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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 to have a comprehensive understanding of clinical supervision, structure of practice, and the strengths of effective practice as well as the potential harm inflicted on supervisees by less than competent practice.
Supervision may well be the highest calling in psychology and other mental health professions. It entails the transmission of knowledge and art, mentoring, gatekeeping, monitoring and evaluating, and developing a relationship that serves as the foundation for the process. It is the way the profession is communicated and transmitted from generation to generation of practitioners. This process used to be informal and occurred essentially through osmosis. Osmosis refers to the supervisor simply doing either what had been done to him or her as a supervisee or doing something different to prevent harm. We now realize the need for a formal process as the fields have evolved and supervision has become a core competency in mental health. Supervision requires the supervisor to assess and evaluate levels of supervisee readiness, competence, and affect, reflect upon these in the supervisor oneself, and to weave a tapestry of thought and feeling which translates into effective clinical intervention. Major roles of the supervisor are protection of the public, including the supervisees’ clients, and gatekeeping for the professions, ensuring that only suitable individuals enter the respective professions. These supervisory roles may seem inherently inconsistent and require substantial articulation and attention. While the role of supervisor is weighty, it is also replete with potential for growth, development, inquiry, creativity, and excitement.
Until the last decade, remarkably little attention was devoted to the practice of supervision. It was a skill passed from generation to generation of clinicians. When the Association of State and Provincial Psychology Boards (ASPPB) convened their first task force on supervision, they expressed surprise that – given the critical role of supervision in protection of the public and in the training of psychologists – that there were no established requirements for graduate level training in supervision (ASPPB, 2003). ASPPB (2013), American Psychological Association Board of Educational Affairs (APA, 2014), and the National Association of Social Workers (NASW) have developed supervision guidelines and best practices for supervision. They share many essential components, and the various topics of these will be the content of the course.
As licensure may be simultaneous with the assumption of the supervisory role, the training period for new supervisors may be nonexistent unless graduate level supervision training (Scott, Ingram, Vitanza, & Smith, 2000) becomes more pervasive. Unfortunately, over half of all supervisors still have not had formal training in clinical supervision. Even in the pipelines of training for the various mental health professions, over 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 comprising best practices. In competency-based approaches, (Falender & Shafranske, 2004), there is an explicit framework and method for initiating, developing, implementing, and evaluating the processes and outcomes of supervision. The trainee is now evaluated against a standard rather than in comparison to others. Through use of this framework as a standard, the supervision is more systematic with particular domains of knowledge, skills, and values. The approach entails supervisee and supervisor self-awareness of knowledge, skills, and 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.
The purpose of this course is to provide background and methodology for the practice of high quality supervision. Through competency-based supervision, and a strength-based orientation, many supervisee problems will be prevented. An emphasis upon assets, supplemented with encouragement in areas of lesser strength, provides for the sturdiest supervisory relationship – one that can sustain stress and flourish with constructive feedback.
What is Competency-based Clinical Supervision?
Competency-based supervision includes:
1) the identification of competencies that are profession- and setting-specific;
2) an initial assessment of the supervisee’s level of competencies including knowledge, skills, and attitudes/values; (please note that attitudes and values are often overlooked);
3) the establishment of a supervisory relationship; and
4) the construction of a supervision contract which describes supervisory expectations, identifies goals and objectives of the training sequence and how ongoing evaluation and feedback will be given throughout to support their development, and at completion of the supervision sequence.
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 client(s), supervisee (therapist), supervisor, clinical setting of therapy, community, and the associated influences of culture/diversity in its broadest sense (ethnicity, religion, race, gender, gender identity, educational level, age, etc.) and the discipline(s) in which one is practicing. To understand this complexity, one needs to consider the breadth of each domain, and then the interactions among them, the resultant worldviews of each and the impact of these on assessment, intervention, and supervision.
For the client/family, there is the reason for coming to therapy, often precipitated by a traumatic or painful event, revelation, or disclosure. There may also be fears or anger; reticence to enter therapy; anxiety about entry, process, and the therapist; client, therapist, and supervisor expectations; paperwork that may seem to be a barrier; cultural or diversity considerations that may make therapy a dystonic experience; lack of familiarity with the system; fears that secrets may be revealed; and hopes for the future, among other factors.
In the supervisee’s domain, there are his current developmental state; uncertainty of role; feelings of inadequacy; a desire to apply what one has learned in graduate school; optimism; a sense of dominance and knowing the client better than anyone else; eagerness to help the client; eagerness to please the supervisor; fear of failure; theories and ideas of conceptualization, dynamics, and interventions; cultural diversity identification; personal factors including worldview, perspective, curiosity, and identification with the client and/or supervisor; and a desire to individuate and be a competent independent practitioner.
For the supervisor, there are the challenges of the multiple roles (e.g., teacher, supervisor, co-therapist, administrator), the need to integrate supportive and affective components, the feelings of optimism about the supervisory and therapy process, and concerns about the competence of the supervisee (or the supervisor) to tackle this very difficult client/family (Falender, Burnes, & Ellis, 2012). The supervisor is also influenced by personal factors – triggers in the client and supervisee that elicit emotional responses that differ from the normative. In addition, she takes on the primary supervisory functions of teacher, counselor, consultant (Ellis & Dell, 1986), facilitator, administrator (Bernard & Goodyear, 1998), and monitor/evaluator, instructor/advisor, model, supporter/sharer, and consultant (Holloway, 1999).
Contextual variables include all the community, cultural, social, and socioeconomic, circumstances and associated attitudes and values. Each profession brings to supervision – and therapy – beliefs about how mental illness comes about, and how one can intervene most effectively.
Although clinical supervision is practiced by a majority of psychologists, social workers, marriage and family therapists, psychiatrists, nurses, and other mental health professionals, and is the primary form of transmission of clinical skills, formal training and standards have lagged far behind. The Association of State and Provincial Psychology Boards (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, it is surprising that organized psychology, with few exceptions, has failed to establish a requirement for graduate level training in supervision. Few supervisors report having had formal courses on supervision, and most rely on their own experience as a supervisee.” (ASPPB, 2003, p. 1). In 2002 it was judged that fewer than 20% of supervisors have had formal training in supervision (Peake, Nussbaum, & Tindell, 2002). More recently, estimates have been higher but there is still a strong indication that the strongest influence on supervision practice is one’s own personal experience being supervised. Marriage and family therapists and counseling psychologists are possible exceptions. Marriage and family therapists have a certification in supervision which requires supervision of supervision. Counseling psychology training programs more normatively include supervision training.
Historically, social work was very attuned to supervision, but that edge diminished as the roles of social workers evolved but is reemerging as a strength. That supervision is a neglected area is clear, but it has now been recognized as a distinct practice area and is a central domain of training (Falender et al., 2004). Training in supervision in doctoral and graduate programs is variable, with greater occurrence in counseling programs than in clinical, but with a huge variety in value attached to such training and implementation strategies (Scott, Ingram, Vitanza, & Smith, 2000).
There are numerous definitions of supervision. Understanding the definitions of supervision provides a frame for the standard and scope of practice. There are many definitions of supervision reflecting different perspectives of theoretical orientation and perspective (ASPPB, 2003; Bernard & Goodyear, 2009; Falender & Shafranske, 2004, 2008, 2012). Some of the critical components are protection of the client, gatekeeper for the profession, evaluator of the supervisee, wielder of power in the relationship, provider of knowledge and skills, and transmitter of values. Some definitions identify tension between relationship and evaluation, and yet others highlight monitoring, the enhancement of performance functions without addressing mutuality or bi-directionality of the process, and the associated accommodation of the supervisor as he learns and grows.
In the definition of supervision provided by Falender and Shafranske (2004), supervision is viewed in the context of specific processes with protection of client welfare as the top priority with added attention to trainee strengths and encouragement of self-efficacy. There are competing factors of protection of the client and empowerment of the trainee. The collaborative interpersonal process occurs within the context of evaluation and client protection, placing mutuality in context. This represents a movement from a purely hierarchical supervision process to one of collaborative and interpersonal growth and the development of the supervisee and the supervisor in the context of evaluation. The model is synchronous with feminist theory, and some psychodynamic and postmodern supervision models (Falender & Shafranske, 2008; Frawley-O’Dea & Sarnat, 2001; Bob, 1999). The introduction of self-assessment transforms responsibility for evaluation to a shared task between supervisor and supervisee. In an intriguing definition, described by Bernard and Goodyear (1998) in Acker, the supervisory relationship is described as one between unequals, with the objective of equalization. Although seemingly an inherent contradiction, or a paradox, this is the challenge in supervision.
Falender and Shafranske (2004) defined clinical supervision as:
“a distinct professional activity in which education and training aimed at developing science-informed practice is facilitated through a collaborative interpersonal process (mindful of the power differential). Supervision involves observation, evaluation, self-assessment and feedback, the acquisition of knowledge and skills by instruction, modeling and mutual problem solving, and encourages self-efficacy, building upon the recognition of the strengths and talents of the supervisee. Supervision insures that clinical consultation is conducted in a competent manner in which ethical standards, legal prescriptions, and professional practices are employed to promote and protect the welfare of the client, the profession, and society at large.” (p. 3)
Particularly important in this definition are the concepts of collaboration – that the supervisee learns from the supervisor while the supervisor learns from the supervisee – which is a step away from the usual hierarchical supervision model in which the supervisor is on a pedestal. However, both are ever mindful of the power differential because it the supervisor who will sign off on the successful completion of the training and who will write the letters of recommendation – and who thus carries the significant power in the supervisory relationship.
Another definition of supervision, which comes from the counseling psychology perspective, is that of Bernard and Goodyear (2009) who defined supervision as “an intervention provided by a more senior member of a profession to a more junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s), monitoring the quality of professional services offered to the clients that she, he, or they see, and serving as a gatekeeper for those who are to enter the particular profession” (p. 7).
NASW in their Best Practices defines professional supervision as “... the 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).
ASPPB describes supervision as a distinct, competency-based professional practice, a collaborative relationship between supervisor and supervisee that is facilitative, evaluative, and extends over time. It has the goal of enhancing the professional competence of the supervisee through monitoring the quality of services provided to the client for the protection of the public, and provides a gatekeeping function for independent professional practice (Bernard & Goodyear, 2014; Falender and Shafranske 2004) (ASPPB, Draft Guidelines, 2013, p. 5).
The American Psychological Association (APA) defines supervision: Supervision is 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 term “supervision” is derived from the Latin for super (above or over) and vision or sight.
Each definition has a different focus. Falender and Shafranske place significant emphasis not simply on the relationship, but also on self-assessment, processes of supervision, and the legal, ethical, and general context in which supervision occurs. They emphasize collaboration between supervisor and supervisee – a respectful interchange that remains mindful of the power differential. NASW shares this conception. Through collaboration and relationship, the supervisee grows. Highlighting the concept of mutual experiential learning establishes the foundation of competency-based clinical supervision and paves the way towards collaboration.
Bernard and Goodyear emphasize the transmission of knowledge from a senior member to another in the context of evaluation with regard for legal and ethical considerations. 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 towards 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.
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 the self-assessment tool (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 you…to transform to a competency-based clinical supervision environment. As you will see as we proceed, competency-based supervision is more accountable, and provides a transparency that serves to enhance the supervision relationship between you and your supervisees (Kaslow, Falender, & Grus, 2012)
Consider that the essential components include supervisee self-assessment of competency corresponding to his/her profession, collaborative development of supervisee goals and tasks for supervisor and supervisee, monitoring and tracking of competence, ongoing corrective and positive feedback to the supervisee, multicultural and diversity competence and infusion into all aspects, identification and management of reactivity or countertransference, and supporting the supervisee’s self care, development, and competence.
APA’s Guidelines for Clinical Supervision of Health Service Psychologists (APA, 2014) 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 Guidelines on Supervisor Competence (APA, 2014):
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)
This new document provides for 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
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
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
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
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
Terminating the supervisory relationship
For elaboration refer to the complete document at naswdc.org.
The supervisee enters supervision for the first time. She is eager and a little anxious, and is unsure what the supervisor expects. The supervisor has a set of expectations, but the supervisee is not privy to these.
The supervisor is:
a. Warm and welcoming,
b. Distracted, dealing with a crisis, or
c. Anxious and seemingly worried about supervisee competence.
It is easy to conclude which of these would be preferable as a foundation for a supervisory relationship. That is not to say that a distracted or anxious supervisor cannot “save” the relationship through effort and explanation, and attending to the supervisee, entry and the setting.
The supervision relationship is a complex dance in which supervisor and supervisee forge a relationship. 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. We will discuss these later. Also, remember, relationships take time to develop. And abundant data supports the idea that without a secure supervisory relationship, the supervisee does not disclose as much client or session information. Trust must be a critical part of the supervisory relationship.
A critical first step in the supervisory process is establishing the supervisory alliance. A cardinal rule of supervision is to balance the power differential of the supervisor with the evaluative function; this is implicit in the supervisory role with the development of the supervisory alliance in which both develop shared goals, tasks to achieve these, and an emotional bond (Bordin, 1989). The clearer the expectations are for the supervisory relationship, the better. To establish the supervisory alliance, supervisor and supervisee must create a relationship of trust. Through the interaction that ensues, the supervisor and supervisee develop a set of goals that are relevant to the developmental level of the supervisee and are specific to the setting and context in which the supervision occurs. Once established, specific tasks to achieve these are formulated. The emotional bond is created and strengthened through this course of action in which supervisor and supervisee are focused on the specifics of the supervision process.
Examples of supervisory goals:
Sample specific tasks:
It is possible to develop goals and tasks using multiple theoretical orientations.
Think of a supervisee that you are currently supervising or about to begin supervising. Identify tentative ideas about developmentally appropriate supervisory goals and tasks. For practice, role-play the supervisor-supervisee alliance formation process with a colleague.
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 format for supervision; what the supervisee should bring in terms of written, audio, or video materials; two-way feedback expectations; cultural and diversity competence, ethical, legal, and site regulations; and general expectations such as being interactive, and coming to supervision with a formulation or questions. 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.
Another interesting aspect of role invocation is its possible contribution to dialogic reflexivity (Hawes, 1993). Dialogic reflexivity refers to “a process of explicitly turning one’s critical gaze back on oneself as well as the professional, historical, and cultural discourses that empower and constrain one’s capacities to think and act in the context of the relationship” (Hawes, 1993, p. 105-106). Two processes occur – the private thoughts of the participants and the dialogue between them – each considered in the broader context. Through role invocation, the supervisee becomes acquainted with the expectation that both of these variables are to be considered and with the substantial supervisee role in the process.
In proposed collaborative forms of supervision, concern has been expressed that there is the reality of the power differential, which manifests itself in knowledge disparities, and in legal and ethical mandates, including protection of the client’s welfare as the supervisor’s highest duty. Through dialogic reflexivity, the supervisor and supervisee can develop a dialogue about the contextual factors and the particular manifestations of power, both through role invocation in setting the stage and in an ongoing manner. The supervisor can and should initiate this discussion. The power differential is discussed with the supervisor promising that if he/she has any concern about the supervisee’s competence or development of competence, the supervisee will be the first to learn of it. That is, feedback will be given promptly when the supervisor identifies a competence problem or issue. Also the supervisor will be open to discussion in order to understand the context and the complexity of the issue and to hear the supervisee’s perspective. The supervisor holds the ultimate power and liability for the supervisee’s work.
It is very important to infuse supervision with informed consent so that supervisees are aware of the evaluation component, so that feedback will be forthcoming and ongoing, and so that it will never be a surprise. This is directly addressed in the sections on feedback and informed consent.
With Susan in the vignette above, before this section, 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 Susan’s experience and training that will be facilitative in this setting, and to explore as well areas that are perhaps less familiar to Susan such as establishing a therapeutic alliance and identifying and processing her own unusual emotional reactivity. To improve Susan’s competence, the supervisor might suggest reading (e.g., Falender & Shafranske, 2012; Gehlert, Pinke, & Segal, 2014) to enhance her knowledge and skills.
Relationship is critical to effective clinical supervision. With relationship comes trust and the ability to disclose, receive difficult feedback, and confront complex issues in therapy and supervision.
