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"You Said What?" - Becoming a Better Supervisor
by Carol Falender, Ph.D.

6 CE Hours - $179

Last revised: 06/05/2018

Course content © copyright 2005-2018 by Carol Falender, Ph.D. All rights reserved.


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Learning Objectives

This is an intermediate-level course. After taking this course mental health professionals will be able to:

The materials in this course are based on the most current information and research available to the author at the time of writing. The field of clinical supervision is growing exponentially, and new information may emerge that supersedes or supplements these course materials. This course material is designed to equip supervisors with a comprehensive understanding of clinical supervision, structure of practice, and the strengths of effective practice as well as an understanding of the potential harm inflicted on supervisees by less-than-competent practice.

Course Outline

Introduction: Background and Current Status

Supervision may well be the highest calling in psychology as well as in other mental health professions. It is the way the profession is communicated and transmitted from generation to generation of practitioners. Until the last decade, remarkably little attention was devoted to the practice of supervision. Generally, most supervisors learned to supervise through osmosis, or by internalizing their own supervision experience. The way osmosis worked, the supervisor simply did what had been done to him or her as a supervisee, or did the opposite as their supervisor’s practices had been ineffectual, inadequate, or harmful. The Association of State and Provincial Psychology Boards (ASPPB) 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 [and this author believes for all of mental health], it is surprising that organized psychology [and all mental health disciplines], with few exceptions, has/have 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).

Becoming a competent supervisor is complex, as it entails developing particular competencies and learning about the research and empirical support for them, all while being mindful of the personal contributions we bring to clinical practice and supervision. Realizing this state of affairs, there is a need for a formal process of training in clinical supervision as it is – or should be – a core competency in all mental health professions. The supervisor has major responsibility to assess and evaluate levels of supervisee readiness, competence, and affect, to reflect upon these, and then to translate it all into effective clinical intervention. The highest duties of the supervisor are: first and foremost, protection of clients and the public; to serve as gatekeeper, ensuring that only suitable individuals enter the respective professions; and to provide enhancement and support for the development of competence, professionalism, and identity. While the role of supervisor is weighty, it is also filled with potential for growth, development, inquiry, creativity, and excitement.

Because assumption of the supervisory role may be simultaneous with licensure (or, as in California, it may require two years of licensed experience for anyone supervising Marriage and Family therapists, social workers, and licensed professional counselors who are collecting hours for licensure), the training period for new supervisors may be nonexistent or may not contain any specific training in supervision. Even in the pipelines of training for the various mental health professions, more than half of supervisees in training are not receiving systematic preparation to be supervisors. Individuals beginning to supervise require knowledge of the latest information and standards that comprise best practices.

In competency-based approaches (Falender & Shafranske, 2004; 2017), there is an explicit framework and method for initiating, developing, implementing, and evaluating the processes and outcomes of supervision. The trainee in this methodology is evaluated against a standard rather than in comparison to others. Through use of this framework as a standard, supervision becomes more systematic, with particular domains of knowledge, skills, and values. The approach entails supervisee and supervisor self-awareness of knowledge, skills, values, and attitudes. Through development of a schema of supervisor competency, increased attention may be devoted to competence evaluation, supervisee and supervisor development, and support of the supervisor’s skills, all of which will benefit the supervisees.

There is evidence that there are few differences in concepts, attitudes, or practice between psychologists and other mental health professionals (Kavanagh, Spence, Strong, Wilson, Sturk, & Crow, 2003). That is, there is agreement on best practices of supervision across disciplines.

Bernard and Goodyear (2014) emphasize the transmission of knowledge from a senior member to another in the context of evaluation with regard to legal and ethical considerations. In reality, there are increasing variants on this more traditional stance in that less senior – even less experienced clinicians are in roles of clinical supervisor and must learn to maximize their ability to supervise effectively.

As we progress toward more evidence-based approaches to supervision and therapy, there is the need for a definition that can be operationalized or translated into measurable categories (Milne, Aylott, Fitzpatrick, & Ellis, 2008). Each supervisor must come to his or 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 and transparency in the relationship – the greater the success of the supervisory relationship.

Supervision guidelines and best practices for supervision have been developed by the Association of State and Provincial Psychology Boards (ASPPB, 2015), American Psychological Association (APA) Board of Educational Affairs (2014, 2015), and the National Association of Social Workers (NASW, 2013). Marriage and Family Therapists have the opportunity to become an Approved Supervisor. These guidelines and best practices share many essential components, and the various topics of these will provide the structure for this course.

More specifically, this course will provide background and methodology for the practice of high quality supervision in a competency- and strength-based orientation that is proactive. In addition to the components of competency-based supervision and their implementation, approaches to prevention of many supervisee dilemmas and problems will be addressed. An emphasis on assets, supplemented with encouragement in areas of lesser strength, provides for a strong supervisory relationship – one that can sustain stress and flourish with ongoing constructive feedback.

What is Competency-based Clinical Supervision?

Competency-based supervision is an approach that explicitly identifies the knowledge, skills and attitudes or values that are assembled to form a clinical competency and develops learning strategies and evaluation procedures to meet criterion-referenced competence standards in keeping with evidence-based practices and the requirements of the local clinical setting (Falender & Shafranske, 2007).

Increasingly, mental health professionals identify competencies in order to define performance of service and developmental trajectories toward competence.

Competency-based supervision is an international phenomenon with multiple countries adopting it (e.g., Australia, New Zealand, U.K.).

Components of Competency-based Supervision

The self-assessment that is the foundation of supervision planning should be conducted using a competencies measure, described later in this course.

Contextually, supervision consists of relationships among:

To understand this complexity, one needs to consider each domain, the interactions among them, the resultant worldviews of each, and the impact of these on assessment, intervention, and supervision.

Competency-based supervision is defined in the Guidelines for Clinical Supervision in Health Service Psychology by the APA as:

“A metatheoretical approach that explicitly identifies the knowledge, skills and attitudes that comprise clinical competencies, informs learning strategies and evaluation procedures, and meets criterion-referenced competence standards consistent with evidence-based practices (regulations), and the local/cultural clinical setting (adapted from Falender & Shafranske, 2007). Competency-based supervision is one approach to supervision; it is metatheoretical and does not preclude other models of supervision.” (APA, 2014, p. 5).

Definitions of Supervision

The National Association of Social Workers and the Association of Social Work Boards define clinical (professional) supervision as:

“[T]he relationship between supervisor and supervisee in which the responsibility and accountability for the development of competence, demeanor, and ethical practice take place. The supervisor is responsible for providing direction to the supervisee, who applies social work theory, standardized knowledge, skills, competency, and applicable ethical content in the practice setting. The supervisor and the supervisee both share responsibility for carrying out their role in this collaborative process.” (NASW, 2013, p. 6)

The American Psychological Association (APA), in the Guidelines for Clinical Supervision in Health Service Psychology, defines clinical supervision as:

“[A] distinct professional practice employing a collaborative relationship that has both facilitative and evaluative components, that extends over time, which has the goals of enhancing the professional competence and science-informed practice of the supervisee, monitoring the quality of services provided, protecting the public, and providing a gatekeeping function for entry into the profession. Henceforth, supervision refers to clinical supervision and subsumes supervision conducted by all health service psychologists across the specialties of clinical, counseling, and school psychology.” (APA, 2014, p. 5)

The AAMFT defines MFT supervision as:

“[T]he process of evaluating, training, and providing oversight to trainees using relational or
systemic approaches for the purpose of helping them attain systemic clinical skills. Supervision is provided to an MFT or MFT trainee … through live observation, face to face contact, or visual/audio technology assisted means as allowed in this handbook. When a supervisor candidate intends on receiving credit for supervisory experience toward the AS designation, he or she must be actively involved in the supervision; simply observing other supervision, although valuable, does not qualify toward requirements.

Supervisors, supervisor mentors, and supervisor candidates must ensure that supervision using technology complies with applicable laws for ensuring privacy and security of confidential information.” (AAMFT, 2014, p. 5)

Note the commonalities and differences. In common, they all place major focus on:

Steps to Achieve Competence in Supervision Practice

Falender and Shafranske (2007) described the steps to achieve competence in supervision practice:

(a) the supervisor examines his own clinical and supervision expertise and competency;

(b) the supervisor delineates supervisory expectations, including standards, rules, and general practice;

(c) the supervisor identifies setting-specific competencies the trainee must attain for successful completion of the supervised experience;

(d) the supervisor collaborates with the trainee in developing a supervisory agreement or contract for informed consent, ensuring clear communication in establishing competencies and goals, tasks to achieve them, and logistics; and

(e) the supervisor models and engages the trainee in self-assessment and the development of metacompetence (i.e., self-awareness of competencies) from the onset of supervision and throughout.

(Falender & Shafranske, 2007, p. 238)

Coupled with the use of supervisee self-assessment tools (described in Supervisee Competencies) as an ongoing guide to the supervision process, with development and feedback linked to supervisee self-assessment of competencies specific to the setting, these best practices establish a basic framework for supervision.

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. Competencies are organized and prioritized differently by each professional discipline, so making a tentative list of which are most important to you is useful at this point.

In addition, think about what changes need to occur in your setting – or in your own supervision practice – to transform to a competency-based clinical supervision environment. As you will see as we proceed, competency-based supervision is more accountable and provides transparency that serves to enhance the supervisory relationship between you and your supervisees (Kaslow, Falender, & Grus, 2012)

Consider that the essential components include:

Your Preliminary Self-Assessment

  1. What is the greatest influence on your supervision practice? Personal experience of having been supervised; education, training, literature and workshops on supervision, or a psychotherapy model?
  2. Have you taken formal coursework in clinical supervision?
    1. A six hour or some other length course for each licensure period?
    2. A semester or term course?
    3. Have you been supervised on your supervision practice?
    4. Would you describe your supervision as systematic, ensuring attention to multiple competencies and factors in each supervision session with targeted feedback?
  3. How would you describe your model of supervision?

Supervision Guidelines

Psychology

In 2014, the American Psychological Association adopted the: APA Board of Educational Affairs (BEA) Guidelines for Clinical Supervision for Health Service Psychologists. You may reference the full document at: apa.org/about/policy/guidelines-supervision.pdf.

The domains of competence include:

Domain A: Supervision Competence

Domain B: Diversity

Domain C: Supervisory Relationship

Domain D: Professionalism

Domain E: Assessment/Evaluation/Feedback

Domain F: Professional Competence Problems

Domain G: Ethical, Legal and Regulatory Consideration

The following is an excerpt from the APA BEA Guidelines on Supervisor Competence (APA, 2014):

Supervisor Competence

Supervisors strive to be competent in the psychological services provided to clients/patients by supervisees under their supervision and when supervising in areas in which they are less familiar they take reasonable steps to ensure the competence of their work and to protect others from harm.

Supervisors possess up-to-date knowledge and skills regarding the areas being supervised (e.g., psychotherapy, research, assessment), psychological theories, diversity dimensions (e.g., age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socio-economic status), and individual differences and intersections of these with diversity dimensions. Supervisors also have knowledge of the clinical specialty areas in which supervision is being provided and of requirements and procedures to be taken when supervising in an area in which expertise has not been established (Barnett et al., 2007; Goodyear & Rodolfa, 2012; APA, 2010, 2.01, 2.03).

Supervisors are knowledgeable of the context of supervision including its immediate system and expectations, and the sociopolitical context. Supervisors are knowledgeable too about emergent events in the setting or context that impact the client(s)/patient(s) (Falender et al., 2004).

1. Supervisors seek to attain and maintain competence in the practice of supervision through formal education and training. Competence entails demonstrated evidence-based practice as well as in the various modalities (e.g., family, group and individual), theories, and general knowledge, skills, and attitudes and research support of competency-based supervision. Supervisors obtain requisite training in knowledge, skills, and attitudes of clinical supervision (Newman, 2013; Watkins, 2012). Supervisors are skilled and knowledgeable in competency-based models, in developing and managing the supervisory relationship/alliance (Bernard & Goodyear, 2014; Falender & Shafranske, 2004; Ladany, Mori, & Mehr, 2013), and in enhancing the supervisee’s clinical skills (Milne, 2009). The formal education and training should include instruction in didactic seminars, continuing education, or supervised supervision. At a minimum, education and training in supervision should include: models and theories of supervision; modalities; relationship formation, maintenance, rupture and repair; diversity and multiculturalism; feedback, evaluation; management of supervisee’s emotional reactivity and interpersonal behavior; reflective practice; application of ethical and legal standards; decision making regarding gatekeeping; and considerations of developmental level of the trainee (Bernard & Goodyear, 2014; Falender & Shafranske, 2012; Newman, 2013). The supervision reflects practices informed by competency- and evidence-based practice to enhance accountability (Milne & Reiser, 2012; Reese et al., 2009; Stoltenberg & Pace, 2008; Watkins, 2011; Watkins, 2012; Worthen & Lambert, 2007). Assessment entails use of outcome measures and ratings from multiple supervisors (e.g., Reese et al., 2009, Watkins, 2011; Worthen & Lambert, 2007). Assessment strategies include both formative and summative evaluation and procedures for competence assessment.

2. Supervisors endeavor to coordinate with other professionals responsible for the supervisee’s education and training to ensure communication and coordination of goals and expectations. Coordination can assist supervisees in managing these multiple roles and responsibilities as well as supervisory expectations. Coordination is especially important to seek when a supervisee is exhibiting competence problems, when the supervisory relationship is under stress, or when the supervisor seeks another perspective (Thomas, 2010).

3. Supervisors strive for diversity competence across populations and settings (as defined in APA, 2003). Diversity competence is an inseparable and essential component of supervision competence that involves relevant knowledge, skills, and values/attitudes (for more information, see Domain B: Diversity).

4. Supervisors using technology in supervision (including distance supervision), or when supervising care that incorporates technology, strive to be competent regarding its use. Supervisors ensure that policies and procedures are in place for ethical practice of telepsychology, social media, and digital communications between any combination of client/patient, supervisee, and supervisor (APA, 2013b; Fitzgerald, Hunter, Hadjistavropoulos, & Koocher, 2010). Considerations should include services appropriate for distance supervision, confidentiality, and security. Supervisors are knowledgeable about relevant laws specific to technology and supervision, and technology and practice. Supervisors model ethical practice, ethical decision-making, and professionalism, and engage in thoughtful dialogues with supervisees regarding use of social networking and internet searches of clients/patients and supervisees (Clinton, Silverman, & Brendel, 2010; Myers, Endres, Ruddy, & Zelikovsky, 2012). (APA, 2014)

Social Work

In 2013, the National Association of Social Workers published Best Practice Standards for Supervision. For elaboration, refer to the complete document at: socialworkers.org.

Guidance for social work is provided in the best practice standards for the social work profession. There is a high degree of agreement on supervision practices across disciplines.

