and to learn about evidence-based practice.
Vignette: Select a case you are currently supervising and identify one critical incident that has occurred. It could be conflict, disagreement, lack of resolution, or simply an uncomfortable feeling you had after completing supervision. Identify the rupture marker if you can. Think about the actions you have taken to repair the situation or the actions you plan to take. Use metacommunication and a strength orientation.
The practice of supervision is the highest calling in psychology and other mental health professions. It is the dissemination of learning, professionalism, and ethical practice from one generation to the next, and in the process, it provides the supervisor with the opportunity to learn and develop from the experience.
As the field moves to increasingly evidence-based assessment and treatment, supervision moves in the direction of competency-based practice. Through this, accountability and standards of practice are maintained. The challenge for each of us will be to maintain some of the “art” of supervision as we develop increasingly sophisticated measurement paradigms for practice.
It is also important to maintain the personal factors of sense of humor, self-assessment, perspective, and ongoing self-care to ensure that we each function at our best in increasingly stressful and demanding environments. Through supervision and levels of supervisory support, we can provide guidance and assistance to each other, empowering our supervisees and ourselves.
Benchmarks for the entire process of the development of the psychologist are in preparation by an APA Workgroup and will be available shortly. This will provide additional structure to the competencies movement.
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