Harlan began supervision eagerly, came with extremely strong recommendations, and knew several manualized treatment models. When assigned his first client, a mother-child dyad with separation anxiety, he assured them in the first session that the problem would be resolved in less than 6 sessions. The supervisor urged caution and consideration of the longevity of the presenting problem, cultural and familial aspects, and potential reasons why the changes he wanted to institute might impact the entire family including extended family members. Harlan saw quickly that the supervisor was correct and adopted a more nuanced approach.
Consider what you would recommend? A very good sign is that Harlan was open to supervision. Another supervisory step would be to caution Harlan that clinical work in general should not be tied to a particular promise of length.
Several researchers provide empirical support for the importance of relationship. Holloway (1992) summarized that, in literature on supervisee characteristics across levels of experience, the only differences were between beginning practicum and intern-level supervisees, and that these involved relationship characteristics. Beginning supervisees appeared to require more support and encouragement while interns were striving for independence and wanting to explore personal issues like countertransference. Cook and Helms (1988) reported that the supervisor’s liking and positive feelings towards supervisees accounted for 69.4% of the variance predicting satisfaction in supervision. The stronger the emotional bond between supervisor and supervisee, the less role conflict was experienced by the supervisee (Ladany & Friedlander, 1995). The emotional bond was also positively related to satisfaction with supervision (Ladany, Ellis, & Friedlander, 1999). Efstation et al. (1990) defined three factors of the working alliance in the context of relationship: client focus, rapport, and identification. These were postulated to be pivotal in development, and provide a different approach to the analysis of relationship.
Support should be a constant throughout the training process (Heppner & Roehlke, 1984; Worthen & McNeill, 1996; Worthington, 1984). The manifestation of support changes with personal characteristics and with the experience level of the supervisee. The supervision progression seems to move from a supportive relationship to the encouragement of growth to being empowering and trusting enough to explore countertransference issues and to encourage creativity and innovation. For the supervisee, the relationship seems to evolve from dependency to growth of trust to individuation or the evolution of the relationship to that of colleagues. Based on existent research, it is impossible to define empirically a quality relationship. Whiston and Emerson (1989) caution that the supervisor needs to ensure that “promoting insight, sensitivity, and personal growth in supervisees does not become counseling” (p. 321). Maintaining appropriate boundaries and not moving into the therapy domain is a central element of effective supervision.
Returning to Harlan, consider how you would broach giving feedback without creating a process in which Harlan feels devalued or undermined ... and possibly communicates that to the family. Consider how you could support Harlan? Consider Harlan’s strengths.
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 it was difficulty with forming the relationship or whether it was something that happened after a relationship was established. What is the role of culture – culture of client(s), supervisee, and supervisor in the supervisory relationship?
The premise that relationship is undervalued in the formulation and articulation of developmental theories is central in Ellis and Ladany’s (1997) critical review of developmental research in support of theory. They concluded, “The quality of the supervisory relationship is paramount to successful supervision” (p. 495). Holloway (1987) suggested that the supervisory process can more parsimoniously be explained in the supervisor-supervisee relationship; and is “as a result of being in an intensive, evaluative, ongoing, and demanding relationship.” (p. 215)
Attachment theory, personality, and intellectual variables are also important to the formulation of relationships. Attachment theory aids the supervisor in the understanding of the fragile process of attachment-individuation within supervisory relationships. Watkins (1995) suggested that attachment styles be used in understanding pathological relationships in supervision. His premise is that the majority of supervisees develop secure attachments with their supervisors. Such attachments provide a basis for trust and relating throughout the supervisory relationship, and set the stage for evaluative feedback, which is such a central part of development. Watkins opined that the one-on-one supervisory relationship may be the first place in graduate school where such a “different focus, relationship, process, and demands” (p. 339) are experienced. Equally important is cognizance of the more normative attachment process in which the supervisor may serve as a secure base for exploration, and has the opportunity to shift onus and responsibility gradually to empower the supervisee. The secure base, a concept derived from Bowlby (1988), provides for reduction in feelings of isolation by supervisees, a sense of confidence in monitoring and supervision, and a constant resource – the supervisor, available anytime (while the supervisee is performing clinical work), without fail (Pistole & Watkins, 1995). The sense of awe, enthusiasm, wonder, and curiosity instilled in supervisees is akin to solution-focused therapists’ approach to both clients and supervision. Add to this respect for the values, learning, and thoughts of the supervisee, and one has the essential elements of quality supervision.
Another important aspect of relationship in supervision is Erikson’s theory of development (Loganbill, Hardy, & Delworth, 1982), and more specifically, a focus on the positive, optimistic, and trusting aspects of supervisees and supervisors as adaptive human beings in their journey (Erikson, 1968). What has been misplaced in some of the theories is this basic optimism about development along with Erikson’s focus on fostering “competence, identity, love, and wisdom.” By allowing cognitive theories to supersede these variables, some of the essential core of developmental theory has been lost.
As Seligman and Csikszentmihalyi (2000) described in their positive psychology, we have also ignored our “hope, wisdom, creativity, future-mindedness, courage, spirituality, responsibility, and perseverance” (p. 5). This is evident in the process of supervision where the focus on pathology has seriously constricted the range of relationship and experience. The application of positive psychology to the entire supervisory process is powerful. Thinking preventively and positively are the hallmarks of successful supervision.
Vignette: The supervisee comes for the first supervision session. You have met her one time before and felt very positively about her. How will you begin establishment of the supervisory alliance? What will you say? What forms of information and assessment are necessary? What aspects of role invocation will you use?
Elements: Building the supervisory relationship includes both the emotional tone and the specific components. One thing to include at the beginning is a general conversation with the supervisee about such topics as adjustment to the setting. Then the discussion can lead to supervisee strengths (knowledge and skills as well as areas of special interest) and previous experience what particular goals and tasks the supervisee has been considering for the current placement. Should this process seem difficult, normative use of a profession-specific competency-based tool is a wonderful way to move towards identification of objectives. These tools are described below under Competencies. Other elements to include are encouraging the supervisee to understand the elements of the supervisory contract, such as the expectation of two-way feedback, and the importance of diversity and recognizing individual cultural differences. These aspects will be described more fully in later sections. The supervisory goal at this juncture is to achieve consensus on goals and tasks of supervision. In addition, the supervisor should be responsive to supervisee input and self-assessment and not assume competence based on level of training.
The other element often shortchanged or ignored is the evaluative function, which provides a context and an ethical and professional structure to the relationship. It is also the sine qua non from the perspective of universities, professional schools, and licensing bodies. That “evaluation is one of the most critical issues in establishing the supervisory relationship” (Holloway, 1995, p. 3) is a core concept. To varying degrees, at all levels of training, the supervisee, and supervisor are cognizant that the supervisor is a potent force in the supervisee’s future in terms of the evaluation of specific competencies. Although there is ample literature on supervisors’ aversion to evaluation (Robiner et al., 1993), this is not a justification for its omission. Supervisors do not evaluate or give corrective feedback (essential components of supervision practice) for fear of disrupting the supervisory relationship, believing tools have no empirical support, not wanting to risk departmental ire, or fear of adding a negative valence to the reputation of the setting/program in the community. A limitation of some of the research has been a failure to consider how the evaluative stance influences each step of the supervisee’s journey. Hansen (1965) described the limitations evaluation placed on supervisees’ expectations of supervisory relationships. Role ambiguity was defined by Olk and Friedlander (1992) as the supervisee’s uncertainty about how she would be evaluated.
But how can a supervisor be an evaluator and have a strong supervisory alliance? The most highly rated supervisors are those who give evaluative feedback. Clarity and communication of expectations are critical components underlying relationship, and therefore the working alliance. Ellis and Ladany (1997) supported the position that evaluation, being central and implicit in supervision, needs to be operationalized and incorporated into the research. Holloway (1999) described the supervisory act of monitoring and evaluating performance as a “function of supervision” (p. 20), but warned of the reward and coercive powers of the supervisory role. Evaluation is the backdrop against which supervision is conducted when supervisors have a sense of standards to which they are comparing performance. Evaluation should also be viewed as constructive, with frequent, ongoing input on the direction of the intervention and therapy. It should not be a distant hallmark at the end of the training sequence.
It is important to lay groundwork for evaluation by letting supervisees know you will be giving feedback at every session and that the “law of no surprises” is operative; the supervisee will be the first to know if you have competence concerns. 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 his competence or interventions that may have seemed different to the supervisor.
Feedback – corrective, positive, or negative – is a critical part of supervision. Feedback is helpful in the development and growth of the supervisee, and also in the clarification of goals, intent, and actions. 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, and supervisees will give ongoing feedback to supervisors as well. There is increasing evidence that self-assessment and reflective processes facilitate accepting and integrating supervisory feedback. This finding punctuates the necessity of self-assessment by both supervisee and supervisor, and the critical nature of the self-reflective process, as spelled out in the benchmarks document (Fouad et al., 2009).
From the onset of supervision it is critical to inform and model for the supervisee that you will be giving feedback anchored in each supervisee’s development of specific competencies. You will be acknowledging strengths and growth, and identifying areas in which there is need for improvement. Feedback is a normative part of supervision and the supervisor is also open to and receptive of feedback from the supervisee.
Your supervisee is excellent at obtaining complete information in the intake process. Every single topic is covered comprehensively and documented. Your concern is that two out of his first three clients did not return for a second session and they have not responded to phone calls. Your supervisee calls it “the luck of the draw.” How do you discuss this sensitively, and what will be some of the ways you might begin to hypothesize areas that could be in need of development?
First, turn to the supervisee’s self-assessment and survey – what areas of relationship: rapport, engagement, and relating were indicated as strengths and which were developing? Then, think about the processes of relating with you in supervision and how the supervisee responds to a nonjudgmental discussion of the possible reasons several clients did not return. It is a critical competency for supervisors to confront issues early on. It is possible this was an unusual event, but still is worth exploring. Nondefensive response to feedback is a great strength in supervision, and should be lauded.
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?
An interesting approach was described by Sobell, Manor, Sobell, & Dum in 2008. They suggested 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.
A significant portion of early supervision is socialization and patterning of the supervisee into the interactive mode of supervision, and honing the shared experience with a sense of humor and perspective. There is also the instilling of curiosity into the process so that the supervisee can approach each new client/ family with a spirit of openness and active, accepting curiosity. This approach is along the lines of the solution-focused therapy model. The relationship quality may have mediating or moderating effects. Hess (1987) observed, “ …because supervision is primarily growth oriented, deals with putatively healthy people, has skill and value inculcation as its goals, and is centered on the relationship, a theory specific to the supervisory relationship is central” (p. 187). In addition, we know that often what happens in supervision is replicated in the therapy process – in a “parallel process” or a reenactment of the process of supervision. Thus, if a supervisor is challenging and angry with a supervisee, that same process may be enacted between the supervisee and the client.
In cognitive-behavioral supervision, the contract can be constructed around requirements specific to setting and competencies to be attained. Evaluation can focus on the competency document as can frequent and ongoing feedback and assessment.
The following were your observations as you watched a video of a session with your supervisee. The supervisee/therapist entered the session (the third intake he had ever conducted) with a clipboard and proceeded to go down the list of intake items one by one. When the client displayed sadness, hesitation, or any type of emotional response, you noted that the supervisee simply moved on to the next item. When the client introduced information that seemed to need follow up (“my childhood was rough”), the supervisee said OK and moved on to mental status. The supervisee asks you for directives on what information had been omitted and what else needed to be done. How should you, the supervisor, proceed? How would you use a strength-based approach to facilitate the supervisee’s growth while ensuring the client is given the best quality of service?
How could you move the supervisee to be more reflective on what happened in the session. What was it like for the supervisee when the client made emotional disclosures? Was it that the supervisee/therapist felt overwhelmed and reverted to the form for safety, or that the supervisee simply did not or what to do? Alternatively, the supervisee may be coming from a research role, and believe that information collecting is a significant part of therapy. The supervisor would have responsibility to assist the supervisee to make a developmental leap to being “therapist” and becoming interested and responsive to client disclosures, encouraging elaboration. The supervisor could model interest, through understanding what the supervisee’s thinking, fears, and objectives were in the intake session.
It is critical to differentiate supervision from therapy – and also from consultation. This is a topic that will arise several times in this course. Studies of good and effective supervisors versus those who are poor and unsuccessful show us that supervisors who cross the boundary and become therapists to their supervisees inflict substantial harm. Whiston and Emerson (1989) described the difficulty of switching from the empathic supervisor to the evaluator (and critiquer of the supervisee’s work); they emphasize the importance of remaining focused on the professional development of the supervisee in the context of her work with the client, rather than segueing to the development of action plans for the supervisee’s personal problems. A line must be drawn and maintained to keep the focus on the supervisee’s process and behavior with the client. This becomes an issue of informed consent, with it being extremely important for the supervisor to establish from the beginning that supervision is a distinct practice area separate from therapy or counseling.
Whiston and Emerson proposed use of Egan’s (1986) model where, through informed consent, the role of the supervisor when problems arise is elaborated upon, and clarified and explored to determine if the supervisee’s personal problems are interfering with client work. It is possible the process of supervision per se will be creating tensions or increasing personal issues of supervisees. Nevertheless, the supervisor should only explore and clarify problems of supervisees that are creating impasses in their clinical work. It is not the role of the supervisor to move beyond that exploration and clarification. In the second and third stages of Egan’s model, the line from supervision to counseling or therapy is crossed and thus, these stages should not be approached in supervision, but by an independent therapist. These stages entail establishing an action-oriented understanding of the personal problem of the supervisee, and determining through this exploration whether the personal problems are the reasons for difficulty with a particular client. Then, means are determined to accomplish goals to address the problems defined. This distinction will also be discussed later in the context of countertransference.
An important rule is that supervision keeps focus on the client and on the supervisory process. When the supervisor slides 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 – pausing and reflecting to the supervisee, that a boundary has been crossed.
Decide which of these situations are appropriate for supervision and which would require a referral for therapy or other external support:
- Supervisee discloses that client reminds her of her mother.
- Supervisee becomes tearful week after week in supervision when discussing particular cases, even after extensive intervention on countertransference. Supervisee discloses he also became tearful with the client in the previous week for no apparent reason he could identify.
- Supervisee repeatedly asks supervisor to give advice on her impending separation and divorce, as she knows the supervisor has recently gone through a similar thing.
- 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 his needs are met outside of supervision. This process could even, if deemed necessary, entail a leave of absence.
In #3, the supervisee 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.
In #1 and #4, the supervisee can explore countertransference when the supervisee is in a less reactive state, and most likely, lead an exercise in differentiating the supervisor 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.
Supervision must also be distinguished from consultation. The difference is that, in supervision, information is passed from a licensed person, who holds legal responsibility, to an unlicensed person. The unlicensed person is required to follow the directives of the licensed individual who is his supervisor. In consultation, both parties are licensed and usually peers, and the recipient of the consultation is not required to follow the directives or advice of the consultant. Nor is the consultant 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 both circumstances, individuals function with informed consent. In supervision, clients need to be informed that they are being seen by a supervisee who is not licensed and who is functioning under the licensure of a supervisor who is named and who will have access to their clinical records. In consultation, clients are informed that their therapist will be consulting with an individual regarding their case and that individual will be given information regarding the client.
What do you do if another supervisor’s supervisee comes to you for “consultation”?
It would be important to clarify roles and responsibilities – and to coordinate with the other supervisor, perhaps arranging a joint meeting to “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.
Supervision always involves an evaluative component. In mentoring, the protégé typically chooses the mentor, the mentor does not evaluate the protégé, and the mentor assists the protégé in professional role development, providing contacts with relevant colleagues, research opportunities, and a multitude of professional activities including attending conferences and meetings. Some supervisors do mentor but they use informed consent to think proactively about the possible conflicts that might arise when both roles are occurring with a single supervisee-protégé. Possible worst-case scenarios might include having to give negative, constructive feedback to the supervisee and then presenting a paper together later the same day! Or having to hold a supervisee back from going on to internship having just introduced them to colleagues with whom they might collaborate in research. Generally, however, mentoring is an important part of supervision with advanced supervisees who are nearing licensure or post-licensure.
The process of becoming a supervisor is one of integrating theory (of supervision and of therapy), interpersonal skills, and focus. An important part of this progression is consideration of the system in which you are functioning. You need to gain understanding of the system in all its complexity: requirements, personnel practices, diversity contexts, legal and ethical standards, and any particular standards that relate to supervision. In some states, the transition is accompanied by courses you are required to take specific to the practice of supervision.
