Supervision

Supervision

Introduction

Those new at supervision must appreciate that supervision is an extensive personal and professional skill set that requires fostering, just as the supervisors clinical skills required nurturing. Fortunately, much of the supervisor's clinical wisdom can be employed in understanding and establishing a positive working relationship with interns.

Core functions: The core objectives of clinical supervision are to ensure quality of care and professional development of clinical staff. It is a primary means of ensuring that these objectives are met. Supervision provides the bridge from the classroom to the actual practice of clinical skills by helping therapists acquire the knowledge and skills they need in order to make that transition. Supervision is necessary to enhance treatment, professionalism, and ethics. Supervision is defined as interaction between a supervisee (MFT/SW trainee/intern) and a supervisor. The main purpose of supervision is to have a more experienced individual (supervisor) guide and educate less experienced individuals (supervisees). Supervision is an environment in which the supervisee feels comfortable sharing their doubts, problems and issues surrounding their role as therapist/social worker. Let us not forget, however, that supervision is also part of the gatekeeping process of the profession. If it is too heavy-handed, it poses an obstacle to good potential clinicians, and serves a guild mentality. If it is too relaxed, it may result in incompetent care by trainees who should have been screened out.

Roles: The supervisor role is distinct from that of counselor or administrator. Supervisors must take care not to veer so far into being supportive of supervisees that they become the intern's therapist, or so far into administrative functions that they miss important clinical concerns in an excessive focus on regulatory and documentation requirements.

The role relies upon a positive, solution-focused relationship with supervisees that has sufficiently strong boundaries and commitments to clinical care that the supervisor can take appropriate action to deal with any deficiencies in the intern, up to and including expressing concerns to the board or documenting a failure to comply with directives or a corrective action plan.

The role is a constellation of diverse roles that include teaching, coaching, consulting, mentoring, evaluation, and administration. (Center for Substance Abuse Treatment, 2009) The supervisor may need to bring personal issues of the intern into focus and help the intern develop a plan for remediation or personal development that is key to progress in the intern's clinical and professional skills. This requires developing a relationship in which the intern trusts the supervisor to respond in a constructive and insightful way that will produce relevant discussion and meaningful results.

Of course, these skills interface with the supervisor's clinical assessment and treatment skills as they are employed in reviewing the supervisees cases and approach.

Organizational need: At the same time, organizations that provide or oversee care must provide proper supervision of all staff with clinical responsibilities, particularly interns, in order to ensure quality care and control of liability. Clinical supervision is an essential component of clinical programs. Ultimately, the investment in quality supervision can be cost-saving through its capacity to improve efficiency of service delivery and administration, and to generate workforce satisfaction and retention. It also ensures reduction of liability through promoting adherence to legal and ethical mandates. If agency management is not adequately supportive of supervision, staff must attempt to get the needed support by educating and working with the administration. Supervisors may find in some agencies that their efforts to comply with some ethical or legal requirements are not adequately understood by some administrative staff, or that the nuances of supervising early career professionals are not respected in some ways.

Challenges: Supervisors may face many challenges such as ethical and legal dilemmas, defensiveness and resistance on the part of the supervisee, and tensions that may arise between supervisor and supervisee. These difficulties are common in supervision and must be dealt with effectively for successful progress in supervision.

Supervisor Roles

Teacher: In the context of clinical practice, the intern will have an immediate need to fill knowledge gaps that are directly relevant to immediate client needs. This will include specific mental health information as well as broader matters of application of the psychotherapy theory. In addition to helping the intern get answers to such questions, the supervisor can help the intern to build skills in finding information and to build the self awareness and confidence to recognize and respond to knowledge gaps effectively. Also, the intern is practicing nascent skills. For the first time, weakness in these skills will be apparent. The supervisor has the opportunity to provide additional training or to refer for more extensive additional training so that the intern may produce a well-rounded and relevant approach to psychotherapy for clients whose needs are within the intern's scope.

Consultant: This role goes beyond training and providing information because it involves oversight and examination of the intern's therapy and case management processes. It assertively identifies needs and provides consultation toward enhancement and remediation. Assistance with case conceptualization provides the intern with the foundational perspective necessary to begin formulating a treatment plan and determining the general approach to the client.  The supervisor even moves to the meta-level, examining and consulting on matters such as how to best utilize supervision, and how to enhance the process of supervision. This may involve identifying challenges to the relationship between the supervisor and intern. It may require the supervisor to be candid about ways that the supervisor has made missteps and will be modifying the approach to better serve the intern. This candidness is, in itself, a form of modeling that benefits the intern by desensitizing the intern to open, outcome-focused, evidence-based discussion of errors and corrective planning.