Consider this outline of the social work document:

Protection of the client

Ethical practice

Collaboration in supervision – but supervisor makes the choice what model is used

Administrative; educational; supportive functions

They advocate for three years of experience post licensure prior to supervising

Addressing strengths and challenges of supervisee; modeling and discussing ethical practice; supporting and encouraging learning

Supervision contract

Establish goals, responsibilities, time frames

Monitor progress with regular feedback

Process for addressing and resolving communication problems

Identify feelings about clients that may impact treatment

Confidentiality – respect for

Contractual relationship between agency, supervisee and supervisor – potential risks noted

Leadership and role model

Supervisors know limits of personal competence

Careful only to sign off on hours accrued

Model self-care

Direct and vicarious liability; liability insurance

Risk of supervisee assigned too difficult of a case for level of competence

Multiple relationships – not to supervise a family member or have therapeutic relationship with supervisee

Document supervision

Identify actions that may pose danger to supervisee’s clients and take remedial action

Abide by supervision regulations including possibly contract and plan before supervision; supervision usually is required by a licensed social worker

Documentation is a legal tool

Documentation of supervision by supervisor AND supervisee

Professional ethics, core values and personal moral beliefs and distinguish these elements when making practice decisions. Supervisors can use the supervisory relationship to address these

Ethical decision-making

Power differential

Terminating the supervisory relationship

How is Supervision Distinguished from Therapy and Consultation?

From Therapy

It is critical to differentiate supervision from therapy – and also from consultation.

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 that supervision is a distinct practice area and that it is distinct from personal therapy or counseling.

Should the supervisor slide into elaborate exploration of the supervisee’s psyche, early childhood, etc., drifting into a therapist role, a boundary has been crossed and the supervisor has the responsibility to not do that.

Exercise:

Decide which of these situations are appropriate for supervision and which would require a referral for therapy or other external support:

  1. Supervisee discloses that client reminds her of her mother.
  2. Supervisee becomes tearful week after week in supervision when discussing particular cases, even after extensive reflective management of countertransference – and discloses being close to tears in most client sessions.
  3. Supervisee repeatedly asks supervisor to give advice on her impending separation and divorce, as she knows the supervisor has recently gone through a similar event.
  4. Supervisee tells supervisor that he feels mildly angry with the mother in the family he is seeing.

Most supervisors would find #2 and #3 to be problematic and requiring additional steps. In #2, immediate attention should be given to the possibility that this client should be transferred to another therapist, as a cardinal rule of every profession is “do no harm” and the highest duty of the supervisor is to protect the client. Then, the supervisor needs to discuss the pattern of response of the supervisee and plan with the supervisee specific steps to ensure that these issues are met outside of supervision.

In #3, the supervisor needs to reinforce the supervisee’s willingness to consider personal situations in the context of therapy she is providing, empathize with the difficulty, 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 the clients being seen by the supervisee. The supervisor is cautioned to be reflective about personal self-disclosures and institute appropriate self-care. This is especially true if the supervisor is taking time from supervision to discuss the supervisor’s own personal matters with the supervisee. This is a category of negligent supervision, as the clients are not being addressed.

In #1 and #4, the supervisor and supervisee should explore countertransference when the supervisee is in a less reactive state, and most likely, lead an exercise in differentiating the client from the mother or separating the client from other individuals with whom the supervisee might feel or have felt angry; this is likely to have good results. If not, and a pattern emerges, then the additional steps taken in #2 and #3 could be implemented.

From Consultation

Supervision is also distinct from consultation. The difference is that in consultation, the parties may be peers or colleagues. The consultant is not required to obtain all the information about the case, but simply to respond to the question being asked. The supervisor has responsibility to know the case thoroughly. 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.

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 “provide input” with the supervisor if he/she is willing. It is important to remember that the supervisor of record is legally responsible for the supervisee’s therapy with the clients. Specialized information can be integrated into the next regular supervision session to ensure the client receives the most competent treatment.

How Do I Do This? How Do I Become a Supervisor?

Clinician to Supervisor

Supervision is a distinct professional activity that requires training and education. Taking this course is an excellent beginning! The process of becoming a supervisor is one of integrating theory (of supervision and of therapy), interpersonal skills, and focus.

There needs to be a shift from therapist to the new role of supervisor.

There is a significant “mind-shift” in becoming a supervisor. Borders (1992) describes the cognitive shift from clinician to supervisor. Here are some examples of ways – two of which are problematic – clinicians take their skills into the supervisory arena:

  1. Supervisors who think like clinicians and see supervisees as surrogates. These beginning supervisors make thorough, copious notes about the client when they review tapes, generate numerous hypotheses about dynamics, and devise plans for working with the client. They come to supervision very well prepared and tell the supervisee exactly what to do, or actually what they should have done – a monologue or mini-lecture. They act as if they are not aware of supervisee reactions, and fail to hear anything that the supervisee has to say. The supervisee emerges from supervision feeling inadequate and overwhelmed, unable to enact the supervisor’s directives as the next session does not go exactly as planned or as the last one did, and because they have not integrated the supervisor's ideas or conceptualizations into their thinking.
  2. Supervisors who focus on the supervisee as a client. These supervisors are highly attuned to supervisees’ personal issues; they assume supervisee intrapsychic dynamics are the sole reason for shortcomings in the supervisees’ performance (“What keeps you from doing that?” “Is that true in other areas of your life?” or “I am thinking the depression is actually in you and only being mirrored by the client.”). These supervisors do not assess what skills the supervisee actually has.
  3. Supervisors who think of supervisees as learners and themselves as educators.
    1. Such supervisors give priority to learning needs and meeting supervisee needs.
    2. “How can I intervene so that this counselor will be more effective with current and future clients?”

Some of these developing supervisees in the categories above (#1 and #2) do not progress onward to become good supervisors. This is, of course, a very big problem for their supervisees.

Additional types of problem supervisor styles inform the development of a supervision style distinct from therapist (adapted from Liese & Beck, 1997 in Watkins, 1997) include:

Falender and Shafranske (2004) describe the 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. To collaborate in the context of the distinct power differential is a high-level skill. Components of the collaborative approach include engaging in supervisee self-assessment and supervisor feedback to the supervisee on the accuracy of the self-assessment, modeling supervisor lifelong learning, modeling the capacity to set the stage and engage in collaborative reflection; and stepping back from the content and process to look at it nonreactively. This process is facilitated by video or live review of the client session, as reflection can then focus on the process being observed, the emotional state of the participants, and reflection on the process and factors that might have enhanced it.

Making the Cognitive Shift to Supervisor

In a number of states, by regulation, the experience level of the beginning supervisor is such that one may begin supervising at the point of licensure, often with minimal or no training in supervision. Supervisor training and support will result in supervisor competence and confidence in the process. “Supervision-of-supervision” is an excellent modality to support the cognitive shift.

Supervision of supervision (or “sup of sup” as this is often referred to) is a wonderful opportunity for beginning supervisors – and a great skill-building activity for all involved. A very experienced supervisor meets with one or more (a small group is ideal) of novice supervisors, reviewing their supervision sessions, ideally using video or audio review with consents from all parties. The session would focus on:

Supervision of supervision provides support, knowledge, skill, and often values and attitudes to assist supervisory development.

A resource to enhance the supervisees’ experience is Getting the Most Out of Clinical Training and Supervision:  A Guide for Practicum Students and Interns (2012) written by this author (Carol Falender) and Edward P. Shafranske.  By preparing the supervisee to maximize and understand the supervision process, the role of the supervisor is streamlined and enhanced. 

Competencies

A critical part of competency-based supervision is attention to the specific competencies. 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). This definition, which identifies core aspects of the concept of competency, has been widely adopted across disciplines. It is an important part of understanding competency-based supervision. Supervision competencies are generally defined as knowledge, skills, and attitudes or values associated with supervision. In 2002, the Association of Psychology Postdoctoral and Internship Centers organized the Competencies Conference. The outcome of the Conference was a series of papers on competencies relating to different aspects of practice. One was devoted to Supervision Competencies (Falender et al, 2004).

The Supervisor Competencies Framework

The framework for supervisor competencies is laid out in the areas of knowledge, skills, values, and social context. This self-assessment is a result of the workgroup sponsored by the American Psychological Association to develop Guidelines for Clinical Supervision of Health Service Psychologists (2014, 2015). The full article describing the guidelines is available at: societyforpsychotherapy.org/guidelines-clinical-supervision-health-service-psychology/

Supervisor Competency Self-Assessment

This supervisor competency roadmap is intended to help you to identify both your strengths as a supervisor as well as those areas in which you can develop greater supervisor competence through continued professional learning and practice. Please rate each item using the scale below.

How characteristic of your own behavior is this competency description?
Not at all/slightly
Somewhat
Moderately
Mostly
Very
 
0
1
2
3
4
 

Domain A – Supervisor competence

 

 

1. I’m competent in the areas of clinical practice that I supervise. When I supervise a case outside my area of expertise, I work to develop my own knowledge, skills, and attitudes in this new area.

K/S/A

 

2. I’m committed to learning more and getting better at providing supervision.

K/S/A

 

3. I communicate and coordinate with colleagues who are also involved in the training of my supervisee.

S

 

4. I learn about the diversity of populations and settings that my supervisees encounter.

K

 

5. When (if) I employ technology in the supervisions that I conduct, I’m competent in its use

K/S

 

Domain B – Diversity

 

 

6. I pay attention to my own diversity competence, strive to keep my knowledge, skills, and attitudes up in this area of practice, and serve as a good role model of a self-aware psychologist vis-a-vis diversity issues.

K/S/A

 

7. I make efforts to be sensitive to individual differences and diversity in the interest of establishing positive relationships with all of my supervisees, inclusive of their background or individual characteristics.

K/S/A

 

8. I pursue learning opportunities that increase my competence in diversity.

K

 

9. I’m knowledgeable about the effects of bias, prejudice, stereotyping, and other forms of institutional or structural discrimination that may impact my supervisees and/or their clients/patients.

K

 

10. I’m familiar with the literature regarding the impact of diversity in supervision, including the importance of navigating conflicts between personal values and professional practice in the supervision of supervisees (e.g., assisting a client/patient with an issue that conflicts with one’s religious beliefs).

K/S

 

Domain C – Supervisory relationship

 

 

11. I create and maintain a collaborative relationship with my supervisees.

K/S/A

 

12. At the outset of a new supervisory relationship with a supervisee, I discuss the responsibilities and expectations for each of us.

S

 

13. I regularly revisit the progress of supervision with my supervisee, the effectiveness of our relationship, and address characteristic interpersonal styles that may affect the supervisory relationship and process.

S

 

Domain D – Professionalism

 

 

14. I’m professional in my interactions with supervisees, and help them learn how to similarly conduct themselves as professionals.

S

 

15. I provide my supervisees with on-going (e.g., formative) as well as summative feedback about their progress in developing professional behavior.

S

 

Domain E – Providing assessment, evaluation & feedback

 

 

16. I am straightforward and sensitive in providing feedback that is linked to the supervisee’s learning goals.

S

 

17. I’m careful to observe and monitor my supervisee’s clinical performance, so that my evaluation is based on accurate information.

S

 

18. My feedback is clear, direct, and timely. It is behaviorally anchored so that my supervisees know explicitly what they do well and how they could improve. I monitor the impact of my feedback on our relationship.

S

 

19. I help my own supervisees to get better at accurate self-assessment, and incorporate their self-assessment in my evaluation of them.

S

 

20. I seek feedback from my supervisees about the quality of supervision I provide to them, and use it to improve my own competence as a supervisor.

K/S

 

21. When dealing with supervisee performance problems, I address them directly and in accordance with relevant policies and procedures of my setting, institution and jurisdiction.

S

 

Domain F – Managing professional competence problems

 

 

22. If I see a performance problem, I identify and address it promptly with my supervisee, so that they have reasonable time to improve.

S

 

23. I am able to develop and implement a formal remediation plan to address performance problems.

S

 

24. I understand that supervisors have an obligation to protect the public from harmful actions by supervisees, and take seriously my role as a gatekeeper to the profession.

K/S/A

 

Domain G – Ethical, legal, and regulatory considerations

 

 

25. I serve as a positive role model to my supervisees by conducting myself in accordance with professional standards, ethics and laws related to the practice of psychology.

K/S/A

 

26. My primary obligation as a supervisor is to protect the welfare of my supervisee’s clients. This remains at the forefront of my supervision.

K/A

 

27. I provide clear information to my supervisees about what is expected of them in supervision.

K/S

 

28. I maintain timely and accurate documentation of my supervisee’s performance.

S

 

Note: K = knowledge, S = skill, A = attitude

Scoring: Now that you’ve completed this self-assessment, please take a quick scan at the lowest-rated items. These are areas in which you can focus (and model) your own competency development. If you find that low-rated items cluster in any particular domain, you might consider directed reading, peer consultation and/or continuing education in this area.

Reprinted From: Falender, C. A., Grus, C., McCutcheon, S., D., Goodyear, R., Ellis, M. V., Doll, B., Kaslow, N. (2016). Guidelines for Clinical Supervision in Health Service Psychology:

Evidence and implementation strategies. Psychotherapy Bulletin (Division 29), 51(3), 6-18. societyforpsychotherapy.org/guidelines-clinical-supervision-health-service-psychology  Appendix A.

After completing this self-assessment, highlight sections that are aspirational for you and describe how you plan to enhance your competence. If you are unsure, continue on with the course and return to this later.

For individuals who supervise in Substance Abuse, another document on Supervisor Competencies is the Technical Assistance Publications Series by SAMHSA – TAP 21A. It is available online at: Competencies for Substance Abuse Treatment Clinical Supervisors.

In this document, the following areas are the five foundations for clinical supervision:

The competencies for FA1: Theories, Roles and Modalities of Clinical Supervision are:

Refer to the full document for each set of competencies. You may find them useful in your individual or site assessment as a framework.

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 the above self-assessment was designed for psychology supervisors, think about what other aspects should be added or rearranged to reflect your particular discipline. Some ideas will be available in the competency assessments (for supervisees) that follow.

Supervisee Competencies

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. In this course, we will consider psychology, social work, and marriage and family therapy. Ideally, you will use these various documents with supervisees for whom you provide supervision, and thereby help them self-assess and develop goals for their future development.

Psychology Competencies

Competencies Benchmarks is the comprehensive framework for the measurement of competencies. The most current documents are available at: www.apa.org/ed/graduate/benchmarks-evaluation-system.aspx

This framework, referred to as Benchmarks (see Fouad et al., 2009 and Hatcher et al., 2013) focuses on the assessment of development for each of the following transition points for psychology students in preparation to enter professional practice:

Foundational competencies include:

The Benchmarks group added Professionalism, which was not represented in the original cube model.

Functional competencies are:

Supervision and Teaching were revised as separate competencies and Advocacy was added to the original cube model by the Benchmarks group after review by multiple constituencies.

The entire Benchmarks documents are also available in Fouad et al. (2009) and Hatcher et al. (2013). The document that is fully elaborated is Fouad et al (2009) – it has more extensive behavioral anchors.

In Benchmarks, baseline competencies are described as those that supervisees should possess and demonstrate prior to beginning their first practicum placement, internship, and entry to practice. These areas include:

It is important to review these documents carefully as this is a standard of practice, establishing criteria for individuals entering the field of psychology.

Social Work Competencies

Significant effort has gone into the development of the CalSWEC (California Social Work Education Center) documents. They are exemplary and are excellent evaluation and monitoring tools used by many schools of social work and field placements. They address foundational and advanced practice levels. The following is the website to access the CalSWEC documents. The latest version is the 2017 revision:
calswec.berkeley.edu/sites/default/files/2017_calswec_curriculum_competencies_0.pdf.