Specific aptitudes for the supervisor will be described later in this course. There needs to be a shift from therapist to the new role of supervisor. One of the significant changes is that you must broaden your perspective; your total focus will not be on the client, but will expand to include interactions among client, client and supervisee/therapist, client-supervisee/therapist-supervisor; and supervisee-supervisor. In addition, you will become more acutely aware of contextual and administrative factors for which you will be responsible to enact or enforce.
Furthermore, standards for entry-level supervisors are increasingly being implemented. As a beginning supervisor, you will be self-assessing your level of competency and planning continued education and growth to strengthen your functioning. Because these standards are being instituted throughout disciplines, there are specific expectations and requirements for supervisor behavior.
There is also 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:
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 (adapted from Liese & Beck, 1997 in Watkins, 1997) include:
Falender and Shafranske (2004) posit that there is an even “higher” outcome in which supervisors see supervisees as active contributors to the process, and as collaborators in the supervision process, so that supervisee and supervisor both grow through the interaction. To collaborate in the context of the distinct power differential is a high level skill. Components of the collaborative approach include supervisee self-assessment, supervisor life-long learning, capacity to set the stage and engage in collaborative reflection: stepping back from the content and process and looking 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.
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. Beyond what Borders described, it could be focused on topics specific to the context (domestic violence, child abuse, corrections, etc.) with particular topics identified which intensify the difficulty of the supervision process. One could build from preliminary skill-building group sessions with discussion of establishing the supervisory relationship and barriers to setting specifics to development of a resource network with individual supervisors identified as resources in particular skills or areas. Supervision of supervision provides support, knowledge, skill, and often values and attitudes to assist supervisory development.
An excellent resource for beginning supervisors is Susan Neufeldt’s Supervision Strategies for the First Practicum (2007) in which the author provides a manualized approach to supervision through use of topical areas and targeted dialogues.
Another 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.
A recent development in supervision is identification of the specific competencies that define it. 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. Consider it carefully, as 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). In addition, workgroups are underway through both the Association of State and Provincial Psychology Boards and the American Psychological Association Board of Educational Affairs.
The framework for supervisor competencies is laid out in the areas of knowledge, skills, values, and social context. These are conceptualized as basic, entry-level competencies. A full description is available in Falender et al. (2004). Please note these were defined for the psychology supervisor and were a product of the Association of Psychology Postdoctoral and Internship Centers Competencies Conference (APPIC), which occurred in 2002.
Increasingly, a best practices step is the review of supervisor competencies and ensuring each supervisor meets minimum standards to supervise (Falender, Cornish, Goodyear, Hatcher, Kaslow, Leventhal, Shafranske, Sigmon, Stoltenberg, & Grus, 2004).
Please self-assess your supervisory competencies – presently and that to which you aspire. Think about your current practice and directions you would like to take to increase your knowledge, skills, values and attitudes, and contextual competence.
Supervision Competencies Framework*
(Rank present from 7 (superior) to 1 (absence of knowledge, skill, value); signify high priority to enhance competence items in column with “X”)
Of area being supervised
Of models, theories, modalities, and research on supervision
Of professional/supervisee development
Of evaluation, process/ outcome
Awareness of diversity in all forms
Sensitivity to multiple roles: Perform and balance
Provide effective formative and summative feedback
Promote growth and self-assessment in trainee
Conduct own self-assessment
Assess learning needs and developmental level of supervisee
Encourage and use evaluative feedback from trainee
Teaching and didactic skills
Set appropriate boundaries and seek consultation when supervisory issues are outside domain of supervisor competence
Scientific thinking and translation of scientific finding to practice throughout professional development
Responsibility for client and supervisee
Responsibility for sensitivity to diversity in all forms
Balance between support and challenging
Commitment to lifelong learning and professional growth
Balance between clinical and training needs
Value ethical principles
Commitment to knowing and utilizing available psychological science related to supervision
Commitment to knowing one’s own limitations
Social Context Overarching Issues
Ethical and legal issues
Knowledge of immediate system and expectations within which the supervision is conducted
Creation of climate in which honest feedback is the norm (supportive and challenging)
Training of Supervision Competencies
Coursework in supervision including knowledge and skill areas listed
Has received supervision of supervision including some form of observation (video or audiotape) with critical feedback
Assessment of Supervision Competencies
Successful completion of course on supervision
Verification of previous supervision of supervision document readiness to supervise independently
Evidence of direct observation (e.g., audio or videotape)
Documentation of supervisory experience reflecting diversity
Documented supervisee feedback
Self-assessment and awareness of need for consultation when necessary
Assessment of supervision outcomes – both individual and group
Other to be defined by supervisor/setting
|*Derived from Falender, C.A., Cornish, J.A.E., Goodyear, R., Hatcher, R., Kaslow, N.J., Leventhal, G., Shafranske, E., & Sigman, S. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771-785, with permission of publisher and author.|
Rings, Genuchi, Hall, Angelo, and Cornish (2009) queried predoctoral internship training directors and found significant support for the importance of these supervision competencies.
Supra-ordinate factors were:
(Falender et al., 2004)
After completing this self-assessment, highlight sections that are aspirational for you and describe how you plan to enhance your competency. If you are unsure, continue on with the course and return to this later. Another document on Supervisor Competencies is the Technical Assistance Publications Series by SAMHSA – TAP 21A. It is avaliable 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:
(SAMHSA, TAP 21A, 2007, p. 15)
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.
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 self-assess using each document of a discipline for which you provide clinical supervision. As we progress through this section, download the relevant documents and perform your own self-assessment.
The ADPTC/APTC document defines competencies of readiness for practicum and those at completion of practicum. This document is in use by many practicum settings and in university and professional schools to track and assess competency development.
The next step in the development of competencies in psychology was Benchmarks. The Benchmarks conference was held with a wide range of individuals representing different constituencies being given the assignment of working in small groups to identify particular behavioral markers for the competencies previously demarcated and developmental progression. Benchmarks (Fouad et al., 2009; Hatcher et al., 2013) also focused on the development of assessment for each of the following transition points:
This document was based on the cube model (Rodolfa et al., 2005), an outgrowth of the 2002 Competencies conference, which defined foundational and functional competencies and the developmental trajectories.
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 document is available at http://www.apa.org and in Fouad et al. (2009) and Hatcher et al. (2013).
A new innovation is A Practical Guidebook for the Competencies Benchmarks (2012), also available at the same website.
This website also has links to other competency documents for psychology and various disciplines.
Social Work Competencies:
Significant effort has gone into the development of the CalSWEC II (California Social Work Education Center) documents. They are exemplary and are already adopted as evaluation and monitoring tools for many schools of social work and field placements. The following are the websites to access the CalSWEC documents.
Marriage and Family Therapy Competencies:
A document is available for supervisee competencies
An article explaining the development of core competencies is:
Nelson, T.S., Chenail, R.J., Alexander, J.F., Crane, D.R., Johnson, S.M, & Schwallie, L. (2007). The development of core competencies for the practice of marriage and family therapy. Journal of Marital and Family Therapy, 33, 417-438.
An article exploring the impact of competencies in graduate training and some preliminary outcomes is:Nelson, T. S., & Graves, T. (2011). Core competencies in advanced training: What supervisors say about graduate training. Journal of Marital and Family Therapy, 37, 429-451. doi:10.1111/j.1752-0606.2010.00216.x
The 2009 CACREP Standards are available at: http://www.cacrep.org
Information on additional competencies in areas such as nursing, professional chaplains, CBT training, health psychology, neuropsychology, family, gerontology, forensic/correctional, child and adolescent can be found in Appendix II.
These sets of documents are important to review and understand if you are training supervisees, students, or staff members in the various professions. Reviewing this material is a wonderful way to begin to understand the frame and approach of a particular discipline and the development of competencies. In fact, developing greater competence through knowledge of these competencies can implicitly guide your monitoring of your supervisee’s progress and development in this competence era.
In Hatcher and Lassiter, and Benchmarks (Fouad et al., 2009; Hatcher et al., 2013) 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 personality characteristics and intellectual and personal skills such empathy and respect for and interest in other’s cultures, values, etc. Integrity, honesty, valuing ethical behavior, affect tolerance, tolerance of ambiguity, and openness to new ideas, personal organization, personal hygiene, and appropriate dress are also identified. It is important to review these documents carefully as this is a standard of practice, establishing criteria for individuals entering the field of psychology.
In the CalSWEC II documents, foundational competencies include Culturally and Linguistically Competent Generalist Practice. This area includes knowledge and understanding of all aspects of diversity, trauma, and legal and historical relationships, especially with the US government and the American Indian/Alaskan Native nations; values of traditional practices; issues facing immigrants and how these relate to mental health and services; assimilation and acculturation; and how social work values impact the individual and each of these, as well as how the student’s own diversity variables and status impacts each client including biases, prejudices, and awareness of disparities.
This is only one example of an extensive list, all elements of which is exemplary and demonstrates the significant focus in social work training 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 II document goes on to describe competencies for practice with individuals, families, groups, community, human behavior and the social environment, and workplace management. This is also a critical document to examine if you are training social workers. Many universities are using it, or a derivative, for evaluation purposes.
CalSWEC II also includes multiple developmental levels: Foundational, Advanced, and Specialization competencies.
The AAMFT Competencies is a one point competency document, at the point of entry into the profession (licensure). They are organized around six primary domains and five secondary areas: admission to treatment (interactions leading to establishing the therapeutic contract), clinical assessment and diagnosis, treatment planning and case management, therapeutic interventions, legal issues, ethics, and standards, and research and program evaluation. Types of skill and knowledge are conceptual, perceptual, executive, evaluative, and professional. It is critical to review this document carefully and track your supervisee’s competence if you are supervising MFT trainees or interns.
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 health care environment and may need to be prepared to help trainees develop skills that may not have been as important as before some of the changes occurred.
The CACREP Standards document was finalized in 2009. It is for master’s level counseling, career counseling, counseling and supervision, and a broad range of related areas.
Again, remember that self-assessment is a core value of supervision. Self-assessment with as many of the above documents will be an important part of your determination of your own competencies as a supervisor of your individual supervisees. 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 originated as a means of ensuring ongoing professional competency.)
Each supervisor should download a copy of the respective documents for the disciplines she supervises as well as the respective codes of ethics for the discipline. Keep them on your desk and refer to them frequently to model good, ethical practice to the supervisee.
An outgrowth of Benchmarks is the “Toolkit,” which is composed of methods of assessing competency. These are an important advance and are available at: http://www.apa.org and with elaboration in Kaslow et al. (2009).
The following are the component parts outlined at the website for the assessment of competency. The documents describe the strengths and limitations of each technique.
Rating of live or recorded performance requires observers to be trained to achieve reliability – and for the rating format to be valid (i.e. reflective of what is to be measured. Thus, identification of critical components underlies effective performance. Objective structured clinical examinations need to be designed with reliability and established validity. Portfolio review requires the accumulation of multiple modalities (intake reports, assessment reports, video or audios, case notes, process notes, etc.) There is the necessity to rate these materials to determine a level of competency. Record review is a more narrow clinical practice review – and there is still the issue of determination of competency from that. Simulations and role-plays are extremely useful teaching tools and can be used to assess competency, but require standardization by setting, context, population, and effective rating scales or devices to determine competency. Structured oral exams like those used for diplomates are a promising direction. Standardized patient/client interviews are used in medical fields and can be simulated (even with robot client/patients) with hired actor patients, or with actual patients. Written exams exist for every discipline; these are needed to ensure a level of validity to the area of practice to which one is aspiring. 360-degree feedback is typically used strictly for feedback, not evaluation, and would have to be carefully structured to reduce the risk of rater bias and other personal agendas.
Competency-based supervision is an approach that explicitly identifies the knowledge, skills and values that are assembled to form a clinical competency and develop 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 towards competence. APPIC sponsored the “Competencies Conference” in an effort to describe more thoroughly specific competencies of different aspects of professional functioning. As an outcome of the APPIC Competencies Conference, a number of papers were published. One of these papers, mentioned earlier, was on competencies of the supervisor, by Falender, Cornish, Goodyear, Hatcher, Kaslow, Leventhal, Shafranske, Sigmon, Stoltenberg, and Grus (2004).
Competency-based supervision is an international phenomenon with multiple countries adopting it (e.g., Australia, New Zealand, U.K.).
Assessment of competence is complex and takes into account developmental factors and self-assessment, and should be multi-trial, multi-method, and multi-informant (Kaslow, 2004). Kaslow (2004) advocated 360-degree feedback that is actually not conceptualized as evaluation but as developmental feedback, in which input is received from multiple constituencies including supervisors, peers, clients, and other parties and involves many skill, knowledge, attitudinal, and interpersonal, emotional factors. The input is collected, integrated and scored, and then presented by a neutral individual back to the person at the center of the 360-degree feedback – the individual being rated. A major advantage of this feedback is the varied perspectives it represents and how useful it can be for professional development. It is typically not used for evaluation as there are biases inherent in the system of collection (e.g. if one of the raters was not promoted and the individual being rated was, if the rater was angry about an external event so responded negatively to the rating process, etc.). This process is derived from business and organizational psychology.
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 psychometry report-writing). It appears that a strong alliance may 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. It is important for a training site or an individual supervisor to consider the existing documents on competencies and the particular site requirements to determine which competencies are relevant for supervisees in a particular setting. Supervisors who function in specialized settings should seek out supervision literature specific to the models they are using. For example, in Falender and Shafranske (2008), eminent contributors represent cognitive behavioral, psychodynamic, and family systems as well as other applied models of supervisory experience. Neill (2006) provided approaches to particular child supervision derived from therapy models such as filial therapy, multisystemic, and dialectical behavioral therapy. Whatever the context or model, there should be a direct relationship between the competencies document and assessment of the supervisees and the training contract 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 life-long learning, an essential aspect of supervision and competence in general.
The contract or supervisory agreement (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. The state-mandated agreement typically includes all the state regulations relating to supervised professional experience, accumulating hours for licensure and/or to maintaining a particular unlicensed status.
Components of the supervision contract include:
An additional section collaboratively developed, is a determination of the current strengths and areas in development of the supervisee. From this discussion, based on a competencies document and considering education, training and experience prior to this setting, 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 or agreement is a critical part of the supervisory relationship as it fulfills both informative and collaborative functions. It is the set of expectations that is translated into the evaluation prototype, which is also presented to the supervisee at the onset of the training sequence. Please note that each setting will have its own criteria and competencies, although there may be more overlap in the specific performance expectation section. For this reason, each setting should tailor its competencies, agreement, and evaluation to meet its individual needs.
Before you begin this section, think about what models and theories of supervision influence your practice. List them. Then as you progress through this section, think about which of these relate most readily to your own practice.
Among the approaches to supervision are the psychotherapy-based approaches, including psychodynamic, cognitive-behavioral, intersubjective or narrative, and dialectical behavioral therapies, and systemic and family systems. Increasingly, psychotherapy-based models are being translated into competency-based (Falender & Shafranske, 2010). In these models, typically supervision mirrors the therapy process reflected in the theoretical orientation. A concern is that such supervision may not systematically address all the areas critical for supervision (e.g., reactivity or countertranference, diversity or multiculturalism, legal and ethical). Superimposing a competency-based approach onto the theoretical model deals with that problem (Falender & Shafranske, 2010). Models also include process-oriented approaches, systems-oriented approaches, and developmental approaches (Falender & Shafranske, 2004; 2008).
Although there are multiple models that reflect the psychodynamic orientation, Eckstein and Wallerstein (1972) were very influential in describing the relationships among the three parties in supervision – client, therapist, and supervisor – and how the relationships reflect upon each other. Interest in transference, countertransference, and working alliance and parallel processes have all been exceptionally important to the understanding of supervision and are discussed throughout this course. A compendium of psychotherapy-based approaches (cognitive therapy (Beck), family therapy (Barenstein), and psychodynamically-oriented therapy (Sarnat) supervision are presented in Chapter 4 of Falender and Shafranske (2008). Sarnat described the relational psychoanalytic model in which client, therapist and supervisor are considered as cocreators of the clinical and supervisory relationship which are intertwined. Symbolic communication between supervisor and supervisee, a widely neglected aspect, addresses unsymbolized affective states that arise. The complexity of the supervisor role, as a model for the therapist, didactic, and mentoring, as well as accessing and exploring supervisee unconscious material as it relates to the client and supervised treatment. The supervisee 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, 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). They 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 Falender and Shafranske, 2008, section of the chapter by Judith Beck (Chapter 4).
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) described a competency-based approach to family systems.
Humanistic-Existential (Farber, 2010).
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 to supervision include those in which component tasks and roles are defined (Bernard, 1997). In their Discrimination Model, Bernard and Goodyear (1998) described “teacher,” “counselor,” and “consultant” roles with different foci (intervention, conceptualization, and personalization). Hess (1980) described roles (he described these as models) including lecturer, teacher, case reviewer, colleague-peer, monitor, and therapist. Bernard and Goodyear (1998) cited other models with expanded conceptions of supervisor roles including facilitator, evaluator, monitor, and administrator. Each of these models is useful in discussions with supervisees in order to determine what roles the supervisor does, in fact, play during the supervisory session, if these roles are balanced, and if the supervisee would prefer more or less of one or another. It is also useful to determine whether the supervisee feels that the descriptors are adequate to encompass the entirety of the supervisory process, and if not, what could be added.
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; consultant is confusing as it does not entail the legal liability implicit in supervision.
Holloway’s model provides a systems approach. The following grid represents the aspects of the model:
|Counseling Skill||Case Conceptualization||Professional Role||Emotional Awareness||Self-Evaluation|
It is possible to consider many aspects of the supervision process by discussing them in the context of the grid (which is presented in three-dimensional format in Holloway’s work). Thus, 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 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 supervisee thinks, intuits, and feels during therapy is disregarded automatically because allowing these perceptions to surface would confront the basic predisposition to be diplomatic. The purpose of IPR is to give the supervisee a safe place for internal reactions. The supervisor’s role is that of facilitator, stimulating awareness beyond that which occurred during the therapy session.
The actual IPR process entails the supervisor and supervisee viewing prerecorded video of the counseling session. At any point, when either perceives an important moment that was not being addressed, they stop the video and the supervisee reflects. The supervisee may indicate frustration, anger, impatience, or other emotional reactions. The supervisor does not adopt a teaching stance but allows the supervisee the space to explore internal processes of resolution. The supervisor may ask a series of questions that might include, “What do you wish you had said to her?” “How do you think she would have reacted had you said those things?” “What kept you from saying what you wanted to say?” and “If you had the opportunity now, how might you tell her what you are thinking and feeling?” The process continues with the tape advancing once again. This is an extremely slow process and puts interpersonal dynamics under a microscope that may be magnified so greatly as to be distorted. The role of the supervisor is to determine which interactions are important. This is a technique that should be used only after a significant supervisory alliance is established.
Another model of supervision was proposed by Hawkins & Shohet (2000) who suggested the “seven-eyed supervisor model” in two interlocking matrices useful as tools to direct the supervisory process. They advocated attention of supervisor and supervisee directed to therapy sessions themselves with the following foci:
This is a very interesting model as it integrates many of the aspects of supervision that will be addressed throughout this course.
The supervisee is worried that the daughter in the family she is seeing 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. 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.
Because developmental theory is a meta-theory and has been so influential in supervision thinking, substantial attention will be devoted to understanding the state of the art in this area.
Developmental theories of supervision have been at the forefront of theory and research for the past four decades, and have been referred to as the “zeitgeist of supervision thinking” (Holloway, 1987, p. 209). There has been such a profusion of models that Watkins (1995) joined Borders (1989) in urging that a halt to development of any further new models of supervision take place and that the focus turn to consolidating existing models. Developmental models have been central to training in counseling psychology but have been less dominant in clinical psychology training.
The premises of developmental models include:
Developmental models contain 3 to 5 stages of supervisee development.
Rather than levels or stages, it seems more useful to conceptualize a continuum of development in which movement may be forwards or backwards, with fluidity, after Hogan (1964) such that cycles and stages are not linear and may repeat themselves. This eliminates the critiqued issue of a time line in training and even the extreme time variability within discipline and across individuals (Holloway, 1987; Stoltenberg & Delworth, 1988). For example, some practicum or first year supervisees may be more sophisticated clinically than someone who has completed his or her degree program. It is useful to realize also that not all supervisees develop in all areas uniformly. Thus, one supervisee could be exceptionally sophisticated in cognitive behavioral interventions for depressed children but at a very beginning level in comments and reflection on the process in therapy or in structural or strategic family therapy.
An omission in the developmental models has been the absence of a set of skills or competencies towards which the supervisee aspires. Beutler and Kendall (1995) suggested that targeted goals in the context of skill acquisition are a key to professional psychology training. The necessity for a more explicit and empirically established set of competencies defined for supervisees at each level of training and for supervisors was advocated by Holloway (1992). Hess (1983) identified behaviors of supervisees critical from the perspective of supervisors:
Holloway asked a question which is very important to this discussion (Holloway 1997, 1998) – Is developmental theory, or a derivative of such a theory, of value in the determination of the structure of the supervisory situation, the behavior of the supervisee and/or supervisor, or the prediction of performance issues?
A large amount of research and theory regarding developmental conceptualizations of supervision has been advanced over the past four decades. Numerous conceptual frameworks and developmental paths have been put forth and then revised, leading to researchers’ lamenting the lack of progress to provide support for developmental theory in research that occurred other than Holloway’s (1992) review, Ellis and Ladany’s (1997), and Goodyear and Guzzardo’s (2000) reviews.
A predominant developmental theory of supervision was advanced by Stoltenberg (1981), Stoltenberg and Delworth (1987) and refined in Stoltenberg, McNeill, and Delworth (1998). This theory provides a framework for clinical supervision including the stages through which the supervisee progresses and the environment the supervisor should provide.
The most recent revision of the Stoltenberg et al. theory, IDM (or Integrated Developmental Model (Stoltenberg, McNeill, and Delworth, 1998; 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 defining individuation and independence as it evolves. Some of the concepts the authors postulate as most central to the development of the supervisee are carefully described in auxiliary chapters but are not integrated into the theory per se. These include the relationship of supervisee to supervisor, the supervision environment, and the development of the supervisor. Around these three central structures, the authors weave a sequence of development of increasing autonomy, shifting awareness from self to client, and independent functioning.
Thus, for example, the Level 1, or beginning therapist is highly anxious, highly motivated, and highly dependent on the supervisor. Focus in therapeutic interventions is primarily on 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 the Level 3i, or integrated, development, in which the therapist integrates the highest level of proficiency and skill across all levels of practice, it is clear that development never stops – lifelong learning is essential.
More autonomy for supervisee
Exception in crisis cases
Supervisor provides structure
Less supervisor-imposed structure
Supervisee imposed structure
Focus on personal/professional integration
Exception in crisis cases
Interpretive of dynamics*
Balance of ambiguity/conflict
Address strengths, then weaknesses
Closely monitor clients
Interpret dynamics, parallel process
Strive for integration
Empathic, understanding Affirmation through self-disclosure
Interpersonal processing better left until transition to L2
Respect, Understanding of expectations, Definition of supervisory relationship
Processing personal issues
Supportive, safe environment
Encouragement to experiment and explore
Use relationship to increase insight, use of parallel process
Mutual respect and collegial exploration
Evaluative Function +
Interface with Agency
*Derived from Stoltenberg + Falender & Shafranske
This arrangement of the information presented by Stoltenberg, et al. (1998) is a synthesis of some of the most intriguing portions of the model. Encircling relationship and evaluation around this structure seems to be a very effective way of presenting developmental theory. Development is conceptualized as one factor, albeit a very potent one. 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.
Another group of developmental theories is that of supervisor development. With recent changes in state regulations, the experience level of the beginning supervisor is lowered. A supervisor may be a Level 2 supervisee. As the supervision practicum occurs very early in the training sequence in graduate curricula, one could imagine even less sophisticated therapists assuming a supervisory role. Supervisors with no clinical experience are less effective than those with significant experience (Russell & Petrie, 1994). We share the concerns expressed by Bernard and Goodyear (1998) regarding potential parallel tendencies of novice supervisors paired with novice supervisees to intervene in a rigid and overstated manner. There is concern as well for lack of support, insight, humor, perspective, and flexibility.
The theories of supervisor development share many of the characteristics of the supervisee development models: meta-theoretical, sequential, and progressing to a fixed endpoint. Supervisory developmental models have been articulated by Stoltenberg et al. (1998), Watkins (1993), Rodenhauser (1994), and Hess (1986, 1987).
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.
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, 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 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.
Vignette: A supervisee enters her first supervisory hour with a new case, a chaotic family. The mother and daughter are being treated for chronic pain secondary to severe physical abuse by a father who is no longer with the family. The child is depressed, withdrawn, and not eating, but is a straight-A student. Mother describes her as an “overachiever.” The supervisee expresses worry to the supervisor about the severity of pathology. The supervisor immediately says she will be a co-therapist to the supervisee,
Conceptualization: A session should have occurred before the case assignments in which levels and previous training and experience are discussed, and a supervision plan is developed. Great specificity should be used to understand the supervisee’s level of competence with different diagnoses, developmental levels (of children and adolescents), and modalities. Also at that time, the evaluation measures and criteria would be introduced and discussed as well as particular parameters and contractual requirements of the supervision (use of video/audio tapes, timing of turning in progress notes, procedures for emergency contact, what comprises an emergency, etc.). Having the supervisor jump in might undermine the supervisee’s confidence, or might be justified given the severity of the presenting problem and the level of supervisee.
This is a very difficult situation, as it requires the supervisor to balance his duty to the client, which is the supervisor’s ultimate responsibility, with duty to the supervisee. It also requires consideration of supervisee personal factors and possible transference, or countertransference (the client triggering “subjective” emotional responses in the supervisee-therapist or supervisor), as well as the supervisee’s developmental trajectory and normative anxiety – or whether it is accurate that this is too difficult a case for the supervisee to handle alone. Major factors would be lethality, severity of the presentation (how long has she not been eating, what is her weight, what is her physician’s recommendation and finding, etc.) If in the supervisor’s judgment, the case is beyond the current competency of the supervisee even with intensive supervision, it is necessary for the supervisor to take appropriate action: and that could include stepping in as co-therapist.
What are the developmental considerations that would dictate an approach to this situation? What are the assessment steps that could be taken to determine supervisory approach?
Analysis of Level of the Supervisee
Analysis of Level of the Supervisor
A preliminary analysis would be to consider the anxiety level of the supervisee and the supervisor. This was an initial supervisory session, and neither engaged in the usual introductory behavior, including evaluating the level of the other. Most critical is that the supervisor has a clear sense of the experience, conceptual, and clinical level of the supervisee:
What steps could be taken in such a supervisory scenario to prevent premature closure or inappropriate interventions? It is critical to approach the anxiety of the supervisee and to consider the impact of alternative approaches:
Depending on the response to this, the supervisor needs to outline the treatment issues, and integrate information from the supervisee’s description into a formulation and hypotheses about proceeding clinically. The amount of input from the supervisee should be supplemented and framed by the supervisor. If the supervisor suspects the supervisee is not describing all that she actually could, some gentle prompting is indicated. The supervisor could say, “I noticed you worked with abused children last year. How would that experience contribute to your understanding of this case?”
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 provide feedback, both positive and supportive and 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) described positive or “best” supervision strategies. In a description of best practices of supervision, O’Donovan, Halford, and Walters (2011) described 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 suggested that contracting should occur in supervision, data should be collected and used for the normative and formative functions (e.g., assessing competency of supervisee) of supervision, communicate formative feedback and promote supervisee self-assessment, manage tension between formative and summative evaluation.
A set of 22 “positive supervision strategies” was devised by Kavanagh et al. (2003). Consider each strategy and think about how often you use it, whether it is a strategy you would like to use more, and which strategies your own supervisors have used with you.
Kavanagh, Spence, Strong, Wilson, Sturk, & Crow, 2003, p. 99.
This is a particularly important set of strategies as it includes the identification of some form of observation of supervision whether it be audio, video, or live – or co-therapy. It also describes skill, knowledge, and attitudinal sets implicit in the supervision process. Think about what other aspects you would identify as important strategies of supervision that are not listed.
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 orientations for three to five years following the conclusion of the training experience.
Descriptions of best supervisor have included:
(Summarized in Falender & Shafranske, 2004)
(Henderson, Cawyer, & Watkins, 1999; Worthen & McNeill, 1996)
The last two points are especially important as they highlight the importance of two-way feedback: supervisor to supervisee AND supervisee to supervisor.
Putney, Worthington & McCullough (1992) reported that theoretical orientation might mediate relationship in that cognitive-behavioral supervisors were perceived to be in a consultant role and to focus on skills and strategies more than humanistic, psychodynamic, or existential supervisors were. Those latter were perceived as using a relationship model with a focus on conceptualization. However, they found no differences in use of growth and skill development models or focus on the supervisee as a function of theory.
Nelson (1978) concluded that interest in supervision appeared to override experience and knowledge as an essential component. Other factors in “best” supervision included theoretical grounding or working within a cohesive theory (Allen et al., 1986), a shared theoretical framework (Kennard et al., 1987; Putney, Worthington, & McCullough, 1992), and comments focused on the client (Shanfield, 1992).
There has been some research to support developmental theory, leading Ellis and Ladany (1997) to conclude that:
Although the sample was very small, Nelson (1978) reported supervisee discipline differences in supervisor characteristics preferred. Social work supervisees preferred genuineness and ability to provide feedback above interest and experience in supervision. Advanced psychiatry supervisees preferred research and academic pursuits by their supervisors rather than applied work. Psychiatric residents did not favor the supervisor functioning as a CO-therapist
Social work supervisees and supervisors both reported strengths in supervisors related to knowledge skills, experience in the work being supervised, and the ability to develop positive supportive relationships with supervisees (Kadushin, 1992). A specific theoretical orientation, a structured, directive style, and clear, unambiguous directives were preferred (Lazar & Eisikovits, 1997). Among marriage and family therapy supervisees, results (Anderson, Schlossberg, & Rigazio-Digilio, 2000) bore some similarity to Allen et al.’s (1986) results with psychology supervisees. Variables associated with best supervisory experiences included longer duration, more frequent contacts per week, and a balance of personal growth with development of technical skills. Best supervision was in a facilitative environment of openness, respect, support, and an appreciation of individual differences. Better experiences were associated with viewing the supervisor as more interpersonally attractive, trustworthy, and expert. Wetchler’s (1989) results with marriage and family therapists highlighted the importance of interpersonal skills including respect, helping the supervisee assess his/her own strengths and growth areas, and encouraging the development of personal style.
In family therapy supervision, Liddle, Davidson, and Barrett (1988) described criteria for supervisor competence correlated with supervisee satisfaction. These included supervisor’s relationship skills (humor, sensitivity, communication, respect, challenge, support, and enthusiasm); supervisory feedback; supervisor’s conceptualization ability; supervisor as role model; and a supervisor who can provide:
There is some suggestion that what was viewed as best at the time of supervision may not persist over time, but may in fact be replaced by alternate supervisors. Close to the time of supervision, those rated best might be those who were warm, supportive, and congenial. However, in retrospect, if the same individuals were interviewed years later, they might view as best those supervisors who were strict, demanding, and challenging, even though at the time of supervision, they seemed more difficult and perhaps unduly rigorous or demanding.
What emerges is that supervisees view as “best” a supervisor who focuses on supervisee personal development and enhanced self-understanding, while creating a safe environment for risk-taking.
Many supervisees can remember more “worst” than “best” supervision situations. Some of the worst seem to be very memorable.
Worst experiences were more diffuse and difficult to define – no single characteristic was identified as critically important in a majority of worst experiences. It seems to be characterized by what the supervisor failed to provide rather than by what actually occurred. Exceptions are authoritarian, unethical, or sexist behaviors by supervisors. Other cited supervisor behaviors included disrespect; distance; disinterest; preoccupation with the supervisor’s own process, cases, insights, or personal dilemmas; failure to assess supervisee developmental level and act appropriately; and insensitivity to the supervisee (Falender & Shafranske, 2004: Magnuson, Wilcoxon, & Norem, 2000).
Communication is central to best and worst supervision.