In the CalSWEC documents, there is a significant focus on culture and linguistically competent practice. Every discipline should find these competencies useful, as they are expansive and comprehensive – and very enlightening. Supervisors will find it useful to self-assess on each document used with supervisees as the presumption is that supervisors will be at least as competent – and hopefully more so – as the supervisees they oversee. The CalSWEC 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, for evaluation purposes.

For continuing competence development for social workers, the American Board of Examiners in Clinical Social Work, published Professional Development and Practice Competencies in Clinical Social Work (March, 2002). It can be accessed online here: acswa.org/wp-content/uploads/Competen.pdf.

Marriage and Family Therapy Competencies

AAMFT Competencies is a one point competency document, applicable to the point of entry into the profession (licensure). Competencies are organized around six primary domains and five secondary areas:

Types of skills and knowledge are conceptual, perceptual, executive, evaluative, and professional. It is critical to review this document carefully and track your supervisee’s competence if you are supervising MFT trainees or interns.

The document is available at the following website: coamfte.org/Documents/COAMFTE/Accreditation%20Resources/MFT%20Core%20Competencies%20(December%202004).pdf

An analysis of a group of graduates at the point of entry into the profession revealed that the AAMFT competencies are not being achieved at the hoped-for rates, indicating a greater responsibility for supervisors to assist supervisees in targeting competency development (Nelson & Graves, 2011).  The data suggest few AAMFT core competencies trainees have (fully) mastered them at the time of graduation from master’s programs (Nelson & Graves, 2011) (<10% of competencies). Although graduates may not be performing as well as supervisors might like, they are following the general trend of importance that is set by the expectations of the supervisors. Supervisors may also not be keeping pace with training needs in the current healthcare environment and may need to be prepared to help trainees develop skills that may not have been as important as they were before some of the changes occurred.

Following are two helpful articles that it is recommended for supervisors to read.  You will find these in the reference section of this course:

An article explaining the development of core competencies, by Nelson, T.S., Chenail, R.J., Alexander, J.F., Crane, D.R., Johnson, S.M, & Schwallie, L. (2007); and

An article exploring the impact of competencies in graduate training and some preliminary outcomes, by Nelson, T. S., & Graves, T. (2011). 

Summary

Remember that self-assessment is a core value of supervision. There is a growing international movement to have individual practitioners self-assess to identify areas in which continuing education would enhance competency. (Remember that continuing education is actually a means of ensuring ongoing professional competency.)

See Appendix II for information on additional competencies in areas such as nursing; clergy; CBT training; health psychology; neuropsychology; gerontology and family psychology, forensic/correctional psychology, and child and adolescent psychology.

Each supervisor should download a copy of the respective documents for the disciplines she supervises as well as the respective codes of ethics for those disciplines.

Direct Observation in the Assessment of Competence

The American Psychological Association now requires each supervisee in practicum, internship, and post-doctoral fellowship to undergo direct observation by a supervisor during each training period. (APA, CoA, Implementation Standards).

That observation may be live, video, or, if necessary, audio review of the supervisee’s performance. Ideally, these observations will be planful, organized around an assessment of the supervisee’s competencies.

This author strongly advocates direct observation for ALL supervisees at least once during each training term or rotation.

Interprofessional Supervision

Increasingly, supervisors are conducting interprofessional supervision, supervising individuals who are from different disciplines with varying scopes of practice. These might include social work, marriage and family therapy, psychology, psychiatry, alcohol and drug treatment counseling, and other mental health and health professions.

Complexity arises when the supervisor is from a different discipline and views the clinical work through a different lens. Guidance is provided by Core Competencies for Interprofessional Collaborative Practice (2016).

Four core competencies are essential:

Competency 1

Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics for Interprofessional Practice)

Competency 2

Use the knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of patients and to promote and advance the health of populations. (Roles/Responsibilities)

Competency 3

Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. (Interprofessional Communication.) Function effectively in different team roles to plan, deliver, and evaluate patient-/population- centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. (Teams and Teamwork)

Competency 4

Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient-/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. (Teams and Teamwork)

Interprofessional Education Collaborative (2016), p.10. tamhsc.edu/ipe/research/ipec-2016-core-competencies.pdf

These competencies set the stage for interprofessional collaboration that respects the competencies of each profession and builds upon the strengths of each in collaboration.

Other Models and Theories of Supervision

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. Remember that Competency-Based Supervision is applicable to all models as it is metatheoretical (Falender & Shafranske, 2010).

Theory-based Models

Among the approaches to supervision are psychotherapy-based approaches; including psychodynamic, cognitive-behavioral, intersubjective or narrative, and dialectical behavioral therapies; and systemic and family systems. In these models, supervision typically mirrors the therapy process reflected in the theoretical orientation. A concern with such supervision is that it may not systematically address all the areas critical for supervision (e.g., reactivity or countertranference, diversity or multiculturalism, legal and ethical issues). Superimposing a competency-based approach onto the theoretical model ameliorates that problem (Falender & Shafranske, 2010). Models also include process-oriented approaches, systems-oriented approaches, and developmental approaches (Falender & Shafranske, 2004; 2008).

There are multiple models that reflect the psychodynamic orientation, and 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 are discussed throughout this course.

A compendium of psychotherapy-based approaches (cognitive therapy [Beck], family therapy [Barenstein], and psychodynamically-oriented therapy [Sarnat]) are presented in Chapter 4 of Falender and Shafranske (2008). Sarnat describes the relational psychoanalytic model in which client, therapist, and supervisor are considered as cocreators of the clinical and supervisory relationship that are intertwined. Symbolic communication between supervisor and supervisee – a widely neglected aspect – addresses unsymbolized affective states that arise. The complexity of the supervisor role is as a model for the supervisee/therapist includes exploring supervisee emotional reactions as they relate to the client and supervised treatment. The supervisor is encouraged to set limits on exploration. The supervisor has the shared responsibility of exploration of personal dynamics as they impact the supervision and therapy. Focus is always directed to client work and the client, however.

Complete issues of Psychotherapy: Theory, Research, Practice, Training (2010) and the Journal of Contemporary Psychology (2012) are devoted to transforming psychotherapy-based models to competency-based and discussing the competency-based movement.

Cognitive therapy (CT) supervision parallels the therapy. Cognitive-behavioral models have provided for structured supervision protocols and even for manualized supervision (Henggeler & Schoenwald, 1998). The authors provide an excellent structure for supervision of cognitive-behavioral therapy.

The following organization is presented by Liese and Beck (1997) and provides excellent structure to the supervision process in a CT context:

(Liese & Beck, 1997; p. 121)

For examples of CT supervision, see the section of Chapter 4 of Falender and Shafranske, 2008, by Judith Beck.

Family therapy revolves around family systems conceptualizations. Attention is focused on strengths and resources of individuals and the family unit, stories the family tells that support the presenting problem, and parallel or isomorphic processes that occur across the family and supervision sessions. Kaslow, Celano, and Stanton (2005) describe a competency-based approach to family systems.

Humanistic-Existential therapy (Farber, 2010). Use of empathy, acceptance, and genuineness creates a safe and collaborative environment for supervisees and provides a model for the clinical process. Emphasis is on facilitating the client's experiential awareness and use of the psychotherapy relationship to engender change, and the growth, development, and self-learning of the supervisee in a parallel manner in supervision.

Dialectical-Behavioral therapy (DBT) 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.

In DBT supervision, there is a balance of finding, valuing, and nurturing supervisee’s inherent ability to help others in skillful manner – while ascertaining which skills are not in the supervisee’s repertoire and assisting her in acquiring these skills. Some aspects of DBT supervision are:

(Linehan & McGhee, 1994; Fruzzetti, Waltz, & Linehan, 1997)

DBT provides for rich clinical supervision but requires elaborate training in the model for therapeutic implementation and for supervision.

Narrative or intersubjective models, also known as Postmodern, deal heavily with context and social interaction. Supervision mirrors the therapy in which the clients present their stories 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

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) describe “teacher,” “counselor,” and “consultant” roles with different foci (intervention, conceptualization, and personalization).

Care should be taken to define terms to ensure clarity should these frameworks be used as “counselor” might be construed as constituting a boundary crossing; and “consultant” is confusing, as it does not entail the legal liability implicit in supervision.

Other Models

Holloway’s model provides a systems approach. The following grid represents the aspects of the model:

Functions
Tasks

 

Counseling Skill Case Conceptualization Professional Role Emotional Awareness Self-Evaluation
Monitoring/Evaluating          
Advising/Instruction          
Modeling          
Consulting          
Supporting/Sharing          
Holloway, 1995

To implement this model, for example, if a supervisor were having difficulty with a supervisee who is working with a client with whom she is over-identified, but similar to demographically, while the supervisor is from a different cultural and ethnic group, one could use the grid to identify possible interventions of supporting and sharing in the context of self-assessment, advising, or instructing while assisting in case conceptualization – and assisting the supervisee with teasing out personal factors which may be intersecting with the professional role.

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 the 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 of them 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 suggest the “seven-eyed supervisor model” in two interlocking matrices useful as tools to direct the supervisory process. They advocate the attention of supervisor and supervisee be directed to therapy sessions themselves with the following foci:

  1. Reflection on content of the session especially from client’s perspective.
  2. Consideration of therapist interventions and strategies to determine alternatives and effectiveness.
  3. Exploration of dynamics of process and relationship through attending to boundaries, nonverbal behavior, and variables such as images, hunches, and metaphors in material presented. The supervision process is the vehicle through which issues are addressed.
  4. Therapist’s countertransference – reactions to the client stemming from the therapist being unaware of his/her internal process that the supervisor brings to awareness in the supervisory session.
  5. Parallel or mirroring process in which changes in the supervisor-supervisee relationship are addressed to gain insight into dynamics of therapist/supervisee-client relationship.
  6. Supervisor’s countertransference – significant material missed by the therapist in session is manifested in the supervisor’s mood changes or unrelated feelings (e.g., boredom, fatigue, embarrassment).
  7. Supervisory context – including the impact of the organization in which supervision occurs, multicultural diversity aspects, codes of ethics, and social context and expectations of each party. This also includes communication of the professional expectation for practice and the supervisor’s role, as an active process with the supervisee in supervision.

This is a very interesting model as it integrates many of the aspects of supervision that will be addressed throughout this course.

Consider this vignette:

Vignette: The supervisee is worried that the daughter in the family she is seeing (that is much like her own family…and herself) is so remote and cut off from the parents. The supervisee is having significant difficulty deciding how to approach her. 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 and some identification as it is very much like her own role in her family. Considering the models described above, describe two alternate approaches to this situation.

Consider whether there may be a parallel or isomorphic process at play with the behavior of the supervisee/therapist mirroring that of the client.

Meta-theory: The Developmental Model

Developmental Theories and Models

Developmental theories of supervision have been at the forefront of theory and research for the past four decades, and were 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, social work, and marriage and family training.

To date there is virtually no evidence supporting developmental models derived from Delworth’s and Stoltenberg’s research (discussed below).

That is in contrast to the developmental structures of competencies (e.g., Benchmarks, CALSWEC) that ARE receiving empirical support.

The premises of developmental models include:

Stoltenberg, McNeill, and Delworth’s Developmental Theory

The most recent revision of the Stoltenberg et al. theory, IDM (or Integrated Developmental Model (Stoltenberg, McNeill, and Delworth, 1998; Stoltenberg & Delworth, 2010)) 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 in defining individuation and independence as it evolves. Some of the concepts the authors postulate as being 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.

The Level 1 – or beginning – therapist may be highly anxious, highly motivated, and highly dependent on the supervisor. Focus in therapeutic interventions is primarily on the therapist’s behavior and performance. Supervisory interventions are structured, contained, 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 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. The arrangement of information presented by Stoltenberg, et al. (1998) conceptualizes development as one factor, albeit a very potent one.

Catalytic Interventions are those 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.

Vignette: A supervisor requested a first-year practicum supervisee make an audiotape 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 safety concerns are raised?  What would you say and how would you approach discussion of the session on the audiotape? How much assessment should occur? Was that anxiety on the part of the supervisee, an accurate presentation 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.

Commentary: The supervisor, listening to the tape, was very distressed, feeling that this supervisee was much less sophisticated than she had thought, and at a loss to understand what in the world he was doing spending so much of the session talking about food. When the supervisee came in the next day for supervision, the supervisor was about to begin with some feedback about the tape, praising him for making it and bringing it to her so early in the training sequence, but inquiring as to what his agenda had been. Before she could begin, he launched into saying that, as they had described in the goals, he had spent much time thinking about that session and what it had evoked in him. First of all, it reminded him so much of his own mother, a single mom, and the difficulties she had with him and his brother. In addition, he said he had not taken the time to read the parenting manuals that had been assigned and had little to no experience in parent training. And finally, he said that he began the discussion because in the previous session the mother seemed to be resistant to establishing rapport with him, and he saw this as a way to begin to talk with her and approach some of the cultural factors which were different for them, as he was a white male and she and the children were Mexican-American. After a discussion of the personal factors and the engagement strategy, the supervisor suggested the supervisee call the client mother and talk on the phone about how she was doing – particularly with her worry about hitting the children – do a quick phone check-in, and possibly arrange for a sooner session, and give her specific tools to use with the children. In addition, he should praise her for her disclosure about her feelings – perhaps also a parallel process in therapy and supervision with both the client and the supervisee disclosing what they were most worried about.

A lesson to be inferred from this is that the supervisor had established enough “ground work” that the supervisee was able to disclose personal factors and be vulnerable, and the supervisor was then able to help the supervisee to develop appropriate skills and differentiate his own childhood experience from that of this family. It also assisted in the development of the supervisory alliance, which we know translates to the strong development of the therapeutic alliance.

If one were to give this supervisee further feedback, it would be to reinforce the disclosure and his motivation and efforts, and to highlight the value of his willingness to learn – and to identify the high risk factor of a mother who is feeling out of control with her children, and how serious this can be if not addressed. It would serve as a beginning lesson for the supervisee on one of the supervisor’s multiple roles – always keeping the safety of the client as the foremost priority.

Best Clinical Supervision

Features of Good Supervision

What are some of the aspects of good supervision? In Competency-based supervision, supervisors are attentive to knowledge, skills, and values/attitudes throughout all supervision.  The competencies serve as a framework to support supervisee strengths, development, and monitor supervisee progress, and to provide feedback, both positive and supportive/corrective. Ideally, this will be achieved through live observation of the supervisee conducting clinical work at intervals.

Both O’Donovan, Halford, & Walters (2011) and Kavanagh et al. (2003) describe positive or “best” supervision strategies. In their description of best practices of supervision, O’Donovan, Halford, and Walters (2011) describe functions and processes of supervision (highlighting the intense emphasis in the literature on alliance), contracting, evaluating therapy outcomes for supervisee’s clients, evaluating supervisee competence, the supervisory relationship, and developing supervisee knowledge and skills. They suggest that contracting should occur in supervision, data should be collected and used for the normative and formative functions of supervision (e.g., assessing competence of supervisee). Supervisors should communicate formative feedback and promote supervisee self-assessment, and manage tension between formative and summative evaluation.

Effective Supervision

These effective supervision practices are elaborated from those described by Falender, Shafranske, and Ofek (2014).

Attitudes

Skills (including the requisite knowledge of each in order to enact)

Please consider how you assess your supervisee’s development/competence. Are you basing all supervision on the supervisee’s self-report? Or do you have live, video or audio review of supervision? If you are using only supervisee self-report, consider if there is a way to directly access or provide co-therapy with your supervisee. It is very essential to observe your supervisee at least once during each training segment (a requirement for psychologists under the Committee on Accreditation Regulations).

Your Best Supervisor

Form a visual mental image of your best supervisor – visualize that person in as much detail as you can, remembering appearance, style, interactions, and any other dimensions you can recall. Then think of words describing this individual. You will probably find that the words you generate correspond very closely to the literature on best supervisors, although they will probably 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 orientation for three to five years following the conclusion of the training experience.

Inadequate and Harmful Supervision

Increased attention has turned to inadequate and harmful supervision. Supervisees surveyed reported very high rates of inadequate supervision in numerous studies (e.g., Ellis et al., 2014; Ellis, 2017; Ladany, 2010). Harmful supervision is defined by Ellis (2017) and others as supervisor actions directly harming the supervisee and actions known to cause harm although the supervisee may not identify them as such. For example, in the Ellis and colleagues sample (2014), more than 90% of supervisees surveyed were currently receiving some inadequate supervision and 35.3% were currently receiving harmful supervision. More than half of the supervisees had received harmful clinical supervision at some point. More than half reported their supervisor did not use a supervision contract or consent, and nearly 40% reported their sessions were not monitored, viewed, or reviewed, both of which are standards of practice. A majority of doctoral student respondents enrolled in American Psychological Association accredited programs reported problems in professional competence with faculty in their programs and that these had impacted them (Furr & Brown-Rice, 2016). Among the problematic behaviors reported at high frequencies were: educators’ cultural insensitivity, inadequate supervision skills, unprofessional behavior such as dishonesty, excessive tardiness, class absences, inappropriate boundaries, and inability to regulate their own emotions. Because of the power differential inherent in clinical supervision, supervisees are not likely to initiate discussion of supervisor competence or ethical concerns. Ladany and colleagues (1999) reported that more than half of supervisees in their sample reported at least one ethical infraction by their supervisor during the course of training, and in a replication, Wall (2009) found that 23% of her sample indicated their supervisor had conducted at least one ethical lapse or violation, while 26% questioned their supervisor’s ethical judgment on at least one occasion during the internship.

In their most recent study, Ellis and colleagues (2014) describe examples that include the supervisor threatening the supervisee physically, having a sexual relationship with the supervisee, sharing drugs, or being aggressive or abusive with the supervisee. All of these are negligent supervision – not only is it harmful to the supervisee, it can cause significant harm to the clients being served by virtue of the supervisee not receiving appropriate supervision, the supervisee having experienced harm, thus placing the client(s) at high risk. These examples and this study reinforce the clear and urgent need for training in clinical supervision and for guidelines that provide for appropriate practice. Without specific training, individuals who simply begin supervising are generally not engaging in intentional and systematic supervision. Nor do they value the supervision process.

Beginning the Supervisory Relationship

Supervisory Alliance

The supervisee enters supervision for the first time. She is eager and a little anxious, and is unsure what the supervisor expects. The supervisor is welcoming, encourages the supervisee to discuss her previous experience and what she is hoping to learn in this setting, and provides structure and encouragement to her. The supervisor also explores her theoretical orientation(s), perceived strengths, and asks for feedback on her profession’s competency document that she completed prior to the meeting.

Together they plan two goals and tasks for each to perform. The supervisee particularly wants to gain additional competence in Parent-Child Interaction Therapy (PCIT), and would like feedback about her skill development. The supervisor describes how it would be possible to observe her several times and give feedback. Her second goal relates to the impact of child trauma on her personally, and how to manage that when she sees a traumatized client; in the next session they will develop specific goals relating to that, which may include self-care.

The supervision relationship is a complex one. This relationship provides the platform for sharing, disclosure, and mutual problem-solving. Most supervisors rely almost or totally exclusively on supervisee disclosure: what supervisees tell the supervisor about the client(s) and the session. We caution that there are many factors that implicitly impact what supervisees recall and disclose. Also, remember that relationships take time to develop – sometimes it is estimated to take from one to seven supervision sessions. And abundant data supports the idea that without a secure supervisory relationship, the supervisee does not disclose as much client or session information. Trust is a critical part of the supervisory relationship.

The clearer the expectations are for the supervisory relationship, the better.

Examples of other supervisory goals:

Sample specific tasks:

Exercise: Think of a supervisee that you are currently supervising or about to begin supervising. Identify tentative ideas about appropriate supervisory goals and tasks, considering the supervisee’s previous experience and training. For practice, role-play the supervisor-supervisee alliance formation process with a colleague.

 

Vignette: Susan, your new supervisee, comes to you with extensive training in evidence-based practice from graduate school.  She has been research assistant to a professor who has developed models to treat anxiety.  In the first supervision session, she is enthusiastic and is eager to use checklists she has found to begin the session. How could you as supervisor help her to understand the importance of her strengths…and the importance of establishing a therapeutic relationship early on with the client and family?

Role Invocation

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.” Through role invocation, the supervisor can specify particular behaviors either from Vespia et al.’s (2002) Supervisory Utilization Rating Form (SURF) or simply by making a list of behaviors most important to the individual supervisor or setting. Items from the SURF for use with supervisees is available in Falender and Shafranske (2012).

The types of areas to be covered in role invocation include the expectations and ground rules of supervision, starting with such basics as:

The supervisor may also elicit from the supervisee expectations for the supervisor. Thorough role invocation is an excellent part of establishment of the supervisory relationship.

Although supervision is collaborative, there is the reality of the power differential,that is, the supervisor holds the power to evaluate the supervisee and is the gatekeeper who decides whether the supervisee is suitable to progress to the next level of training and to enter the profession. The supervisor holds the ultimate power and liability for the supervisee’s work.

With the supervisee in the vignette above, how important might it be to consider having her conduct a thoughtful self-assessment to bring to supervision to share – to collaboratively identify aspects of the supervisee’s experience and training that will facilitate client work, and to explore as well areas that are perhaps less familiar to her such as establishing a therapeutic alliance and identifying and processing her own unusual emotional reactivity.  To improve competence, the supervisor might suggest readings (e.g., Falender & Shafranske, 2012; Gehlert, Pinke, & Segal, 2014) to enhance her knowledge and skills. Role play between the supervisor and the supervisee is also highly effective – with the supervisor playing the role of the client and then reversing to play the role of the supervisor.

The supervision progression is built on the foundation of a supportive relationship that encourages growth empowerment and trust so that issues of countertransference can be identified and explored, and creativity and innovation supported. For the supervisee, the relationship seems to evolve from dependency to growth of trust, on to individuation or the evolution of the relationship, and on to that of colleagues. Boundaries are very important in clinical supervision. Maintaining appropriate boundaries and not moving into the personal therapy domain is a central element of effective supervision.

Think about some barriers in the development of the supervisory relationship. If you are an experienced supervisor, think of examples of supervisees with whom it has been unusually difficult. If you are just beginning, draw upon your experience of having been supervised and think about what facilitated and what inhibited such a relationship. Make a note of these examples for later so you can think about them in order to gauge whether you had difficulty with forming the relationship or whether it was something that happened after a relationship was established. What is the role of multicultural factors, or of multicultural intersections of client(s), supervisee, and supervisor in the supervisory relationship?

Evaluation and Relationship: How Can You Do Both?

The other element that is often shortchanged or ignored is the evaluative function, which provides a context and an ethical and professional structure to the relationship. Supervisors often do not evaluate or give corrective feedback (essential components of supervision practice) for fear of disrupting the supervisory relationship.However, feedback and evaluation are critical supervision responsibilities and are essential so the supervisee knows how to enhance client practice, professionalism, and behavior and fulfill the informed consent aspect of ensuring that the supervisee knows how the supervisor perceives the supervisee’s competence development.

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. Failure to give feedback is a violation of the supervisee’s right to know – and to improve performance. Give brief feedback every supervision session on strengths and areas perceived to be in development. This brief feedback is anchored to the goals that were collaboratively developed. New goals are developed as each one is achieved.

It is important to lay groundwork for evaluation by letting supervisees know you will be giving feedback at every session and that the “law of no surprises” is operative; the supervisee should be the first to know if the supervisor has concerns about the competence of the supervisee. This introduces a significant transparency into the supervision process in that it gives the supervisee every chance to grow and improve, as well as to clarify aspects of behavior or interventions that may have been misunderstood in supervision.

Feedback – corrective, positive, or negative – is a critical part of supervision. Assessment and self-assessment are essential ingredients of the alliance, as is instilling the concept of two-way feedback wherein feedback will be a part of every supervision session; supervisees should be encouraged to give ongoing feedback to supervisors as well. Supervisee feedback could be as simple as asking if there are other things the supervisee wishes were covered, or providing a simple checklist and asking the supervisee if all these were accomplished in the supervision session (e.g., multicultural discussion, evaluation, attention to supervisee goals). Self-assessment by both supervisee and supervisor are critical aspects of the self-reflective process, as spelled out in the Benchmarks document (Fouad et al., 2009), as well as in documents for marriage and family therapist (AAMFT, 2004), social work (ABECSW, 2002), and nursing.

Exercises:

Review the following scenario and how you might 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 you could do this.

A major factor 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, or 3) asking how the supervisee is feeling in the session with the client, and what self-reflection she will engage in to discuss processes and feelings. Think of approaches you currently use and identify which are most effective. How do you enhance self-reflection? How do you vary your approach with different supervisees? What are some of the variables you take into consideration?

Think about the issue that if you become very directive, you will be modeling the very behavior you do not want the supervisee to engage in. How could you adopt a reflective approach?

An interesting approach was described by Sobell, Manor, Sobell, & Dum in 2008. They suggest that supervisees engage in review of their own sessions, and then discuss the audio or video review in supervision with supervisors using principles of Motivational Interviewing (MI).

Some questions might ensue:

After asking permission, the supervisor could say, “Tell me a bit about what you heard on your tape and how you might phrase things differently in a similar situation next time?” This could be followed with open-ended questions that are also part of MI (e.g., “What other things might you do differently?” or “What do we need to work on in supervision to get you to a higher level?”). Open-ended questions provide for a conversational approach that allows trainees to reflect on their own progress, and it encourages trainees to decide to make changes (i.e., talk or interact differently with patients).

In MI, getting trainees to “give voice” to the need to make changes in how they are responding to patients (e.g., “I asked too many dead-ended questions and rarely reflected what the patient said.”) is viewed as more likely to get them to consider making a serious change attempt than if the supervisor tells trainees what they must change. Giving voice has similarly been referred to as self-assessment. Self-assessment also is enhanced by a reflective process – waiting until the supervisee (and for that matter, the supervisor) are not reactive – upset, angry, distressed – and then stepping back and reflecting on what happened, what the alternatives are, what feeling states were elicited, and how the supervisee could respond when such issues arise going forward.  Supervisors can practice reflecting rather than judging.

In cognitive-behavioral supervision, the contract can be constructed around requirements specific to the setting and competencies to be attained. Evaluation can focus on the competency document as can frequent and ongoing feedback and assessment.

Contract or Training Agreement

The supervisory contract (which is supplemental to the basic supervisory agreement or responsibility statement required in some states) is a means of articulating the roles, responsibilities, expectations, and requirements of the training period. A state-mandated agreement typically includes all the state regulations relating to supervised professional experience, accumulating hours for licensure, and/or maintaining a particular unlicensed status.

In contrast, components of the supervision contract include:

To develop the goals, the supervisor and supervisee discuss strengths and areas in development of the supervisee based on supervisee self-assessment of the discipline’s competency document (e.g., Benchmarks, Calswec, AAMFT).  From this discussion, goals and tasks can be developed and stated.  This is a living document:  when goals are attained, the supervisor and supervisee collaboratively establish new ones.

The contract is a critical part of the supervisory relationship as it fulfills both informative and collaborative functions.

Supervisory Format

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 or not 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 to 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 videotape or audiotape. 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.

Whichever framework is used, Competency Benchmarks and the other professions’ competencies provide the essential framework for formative feedback and bridge the gap for supervisees, removing the surprise of corrective competence feedback being introduced at the four- or six-month point with no previous notice or opportunity for the supervisee to address and improve. The steps in these frameworks include:

(Derived from Liese & Beck, 1997; p. 121)

We find that supervisees appreciate structure, not necessarily all of these steps, but at least setting a supervisory agenda and following it – collaboratively deciding on priorities for the session, and then using capsule summaries to ensure supervisee and supervisor are in agreement moving forward with respect to client care. Doing so can increase the supervisee’s feeling of collaboration and control, and can also provide a comprehensive framework for productive supervision. (See Falender & Shafranske, 2012 for specific examples and protocols.)

Supervision Efficacy

Milne, Pilkington, Gracie, & James (2003) describe the following categories to assess supervision effectiveness:

Although these researchers were looking for transfers from supervisory interventions to the therapy setting, this type of analysis or framework would also be useful for application to the actual supervisor-supervisee interaction. For example, one could ask the supervisee which behaviors she would prefer in the supervisory process and then, either through videotaping the supervisory session or by the 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 could lead to a discussion of the types of presentation or material useful to ensure that the supervision moves in a useful direction.

Beginning supervisors use an abundance of listening, and beginning supervisees use abundant reflection. With experience and training, there is movement toward use of a broader range of behaviors, including those that are more constructive for the supervision experience.

Conflict and Resolution in Supervision

Strain and Rupture in the Supervisory Relationship

Supervisors are generally poor at identifying when strain or conflict arise in the supervision relationship. In Moskowitz & Rupert, (1983), we see that when conflict arose, the worst-case scenario was when supervisors did not initiate discussion of the conflict or move toward 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. 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 is the ultimate legal responsibility of the supervisor.

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 a good supervisory relationship as empathic, nonjudgmental, validating, and with encouragement to explore and experiment. This set the stage for non-defensive analysis by the dyad, as confidence in the relationship was strengthened. In addition, supervisees reported an increased perception of therapeutic complexity, an 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.

Safran and Muran (2000) describe 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 be the one to do this whenever feasible. 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.

Types of Conflict

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, at least to some extent, as 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 (2017)).

Multiple events may result in strains or ruptures in the supervisory alliance. Strains may be brought about by:

(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.

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 the results reported by Rosenblatt and Mayer (1975), found that some of the students engaged in spurious compliance. They concealed relevant information, especially their personal feelings. This might be manifested in the 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 of it, 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.

Nondisclosure

Since disclosure is the primary means for supervisors to gain information for the supervision process (in the absence of video, audio, or live supervision), it is essential for supervisees to disclose relevant data to the supervisor.

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 some supervisors did not disclose negative reactions to supervisee’s therapy and professional performance, which may have occurred because the supervisor may have been considering the supervisee’s developmental trajectory, and could have possibly ended 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 impacting 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. Rationales 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 the dynamics of the training site. These nondisclosures were viewed as appropriate boundary-setting. Next was the 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 competence 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 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 thought 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 a high potential for shame, such as acknowledging they made an error or disagreeing with the supervisor, more than one-third of their sample affirmed they would tend to withhold information or tell the supervisor what she seemed to want to hear (back to spurious compliance).

In another study of supervisee nondisclosure, by 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 withheld 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 thereof. 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). Ideally the supervisor will be even more proactive, identifying a possible strain or rupture event, and suggesting a possible connection to the supervisee’s changed behavior – and most importantly, the supervisor taking responsibility for errors.