(Neufeldt, Beutler, and Banchero, 1997)
Unfortunately, there is still an abundance of substandard or even harmful supervision, defined as supervision that inflicted emotional or even physical harm upon the supervisee. Supervisor shaming, ridiculing, stigmatizing, and touching inappropriately all fall within the category of harmful. Ellis et al. (2009). In his most recent study, Ellis and colleagues (2014) reported 90 percent of supervisees indicated they had experienced at least one instance of harmful supervision. Examples included the supervisor threatening the supervisee physically, having a sexual relationship with the supervisee, sharing drugs, or being aggressive or abusive with the supervisee. These examples and this study reinforce the clear and urgent need for training in clinical supervision and for guidelines that provide for appropriate practice.
Supervisors are generally poor at identifying when strain or conflict arises in the supervision relationship. When conflict arose, the worst-case scenario was when supervisors did not initiate discussion of the conflict or move towards some type of resolution so that supervisees engaged in “spurious compliance” or essentially not telling supervisors what they were actually doing, but pretending to be following supervisory directives (Moskowitz & Rupert, 1983). This is the worst-case outcome of supervision as the supervisor is legally and ethically responsible. This will be discussed further in the legal and ethical section; respondeat superior is the ultimate legal responsibility of the supervisor.
Worthen and McNeill (1996) investigated “good” supervision events. There is a fragile and fluctuating level of confidence and a generalized state of disillusionment and demoralization with the efficacy of providing therapeutic interventions – supervisees may be anxious and sensitive to supervisor evaluation.
Anxiety level actually decreased when supervisors helped to normalize struggles as part of the ongoing developmental progression. This is especially powerful as a supervisor self-disclosure. (Example: “I remember the first time I had to give a family a diagnosis of autism for their child whom they thought was gifted.”) These authors characterized the good supervisory relationship as empathic, nonjudgmental, validating, and with encouragement to explore and experiment. This set the stage for nondefensive analysis by the dyad, as confidence in the relationship was strengthened. In addition, supervisees reported an increased perception of therapeutic complexity, expanded ability for therapeutic conceptualizing and intervening, positive anticipation to reengage in previous difficulties and issues with which they had struggled, and a strengthening of the supervisory alliance.
(McNeill and Worthen, 1989)
Social work supervisees and supervisors concurred that giving a low to supervision, interruptions in the supervision, and ineptness in exercising administrative authority are what is wrong in social work supervision (Kadushin, 1992). In a social work supervisee study, Rosenblatt & Mayer (1975) described objectionable supervisors as those who limited supervisee’s autonomy; failed to provide adequate direction or clarity; were cold, aloof, and/or hostile; and contributed to student stress. They identified objectionable styles that included constrictive, amorphous, unsupportive, and therapeutic supervision. For marriage and family therapy supervisees, the worst experiences were marked by an emphasis on weaknesses and shortcomings of the students, encouraging unthinking conformity, and intolerance for divergent viewpoints (Anderson, Schlossberg, & Rigazio-Digilio, 2000).
Before you begin this section, think about your preferred supervisory format. Do you meet one-to-one with your supervisee? Observe behind a one-way mirror? Conduct group supervision? The majority of supervision occurs in the case consultation model: a supervisor meeting individually with a supervisee, and the supervisee reporting a synopsis or some data from the clinical session. Whether 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 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 frame is used, Competency Benchmarks provides the essential framework for formative feedback and bridges the gap for supervisees – removing the surprise of corrective competence feedback being introduced at the 4 or 6 month point with no previous notice or opportunity for the supervisee to address and improve.
Derived from Liese & Beck, 1997; p. 121
We find that supervisees find structure, not necessarily all of these steps, but 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 framework for productive supervision that is comprehensive. (See Falender & Shafranske, 2012 for specific examples and protocols.)
For excellent supervision to occur, it is important to have:
(Falender & Shafranske, 2004)
Although multicultural competence is a necessity in supervision, supervisees continue to find it an area of uneven competence or deficit in their supervisors (e.g., Falender, Shafranske, & Falicov, 2014; Jernigan et al., 2010; Singh & Chun, 2010).
Falicov (2014 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 in 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- and underinvolvement 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, and other forms of powerlessness, underrepresentation, lack of entitlement, and access to resources.
Family organization – consideration of 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 influence of the extended family or elders.
Family Life cycle included the timing of stages and transitions, the constructions of age-appropriate behavior, various growth mechanisms, and life cycle rituals and rites to name a few. Therapists’ understanding of similarities and differences between themselves and their clients, shaped in part by nationality, social class, or religion, regarding life cycle 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, 2014 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 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, self-assess in this vital area and be particularly mindful of your 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’s 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 relationship prior to difficult feedback to their supervisees. Supervisor feedback often focused on supervisee lack of sensitivity to cultural issues or that interpersonal style (e.g., directness) was interfering with the client alliance. Supervisors reported fearfulness of imposing own culture or injuring the supervisee, but ultimately found there were positive results of difficult feedback.
Kadushin (1968) wrote extensively about the games supervisors and supervisees play in the supervision process. In these, communication leads off the supervision track into areas that will be discussed more extensively in the section on legal and ethical considerations. In one situation, the supervisee praises the supervisor’s extensive knowledge and skill, discloses the reverence with which she holds the supervisor, and as a result has elevated the supervisor to a position in which he is infallible, thus interfering with supervision. In another, the supervisee tells the supervisor that she views the supervisor as a wise parent, and would like to get some of that parental advice on a pressing issue she is now facing. This would cross the boundary of supervision. In another, the supervisee or supervisor tells the other that he is hungry as supervision is so close to the lunch hour, and wouldn’t it be great to walk down to the coffee shop to get a snack. It is impossible to discuss cases on the walk, at the cafe, or on the way back, so personal issues are discussed, and the supervisory relationship morphs to one of friendship – and no supervision occurs as the hour is over by the time they return. There are numerous combinations and permutations of these dances, some supervisee-initiated and some supervisor-initiated, albeit not intentionally.
Developmental variables are important – the stages of the intern and supervisor’s development, personal and personality factors, theoretical dimensions, perceived competence and expertise, clinical approach and technique, degree of structure, communication style, and the supervisor’s attitude towards the supervisee. What is necessary for adequate supervision, and what dimensions are associated with the most highly rated supervision? What is the role of the supervisee in the process of achieving optimal supervision? To address aspects of supervisor competence for adequate supervision, the following are some characteristics marking such performance:
Attributes of the supervisor, relationship aspects, behavior of supervisor towards supervisee, clinical competence, and facilitative factors are categories of variables associated with “better supervision.”
Shanfield et al. (1989) devised an inventory for use with supervisees to assess the supervisory session. They urged analysis of the following qualities of the supervisory hour and reflection on these with the supervisee.
Another framework for analysis is provided by Milne, Pilkington, Gracie, & James (2003). The following categories are among those that they used in the analysis of effectiveness:
Although these researchers were looking for transfers from supervisory interventions to the therapy setting, this type of analysis or 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 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 towards use of a broader range of behaviors, including those that are more constructive for the supervision experience.
Think about critical incidents that have occurred for you in supervision – times in which things have happened that stand out in your memory as being very problematic. Think about any times when there might have been conflict between you and the supervisee.
In supervision, there are times when there is covert conflict between supervisor and supervisee. In many instances, one or the other is not aware of the conflict and – because of the power differential – it is extremely difficult for the supervisee to raise it in supervision. Supervisors have varying degrees of comfort with power differential and discuss it accordingly. If supervision is structured to be unidirectional, from supervisor to supervisee, there is clarity in the tradition of top-down supervision. However, supervision is increasingly envisioned as, at least to some extent, bi-directional, with the supervisee and supervisor mutually influencing the other and creating a dialogue. It is very important to insert discussion of the nature of the power differential, as it has not vanished. The supervisor still is the legally responsible entity for all supervision and for the welfare of the client. As such, establishing parameters of legal and ethical responsibility, as well as the significant gatekeeping responsibility to the field, must be discussed. Gatekeeping refers to the supervisor’s responsibility to ensure that particular competencies have been met to responsibly allow the supervisee to progress to the next level of training or practice. Within the gatekeeping function is the evaluative one – that the supervisor must systematically evaluate the supervisee according to a format previously disclosed to the supervisee (See 7.06 in the Ethical Principles of Psychologists and Code of Conduct (2010)).
There is some evidence that sheer role conflict is a major source of discomfort amongst supervisees. Moskowitz and Rupert (1983) surveyed practicum students and found that over 1/3 reported they had experienced a major conflict with their supervisor. Although many of the supervisees in the study did initiate discussion with the supervisor, less than half of those who experienced conflict ultimately experienced improvement.
The power differential is such that supervisees may be fearful that such discussions would be reflected in their evaluations, be personalized to the interaction, or simply would be hopeless.
Moskowitz and Rupert (1983), supporting results by Rosenblatt and Mayer (1975), found that some of the students engaged in spurious compliance, or pretending to follow supervisory directives while in fact doing whatever they thought to be correct. They concealed relevant information, especially their personal feelings. This might be manifested in distortion of progress notes. This is a terrible outcome for supervisors as they hold legal responsibility for the actions of the supervisee. Spurious compliance is something to be avoided through enhanced communication and sensitivity to the supervisee. It is also important for the supervisor to take the initiative in identifying and exploring the conflict, and to be receptive to discussion should a supervisee raise the subject. This is one of many areas in which the supervisor bears responsibility. In cases where conflicts were addressed, there was good resolution in many cases and a positive learning experience that strengthened the supervisory alliance.
Another responsibility relating to conflict for the supervisor is to disclose possible conflicting roles that the supervisor may carry out in the training setting, or outside, and anticipate what conflicts might arise as a function of these. Thus, for example, if the supervisor were in a very small rural area, and had the potential for multiple relationships with clients of the supervisee, it would be important to discuss these, to direct the supervisee to current literature on the subject, and to devise strategies or general guidelines of how this would be approached if it were to arise.
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 supervisors did not disclose negative reactions to supervisee’s therapy and professional performance, which may occur because the supervisor may be considering the supervisee’s developmental trajectory, and possibly end up placing it above that of client welfare. Another rationale for nondisclosure was that it was addressed nondirectively.
Another area where supervisors did not disclose was their negative reactions to supervisee’s supervision performance. This was a less frequent type of nondisclosure. Ladany and Melincoff (1999) suggested that nonconfrontation of supervisee problematic supervision performance may impede supervisee growth. It may also be associated with supervisees who are later identified as having significantly problematic behavior.
A third category of nondisclosure was the supervisee’s personal issues. It would be critical to be respectful of the supervisee’s privacy, and of not crossing the line to convert supervision into therapy, while at the same time being mindful of supervisory responsibility for addressing how supervisee issues may be 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. Rationale for not disclosing included that the supervisee need not be privy to supervisor insecurity, however it was highly recommended that supervisors seek consultation to distinguish his/her issues from those related to the supervisee.
The fifth category was dynamics of the training site. These nondisclosures were viewed as appropriate boundary setting. Next were supervisors’ clinical and professional issues. The authors indicated that it would be important to balance keeping professional boundaries and professional mentoring in this category. Supervisee appearance was another category, and should be addressed if it is affecting the supervisory alliance or the therapeutic relationship with the client. Positive reactions to the supervisee’s therapeutic and professional 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 a significant literature on supervisee nondisclosures. Supervisees have significant power over what they disclose in supervision, especially when sessions are not videotaped or audiotaped. The most frequent type of supervision practiced is individual case consultation in which the supervisee describes his/her impressions of the therapy session. Supervisees may disclose certain aspects of the session to the exclusion of others.
Yourman and Farber (1996) reported that 60% of their (small) sample never or rarely failed to tell supervisors of what they perceived to be clinical errors, but about 40% said they distorted reports. Forty-seven percent of the sample said they told supervisors what they wanted to hear fairly frequently, and nearly 60% said they generally felt uncomfortable disclosing negative feelings toward their supervisor. Yourman and Farber summarized that, in instances with a high potential for shame, such as acknowledging they made an error or disagreeing with the supervisor, over 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, Ladany, Hill, Corbett, and Nutt (1996), categories were developed. Categories not disclosed to the supervisor were:
Supervisees reported a mean of eight nondisclosures of moderate importance during the course of supervision to date, and that almost all (97% of this sample) of supervisees withhold some information from their supervisors.
Many reasons were given for not disclosing, including not thinking the information was important, it was too personal, negative feelings about the nondisclosure, alliance difficulty with the supervisor, worry about the impression it would make on the supervisor, or deference to the supervisor.
Generally, it is important for supervisors to be aware of the categories of behavior supervisees AND supervisors do not disclose and to be thoughtful and proactive in interactions about this. A useful technique is to introduce this information during supervision and process it with supervisees to increase openness and potential for discussion.
Red flags and warning signs of conflict or other difficulty in supervision:
The supervisor is responsible for identification of warning signs and initiating discussion. Garrett, Borders, Crutchfield, Torres-Rivera, Brotherton, and Curtis (2001) suggested the use of supervisory statements like “I’m sensing some tension right now between us. I’m wondering if you are experiencing it too, and what sense you make out of it” (p. 153).
In a small sample (N=12), supervisees reported generally positive effects when supervisors disclosed regarding personal information or clinical experiences when supervisees perceived 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.
A counterproductive event takes place when a supervisee perceives the supervisor to be less than helpful, hindering, or even harmful (Gray, Ladany, Walker, and Ancis, 2001). Categories that Gray et al. described included the supervisor dismissing supervisee’s feelings or ideas, or being unempathic.
An example that comes to mind was that of a supervisee who was terminating a case management case, and was calling the family to schedule the last session after the family had cancelled. She reached the father on the phone. He commenced to tell her how attractive she was, and said that now that therapy would be ending, he wanted to take her out to a play or to dance, and would like to have a date after the last session with his child. The supervisee was shocked and quickly said, “No,” but was unsure how to proceed beyond telling him that would not be appropriate at all. She told him she needed to talk to her supervisor and would get back to him, but that she definitely could not go out with him – that that is strictly prohibited. The supervisee called her supervisor to let her know of the incident; the supervisor responded very unempathically to the supervisee’s sense of overwhelm, stating that she could not understand what the supervisee was so shocked about, that that is predictable behavior, she should have expected it to happen sometime, and that he was even more shocked at how the supervisee had handled it. This left the supervisee feeling lost, alone, and completely overwhelmed as well as uncertain what it was she had done wrong besides disclosing to her supervisor her feelings.
A response that would not have led to a counterproductive interaction would have been for the supervisor to empathize with the surprise of the supervisee, to discuss the fact that client sexual attraction to therapists is in fact a common phenomenon, to praise the supervisee for setting a clear limit, and to advise her on the next steps to finish the case and complete the transfer or closing, including how to deal with the father in the final session if he was present. A big part of this would be processing the supervisee’s feelings and, while keeping it in the context of the client interaction, problem-solve about what made the interaction so shocking, and how the supervisee could move ahead to feel more prepared to see this father and others in the future when this could happen. It would also be important to analyze the interaction in terms of what transpired and what the supervisee wished she had done, if there was anything she so wished.
Other analyses of critical issues in supervision highlight that relationship issues and personal issues may not be adequately addressed in some models of supervision. Ellis (1991) found that issues of relationship, competence, emotional awareness, autonomy, and personal issues were all identified as critical issues. In contrast, issues of identity, individual differences, ethics, and personal motivation were only infrequently identified as critical issues. It would appear that these findings are supportive of developmental models in that self-esteem, and general competence and individuation considerations are central to development of the supervisee.
Critical incidents may arise from a wide variety of events, but there are predictable areas for which to be vigilant and sensitive.
Many of the instances referred to as counterproductive or critical situations reflect supervisee or supervisor countertransference. We now know that personal and professional sources influence the course of behavior, treatment, and supervision – and become intertwined. Our conscious beliefs, cultural- and diversity-embedded values, and unresolved conflicts are all interwoven (Falender & Shafranske, 2004). 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 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 towards exploration of factors relating to the supervisee’s relationships and life apart from reactions to and feelings about the client, the supervisor should stop, rethink, and consider alternatives. This would definitely be the case should the supervisee present a pattern of countertransference (angry with the father in every family case, for example), should the supervisee have reactions which interfere with his/her ability to conduct therapy, or have reactions to which it would be inappropriate to expose the client (crying whenever child abuse is mentioned, for example). 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.
Discussion of countertransference or reactivity is an incredibly useful tool, but always within the boundaries of supervision. In order to approach the countertransference issue, it is important to help the supervisee return to a reflective stance from a more reactive one. Once in the more reflective position, it will be more possible to proceed to assess and consider the countertransference.