Supervisor Disclosure

In a small sample (N=12), supervisees reported generally positive effects when supervisors disclosed regarding personal information or clinical experiences and when supervisees perceived such disclosures were planful and aimed at normalizing experience, validating, building rapport, and instructing (Knox, Edwards, Hess, & Hill, 2011).  However, nonplanful and inappropriate personal disclosures (supervisor psychiatric diagnoses, or personal relationship dynamics seemingly requiring supervisee assistance) were not helpful although they may serve to support supervisee future practice of only planfully and thoughtfully disclosing.

Personal Factors

Countertransference or Reactivity

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). As with therapy, supervision 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 in reactions to the client and to supervision. Other supervisees have not had specific training in countertransference or view it as totally tied to psychodynamic theory and thus discount it. Thus terming the phenomenon as “reactivity” or an unusual emotional response to clinical material or a stimulus, is useful. Emphasizing the utter normality of such responsivity – and reinforcing identification as a competence – is important.

Before countertransference or reactivity can be attended to, 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 toward 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), have reactions which interfere with his/her ability to conduct therapy, or have reactions to which it would be inappropriate to expose to the client (crying whenever child abuse is mentioned, for example). Contrast this with responsivity – becoming sad or even slightly tearful when hearing of severely traumatic events to a child – a response that would be normative for most therapists.

The supervisor assists in identifying reactivity or countertransference (either individually by the supervisee, collaboratively by the supervisor-supervisee dyad, or through a change or deviation in practice). For example, if the supervisee is seeming overwhelmed by a particular client when in fact that supervisee has done strong work with previous similar clients it may be indicative of countertransference.

Once the collaborative identification is made, the supervisor discusses steps of integration and differentiation – of the client’s experience from the supervisee’s personal experience – and the supervisee will continue to differentiate, independently, increasing empathy for the client in process. Addressing anxiety management – data is increasingly in support of mindfulness interventions – and discussing the conceptual frame for treatment, are additional steps.

Discussion of countertransference or reactivity is an incredibly useful tool, when it occurs 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 readily possible to proceed to address the countertransference.

Confronting Challenging Situations

An interesting approach is determining how effective a supervisor feels in providing, receiving, and addressing potential challenges in supervision. The following are items describing self-efficacy in solving supervision issues. Think about your own experience as supervisor and/or supervisee and provide ratings on a scale of 1 to 5 with 1 being not at all confident and 5 being extremely confident.

Over the next three months, how confident are you that you can successfully prevent issues in the following areas from reducing the effectiveness of supervision?

  1. Role boundary issues (e.g., friend/supervisor)
  2. Mismatch of goals or expectations
  3. Skill acquisition problems
  4. Problems with providing or receiving feedback
  5. Problems in identifying and managing supervisee emotional response or reactivity
  6. Supervisee feeling overwhelmed by a particular client
  7. Problems with implementing new strategies
  8. Problems with access to needed supervision resources
  9. Suspected violations of professional ethics
  10. Differences between supervisor and supervisee (e.g., profession, theoretical, multicultural)

Over the next three months, how confident are you that you can:

  1. Provide effective supervision?
  2. Identify and successfully resolve problems that emerge in supervision?
  3. Resolve issues that arise from management?
  4. Resolve workplace disputes?
  5. Articulate long-term career plans?
  6. Deal with emotional stress induced by work issues?
  7. Locate resources that can help ensure practice is optimal?

(Adapted from Kavanagh, Spence, Strong, Wilson, Struck, & Crow, 2003, p. 99)

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 has been increasingly withdrawn and unwilling to discuss case material. He is beginning to be angry with her for being withholding. 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 be having 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?

Diversity Competence and Multicultural Supervision

Ethical Standards and Guidelines

An area of training that has been much neglected is that of diversity competence even though it is an ethical standard.

Ethical Principles of Psychologists and Code of Conduct (APA, 2017):

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.”

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.”

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…”

In addition, there are the Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality, (APA, 2017b):

Guideline 1. Psychologists seek to recognize and understand that identity and self-definition are fluid and complex and that the interaction between the two is dynamic. To this end, psychologists appreciate that intersectionality is shaped by the multiplicity of the individual’s social contexts.

Guideline 2. Psychologists aspire to recognize and understand that as cultural beings, they hold attitudes and beliefs that can influence their perceptions of and interactions with others as well as their clinical and empirical conceptualizations. As such, psychologists strive to move beyond conceptualizations rooted in categorical assumptions, biases, and/or formulations based on limited knowledge about individuals and communities.

Guideline 3. Psychologists strive to recognize and understand the role of language and communication through engagement that is sensitive to the lived experience of the individual, couple, family, group, community, and/or organizations with whom they interact. Psychologists also seek to understand how they bring their own language and communication to these interactions.

Guideline 4. Psychologists endeavor to be aware of the role of the social and physical environment in the lives of clients, students, research participants, and/or consultees.

Guideline 5. Psychologists aspire to recognize and understand historical and contemporary experiences with power, privilege, and oppression. As such, they seek to address institutional barriers and related inequities, disproportionalities, and disparities of law enforcement, administration of criminal justice, educational, mental health, and other systems as they seek to promote justice, human rights, and access to quality and equitable mental and behavioral health services.

Guideline 6. Psychologists seek to promote culturally adaptive interventions and advocacy within and across systems, including prevention, early intervention, and recovery.

Guideline 7. Psychologists endeavor to examine the profession’s assumptions and practices within an international context, whether domestically or internationally based, and consider how this globalization has an impact on the psychologist’s self-definition, purpose, role, and function.

Guideline 8. Psychologists seek awareness and understanding of how developmental stages and life transitions intersect with the larger bio-sociocultural context, how identity evolves as a function of such intersections, and how these different socialization and maturation experiences influence worldview and identity.

Guideline 9. Psychologists strive to conduct culturally appropriate and informed research, teaching, supervision, consultation, assessment, interpretation, diagnosis, dissemination, and evaluation of efficacy as they address the first four levels of the Layered Ecological Model of the Multicultural Guidelines.

Guideline 10. Psychologists actively strive to take a strength-based approach when working with individuals, families, groups, communities, and organizations that seeks to build resilience and decrease trauma within the sociocultural context.

It is also important to be knowledgeable about these American Psychological Association guidelines: Guidelines for Psychological Practice with Older Adults (APA, 2014); Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (APA, 2011); and Guidelines for Transgender and Gender Non-Conforming People (2015).

For social workers, refer to these guidelines for transgender and gender nonconforming (TGNC) affirmative education: Enhancing the climate for TGNC students, staff and faculty in social work education. (Council on Social Work Education, 2016).

According to a study of social work students, 65% indicated that TGNC issues are introduced into courses by students rather than instructors, and only 3% of students reported that transgender-specific readings were regularly integrated into their social work classes (Austin et al., 2016, p. 12), a finding that appears true across mental health disciplines.

The NASW Code of Ethics also addresses cultural competence:

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 knowledgebase 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, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability.

(d) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients and how they may use electronic technology. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.

3.01 Supervision and Consultation

(b) Social workers who provide supervision or consultation are responsible for setting clear, appropriate, and culturally sensitive boundaries.

For Marriage and Family Therapists:

CAMFT (2011)

1.1 NON-DISCRIMINATION: Marriage and family therapists do not condone or engage in discrimination, or refuse professional service to anyone on the basis of race, gender, gender identity, gender expression, religion, national origin, age, sexual orientation, disability, socioeconomic, or marital status. Marriage and family therapists make reasonable efforts to accommodate patients who have physical disabilities.

1.1.1 HISTORICAL AND SOCIAL PREJUDICE: Marriage and family therapists are aware of and do not perpetuate historical and social prejudices when diagnosing and treating patients because such conduct may lead to misdiagnosing and pathologizing patients.

4.6 CULTURAL DIVERSITY: Supervisors and educators are aware of and address the role that culture and diversity issues play in the supervisory relationship, including, but not limited to, evaluating, terminating, disciplining, or making decisions regarding supervisees or students.

Competence Issues in Multicultural Supervision

Ethical standards and multicultural guidelines notwithstanding, there is some evidence that therapists are continuing to provide services to some clients whom they do not feel competent to treat (Allison, Echemendia, Crawford, & Robinson, 1996, surveying 90% Caucasian respondents), that supervisors’ knowledge, skills, and values relating to diversity may not be as sophisticated as 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, Schwartz, Marshall, Kalis, Frazier, et al. (2006) suggest 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) show 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.

Informed Consent to Supervisees Regarding Required Personal Disclosures

It is important to consider 7.04 Student Disclosure of Personal Information from the Ethical Principles of Psychologists and Code of Conduct (APA, 2017). (Please note that a similar code is included in the Art Therapist ethics code.)

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 his 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).

A Framework for Multicultural Clinical Supervision

Although multicultural competence is a necessity in supervision, supervisees continue to find it an area of uneven competence or even deficiency in their supervisors (e.g., Falender, Shafranske, & Falicov, 2014; Jernigan et al., 2010; Singh & Chun, 2010). Lack of demonstrated supervisor multicultural competence is often listed among counterproductive or harmful supervision practices.

Falicov (in Falender, Shafranske, & Falicov, 2014) described her Multidimensional Ecological Comparative Approach (MECA) in which supervisor and supervisee consider the aspects of their personal experience in the frame of the client.

The generic ecosystemic parameters she describes are:

In Ecological context, the supervisory dyad examines diversity in where and how the client lives and fits into the broader sociopolitical environment. Consider the client’s total ecological field, including: the racial, ethnic, class, religious, and educational communities in which the person lives; the living and working conditions; and the involvement with schools and social agencies.

Migration/ Acculturation – Multiple symptoms, behaviors (nightmares, separation anxiety), or family over- or under-involvement may be precipitated by separations and reunions. A number of clinical issues are tied to such pre-migration experiences, including traumatic ones or reluctant leave-taking. Other clinical issues, from cultural gender gaps between husbands and wives to intergenerational conflicts between parents and children, emerge over time for many. Therapists should be alert to marginalization, those psychosocial and mental health consequences of marginalized status, discrimination due to race, poverty, and documented or undocumented status, as well as other forms of powerlessness, underrepresentation, lack of entitlement, and access to resources.

Family organization – Consider the family of origin and current family-collectivistic, socio-centric family arrangements that encourage parent-child involvement and parental respect throughout life. In contrast to nuclear family arrangements that favor the strength of non-blood relationships such as husband-wife over that of the influence of the extended family or elders.

Family Lifecycle includes the timing of stages and transitions, the constructions of age-appropriate behavior, various growth mechanisms, and lifecycle rituals and rites to name a few. Therapists’ should strive to understand the similarities and differences between themselves and their clients, shaped in part by nationality, social class, or religion, regarding lifecycle values and experience and where they are in terms of their own perspective (e.g., beginning a family, experiencing loss, expecting grandchildren) – all of which influence worldview.

Falicov’s framework applies to diverse cultural groups, incorporating cultural diversity and social justice lenses. She advocates a postmodern position of not-knowing and curiosity, and respectful approach to the realities of the family.

(Falicov, in Falender, Shafranske, & Falicov, 2014)

Consider a situation you are currently supervising (or were supervised in) and think about these variables for each of the participants:

Consider borderlands or shared identities among the client(s), supervisee, and supervisor. Multiple shared identities may be impactful in assumptions made about the family. If the supervisee and client are closer in age, for example, the supervisee may believe (and may be correct) that he/she share an understanding of some life events that differs from that of the older supervisor. Similarly if religion, ethnicity, sexual orientation, or other characteristics are shared by the two, assumptions and beliefs may be acted upon without being purposefully considered.

How does the borderland with the supervisee impact your supervisory relationship? How does the borderland with the client impact your supervisory relationship and your treatment and assessment planning?
In a study by Dressel et al. (2007), successful multicultural supervision behavior was identified:

(Dressel, Consoli, Kim, & Atkinson, 2007)

This excerpt of their comprehensive list is critical in identifying excellent practices in multiculturally competent clinical supervision. Supervisors are cautioned that there are studies that identify the intent of clinicians and supervisors to be multiculturally competent, but that practice does not keep pace with intent (Hansen et al., 2006). In other words, one should self-assess in this vital area and be particularly mindful of one’s openness and flexibility about taking a leadership role in introducing these topics as a matter of course and in responding to supervisee initiation of these subjects.

Remember, too, that supervisors may not view exposure to cultural differences as influential in supervisee development, while supervisees do. Relationship is pivotal to diversity consideration – negative interactions and conflict in communication impede relationships; discussion cannot occur without a good supervisory alliance (Toporek, Ortega-Villalobos, & Pope-Davis, 2004).

In a small qualitative study (Burkart et al., 2014) European-American supervisors reported problematic relationships prior to difficult feedback to their supervisees. Supervisor feedback often focused on supervisee lack of sensitivity to cultural issues, or interpersonal style (e.g., directness) that was interfering with the client alliance. Supervisors reported fearfulness of imposing their own culture or injuring the supervisee, but ultimately found there were positive results of difficult feedback.

Self-awareness

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 orientation, gender identity, culture, ethnicity, socio-economic status, 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.

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 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 beliefs 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.

Affirmative Supervision Models

In 2009, an American Psychological Association (APA) Task Force on Gender Identity and Gender Variance (TFGIGV) survey found that less than 30% of psychologist and graduate student participants reported familiarity with issues that TGNC people experience. A non- binary gender identity perspective defines gender identity as not exclusive to male or female, but includes genderqueer, gender fluid, gender non-conforming. A person’s gender identity may not conform with sex assigned at birth.

Affirmative supervision models are completely compatible with competency-based supervision and represent the state of the art. A basic premise is that all sexual, gender, and identity orientations are valid, to be respected. The supervision environment is a safe, and respectful place, with emphasis on supervisee empowerment that will translate to client empowerment. Consideration of the multiple identities of client(s), supervisee, and supervisor will be incredibly helpful. Thus age (generation), gender, sexual orientation, gender identity, religion, socio-economic status, national origin, ethnicity, immigration, acculturation, language, and disability are potent influences in treatment planning and conceptualization – to enact with the supervisee.  In this context, consideration of identities that are privileged (e.g., middle or high socio-economic status, male) assist in understanding sources of resilience and trauma and the relationship in psychotherapy between the therapist and supervisor.

Supervisor awareness and direct discussion of power, privilege, and oppression in the context of supervisee empowerment are essential components. A self-reflective process, entailing those aspects and addressing issues of transference and countertransference, empowers the supervisee. Singh and Chun’s (2009) Queer People of Color Resilience supervision model provides guidance for the process of supervision. In the various triads of supervision, the supervisor, supervisee, and/or client may be a sexual minority, and this may be unknown to the others or it may be known. It will be important for the supervisor to bring up issues of sexual orientation and address those in supervision. The supervisor, often privileged, must be self-reflective, negotiate the worldviews, biases, and goals of the client and supervisee, while maintaining focus on processes, case conceptualization, skills needed, and outcomes. The goal is creation of an affirmative empowering environment to proceed with supervision and clinical work.

Generally, since few training programs explicitly address sexual minority clients, supervisees and supervisors may be unprepared (Bieschke, Blasko, & Woodhouse, 2014). However, competence with sexual minority issues is essential prior to beginning to be a supervisor. Writing about working with gay, lesbian, and bisexual clients, Bruss, Brack, Brack, Glickauf-Hughes, and O’Leary (1997) suggest the supervisor assess the supervisee’s level of competence with diversity, being particularly vigilant for inadequate information, anti-affirmative attitudes, attribution of all problems to sexual identity, and tendency to consider family/intimacy issues in heterosexual terms (from Buhrke & Douce, 1991).

Supervisor self-awareness is also critical, 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 the general 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, 2012), Guidelines for Psychological Practice with Transgender and Gender-Nonconforming People (APA, 2015) and Guidelines for Trangender and Gender Non-Conforming Affirmative Education (Austin et al., 2016).

The intersections of LGBT and religion are increasingly challenging and complex, as sexual minority individuals often experience conflicts between their religion and their sexual orientation. This may result in a combination of withdrawing from formal religion, escalating family conflict, and distress.

Consider this scenario: Your recently assigned novice supervisee has an intake today with a client who is self-identified as bisexual and whose presenting problem is depression following a recent relationship breakup and job loss. The supervisee discloses she is a lesbian and wonders whether it would be best to disclose this to the client early on in the intake to enhance the therapeutic relationship and ensure that the client knows that the therapist understands the issues. As supervisor, what issues does this raise? What questions would you want to clarify? How would you decide how to proceed?

Rather than adopting a hierarchical stance, it would be ideal to adopt a reflective stance and discuss with the supervisee the importance of her disclosure and her life experience on her clinical work generally, and potentially with this client. The supervisee should be praised for her insight in raising this issue in supervision as it is an important one. In terms of self-disclosure, what would be the intent of the self-disclosure? For what clinical purpose would it be made? The supervisor could explore the supervisee’s motivation – whether she is making the disclosure to establish rapport, thinking that that will create a strong therapeutic alliance, whether she is interested in the disclosure because she is feeling less sure about how to proceed clinically? How could her understanding and personal experience be useful in the therapy, while ensuring the client’s needs are addressed?

Addressing Multiculturalism in Supervision

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 their 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?” The supervisor may also model some type of self-disclosure such as “We will see clients through different lenses due to our own cultural identities – I am from a different generation and female and those identities frame my perceptions.” Rather than requiring the supervisee to self-disclose, such a disclosure opens the door to discussion when a client is being discussed and the supervisor and supervisee differ on their diagnostic impressions, and about general multicultural frames. Then the supervisor reminds the supervisee of their own contributions to the process.

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 the supervisee’s values, traditions, and worldviews (Daniels et al., 1999).

(“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.

Vignette: The client is a 37-year-old African-American woman whose parents moved to California from the Southern U.S. 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 Caucasian female.

Consider the cultural complexity by comparing each dimension of client-supervisee-supervisor in terms of worldview, migration, place in the family lifecycle, ethnicity, and hypotheses about how different belief structures or perspectives, as well as privilege and oppression, may affect a therapeutic approach.

What are some of the aspects that should be considered? List the factors you view as most important in considering these areas. Some possible considerations include the relationship, attitudes, and worldviews of client, supervisee, and supervisor; historical factors of each (regional, cultural, socioeconomic, age; the history of racism, oppression, and privilege); and the ability to conceptualize all of this in a meaningful manner to move the therapy forward in a culturally sensitive manner. If, for example, the supervisor were to disagree with the client’s belief that she is being overlooked for promotion because of racism, but the supervisee believed strongly that racisim was a significant factor in the client’s workplace based on the client’s descriptions , a strain or rupture could be introduced in all levels of the therapy and supervision, which would ultimately harm the client.

Evaluation, Assessment, and Feedback

An element of supervision that has often 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 universities, professional schools, and licensing bodies. To varying degrees, at all levels of training, the supervisee and supervisor are cognizant that the supervisor, in evaluating specific competencies, is a potent force in the supervisee’s future. 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. Evaluation is inextricably tied to assessment and feedback. The supervisor’s gatekeeping duty requires ongoing assessment, evaluation, and feedback to ensure that the supervisee is meeting competence requirements.

Introduction of competencies by each profession has begun to fill the gap in assessment and evaluation of supervisees. The process entails having the supervisee self-assess using the competencies document (i.e., Competencies Benchmarks, CALSWEC, AAMFT competencies) and then collaboratively develop goals for the supervision during that rotation, with collaborative monitoring and setting new goals as the previous ones are achieved. If supervisors do not agree with the self-assessment, it is beneficial to provide the supervisees with ongoing feedback regarding observed strengths and areas in development.

Thus, a supervisor might note, “You identified, “Listens and is empathic with others” as your primary goal for this rotation. In my observation I see that as an area of strength in your work with clients and peers. From my observation, I suggest we consider a goal and tasks relating to “Monitors and applies knowledge of self as a cultural being in assessment, treatment, and consultation,” as that would be more reflective of your current development. Tasks related to the new goal might include, for the supervisee, reflecting on the process of the session and how multiculturalism of client(s) and therapist were evidenced. The task of the supervisor could be to provide supportive and corrective feedback on these processes. Feedback forms the basis for assessment and evaluation.

The question of how accurate supervisors are when they like their supervisees is very pivotal to supervision. There is some preliminary data that suggest that supervisors may not be as impartial as they think. Gonsalvez & Freestone (2007) reported the possibility that field supervisory assessments are not as reliable or valid as we assume. Supervisors are affected by leniency bias and demonstrate low inter-rater reliability (except for proficiency in case and assessment report-writing). It appears that a strong supervisory alliance may actually introduce bias. These authors recommend variation in structure and frequency of assessment and the use of assessment methods. Ideally, evaluation is not simply based on supervisee report but on observation, and by input from several sources.

Whatever the context or model, there should be a direct relationship among the competencies document and assessment of the supervisees and the training contract so that the expectations of the setting are clear. The greater the clarity, the better the supervision process from beginning to evaluation. Beyond clarity, tracking of competencies and enhancing the supervisees’ self-reflection on development of these, sets the stage for lifelong learning, an essential aspect of supervision and competence in general.

Note 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. Supervisors may experience a leniency bias in evaluation, generally giving high evaluation scores to individuals who they like and/or have strong supervisory alliances with. Remember that performance evaluation – actually, lack of such – is the most common ethical violation reported by supervisees regarding supervision (Ladany et al., 1999). Feedback and attention to competence development should be addressed for a few minutes at the end of each supervisory session.

What are some of the reasons supervisors do not evaluate or, more specifically, do not give negative feedback? Robiner, Fuhrman, and Ristvedt (1993) describe several categories of reasons 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 about 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 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 she has issues that she would prefer not be brought to light. The supervisor may not feel particularly competent, may feel that she has made supervisory errors, or otherwise not want to be under scrutiny. 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 supervisee. Dr. Stone has been working with him for several weeks. The supervision approach is based on assessing Andrew’s strengths and areas needing improvement. 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 to refer to Andrew’s self-assessed areas of development including both foundational and functional competencies 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.

Formative vs. Summative Evaluation

Summative evaluation, the type of final evaluation given to supervisees in written form at the completion of the training year or two to three times during that year, relates to a summary of progress and is a type of grading. There is grave concern that supervisees do not receive adequate ongoing feedback and need clear notice when they are not meeting competence requirements. Summative feedback should never contain surprises for supervisees. They should never first learn of the supervisor’s concerns about their competence in a summative evaluation.

Formative evaluation refers to feedback given to supervisees on an ongoing basis. Ideally it takes the form of monitoring the established goals for the training period and identifying additional goals as they arise. It entails supporting strengths and development, and identifying areas of growth that are needed. Proceeding with behavioral anchors is an excellent technique. So rather than saying, “I am worried about your progress,” saying, “You are making good progress in implementing Trauma-focused CBT protocols with fidelity. An area still in development is the role of your self in the process – your emotional response and how you are managing that within the session and how I am observing that in supervision. You alternate between being very distant and then being tearful.”

An essential part of competency-based clinical supervision is providing abundant formative feedback to the supervisee.  Besides fulfilling an ethical standard, such feedback is a component of the best practices of supervision.  Feedback focused directly on the supervisee’s self-assessed competencies on any of the competencies documents previously described will be highly effective and will assist in bringing the respective fields into the competency era.

Moving Toward Two-way Feedback

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 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.

Outcomes

In addition to tracking outcomes of supervision, it is valuable to introduce 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 presenting problems and having clients rate themselves on these. Whatever 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 of progress. Scott Miller also has outcome rating forms available at his website:  scottdmiller.com/

Routine outcome monitoring is an important part of clinical practice and an invaluable tool in clinical supervision, providing data into the client’s self-observed presenting problems and helping the supervisor and supervisee to chart and monitor interventions.

Recommendations for Effective Evaluation

First, use a competency-based approach for evaluation. Using a self-assessment and any of the discipline competency measures (Benchmarks, CALSWEC, AAMFT), the supervisor should have the supervisee self-assess upon entry into the supervision. Then the supervisor adds his/her initial impressions in a second column, and reflects 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 and to add new goals as each is achieved.

Areas most neglected in evaluation are those of interpersonal competencies:

Other options for evaluation include using measures such as those included in the appendices of the supervision books written by Bernard and Goodyear (2014) 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.

Supervisees Who Do Not Meet Competence Standards

Most supervisees have a productive, developing training experience from which they proceed onward in their placements with enhanced skills and confidence. However, sometimes supervisees do not meet competence criteria or standards. As we move into the era of competency-based supervision, such determinations are supported by the competency documents, which serve as the core of the experience. Individuals who truly do not meet standards and do not benefit from improvement or action plans are infrequent in their occurrence. Some estimate that there is one such supervisee every four to five years in a setting. Certain settings report a higher prevalence (summarized in Falender and Shafranske, 2004).

Some red flags for supervisee competence problems include:

Previously, “impairment” was a term used to denote the supervisee not meeting competence standards. But the word “impairment” has been preempted by the Americans with Disabilities Act (ADA). It now refers to a medical or physical disability. There will be supervisees who apply to or enter a training program who qualify under ADA, but in order to invoke ADA, these supervisees should notify their supervisor(s) and Human Resources of their ADA-qualifying diagnosis and provide supporting documentation. Then, after reasonable accommodations are developed by the Human Resources Department, supervisors can ensure that – with the accommodations – the supervisee meets the established competence standards for the setting/training sequence. It is critical to gain knowledge of ADA and understand fully its implications and all of its aspects. An excellent reference is www.eeoc.gov/policy.

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 Falender, Collins, and Shafranske, (2009) for an extensive discussion with case vignettes and a decision tree to assist in determining courses of action for normative developmental issues, supervisee self-disclosure of a qualifying condition for ADA, and supervisees who do not meet criteria for competence.

Ideally, the supervisor will identify particular behaviors that are not being delivered or are not meeting the competence standard, and will work with the supervisee to improve these. This approach decreases stigmatization, increases the supervisee’s sense of optimism that there can be a positive outcome, and is accountable.

Supervisees Not Meeting Competence Standards Defined

Lamb et al. (1987) defined not meeting competence standards (previously “impairment”) as interference in professional functioning reflected in one or more of the following ways:

(Lamb et al., 1987, pp. 291-292)

In cases of behavior not meeting competence standards:

(Lamb et al., 1986, p. 599)

Lamb and others outlined plans for proceeding once a supervisor has identified a supervisee as not meeting competence standards. 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.

A very important caveat is to be sure there is a process in place before there is a problem with a specific supervisee (Forrest, Miller, & Elman, 2008). 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.

First is a behavioral description of the behavior(s). 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 competency measure, or ideally, both. These may be linked to the competency documents for the respective field. 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. Other categories are problems connected to insufficient training and supervision or difficulties with moral character or psychological fitness:

(Kaslow, Rubin, Forrest, Elman, Van Horne, Jacobs, et al., 2007).

Also, determine whether the competence problem 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.

Then discuss the behavior(s) that are not meeting competence criteria with the supervisee. If you are the only supervisor working with the supervisee, explore whether this is something that he 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. If the supervisee is still in a school program, consult with that program.

For example, there would be a very different course of action for each of the following scenarios:

It would also call for a different response 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.

After determining that a supervisee is not meeting competence criteria, and giving the feedback directly to the supervisee, 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.

An excellent model for a remediation plan is available at: apa.org/ed/graduate/competency.aspx

Be sure to give notice to the supervisee when you identify performance that is not meeting competence standards.

Document every interaction. A timeline 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 track progress.
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 competence problem behaviors do not subside, or if the problem is viewed as increasingly serious, take appropriate steps. Possible steps include:

Continue monitoring and checking in with the supervisee to see how she is doing, feeling, and progressing.

If there is no change after all of the increased supports and monitoring, in conjunction with human resources and administration, and with the school if a student, the supervisor needs to begin to think about probation, moving toward possible termination. This would need to have been clearly spelled out at the beginning 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 toward termination or dismissal would move through steps, with opportunities 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 to correct. 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 peers 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 while clarifying and reassuring other students that as long as a supervisee is meeting competence requirements – and is not informed of problems of professional competence, they are in good standing. However, do not discuss the supervisee who is leaving.

All of the steps must be documented.

Increasingly, we are finding that openness and non-defensiveness to feedback are critical dimensions of development. In a very important set of studies (Papadakis, Hodgson, Teherani, & Kohatsu, 2004), it was found that physicians who were disciplined by state licensing boards, and who graduated from several major medical schools, were more likely to have demonstrated unprofessional behavior in medical school than was a matched control group who were not disciplined. These researchers concluded that patterns of unprofessional behavior in many cases are recognized early and are long-standing. In a subsequent study, Papadakis et al., (2008) found two predictors of disciplinary action against practicing internal medicine residents: unprofessional behavior and a low score on the internal medicine certification examination. One of the measured components in the first study was a failure to accept and integrate feedback.

Ethical Standards

CAMFT (2011)

4.8 PERFORMANCE APPRAISALS: Supervisors and educators provide supervisees with periodic performance appraisals and evaluative feedback throughout the supervisory relationship and identify and address the limitations of supervisees and students that might impede their performance.

4.11 DISMISSAL: Supervisors shall document their decisions to dismiss supervisees.

APA (2017)

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.

Self-care and Burnout

Mental health professionals are not 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. 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 are all examples of this trauma.

There is evidence to suggest that our supervisees – and supervisors-- may be even more vulnerable, as a substantial number of therapists 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 trauma, and to process with care such events with the supervisee. Supervisees report that this is infrequently done, and that supervisees carry feelings with them for years after the incidents.

Signs of burnout include emotional disengagement, fatigue, hypervigilance, hopelessness, avoidance, and survival coping.

Supervisees generally place self-care on a back burner as well. They may only vaguely remember self-care or leisure activities they loved prior to graduate school and must be prompted to recall exercise, art, music, or other activities.  A recent study revealed that quality of sleep and positive supportive relationships are essential self-care factors (Myers et al., 2012). Sleep is a highly important factor in self-care (Goncher et al., 2013).

Although it is a multiple relationship for supervisors (who attempt to maximize the productivity of supervisees while trying to safeguard their own self-care), supervisors need to lead the way in modeling self-care and introducing practices such as mindfulness to supervisees. Wise and colleagues (2012) suggest we should not simply survive, but need to flourish. That includes embedding self-care and self-awareness in our professional activities rather than making these a cumbersome add-on. Some strategies include taking time to eat lunch without multitasking or taking a brief walk or other pleasurable activity during a work day.