Counterproductive events may result in strains or ruptures in the supervisory alliance. Strains may be brought about by challenges inherent in training, conflicts in how goals or tasks of supervision are seen, inadequate attention by one or the other to superordinate values, inadequate technical competence by supervisor or supervisee, boundary crossings or violations, supervisee behavior viewed as problematic, or countertransference and parallel process phenomena (Falender & Shafranske, 2004). Indicators of strains in the alliance include supervisee behavior changes such as withdrawal, decrease in disclosure or supervisory interaction, display of hostility or criticism, or passivity or noncompliance (Falender & Shafranske, 2004). Often in the course of the strain, one or both parties become increasingly rigid, controlling or critical, placing additional strain on the supervisory relationship. Thus, the relationship cycles downward in a negative spiral, resulting in a supervisory alliance rupture.
An interesting approach is 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 confident to 5 extremely confident.
Over the next 3 months, how confident are you that you can successfully prevent issues in the following areas from reducing the effectiveness of supervision?
Over the next 3 months, how confident are you that you can:
(Kavanagh, Spence, Strong, Wilson, Struck, & Crow, 2003, p. 99)
Safran and Muran (2000) described a process of metacommunication in which the supervisor and supervisee attend to the rupture marker, explore the rupture experience, and explore the avoidance. Then, the supervisee asserts and the supervisor validates the assertion. Both may step back from the process and approach it more objectively in order to return to a reflective state. It is critical to address strains and ruptures as quickly as possible. Due to the power differential, it is the responsibility of the supervisor 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.
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 have great difficulty. He wonders if there is a connection.
Using the concepts described above, think about hypotheses about what could have happened and what steps should be taken at this point.
What was the rupture marker? How could you explore this? How would you approach avoidance?
An area of training that has been much neglected is that of diversity competence even though it is an ethical standard.
Ethical Principles of Psychologists and Code of Conduct (APA, 2010):
Principle D: “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices” (APA, 2010)
Principle E: “…Psychologists are aware of and respect cultural, individual, and role differences including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.” (APA, 2010)
2.01b: “Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals…” (APA, 2010).
In addition, there are the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003, 2008), containing prescriptive statements regarding the necessity for cultural competence.
It is important to be knowledgeable about the American Psychological Association guidelines: Guidelines for Psychological Practice with Older Adults (APA, 2003), and Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual clients (APA, 2011).
For social workers, the NASW Code of Ethics 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 knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' cultures and to differences among people and cultural groups.
(c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or physical disability.
3.01 Supervision and Consultation
(b) Social workers who provide supervision or consultation are responsible for setting clear, appropriate, and culturally sensitive boundaries.
Ethical standards and multicultural guidelines notwithstanding, there is some evidence that therapists are continuing to provide services to some clients they do not feel competent to treat (Allison, Echemendia, Crawford, & Robinson, 1996, surveying 90% Caucasian respondents) and that supervisors’ knowledge, skills, and values relating to diversity may not be as sophisticated as is that of their supervisees (Falender & Shafranske, 2004), and that supervisors’ perceptions of their efforts to integrate diversity into supervision may not be in total agreement with the supervisees’ perceptions of the same. Hansen, Randazzo, Schwartz, Marshall, Kalis, Frazier et al., 2006 suggested that we do not necessarily practice what we preach. In a sample of practitioners, they found that even though the majority self-assessed as culturally competent, they often did not follow the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003). For example, they did not necessarily seek out consultation when they felt they did not have adequate cultural knowledge or expertise. Duan and Roehlke (2001) showed how the competence differential between supervisor and supervisee might play out: 93% of the supervisors in their sample reported they had acknowledged their lack of cross-racial supervision experience to their supervisees but only 50% of the supervisees reported receiving the acknowledgment. A smaller differential in the same direction was reported between supervisor and supervisee perceptions of initiating discussion of cultural differences in general.
It is important to consider 7.04 Student Disclosure of Personal Information from the Ethical Principles of Psychologists and Code of Conduct (APA, 2010).
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).
Brown and Landrum-Brown (1995) suggested, “A supervisor’s cultural frame of reference, or worldview, is likely to influence, for example, the therapeutic choices made by supervisees and their supervisors. Furthermore, we argue that worldview conflicts between supervisees and supervisors may be reflected in the evaluation of the supervisee, in the quality of the supervisory relationship, and in each party’s therapeutic approach.” (p. 263-4)
That pervasive quality, supervisor worldview – with biases, assumptions, and belief structures – is an incredibly important component of supervision but one that is often neglected or at least not given a central place in supervision practice.
The supervisory question becomes how to increase diversity competence and multicultural competence in supervision. In addition to the ethical standard, there is the reality that ethnic and social diversity is increasing dramatically and that mental health training is based on Eurocentric perspectives (Daniel, Roysircar, Abeles, & Boyd, 2004). Increasingly, it appears that we need to move from culture as an “add-on” to culture as a driving force in practice models. This entails a shift from cultural content to context, moving focus from the client to the interaction between client and therapist and the process of that (Vargas, 2004). This may result in shifting conceptualization of the problem exclusively from the individual to recognition of social justice and contextual factors. Further, infusion of diversity into training, rather than placing consideration into a specific seminar on the topic, is more useful and communicates a message of integration and inclusion, assisting supervisees in broadening their perspectives, investigating their own feelings and assumptions, and applying these to clinical cases.
A primary issue is self-awareness. Most of the multicultural frameworks (Sue, Arredondo, and McDavis, 1992) consider self-awareness to be an essential first step in the process of becoming more culturally competent. There are multiple deterrents to enhanced self-awareness including the fact that white therapists may not consider themselves to have a culture or if they do, they question whether it is relevant. There is also disregard of white privilege – and as long as it is disregarded, the multiple power differentials in the therapy equation are disregarded. Self-awareness has not traditionally been a part of training programs. As if therapy were value-free – a premise long discounted – training programs have not attended to what values, assumptions, and belief structures each of us brings to our practice of therapy and supervision.
A second key deterrent is resistance to content, i.e., believing there are no differences among ethnic groups, or feeling a lack of safety in discussing diversity or culture.
A third deterrent is neglecting the concept of ecological niches or diversity as an important part of the equation. What are ecological niches? Think of all the descriptors that go into your identity.
For example, gender, religion, profession, sexual 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.
Beyond lack of comfort with the discussion or self-disclosure, deterrents to multicultural competence also include differing developmental levels of supervisor and supervisee in:
Scales of multicultural competence that are useful for assessment include:
Scale Name and Authors
Sample Item and/or scales
Multicultural Counseling Knowledge and Awareness Scale (Ponterotto et al, 2002) or Multicultural Counseling Awareness Scale-Form B (Ponterotto et al., 1996)
Measures general knowledge and Eurocentric worldview bias
Multicultural Counseling Inventory
(Sodowsky, Taffe, Gutkin, and Wise, 1994)
“When working with minority clients I am able to quickly recognize and recover from cultural mistakes or misunderstandings:”
“My life experiences with minority individuals are extensive (e.g., lack of bilingual staff, multiculturally skilled counselors, and outpatient counseling facilities).”
“When working with minority clients I find that differences between my worldviews and those of the clients impede the counseling process.”
Multicultural Counseling Skills, Multicultural Awareness, Multicultural Counseling Knowledge, and Multicultural Counseling Relationship. (Sodowsky, Taffe, Gutkin, & Wise, 1994)
Multicultural Awareness/ Knowledge/ and Skills Survey (D’Andrea et al., 1991)
“Psychological problems vary with the culture of the client.”
Assesses awareness of personal attitudes towards people of color; knowledge about populations, and communication skills,
Cross-cultural Counseling Inventory Revised (LaFromboise et al., 1991)
“Counselor is willing to suggest referral when cultural differences are extensive.”
Subscales: Cross-cultural counseling skill, sociopolitical awareness, cultural sensitivity.
Also useful is self-assessment such as a scale developed by Gargi Roysircar (2004). With this scale, both supervisor and supervisee can identify beliefs and attitudes, knowledge, skills, privilege, internal and external feedback, inter-ethnic countertransference, multicultural awareness, and multicultural counseling relationship.
An important aspect of diversity competent supervision is to draw from positive psychology and take a strength-based approach. In this situation, supervisor and supervisee determine individual and collaborative strengths upon which to build. Similarly, the client is approached from a strength-based perspective. Much of community mental health and mental health in general is focused primarily upon deficits or problems, which must be documented to justify services, while attention to strengths and individual factors in each party are ignored or neglected.
Gonzales (1997) has proposed conceptualizing the supervisor as “partial learner,” which places supervisor and supervisee in a collaborative stance. This is similar to the DBT stance described earlier, in which the supervisor is viewed as fallible. Both of these remove some of the distance between supervisor and supervisee, and allow for a more direct cultural and clinical discussion and mutual problem solving.
It is important to maintain a balance between knowledge leading to stereotypes versus openness to learning and acquisition of knowledge and skills that are sensitive to individual cultural niches. Cultural niche refers to consideration of an individual as multiply determined culturally; for example, I am a female, Caucasian, heterosexual, psychologist, mother – to isolate one of these factors would not be an accurate portrayal of me in my entirety. Increasingly, mental health professionals are considering multiple factors in proceeding with treatment and supervision rather than simply pulling out one, “African-American” for example, and proceeding on stereotyped knowledge acquired about that group which may or may not be relevant to the individual being treated. It might be more relevant that the individual is gay, single, Buddhist, or visually impaired.
There is the danger of over-attention to diversity to the exclusion of good clinical practice. Excellent practice leads to a balance among the factors, and an understanding of how each factor contributes to an individual’s sense of self. Underlying trust in the relationship will lead to cultural understanding.
Writing about working with gay, lesbian and bisexual clients, Bruss, Brack, Brack, Glickauf-Hughes, and O’Leary (1997) suggested the supervisor assess the supervisee’s level of functioning, being particularly vigilant for inadequate information, anti-gay attitudes, attribution of all problems to sexual identity, and considering family/intimacy issues in heterosexual terms (from Buhrke & Douce, 1991). Supervisor self-awareness is critical as well as is willingness to explore countertransference. When gay and lesbian clients were asked about what they wished their therapist understood, they responded that they wished therapists had greater knowledge of how gay and lesbian relationships are invisible, about the coming-out process and how it is not linear, effects of homophobia, and generally the history of gay rights and social action (Biaggio, Orchard, Larson, Petrino, & Mihara, 2003). In addition, therapists should have knowledge of the “Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients” (APA, 2000). Understanding one’s own feelings towards gay, lesbian, transsexual, and bisexual clients is an important first step.
If a supervisee self-identifies, it is important for the supervisor not to view him as an exemplar of that particular group or as an expert. Instead, this should be considered in the equation of client, supervisee, and supervisor characteristics that may influence assumptions, biases, and directions in therapy.
Framing language to begin supervision is an excellent step. It is recommended that the supervisor take responsibility for the initiation of discussion of multicultural issues in supervision. This includes taking responsibility for having awareness and knowledge of one’s own multiple cultural/diversity identities – and having addressed the emotional components. This also entails discovering values, beliefs, biases, and prejudices present in our assumptions about the world, our perceptions, and our actions.
Page and Wosket (2001, p. 212) suggested questions like, “What would you like me to know that would help me to work most effectively with you?” and “What differences between us might we need to address as our relationship develops?”
Other options include general statements about how important differences in background and culture might be to the supervision, and how critical it is to discuss these. One way of highlighting this is expression of interest in understanding and knowing values, traditions, and worldviews (Daniels et al., 1999).
For individuals in a formal training program, describing a training sequence in materials that supervisees receive before selecting the setting (providing informed consent), one can have a seminar or several orientation sessions relating to culture and diversity in order to set the tone. One model was described by Wisnia and Falender (1999) in which supervisors model describing one aspect of their cultural/diversity experience, using a framework derived from Falicov (1998):
Worldview refers to the entire set of an individual’s guiding beliefs, values, logic, concepts of reality, and even concept of self.
Falender and Shafranske (2004) urged consideration of the culture and diversity variables of all parties including client(s), supervisee, and supervisor, and to consider how each of these are consonant and dissonant – all of which casts significant light on the supervision process and direction of therapy.
Using the Wisnia and Falender (1999) framework, each participant chooses one aspect of his/her diversity niche from the above eight possibilities and presents this to the group. The presentation can be an oral presentation, story, objects, video, food, or a combination. Through this sharing, a tone of appropriate self-disclosure and sharing is set, which is then tied to case material. Self-disclosure does carry with it risks, especially as the supervisor is also the evaluator, and information disclosed may end up being used for evaluative purposes.
Vignette: The client is a 37-year-old African-American woman whose parents moved to California from the South. She is in therapy because she is depressed and she is feeling that she is not being promoted at work because her boss is racist. Her therapist, the supervisee, is a 25-year-old intern who was born in Puerto Rico and has lived in Southern California since high school. The supervisor is a 58-year-old Anglo woman.
Consider the cultural complexity by comparing each dimension of client-supervisee-supervisor in terms of worldview, migration, place in the family life cycle, ethnicity, and hypotheses about how different belief structures or perspectives, and privilege and oppression, may affect a therapeutic approach.
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 white 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 discount the client’s belief that she is not being promoted because of racism, but the supervisee believed strongly that was a significant factor, a strain or rupture could be introduced in all levels of the therapy and supervision, which would ultimately harm the client.
There is no separate supervision code of ethics that has been adopted by the APA, NASW, or AAMFT. However, there is a document available from the Canadian Psychological Association: Canadian Psychological Association Ethical Guidelines for Supervision in Psychology
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. In this section, there will be references to the ethics codes listed below when each of the codes has relevant standards. You may use these links to review your own profession’s code in further detail.
The most recent addition to the ethics codes is the Universal Declaration of Ethical Principles for Psychologists which was drafted by an important group of international practitioners and which has been endorsed by the Canadian Psychological Association.
Ethical Codes by Discipline:
For Psychologists, the Ethical Principles of Psychologists and Code of Conduct was amended in 2010. Be sure you have the current document.
MFTs by the AAMFT Code of Ethics (2015)
Other ethical standards include:
In the contract or supervisory 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. Many regulations and practices are state specific as well.
Click here for 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.
Ethical prescriptions are integrally yoked to legal requirements. Ethical codes and principles can often form the basis for legal liability. Even when there is no direct connection, the lack of adherence to ethical norms of behavior can color decision-makers’ actions.
To differentiate ethical from legal decision-making, Stromberg et al. (1988) distinguished ethical categories from legal decision-making categories. These categories are important for general understanding and need to be communicated to supervisees:
In instances when ethics and law conflict, “the degree of the psychologist’s understanding of and ability to evaluate professional principles and practice guidelines as well as the laws governing practice, concern for the client, and the circumstances must be examined in resolving to his or her satisfaction what must be done” (Bennett et al., 1990).
The APA Ethical Principles and Code of Ethics (2010) states:
“If psychologists’ ethical responsibilities conflict with law, regulations or other governing legal authority, psychologists make known their commitment to the Ethics Code and take steps to resolve the conflict. If the conflict is irresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority.” (1.02)
There are also issues of differing burden of proof across contexts. For example, it must be established that harm was done to the plaintiff for damages to be awarded in a malpractice suit. However, a licensing board can discipline professionals for improper conduct without harm having been inflicted. Licensing boards have a much broader range of admissible evidence (e.g., hearsay, prior acts) than does the court (Hansen and Goldberg, 1999).
Respondeat Superior refers to Vicarious Liability. This is a very important term for supervisors to understand as it applies to responsibility for supervisee actions. It is the legal term that refers to one individual holding a position of authority or direct control over another – a subordinate – and as such can be held legally liable for the damages a third individual suffered as a result of the negligence of the subordinate. Generally, clinical supervisors are legally liable for injury caused by the supervisee. Supervisory liability only typically occurs if the negligent acts of the supervisee occurred in the course and scope of the supervisory relationship. Relevant factors include:
(Disney & Stephens, 1994)
Bennett et al. (1990) described four criteria to be met for malpractice:
Keep in mind that there are two forms of supervisory liability:
Sometimes it is not so clear-cut between these two:
The supervisor is gatekeeper in that the supervisor holds power to pass or fail the supervisee by signing off on hours or completion certification, and the supervisor holds the power to protect the client. Supervisors must remember that their highest priority is duty to the client. They must balance responsibility to the training of the supervisee, but always maintain clarity about duty to the client’s safety and well being, with “doing no harm” the highest priority. Generally, supervisors should practice carefully, and be actively involved in supervision. If one makes an error in judgment under those circumstances, the risk is substantially less than for someone who has a history of negligent supervision.
Do supervisors always behave ethically? In one study (Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999), 51% of supervisees reported at least one ethical violation by their supervisor.
The following were the categories of perceived ethical violations:
Ladany et al. (1999) reported that about 35% of supervisees discussed their perceived ethical violations by the supervisor with the offending supervisor. Fifty-four percent discussed it with someone other than the supervisor – a peer, friend, significant other, another supervisor, therapist, professor, or relative.
A supervisor’s unethical behavior was associated with less satisfaction on the part of the supervisee with supervision. Greater supervisory unethical behavior was associated with lower goal and task agreement, and a lower emotional bond between supervisee and supervisor (Ladany et al., 1999).
In this context, with respect to the first category of perceived ethical violations, refer to Ethical Standards for Psychologists and Code of Conduct (2010):
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.
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 (2010)
LCSWs should be guided by the NASW Code of Ethics (2008), and
MFTs by the AAMFT Code of Ethics (2012)
or in California CAMFT (2009)
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 .) (APA, 2010)
There are the same duties to warn and adherence to all ethical and legal codes for the supervisee as for the supervisor as therapist.
Association of State and Provincial Psychology Boards (ASPPB) Supervision Task Force (2003):
Supervisors shall not permit supervisees to engage in psychological practice they cannot perform competently
Supervisor has the responsibility to interrupt or terminate supervisee activities whenever necessary to protect the public and insure adequate skill development
APA Ethical Principles of Psychologists and Code of Conduct (2010):
2.01 Boundaries of Competence
(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.
(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.
(c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.
(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.
(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.” (APA, 2010)
NASW Code of Ethics:
3.02 Education and Training
(a) Social workers who function as educators, field instructors for students, or trainers should provide instruction only within their areas of knowledge and competence and should provide instruction based on the most current information and knowledge available in the profession.
AAMFT Code of Ethics:
Principle IV. Responsibility to Students and Supervisees
4.4 Marriage and family therapists do not permit students or supervisees to perform or to hold themselves out as competent to perform professional services beyond their training, level of experience, and competence.
Supervisors should carefully ascertain at what level their supervisees are performing, and determine what cases are within their competence with what corresponding level of supervisory support.
Supervisors must have knowledge and skills regarding diversity and multiple niches of diversity. If supervisors self assess and determine they do not have the competencies needed, they take immediate action to gain education, training, supervised experience, etc., or they identify a more appropriate supervisor and transfer the supervision to that individual
In “emerging areas” of practice, if generally recognized standards do not exist, supervisors must take responsibility for ensuring safe and competent practice and protect their clients from harm. Supervisors of all disciplines must take care to supervise only in areas in which they have established competence and in compliance with their respective code of ethics.
Now that increasingly elaborate competency-based measures are available for determining supervisor competence and practicum student competence, supervisors have the responsibility of ensuring that those competency levels are met.
Supervisor competence refers to the body of knowledge, skills, and values regarding clients, modalities of treatment, theories of treatment AND supervisees, modalities of supervision, and theories of supervision.
From the Ethical Principles for Psychologists and Code of Conduct (APA, 2010):
4.02 Discussing the Limits of Confidentiality
(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent.)
(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.
(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.
NASW Code of Ethics:
1.02 Privacy and Confidentiality
(e) Social workers should discuss with clients and other interested parties the nature of confidentiality and limitations of clients' right to confidentiality. Social workers should review with 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:
Principle II. Confidentiality
2.1 Marriage and family therapists disclose to clients and other interested parties, as early as feasible in their professional contacts, the nature of confidentiality and possible limitations of the clients’ right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.
Supervisors have 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 to 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 are not private.
Ethical Principles of Psychologists and Code of Conduct (APA, 2010):
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, 2010)
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.
There should be prior agreement regarding expectations for professional functioning, evaluation procedures, criteria, and timing; communication to be expected through formative and summative feedback to remediate perceived performance deficits; communication with the graduate program including progress reports, concerns about development or other issues; development of an action plan for remediation; time lines and consequences of time line not being met; due process procedures for appeal; and time and procedure for responses to feedback.
One of the biggest mistakes supervisors make is not providing for due process – and not telling supervisees what will happen if they do not meet performance criteria – and what recourse they have.
This is the area of supervision relationships that has been most written about and addressed. It has been referred to as dual relationships or multiple relationships. Again, it is useful to review the 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.
3.02 Education and Training
(d) Social workers who function as educators or field instructors for students should not engage in any dual or multiple relationships with students in which there is a risk of exploitation or potential harm to the student. Social work educators and field instructors are responsible for setting clear, appropriate, and culturally sensitive boundaries.
AAMFT Code of Ethics:
Principle IV. Responsibility to Students and Supervisees
4.1 Marriage and family therapists are aware of their influential positions with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships that could impair professional objectivity or increase the risk of exploitation. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists take appropriate precautions.
Critical aspects of supervisor behavior include the avoidance of (1) exploitation, (2) impaired objectivity, and (3) exposing an individual to harm.
With respect to the specific category of 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:
2.07 Sexual Relationships
(a) Social workers who function as supervisors or educators should not engage in sexual activities or contact with supervisees, students, supervisees, or other colleagues over whom they exercise professional authority.
AAMFT Code of Ethics:
Principle IV. Responsibility to Students and Supervisees
4.3 Marriage and family therapists do not engage in sexual intimacy with students or supervisees during the evaluative or training relationship between the therapist and student or supervisee. Should a supervisor engage in sexual activity with a former supervisee, the burden of proof shifts to the supervisor to demonstrate that there has been no exploitation or injury to the supervisee.
Boundary crossings have been distinguished from boundary violations. Boundary crossings refer to those actions which depart from commonly accepted clinical practice and that may or may not benefit the client. Boundary violations refer to departures from accepted practice that place the client or the process of therapy at significant risk.
Examples of boundary crossings include accepting a gift from a client, going to lunch with a client, or in the case of supervision, accepting a gift from a supervisee or engaging in social activities with a supervisee.
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).
Examples of supervisor boundary-crossing are touching (a supervisor hugging a supervisee) or 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 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 lunch. The supervisee has tried not eating (supervisor will not accept this), ordering inexpensive foods (supervisor splits the bill with the supervisee and orders more expensive foods), and asking if the supervisory hour could be changed (supervisor refused citing lack of other available times.) The supervisee feels violated, as he cannot afford expensive lunches, feels he is sacrificing adequate supervision as he cannot discuss his cases (ethically) in a public place, and feels totally trapped and if he protests too much, it may 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 (a) gives no response with a continuation of the offensive behavior, (b) chides and minimizes turning it into the supervisee’s oversensitivity, (c) a negative response of defensiveness or anger that may distort other aspects of the supervisory relationship. In the case of the Facebook request, the supervisee might be concerned that the supervisor would then be able to access the supervisee’s information, some of which the supervisee may not wish to share, but also access the supervisee’s network of friends.
Supervisors have the responsibility to behave ethically and to minimize boundary crossings. If boundary crossings occur, supervisors should consider the impact upon the supervisee and use problem solving frames below.
What, if any, multiple relationships are appropriate between supervisor and supervisee?
Using boundary crossings versus violations as a guideline, it is important to note that individuals who engage in boundary crossing may be at greater risk when later accused of a boundary violation (Gutheil & Gabbard, 1993). That is, engaging in behaviors that in of themselves are only crossings, such as hugging clients, going to dinner with an individual intern, or accepting presents from supervisees can be viewed in retrospect as a loosening of boundaries. The minor boundary violations, then, are part of a pattern of escalating violations along a slippery slope. Gutheil and Gabbard (1993) suggested consideration of:
Supervisors in rural areas have expressed concern about the impossibility of avoiding multiple relationships. The rule that has been proposed is for the relationships to be focused on informed consent and a thoughtful analysis of potential risks or exploitation of the client, and to involve the client in thinking through the relationships. An excellent resource that describes such boundary issues is written by Schank and Skovholt (2005).
Lazarus and Zur (2002) presented a thoughtful analysis of when dual relationships and boundary crossings are therapeutically indicated, and how, in this era of risk management, we have been unduly influenced by attorneys to be risk avoidant – in ways that may not be in the best interests of the client. They urge us not to let risk management considerations take precedence over providing the best possible clinical care to our clients. They argue that some multiple relationships are healthy and promote healing, and that demonizing them has harmed psychologists and the profession. It would seem that there should be some balance in this as in most areas of practice, with adherence to a thorough informed consent process and thoughtful analysis. Please note that 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, and the like.
It is useful to consider Bennett et al.’s (1990) caution that one must always consider what the therapist’s (or, in this case, supervisor’s) behavior means to the client (or supervisee). That is, a hug may be intended as a sign of support and empathy by the therapist (or supervisor), but may be interpreted as a sexual gesture by the client (or supervisee). In fact, when groups of supervisors are asked about their worst supervision experiences, they often refer to boundary issues of touching, back rubs, hugs, or kisses by supervisors who have no idea that the supervisee is feeling that these are boundary crossings or violations.
In fact, there has been a decrease in reported incidence of sexual behavior between clients and therapists, and low reported levels between supervisors and their supervisees (from 1.4-4%). The supervisees report the incidence as between 5 to 6% (Lamb, Catanzaro, & Moorman, 2003; summarized in Falender & Shafranske, 2004). Thus, there is a slightly higher report of sex between supervisor and supervisee by supervisees than by supervisors. Lamb, Catanzaro, and Moorman (2003) reported in their survey that only 3.5% of the 368 individuals who responded to the survey, or 13 individuals, had had one sexual boundary violation as a professional psychologist. In the case of the very small number of individuals who had a sexual boundary violation with a supervisee, all of them occurred after supervision had ended. Although a small sample, it is noteworthy that 40% of those surveyed did not view their involvement as harmful to the other individual.
Sexual advances, seductions, and/or harassment have reportedly been experienced by 3.6 to 48% of psychology and mental health-related students. Although most mental health educators believe it is unethical and/or poor practice to engage in sexual contact with a supervisee or student, especially during the working relationship, it appeared that such practices do occur. Many students (53% – n of 223) would not feel safe to pursue action if they had firsthand knowledge of a sexual contact occurring – due to fear of loss of anonymity and fear of repercussions (Zakrzewski, 2006).
Having sexual feelings or attraction toward a client at some point in one’s professional career is normative, and approximately 80-88% of psychologists report they have experienced those kinds of feelings (Blanchard & Lichtenberg, 1998). Over half of all psychologists reported that their training was not adequate in these matters (Pope, Keith-Spiegel, & Tabachnick, 1986).
In fact, it appears that many supervisees do not self-disclose or process sexual attraction unless the attraction is from the client directed towards the therapist. That type of disclosure is much more common and discussed. Reflect back on your supervisory experience and how many times a supervisee has ever disclosed sexual attraction to a client.
A good way to increase such discussions – as it is very important to process such information rather than allow for the possibility of it being acted upon – would be to provide the supervisee with some normative data or an article about sexual attraction. A book by Pope, Sonne, and Holroyd (1993), Sexual feelings in psychotherapy: Explorations for therapists and therapists in training, is an excellent resource.
Hamilton and Spruill (1999) conducted a retrospective analysis of two students who did engage in sex with their clients. They identified a number of commonalities and risk factors that are useful to consider. The students had been paraprofessionals before returning for graduate training and had had quasi-friendship relationships with their “clients” in those roles. They had moved from different parts of the country and were feeling isolated. Because of limited experience with therapy, they interpreted their clients’ statements of needing them, caring so much for them, etcetera very literally, rather than considering them as transference phenomena and bringing them to supervision (another reason to actively encourage discussion of sexual attraction in supervision). Hamilton and Spruill developed a checklist for risk management purposes of behaviors that are potentially problematic. They included therapists who extended the session regularly, scheduled sessions up to clinic closing time, dressed specially for the client, appeared very preoccupied with the client, failed to document phone calls or contacts or could not remember them.
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 for 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, 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 not necessary most likely, 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, 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.
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 in the Burian and Slimp framework, the same supervisor provided this analysis:
There is no apparent professional benefit to this; personal benefit could be to both. The present professional role is supervisor-supervisee (so it is a definite “No”). The location of the relationship is in the car, not in the office (a “no”). The intern might not be able to leave the activity without repercussion. This might have impact on the uninvolved interns feeling that one was receiving preferential treatment or developing a closer relationship and similar concerns with uninvolved staff members.
These are examples of the types of thought that should go into decisions about multiple relationships with supervisees.
Excellent general frameworks for decision-making are other tools for supervision. One developed by Barrett et al. (2003) has a first step of considering one’s own (add, one’s supervisor’s own) personal (emotional) reaction to the ethical issue. Another added step should be consideration of the role of diversity/cultural considerations in the decision. Koocher and Keith-Spiegel (1998) derived an ethical decision-making model from work by Tymchuk and Haas & Malouf.
Steps after the personal reaction and consideration of cultural/diversity factors are:
(Adapted from Koocher & Keith-Spiegel, 1998, 12-15)
Other relevant ethical standards
Ethical Guidelines for Supervision in Psychology:
This is an extremely important document, and is comprehensive in its approach to supervision and the ethical aspects involved. It has not been adopted by the American Psychological Association or other professional associations, but is widely adopted across Canada. Also available is the Resource Guide for Psychologists, Ethical Supervision in Teaching, Research, Practice, and Administration (Pettifor et al., 2009). It is a code of supervisory ethics, and it has been suggested that, should a suit be brought against a supervisor, it is likely that this and/or the Canadian Ethical Guidelines might be used as standards of care, even though they have not been adopted by the APA.
Other ethical standards include section 7 of the Ethical Principles and Code of Ethics of the American Psychological Association (2010) that 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.
There are some 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
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 towards 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.
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 be fearful to disclose or report due to the power differential and fear of consequences that could be personally detrimental to the supervisee. It is incumbent upon supervisors to ensure that such practices do not occur.
Prosenjit Poddar, who was born in Bengal, India, was a student at the University of California at Berkeley. At folk-dancing classes, he met Tatiana Tarasoff, with whom he fell in love. Although Tarasoff was friendly to him, she was not receptive to his overtures except for giving him a New Year’s Eve kiss. Eventually, she told him she was not interested in a relationship with him. He was devastated by the rejection, and all areas of his functioning were impacted including school, personal appearance, and mental health. Eventually, after Tarasoff had left the country for a trip, Poddar began mental health treatment as per a friend’s suggestion. He was interviewed by a psychiatrist, and eventually began treatment with a psychologist. When he disclosed to his therapist his intent to kill Tarasoff upon her return from her trip, his psychologist consulted with superiors in the department, and they agreed Poddar should be involuntarily committed to a psychiatric hospital. The psychologist informed the campus police and asked them to begin commitment proceedings. However, when they picked him up, Poddar did not appear disoriented or dangerous, and he promised to avoid contact with Tarasoff. Subsequently, Poddar discontinued therapy. When the head of the Department of Psychiatry learned of the police referral, he asked that the psychologist destroy his therapy notes and not attempt to contact Poddar. When Tarasoff returned from her trip, she was unaware of the danger posed by Poddar. In fact, Poddar had convinced Tarasoff’s brother to share an apartment with him. When Poddar went to Tarasoff’s house, she refused to see him, but he shot her with a pellet gun, pursued her, and fatally stabbed her with a knife. Poddar was convicted of second-degree murder, but later the ruling was reversed and Poddar returned to India.
Tarasoff’s parents filed a wrongful-death suit against the Regents of the University of California, which, in the second decision, resulted in a duty to protect and warn by a therapist out of the “special relationship” that exists between therapist and client. The duty to protect arises only when the victim has been identified, or could be identified, “upon a moment’s reflection.” Further, as part of the discharge of their duty, therapists may need to take multiple steps 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.