In a study by Stevanovic and Rupert (2004), respondents who had higher job satisfaction reported various strategies for reducing burnout. These include varying work responsibilities, using positive self-talk, maintaining a balance between their personal and professional lives, spending time with their partners/family, taking regular vacations, maintaining their professional identities, 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.

Legal and Ethical Concerns

Consider the following supervisor and supervisee ethical issues and identify ethical infractions. Identify specifically what ethical infractions occurred – and match them to the appropriate ethical code in the section below.

It is the responsibility of the supervisor to know and keep updated on regulations, laws, ethics codes, and all developments that influence client care and supervision. Supervisees will lose their hours toward licensure if supervisors do not abide by all the rules and regulations in the licensing board regulations. In this section, there will be references to the ethics codes listed below when they have relevant standards. You may use these links to review your own profession’s code in further detail.

Ethical Codes by Discipline:

For Psychologists, the Ethical Principles of Psychologists and Code of Conduct was amended in 2017. In Social Work, NASW updated the Ethics Code in 2017. MFTs: Use the AAMFT Code of Ethics (2015) or CAMFT (2011). Be sure you have the current documents, below.

Reference these ethical standards:

Ethical Principles for Psychologists and Code of Conduct (APA, 2017)

Ethics Code of the National Association of Social Workers (NASW) (2017)

American Association for Marriage and Family Therapy (AAMFT) (2015)

California Association of Marriage and Family Therapists Code of Ethics (CAMFT) (2011)

American Counseling Association Code of Ethics (ACA) (2014)

In the supervisory contract or agreement, the supervisee should agree to abide by the ethics of her profession and the attendant 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 protect and warn provisions may not have been in effect or it may have been illegal to warn, as it is seen as a breach of client confidentiality. Other regulations and practices are state specific as well.

Appendix III has examples of state-specific regulations and practices for California psychologists, as well as 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.

Board of Psychology:

psychology.ca.gov/laws_regs/sb1193_summarypa.shtml
psychology.ca.gov/laws_regs/voe.shtml

Board of Behavioral Sciences:

Change in Registrant title: “Intern” to “Associate”

bbs.ca.gov/pdf/title_change_faq.pdf

bbs.ca.gov/pdf/publications/mft_faq.pdf

Ethics and Law

Supervisors model adherence and attention to the ethical principles of their respective profession and model identifying ethical issues and engaging in ethical problem-solving. In interdisciplinary supervision, the supervisor should be familiar with the ethics codes of the professions one supervises.

Ethical supervision is more than simply abiding by laws – but of course abiding by laws is essential! Rather than being rule-bound in our practices and our supervision, a shift to positive ethics is indicated. Positive ethics focuses on reflective practice and moral excellence (not minimal obligations) and provides supervisees with knowledge, skills, and attitudes regarding identification, and a meaningful approach to ethical practice. Positive ethics also provides a framework for supervisors to identify ethical issues proactively, teaching supervisees that the ethics code contains answers to a multitude of issues raised in clinical practice. The task then is to identify the issue and refer to the code.

Positive ethics is compatible with the aspirational/foundational principles of ethics that are found in each discipline’s ethics codes (e.g., integrity, competence, dignity and worth of the person, non-maleficence or “do no harm”). Knapp and colleagues describe positive ethics as those encouraging the integration of personal ideals into professional behavior and inspiring mental health professionals to fulfill their highest potential (Knapp, Vandecreek, and Fingerhut, 2017).

Supervisors should model a much higher level of ethical practice.

Liability, Malpractice, and Supervision

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 being held legally liable for the damages a third individual suffers 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 within the course and scope of the supervisory relationship. Relevant factors include:

(Disney & Stephens, 1994)

Bennett et al. (1990) describe four criteria to be met for malpractice:

  1. Relationship formed between psychologist and client (legal duty of care);
  2. Demonstrable standard of care that was breached;
  3. Client suffered demonstrable harm or injury; and
  4. Breach of duty to practice within the standard of care was the proximate cause of client injury and the injury was reasonably foreseeable

Keep in mind that there are two forms of supervisory liability:

Sometimes the situation is not so clear-cut between these two:

The supervisor is “gatekeeper” in that the supervisor holds the power to pass or fail the supervisee by signing off on hours or a completion certification, and, importantly, the supervisor holds the power to protect the client. Supervisors must remember that their highest priority is duty to the client. They must attend to their responsibility to the training of the supervisee, but must 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. Most frequently reported was failure to adhere to ethical guidelines regarding performance evaluation.

The following are categories of ethical responsibilities that were perceived to have been violated:

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 with supervision on the part of the supervisee. 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).

Subsequent studies have found the same levels of supervisee perceptions that their supervisors conducted ethical infractions.

In this context, with respect to the first category of perceived ethical violations, refer to all of the sections listed below:

APA 2017 Ethical Principles of Psychologists and Code of Conduct

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.

CAMFT Code of Ethics

4.8 Performance Appraisals

Supervisors and educators provide supervisees with periodic performance appraisals and evaluative feedback throughout the supervisory relationship and identify and address the limitations of supervisees and students that might impede their performance.

Standard of Care

Remember that the same standard of care for services provided by licensed professionals applies to supervisees (Harrar, VandeCreek, & Knapp, 1990).

For psychologists, guidance is provided by the APA’s Ethical Principles for Psychologists and Code of Conduct (2017).

APA 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, must 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 (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 .)

LCSWs should be guided by the NASW Code of Ethics (2017).

MFTs should refer to the AAMFT Code of Ethics (2012), or in California CAMFT (2011).

There are the same duties to warn and adherence to all ethical and legal codes for the supervisee as for the supervisor as therapist.

Competence

The supervisor has the responsibility to function within their limits of competence and, with regard to supervisees, to assess, provide feedback, and as necessary regarding development of competence and professionalism, to interrupt or terminate supervisee activities whenever necessary to protect the public and insure adequate skill development.

CAMFT (2011)

4.2 Competence of Supervisees

Marriage and family therapists do not permit students, employees, or supervisees to perform or to hold themselves out as competent to perform professional services beyond their training, level of experience, competence, or unlicensed status.

4.3 Maintaining Skills of Supervisors

Marriage and family therapists who act as supervisors are responsible for maintaining the quality of their supervision skills and obtaining consultation or supervision for their work as supervisors whenever appropriate.

APA (2017) 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.

...

(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.

NASW (2017) 3.02

(b) Social workers or trainers who function as educators or field instructors for students 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 (2015) 4.4 Oversight of Supervisee Competence

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.

AAMFT (2015) 4.5 Oversight of Supervisee Professionalism

Marriage and family therapists take reasonable measures to ensure that services provided by supervisees are professional.

APA Ethical Principles of Psychologists and Code of Conduct (2017)

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.

NASW Code of Ethics (2017)

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 (2015)

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.

Recommendations to Supervisors Regarding Competence

Supervisors should carefully ascertain at what level their supervisees are performing, and determine what cases are within their competence and 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 must 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.

Confidentiality

Ethical Principles for Psychologists and Code of Conduct (APA, 2017)

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 (2017)

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 clients the 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 (2015)

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.

Confidentiality in Supervision

Supervisors have the responsibility to ensure confidentiality of their supervisees’ clients’ information:

Supervisors have responsibility to ensure that their supervisees understand fully the limits of confidentially (or lack of such) of their communications with their supervisors:

Supervisors have a 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 may not be not private.

Informed Consent

Ethical Principles of Psychologists and Code of Conduct (APA, 2017)

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, 2017)

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. The consequences if one does not complete adequately one or more of the parts of supervision, plus due process steps, should also be disclosed.

Informed Consent NASW (2017)

1.03 (a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients’ right to refuse or withdraw consent, and the timeframe covered by the consent. Social workers should provide clients with an opportunity to ask questions.

(b) In instances when clients are not literate or have difficulty understanding the primary language used in the practice setting, social workers should take steps to ensure clients’ comprehension. This may include providing clients with a detailed verbal explanation or arranging for a qualified interpreter or translator whenever possible.

(c) In instances when clients lack the capacity to provide informed consent, social workers should protect clients’ interests by seeking permission from an appropriate third party, informing clients consistent with their level of understanding. In such instances social workers should seek to ensure that the third party acts in a manner consistent with clients’ wishes and interests. Social workers should take reasonable steps to enhance such clients’ ability to give informed consent.

(d) In instances when clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients’ right to refuse service.

(e) Social workers should discuss with clients the social workers’ policies concerning the use of technology in the provision of professional services.

(f) Social workers who use technology to provide social work services should obtain informed consent from the individuals using these services during the initial screening or interview and prior to initiating services. Social workers should assess clients’ capacity to provide informed consent and, when using technology to communicate, verify the identity and location of clients.

(g) Social workers who use technology to provide social work services should assess the clients’ suitability and capacity for electronic and remote services. Social workers should consider the clients’ intellectual, emotional, and physical ability to use technology to receive services and ability to understand the potential benefits, risks, and limitations of such services. If clients do not wish to use services provided through technology, social workers should help them identify alternate methods of service.

(h) Social workers should obtain clients’ informed consent before making audio or video recordings of clients or permitting observation of service provision by a third party.

(i) Social workers should obtain client consent before conducting an electronic search on the client. Exceptions may arise when the search is for purposes of protecting the client or others from serious, foreseeable,and imminent harm, or for other compelling professional reasons.

Due Process

There should be prior agreement regarding:

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.

Multiple Relationships

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 relevant ethics codes:

Ethical Principles of Psychologists and Code of Conduct (APA, 2010)

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 the client's 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.

(c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)

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, including dual relationships that may arise while using social networking sites or other electronic media. 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.

Sexual Boundary Violation

With respect to the specific category, Sexual Boundary Violation, each ethics code has a separate standard.

APA Ethical Principles for Psychologists and Code of Conduct (2010):

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

2.06 Sexual Relationships

(a) Social workers who function as supervisors or educators should not engage in sexual activities or contact (including verbal, written, electronic, or physical contact) with supervisees, students, trainees, or other colleagues over whom they exercise professional authority.

(b) Social workers should avoid engaging in sexual relationships with colleagues when there is potential for a conflict of interest. Social workers who become involved in, or anticipate becoming involved in, a sexual relationship with a colleague have a duty to transfer professional responsibilities, when necessary, to avoid a conflict of interest.

2.07 Sexual Harassment

Social workers should not sexually harass supervisees, students, trainees, or colleagues. Sexual harassment includes sexual advances; sexual solicitation; requests for sexual favors; and other verbal, written, electronic, or physical contact of a sexual nature.

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.

Boundary violations include having sex with a client, having sex with a supervisee, or strongly urging a supervisee to invest in a joint real estate venture with the supervisor (who sells real estate on weekends).

Boundary-crossing Examples

Consider the situation in which the supervisee is very warm and affiliative and generally touches her peers and her clients, squeezing their arm, patting them on the back, or placing her arm around them. Consider a supervisory reaction, response, and other aspects to consider including ethical, multicultural, or historical.

Examples of supervisor boundary-crossing are touching (a supervisor hugging a supervisee) and requiring the supervisee to go to lunch with him weekly. Or, a supervisor asking to “friend” a supervisee on Facebook. What is your response to these examples? It is so important for a supervisor to keep in mind several factors: the power differential prevents the supervisee from telling the supervisor a genuine response or that the boundary crossing is a violation of the supervisee’s space, or is otherwise intrusive or potentially hurtful or harmful.

Take for example the supervisor who requires the supervisee to go to lunch during supervision, and requires him to pay for his own 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; if he protests too much, it may influence his evaluation or even the supervisor’s signing off on the hours he has accrued.

There could also be the added factor of sexualized complexity, inferences, or pressures. On the walk back to the office, the supervisor starts putting his arm around the supervisee’s shoulder making the supervisee increasingly uncomfortable. For the supervisee who speaks up and asks that the supervisor not do that, the individual may encounter a supervisor who:

Similarly, consider the issues of a supervisor asking a supervisee to “friend” them. Think of the potential downsides for the supervisee and the supervisor. Generally, this is not an appropriate supervisory action. Consider the ethical standards above. Remember that supervisor intent is not as important as what meaning the supervisee draws from the action – and possible outcomes.

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 the 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 may be at greater risk when later accused of a boundary violation (Gutheil & Gabbard, 1993). That is, engaging in behaviors that in and 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) suggest 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. An excellent resource that describes such boundary issues, dilemmas, and problem-solving to approach is written by Schank and Skovholt (2005). For example, if the supervisee resides in a very small town, and is likely to encounter clients in everyday interactions (at the grocery, pharmacy, library, and church), how should the supervisor and supervisee approach that issue? One suggestion was informed consent, informing all clients of the very great possibility of such unintentional encounters, and discussing how the supervisor should respond (ignore, greet, etc.).

Lazarus and Zur (2002) present 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 Lazarus and Zur are clear in their admonition regarding boundary violations. They are referring to boundary crossing or 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 as part of a designated treatment plan.

Some multiple relationships are mandated or unavoidable. Examples of mandated are the military and prisons; unavoidable include rural or small communities, faith, spiritual, and 12-step or other recovery programs (Zur, 2017). Informed consent to ensure acknowledgement of the multiple relationship and to discuss how to handle these are essential.

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 or movement toward friendship 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.

Sexual intimacy and sexual relationships with clients or with supervisees are prohibited by all professional ethics codes.

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 (1.4%-4%). Supervisees report the incidence as between 5% and 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 = 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). More than 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 toward the therapist. That type of disclosure is much more common and more often 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.

Multiple relationships may be implicit and normative in clinical supervision. Supervisees may be a student in a supervisor’s class, co-therapist, writer of letters of recommendation, research team member, attendee of holiday or other celebrations in the setting, or attending a conference with a supervisor, to name a few (Falender, 2017). Many multiple relationships, when carefully constructed, can be beneficial to supervisor and supervisee alike.

Excellent problem-solving frameworks are available about whether to engage in a multiple relationship in therapy (Younggren & Gottlieb, 2004) and in supervision (Gottlieb, Robinson, & Younggren, 2007). The following are some of the questions regarding supervisory multiple relationships:

(Adapted from Gottlieb, Robinson, & Younggren, 2007)

Consider the example of a supervisee who wants to carpool, having discovered that the supervisor lives one block away from him, and the drive to the setting is 45 minutes. What parameters would one consider? Try the analysis/questions from the Gottlieb, Robinson, and Younggren framework first. Here is one individual’s analysis:

“This relationship is most likely not necessary, and although it might save money for gas and wear and tear on both individuals and the cars, 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 beyond one 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 she developed a friendship with the supervisee, making evaluation difficult or impossible, or if she became financially dependent on the supervisee’s provision of gasoline. Also, there is the possibility that the disclosed information from one to the other could irreparably damage the opinion of one about the other – their integrity, morality, or other aspects that they might inadvertently allude to while in a “quasi-friendship” mode while driving.”

Add your own ideas about “worst case scenarios” that might arise.

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 include 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 or could not remember phone calls or contacts.

Burian and Slimp (2000) developed a decision tree and Likert scales specific to decision-making in the internship setting. Dimensions include:

(Burian & Slimp, 2000)

Considering the carpool scenario within 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, and one’s supervisor’s own, personal or emotional reaction to the ethical issue. Another added step should be consideration of the role of diversity/cultural elements 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:

  1. Determine if the matter is an ethical one.
  2. Consult available ethical guidelines that might apply to provide a possible mechanism for resolution.
  3. Consider all sources that might influence the kind of decision you will make.
  4. Locate and consult with a trusted colleague.
  5. Evaluate the rights, responsibilities, and vulnerability of all affected parties.
  6. Generate alternative decisions.
  7. Enumerate the consequences of making each decision.
  8. Make the decision.
  9. Implement the decision.
  10. Consider the impact of the decision.

(Adapted from Koocher & Keith-Spiegel, 2008)

Other ethical standards include Section 7 of the Ethical Principles and Code of Ethics of the American Psychological Association (2017) which addresses Education and Training; and many principles and sections of each professional code of ethics including “do no harm,” beneficence, justice, delegation of responsibility, integrity, assessing supervisee behavior, and responsibility to the profession. For social work, NASW Code of Ethics, Section 3.0 addresses social workers’ ethical responsibilities in practice settings. For marriage and family therapy, Standard IV addresses responsibility to students and supervisees (AAMFT, 2015).

There are some other legal issues specific to training. Among these is “Borrowed Servant,” which 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 has the benefit of the student, and the expectation is that the student will return to the graduate school to complete training. Articulation as to 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. This needs to be a formal written agreement.

Hostile Work Environment

There is an area of law that relates to individuals who create a hostile work environment. Examples of this include use of culturally offensive language or behavior toward individuals, or modeling such behavior. Adherence to standards of professionalism should preclude such behaviors, but be aware that this might be the topic of many lawsuits in the future.

Sexual Harassment

Most workplaces mandate completion of a comprehensive sexual harassment didactic to introduce the workforce to elements of harassment and to underline the unacceptable and illegal nature of engaging in such acts. These might include sexually explicit language, jokes, or pictures, or sexual innuendos. Clearly, sexual harassment is not tolerated in clinical supervision.  Unfortunately, the supervisee may fear to disclose or report due to the power differential and the fear of consequences that could be personally detrimental to the supervisee.  It is incumbent upon supervisors to ensure that such practices do not occur.

Tarasoff for Supervisors

Background information

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, adding to her confidence that he was not a threat. When Poddar went to Tarasoff’s house, she refused to see him, and 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 court’s second decision, resulted in the recognition of a duty to protect and warn by a therapist due to 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 to prevent harm and to protect the intended victim, including warning the intended victim, initiating involuntary commitment, notifying the police, modifying treatment, getting psychiatric/medical consultation, increasing frequency of sessions, hospitalization, or other steps to deter the violence.

What does this mean for supervisors?

It requires supervisors to be knowledgeable and alert to the latest legal status of Tarasoff and its extensions including Duty to Protect. This varies state by state. For example, presently, the duty to protect and warn has been expanded – previously in Ewing vs. Goldstein in the State of California, a communication from a family member to a therapist made for the purpose of advancing a patient's therapy, is a "patient communication" within the meaning of the statute. The father had communicated to a therapist the client’s intent to harm himself and his ex-girlfriend’s new boyfriend. More recently, Weinstock, Bonnici, Seroussi, and Leong (2014) described 2013 legislation that clarified that in California the Tarasoff duty is now unambiguously a duty to protect.

In addition to a thorough understanding of Tarasoff, and the “duty to warn and protect, protect, and predict” (Behnke et al., 1998; Weinstock et al., 2014) (which includes reasonable attempts to protect and, if indicated, communicate the expressed threat 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 have knowledge about the psychologist’s 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:

Training in graduate school may be limited in most of these areas, even though supervisors in internship and practicum settings assume their incoming students have had the training (but will generally provide it as needed). This assumption creates a risk situation unless the actual level of competence of each student is assessed in these areas.

Essentially, supervisors need to ensure that Tarasoff is accurately reflected in informed consent. Supervisors bear responsibility for following the most recent updates on such laws.

The Tarasoff law requires supervisors to have procedures in place for when this or any other emergency or crisis situation arises so that 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 and protect. However, supervisors may not be as current or accurate in their implementation of duty to warn and protect as they believe themselves to be (Pabian, Welfel, & Beebe, 2009). Pabian et al. found that individuals believed they were more aware of and able to implement their state duty-to-warn-and-protect standards than was demonstrated when given actual vignettes.

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. It is incumbent on supervisors to assess level of competence and provide resources and back-up including possibly joining the session or observing if assessed competence (and the supervisee’s ability to perform the task with the level of supervision provided) is not adequate to the severity of the task.

Foreseeability is a critical piece of Tarasoff – and those who are forseeably at risk have been extended by subsequent legal decisions to include 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 come 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.

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 pertinent therapeutic and legal issues is also available (Weiner, 2005).

Documentation

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 the names of clients numerically, 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 license.

Please note that if reference is made to actual clients, the supervision notes may become part of the client record. There are multiple contextual factors to consider in this respect, so consult with other colleagues about the format and type of identification you are using. The normative supervision log is not designed to document supervisees with performance problems. Also note that there is a trend toward the requirement of supervision notes. Certain provinces in Canada (e.g. College of Psychologists of British Columbia) mandate supervision notes and outline minimum requirements.

Some supervisors encourage supervisees to keep their own logs, but it seems most important for supervisors to make note of particular issues that arise that are of concern to them. It should be clearly articulated what notes are to be kept, who holds these notes, where they are to be stored, and for how long. In many instances, it is ideal to have notes co-constructed by supervisee and supervisor.

Letters of Recommendation

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 tends to be huge inflation or overstatement in letters of recommendation, with many 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), mention of that concern could result in the supervisee’s not obtaining a placement or job.

The Canadian Psychological Association adopted a standardized form for letters of recommendation with a compulsory section 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 the use of such a standard, some training directors are moving in that direction with a cover letter explaining that, in the interest 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.

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 discuss 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 supervision between certain dates, listing the activities completed, and stating that the course of supervision was completed, or even just the former of these. The supervisee has the choice of whether he wants such a letter written. If the supervisor feels duty-bound to reveal some aspects of the supervisee’s performance that do not meet competence criteria, she could then inform the supervisee of this.

There is also a movement toward individuals who are writing letters of recommendation requiring informed consent from the supervisee, waiving his right to see the letter. 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.

Ending the Year: Supervisees at the End of the Training Sequence

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 that will be particularly critical to the supervisee’s subsequent placement or practice. The supervisor may worry that for some reason 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 he 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 and supervisee will transform to that of colleagues, 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 activity 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, thus presenting the supervisee with information that would be pivotal to future treatment. The supervisee was devastated, not understanding that perhaps the reason for the disclosure was, in fact, that it was the last session. The supervisee was so guilt-ridden that 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 supervisor requesting resources, translations, and other materials that take significant amounts of time for the former supervisee to produce. The supervisee is not comfortable setting limits with the previous supervisor, and is becoming increasingly stressed by the number of demands on his time and resources. However, the past supervisee has loyalty to his former supervisor and is concerned that he may need a letter of recommendation sometime in the future. Therefore, he 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.

Integration Exercises

Vignette: During the first week of placement, a supervisee is told by her supervisor that he is not sure she is skilled enough for the practicum placement. She is taken aback, since she had applied to, been interviewed by, and 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 placements. However, once she begins seeing cases, he constantly reminds her that her skills are not up to par, but does not provide 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 scenario 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. 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. It is incumbent upon all supervisors to take responsibility and to confront difficult situations head on, and to get consultation on issues that are problematic, such as when a supervisor does not like his supervisee or she has negative associations for him. Also, in the two-way process, supervisees may present with more information about evidence-based treatments than supervisors may. 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.

Future Directions

The practice of supervision is the highest calling in the 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 each 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. As each profession continues to refine competency documents, and some develop supervision guidelines and supervisor competencies, the bar for supervisors is rising – and this will be highly beneficial to supervisees. Supporting supervisee trajectories of development, attending to the requisite competencies identified by our professions is a giant step forward in ensuring that supervision practice is not simply through osmosis but is conducted with design and attention to critical components and practices:  competencies. The challenge for each of us will be to maintain 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.

As competency documents become more articulated and used more consistently, the process of supervision is benefiting.

Appendix I

Psychologists – Board of Psychology

psychology.ca.gov. (Note: The Laws and Regulations book was updated in 2018.)

Board of Behavioral Sciences

Rules and Regulations (2018) are available at bbs.ca.gov.

Some of the changes for psychology:

Social Workers, Marriage and Family Therapists, and Licensed Professional Counselor SupervisorsBoard of Behavioral Sciences

Appendix II

Nursing Competencies:

Nursing competencies are described at:

National Panel for Psychiatric-Mental Health NP Competencies

Professional Chaplain Competencies:

Common Standards and Competencies

General information:
Common Qualifications and Competencies
Links

CBT Training Competencies:

For guidelines for CBT Training  Association for Behavioral and Cognitive Therapies, see link to BT on ABCT.org, middle column.

Competencies for Health Psychology:

France et al., 2008
Kaslow, Dunn, & Smith, 2008
APA.org resources

SAMHSA/HRSA Core Competencies for Integrated Behavioral Health and Primary Care

Neuropsychology

Lamberty & Nelson, 2012
Stucky, Bush, & Donders, 2010
Shultz et al., 2014

Family

Stanton & Welch, 2011
Interprofessional Collaborative Practice, 2011

Gerontology

Karel, Knight, Duffy, Hinrichsen, & Zeiss,  2010
APA Guidelines for Psychological Practice with Older Adults

Forensics/Correctional

Specialty Guidelines for Forensic Psychologists

Varela & Conroy, 2012

Standards for Psychology Services in Jails, Prisons, Correctional Facilities, and Agencies: International Association for Correctional and Forensic Psychology (Formerly American Association for Correctional Psychology) Criminal Justice and Behavior July 2010 37:749-808

Clinical Child and Adolescent

            Finch, Lochman, Nelson, & Roberts, 2012

Clergy and Other Pastoral Ministers Addressing Alcohol and Drug Dependence

Core Competencies for Clergy and Other Pastoral Ministers in Addressing Alcohol and Drug Dependence and the Impact on Family Member

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Appendix III

Regulations Update 2017/2018

Please note that regulations change; when in doubt and for final verification, please consult the respective websites for current regulations; this is just an update and does not contain all regulations. Some of the answers are complex and require amplification from the websites.

Board of Behavioral Sciences

1. Effective January 1, 2018, the titles for marriage and family therapist interns and professional clinical counselor interns will change, as follows:

Marriage and family therapist registrants must use the title “Associate Marriage and Family Therapist” or “Registered Associate Marriage and Family Therapist.” Professional clinical counselor registrants must use the title “Associate Professional Clinical Counselor” or “Registered Associate Professional Clinical Counselor.”

2. Option 1 (Streamlined) and Option 2 (Preexisting Multiple Category Method)

Supervisees must determine whether they will be complying with the “old” structure regulations previously in effect. If so they must turn in their hours prior to December 31, 2020. Hours turned in after that or in compliance with the new regulations must be in compliance with the new system.
B. It is not possible to combine the two regulation sets. One must abide by ALL either the old “structure” or the new ones.
A “Supervisor”
(1) Has been licensed by a state regulatory agency for at least two years as a marriage and family therapist, licensed clinical social worker, licensed professional clinical counselor, licensed psychologist, or licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology.
(2) If a licensed professional clinical counselor, the individual shall meet the additional training and education requirements specified in paragraph (3) of subdivision (a) of Section 4999.20.
(3) Has not provided therapeutic services to the trainee or intern.
(4) Has a current and valid license that is not under suspension or probation.
(5) Complies with supervision requirements established by this chapter and by board regulations.
(6) All of the above.
D. All forms are in revision and were released in December, 2015 or January, 2016. If your supervisee is working under the new regulations (effective, January 1, 2016) you must use new forms.

Licensee and Registrant Information on Telehealth

Individuals who provide psychotherapy or counseling, either in person, by telephone, or over the Internet, to a client located in California, must be licensed in California. Licensure affords the Board authority to take action against a licensee engaged in unprofessional conduct.
Licensing requirements vary by state. If your client is travelling to another state and wishes to engage in psychotherapy or counseling via telehealth with you while he or she is away, you need to check with the state where your client will be to see if this is permitted.

Refer to: bbs.ca.gov/consumers/info.html for additional regulations and parameters for telehealth.

4980.43 Clarifies that associates and trainees shall not be employed or gain experience as independent contractors and/or work reported on an IRS 1099 form.

Advertising

4980.44 The abbreviation “MFTI” shall not be used in an advertisement unless the title “marriage and family therapist registered intern” appears in the advertisement.

4980. 48 Any person that advertises services performed by a trainee shall include the trainee’s name, the supervisor’s license designation or abbreviation, and the supervisor’s license number.

(c) Any advertisement by or on behalf of a marriage and family therapist trainee shall include, at a minimum, all of the following information:

(1) That he or she is a marriage and family therapist trainee.
(2) The name of his or her employer.
(3) That he or she is supervised by a licensed person.

LPCC

Effective January 1, 2017, LPCCs who wish to assess and treat couples or families are required to obtain Board confirmation of qualifications, and provide a copy of that confirmation to the following:

For more information and other requirements go to bbs.ca.gov/pdf/forms/lpc/lpc_scope_practice.pdf

TO SUPERVISE AN MFT INTERN (ASSOCIATE) OR TRAINEE

Licensed Professional Clinical Counselor – LPCCs must:

Board of Psychology

1. Effective July 31, 2017, this bill amended existing law to provide for a four (4) year waiver, with a possible extension of one additional (1) year, (increased from three (3) years) from the licensing requirement by the Board of Psychology for professional personnel, employed or under contract, with the Department of Public Health and the Department of Corrections and Rehabilitation, who are in the profession of psychology and are gaining qualified experience for licensure.

Additionally, this bill amended existing law to provide for a five (5) year waiver (increased from three (3) years) from the licensing requirement by the Board of Psychology for professional personnel employed or under contract with the Department of Health Care Services, who are in the profession of psychology and are gaining qualified experience for licensure, from the date of employment by, or contract with, a local mental health program.

2. CHANGES TO SUPERVISION AGREEMENT psychology.ca.gov/forms_pubs/sup_agreement.pdf

New Supervision Agreement forms are on website of BOP, effective October 1, 2017

You must use the new forms. (The following are excerpts from the new form)

Both the primary supervisor and supervisee shall complete, review, and sign an agreement prior to the commencement of the supervised professional experience. Experience prior to preparation of a signed agreement will not count toward licensure.

The primary supervisor should maintain this agreement until the supervisee completes the SPE.

On a separate page, type your responses to the following items:

  1. Describe the specific duties the supervisee will perform as they engage in psychological activities that directly serve to prepare the supervisee for the independent practice of psychology once he or she is licensed.
  2. Summarize the goals and objectives of this plan for SPE, including how socialization into the profession will be achieved.
  3. Describe how and when the supervisor will provide periodic assessments and feedback to the supervisee as to whether or not he or she is performing as expected.

When answering each of the above questions, describe how the plan will meet the requirements of SPE as:

What kind of information must be reported to the Board on an annual basis by the psychological assistant’s supervisor?

Answer: Every supervisor of a psychological assistant must submit to the Board an update that is completed by the supervisor and signed by both the supervisor and the psychological assistant. The update must be submitted on or before the expiration of the registration for the preceding calendar year showing: 

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