It requires supervisors to be knowledgeable and alert to the latest legal status of Tarasoff and its extensions. This varies state by state. For example, in California presently, the duty to warn and protect has been expanded through decisions in Ewing v. Goldstein, Ewing v. Northridge (2004), and Calderon v. Glick (2005) (all described in an article by Caudill in California Psychologist, 2006). Essentially, supervisors need to ensure that the extension of Tarasoff is reflected in informed consent, letting clients know that if a family member communicates to the therapist a threat the client has made, that may give rise to therapist duty to warn and protect. Supervisors bear responsibility for following the most recent updates on such laws.
This law requires supervisors to have procedures in place for when this or any other emergency or crisis situation arises so the supervisee knows exactly what steps to take to contact a supervisor and to systematically arrange to protect the client, the potential victim, and to appropriately fulfill the duty to warn 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 those who are in close proximity to individuals who have been threatened.
Because of the imminent danger, it may be necessary for the supervisor to be physically present with the supervisee or to arrange for another supervisor to do so to ensure complete coverage.
It is interesting that Slovenko (1980) stated that had the director of the clinic in the Tarasoff case interviewed the patient himself, and came to the determination he was not dangerous to self or others, there would have been no cause of action under foreseeability. This has specific implications for supervisors in this type of high-risk situation.
More recent developments include Ewing v Goldstein in the State of California in which 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. Additional information is available at http://www.apa.org.
Furthermore, duty to protect is the current appropriate interpretation rather than duty to warn and protect.
Ultimate responsibility for execution of Tarasoff lies with the supervisor – to ensure that identification, assessment, and appropriate action plans have been completed. This is part of Respondeat Superior.
In addition to a thorough understanding of Tarasoff, and the “duty to warn and protect, protect, and predict” (Behnke et al., 1998) (which includes reasonable attempts to communicate the threat that was expressed to the victim and the police, and developing action plans to manage and contain the client), supervisees should be trained in all aspects of risk and danger assessment. They should know how to conduct suicide risk assessments; have protocols for management of potentially violent clients, child abuse, and elder abuse; and the knowledge about 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 assessment, supervision and procedures to reach supervisors; steps to take; expectations; reporting to agencies; and follow-up. Training in graduate school is limited or nonexistent in most of these areas, even though supervisors in internship and practicum settings assume their incoming students have had the training. This creates a risk situation unless the actual level of competence of each student is assessed in these areas.
It is clearly highly traumatic for a supervisee to have a client suicide or make a significant attempt. This is traumatic for even the most experienced professional, and we know that supervisees are more vulnerable and that the effects of such a trauma are long-standing. Care should be taken in how the supervisee is informed of the fact, and of the type of processing and debriefing that occurs (Knox, Burkard, Jackson, Schaack, & Hess, 2006). Discussion of the impact and the therapeutic and legal issues is also available (Weiner, 2005).
Documentation is an important part of the supervisory process. It is important to keep some type of supervisory log so that the supervisor can record which cases were covered in the supervision session
There are legal issues associated with use of client names in supervisory records. It might be desirable to code numerically the names of the clients as the log is actually not about the client, but about the progress of supervision.
The supervisory log should include:
The importance of the log is to document that supervision did occur, that issues were addressed, and that the supervisor is maintaining a reasonable level of scrutiny and responsibility over the supervisee who is functioning under his 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 towards 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, and 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.
Every supervisor at some point is asked to write a letter of recommendation. This is a very difficult issue as it intersects with Human Resources Department guidelines, legal liability, and general issues about how the supervisor viewed the supervisee. In addition, there is a huge inflation in letters of recommendation, with most writers making statements like, “This supervisee was in the 99th percentile of any supervisee I supervised in my 30+ years of supervision.” When supervisors write multiple letters like this, besides defying statistical realities, it creates an environment in which, if a supervisor has legitimate concerns about an area of functioning of a supervisee (which is good, as everyone should be still developing and learning), 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 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 are discussing frankly with their supervisees exactly what they are and are not willing to write. This is an example of informed consent. Thus, in the case of a supervisee with specific difficulties, the supervisor might agree only to a standard letter stating that the supervisee was in 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 towards individuals writing letters of recommendation requiring an 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.
An element that has been shortchanged or ignored is the evaluative function, which provides a context and an ethical and professional structure to the relationship. It is also the sine qua non from the perspective of the universities, professional schools, and licensing bodies. To varying degrees, at all levels of training, the supervisee and supervisor are cognizant that the supervisor is a potent force in the supervisee’s future, in evaluation of specific competencies. Although there is ample literature on the supervisor’s aversion to evaluation (Robiner et al., 1993), this is not a justification for its omission from consideration as a factor. A limitation of some of the research in this area has been the failure to consider how the evaluative stance affects each step of the supervisee’s journey. Hansen (1965) described the limitations evaluation placed on supervisees’ expectations of supervisory relationships. Role ambiguity was defined by Olk and Friedlander (1992) as the supervisee’s uncertainty about how she would be evaluated and what the expectations were. Omission of consideration of the evaluation component was suggested as a possible explanation for poor predictive validity of the working alliance as a predictor of supervisory satisfaction (Ladany, Ellis & Friedlander, 1999). Clarity and communication of expectations are critical components underlying the relationship, and therefore the working alliance. Ellis and Ladany (1997) support the position that evaluation – being central and implicit to supervision – needs to be operationalized and incorporated into the research.
It is so interesting that psychologists, whose profession rests on assessment and methodology, have been so lax in the development of reliable and valid assessment devices for supervisee progress. Also interesting is that it is frequently reported that supervisees get no evaluation until the last day of their training sequence, and then get some negative feedback which had never been mentioned in the course of training. 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 in supervision (Ladany et al., 1999).
What are some of the reasons supervisors do not evaluate or, more specifically, do not give negative feedback? Robiner, Fuhrman, and Ristvedt (1993) described several categories of why supervisors are lenient in evaluation. First is the definition and measurement issue. Supervisors say that they are very concerned about the methodology, reliability, and validity of the scales or measures they use, or they are concerned that anecdotal feedback does not meet criteria for accurate assessment. Thus, for example, since many of the assessment forms in use simply ask the supervisor to list supervisee strengths, areas needing improvement, and several other general questions, there is no way to determine levels, to consider validity or reliability, or to conduct an adequate assessment. Second, supervisors are concerned with legal and administrative issues such as legal liability should the supervisee dispute the feedback (especially in light of the first concern, as they fear the feedback may not be defensible), or should their administrators be concerned or prohibit such feedback. For example, in some settings, for any employee to receive any type of merit increase, the feedback must be all exemplary. If a supervisee were to receive less than exemplary feedback, it might interfere with his/her limited stipend or merit increases. Supervisors also might fear that administrators would decide training is just too much trouble, and discontinue the whole training program, or choose another discipline of student to train, citing difficulties with the particular training program as evidenced by the negative feedback given. They might also be fearful of gaining a negative reputation in the training community for being too “tough” on students.
Third, supervisors may be concerned about interpersonal issues. This might include fears that the evaluation might be turned back upon the supervisor such that 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.
Summative evaluation, or the type of evaluation given to supervisees in written form during the training year, relates to a summary of progress and a type of grading. ASPPB (2003) has suggested summative evaluation be given four times during the training year, raising the bar for programs. Summative evaluation is typically a one-way process with the supervisor or supervisors imparting the evaluation to the supervisee.
Formative evaluation refers to feedback given on an ongoing basis to supervisees. It could take the form of praise or support (ironically, a process which appears to occur infrequently in much of supervision), or constructive feedback focused on analysis or suggestions. This would include, for example, thinking about what other options might have been helpful, wondering about the rationale for particular interventions, thinking more about process than content, affect rather than content, or generally refocusing the therapy process. Depending on the developmental level of the supervisee, the feedback may take different forms. For the beginning (Level 1) supervisee, the feedback could be very specific and directive, while for a more advanced supervisee, it could be more thoughtful and open-ended, resulting in a discussion of options.
An 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 described previously will be highly effective and will assist in bringing the respective fields into the competency era.
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.
In addition to outcomes of supervision, it is valuable to introduce a tracking for outcomes in client progress. Lambert’s Outcome Questionnaire is an excellent tool to use for this, but there are other treatment progress or symptom checklists that would work as well. Some supervisors advocate creating their own scales of 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: http://www.scottdmiller.com/.
As Belar et al. (2001) have suggested, self-assessment is an essential part of supervision and of professional practice. Modeling attention to lifelong learning, the supervisor can construct self-assessments such as the one described in Belar et al. (2001) in order to assess and expand one’s practice areas, or to simply see how current one’s skills and knowledge are. Self-assessment can be woven into every aspect of the supervisee’s training, instilling in him a sense of urgency to be self-aware about competencies.
Self-reflection is a critical process for supervisors and for supervisees. The more practiced one is at self-reflection, the more effective one will be at integrating feedback, engaging in metacompetence activities – thinking about one does not know, and in developing one’s skills, knowledge, and attitudes.
First, use a competency-based approach for evaluation. The templates for each discipline are in the competencies sections above.
Using a self-assessment, or one like it, the supervisor could have the supervisee self-assess upon entry into the supervision. Then the supervisor could add his/her initial impressions in a second column, and reflect on any differences in impressions between supervisee self-assessment and supervisor assessment. This process could be repeated at intervals throughout the training sequence, to chart progress and to address areas that are still developing.
Second, one could conduct “360-degree” feedback that should not be considered evaluation in the sense of making decisions for merit increases or graduation, but is highly useful for developmental feedback. 360-degree feedback, or multi-source feedback, refers to identifying a set of core competencies and asking multiple sources to rate them. Ideally, supervisors would first conduct this process on themselves. Thus, for example, the supervisor would self-assess, and then be rated by peers, administrators, clients, supervisees, clerical staff, and others in the setting. Then the same process is done for each supervisee, with the coordinating supervisor integrating the resulting information to provide a comprehensive feedback mechanism. This should create excellent developmental data to ensure the supervisee understands her impact upon multiple constituents.
The supervisor should be sure that every area that is important to performance in his/her particular setting is included in the evaluation documents, as it is not acceptable to evaluate areas that were not included in the forms supervisees receive at the onset. This is a matter of informed consent.
Areas most neglected in evaluation are those of interpersonal competencies; the impact of personal factors such as biases, assumptions, and countertransference upon the therapy process and supervision; interpersonal skill sets such as congeniality, relationship skills, emotional awareness, autonomy, and diversity competence; and attitude towards training and the profession.
Other options for evaluation include using measures such as those included in appendices of the supervision books written by Bernard and Goodyear (2009) or Falender and Shafranske (2004) which include supervision outcomes, alliance measures, and multicultural and diversity competence assessments, among others.
It is most important for the evaluation to be yoked with the goals and tasks for completion of the training year, and that these all be related to the training agreement.
Summative evaluation is not enough. Formative evaluation should be a part of every supervision session. One strategy is for the supervisor and supervisee to rate the process at the end of supervision to determine whether particular components, such as formative evaluation, occurred during the session.
Most supervisees have a productive, developing training experience from which they proceed onward in their placements with enhanced skills and confidence. However, sometimes supervisees 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. These 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 4-5 years in a setting. Certain settings report a higher prevalence (summarized in Falender and Shafranske, 2004).
Some red flags for supervisee competence problems include supervisee delinquent paperwork, chronic lateness, client cancellations (by client or by supervisee), changes in interaction style or behavior, and inconsistencies between notes and descriptions of cases in supervision.
Previously, “impairment” was a term used to denote the supervisee not meeting competence standards. “Impairment” has been preempted by the Americans with Disabilities Act (ADA). It refers to a medical or physical disability. There will be supervisees who apply or enter your training program who qualify under ADA, but in order to invoke ADA, the supervisee should notify you and Human Resources of their ADA qualifying diagnosis, provide documentation. Then, with the Human Resources Department reasonable accommodations are developed, ensuring 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 its aspects. An excellent reference is http://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 course of action for normative developmental issues, supervisee self-disclosure of a qualifying condition for ADA, and supervisee 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 the supervisee.. 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). First is a behavioral description of the behaviors. 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 competence 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: (a) Moral character: honesty and integrity a person deals with others – relevant to maintaining public trust – integrity, prudence, caring; (b) Psychological fitness: emotional or mental stability of a professional – one’s capacity to practice safely and effectively (Kaslow, Rubin, Forrest, Elman, Van Horne, Jacobs, et al., 2007).
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.
At each step, determine your feelings as supervisor. If you begin to personalize the situation or feel you cannot be objective, get consultation and support from colleagues and peers.
Discuss the behavior(s) that are not meeting 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.
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. Document this meeting. A time line should be constructed with intermediate points for check-in, spaced relatively close together.
Be sure to follow up within a few days of the meeting with the initial check-in to see if significant progress has been made.
If the supervisee begins to improve, do not stop monitoring. Be sure to follow up with each scheduled check-in and continue to monitor to completion of the tasks or until behavior changes, and continue to monitor beyond that point as well.
If the competence problem behaviors do not subside, or if the problem is viewed as increasingly serious, take appropriate steps. Possible steps include:
Continue monitoring and check-ins with the supervisee to see how she is doing, feeling, and progressing.
If there is no change with all the increased supports and monitoring, the supervisor may begin to think about probation moving towards possible termination. This would need to have been clearly spelled out as a possible consequence of not meeting specific performance criteria and a specific due process procedure would have to have been given as part of informed consent at the onset of training. Movement towards termination or dismissal would move through steps with chances for the supervisee to dispute the documentation.
The other supervisees at the site are definitely affected by this entire procedure. Some may have been aware of the problem for some time and may have wondered why it took so long. For others, there may be concerns as to whether they would be next, whether the setting is safe, and what safeguards there are for their peer and for themselves.
It is critical that the supervisors NOT discuss the procedures occurring with the identified student with the other students to protect the supervisee’s confidentiality. However, once it is determined that the individual will be leaving, it would be important to process feelings of the others about the loss, and that discussion might touch on the process that occurred. Supervisors should be very thoughtful about this, protective of the student who is leaving, and respectful and forthright about the importance of preserving the student’s confidentiality and rights.
All of the steps must be documented.
Increasingly we are finding that openness and nondefensiveness to feedback are critical dimensions of development. In a very important set of studies, it was found 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. (Papadakis, Hodgson, Teherani, & Kohatsu, 2004) 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 components in the first study was a failure to accept and integrate feedback.
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 we and our supervisees 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.
Supervisees generally place self-care on a back burner. 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). Although it is a multiple relationship for supervisors (as we benefit and attempt to maximize the productivity of supervisees while trying to safeguard their self-care), supervisors need to lead the way in modeling self-care and introducing practices such as mindfulness to supervisees. Sleep is a highly important factor in self-care (Goncher et al., 2013).
In a study by Stevanovic and Rupert (2004), respondents who had higher job satisfaction reported various strategies for reducing burnout. They included 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.
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 towards 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.
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 had applied, been interviewed, 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 is constantly reminding her that her skills are not up to par, but is not providing much guidance as to what that means. He favors a highly unstructured, play therapy approach and her two clients are elementary school children who have severe aggressive behaviors that have been injurious to other children.
An issue in this 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.
The practice of supervision is the highest calling in psychology and other mental health professions. It is the dissemination of learning, professionalism, and ethical practice from one generation to the next, and in the process, it provides the supervisor with the opportunity to learn and develop from the experience.
As 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 competencies 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 competencies documents become more articulated and used more consistently, the process of supervision is benefiting.
Psychologists – Board of Psychology
psychology.ca.gov. (Note: The Laws and Regulations book is to be updated in 2015.)
Board of Behavioral Sciences
Rules and Regulations are available (2015) at http://www.bbs.ca.gov.
Some of the changes for psychology:
Social Workers, Marriage and Family Therapists, and Licensed Professional Counselor Supervisors – Board of Behavioral Sciences
Nursing competencies are described at:
Professional Chaplain Competencies:
CBT Training Competencies:
Guidelines for CBT Training Association for Behavioral and Cognitive Therapies (see link to BT on http://www.ABCT.org/ website, middle column).
Competencies for Health Psychology:
France et al., 2008
Kaslow, Dunn, & Smith, 2008
Lamberty & Nelson, 2012
Stucky, Bush, & Donders, 2010
Shultz et al., 2014
Stanton & Welch, 2011
Interprofessional Collaborative Practice, 2011
Karel, Knight, Duffy, Hinrichsen, & Zeiss, 2010
APA Guidelines for Psychological Practice with Older Adults
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
Regulations and practices for California psychologists:
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
For Marriage and Family Therapists:
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