Coach: Supervisors work with their intern's motivation in a variety of ways. Many interns feel quite vulnerable as they step into their role as therapist, and may experience a roller coaster ride creating varying levels of motivation, confidence, and clarity. By intently monitoring these levels and observing the factors that influence them, the supervisor can provide coaching that helps the intern continue to move forward as efficiently as possible.

Mentor and Role Model: The supervisee will most likely look up to the supervisor as mentor and role model, and will benefit from that relationship through the supervisor's extensive experience in the mental health field. The supervisor can draw from experience with myriad professional issues that cannot be adequately addressed in graduate or doctoral training.

Politician: Supervisors must also maintain rapport with agency management and staff of other agencies in order to champion the supervisory function within the agency and the agency's mission in the community. These skills must be respected in the sense that they are not innate to most people, and require a maturational process. Many supervisors should assertively reach out for mentoring and consultation in developing these skills. They could be thought of as an amalgam of politics, public relations, and relationship-building. Also, it is very helpful to understand the roles and motivations of management and other staff and agencies in order to respond constructively and strategically as issues arise.

Models of Supervision

Introduction

Each of the follow models of supervision has a place in the practices of the supervisor. They need not exclude one another. Rather, they comprise a balanced approach to supervision

Competency-based models: In this model, skills and learning needs are emphasized. This involves setting goals that are characterized as SMART goals. This acronym stands for Specific, Measurable, Attainable, Realistic and Timely. The supervisor assists the intern in developing and implementing strategies for achieving their goals.

Treatment-based models: These focus on imparting useful theoretical approaches to counseling and improving fidelity to the approaches. There is a strong emphasis on the capacity of the supervisee to articulate the theoretical basis of treatment planning and the clinical objectives.

Developmental models: These recognize stages of development through which therapists go. Responsibilities, supervision, and training of interns must be sensitive to their developmental needs.

Getting Started as a Supervisor

The new supervisor may suffer from overconfidence in not recognizing where gaps in knowledge may cause trouble. By systematically covering certain basis, the new supervisor can reduce this likelihood. The new supervisor that experiences anxiety in the role, can develop surer footing in the same way. In supervision materials from the U.S. Department of Health and Human Services, it is suggested that new supervisors take the following steps:

Quickly learn the organization's policies and procedures and human resources procedures (e.g., hiring and firing, affirmative action requirements, format for conducting meetings, giving feedback, and making evaluations). Seek out this information as soon as possible through the human resources department or other resources within the organization.

Ask for a period of 3 months to allow you to learn about your new role. During this period, do not make any changes in policies and procedures but use this time to find your managerial voice and decision-making style.

Take time to learn about your supervisees, their career goals, interests, developmental objectives, and perceived strengths.

Work to establish a contractual relationship with supervisees, with clear goals and methods of supervision.

Learn methods to help staff reduce stress, address competing priorities, resolve staff conflict, and other interpersonal issues in the workplace.

Obtain training in supervisory procedures and methods.

Find a mentor, either internal or external to the organization.

Shadow a supervisor you respect who can help you learn the ropes of your new job.

Ask often and as many people as possible, "How am I doing?" and "How can I improve my performance as a clinical supervisor?"

Ask for regular, weekly meetings with your administrator for training and instruction.

Seek supervision of your supervision.

The materials also suggest "eight truths" that a beginning supervisor needs to know:

Eight truths a beginning supervisor should commit to memory are listed below:

The reason for supervision is to ensure quality client care. As stated throughout this TIP, the primary goal of clinical supervision is to protect the welfare of the client and ensure the integrity of clinical services.

Supervision is all about the relationship. As in counseling, developing the alliance between the counselor and the supervisor is the key to good supervision.

Culture and ethics influence all supervisory interactions. Contextual factors, culture, race, and ethnicity all affect the nature of the supervisory relationship. Some models of supervision (e.g., Holloway, 1995) have been built primarily around the role of context and culture in shaping supervision.

Be human and have a sense of humor. As role models, you need to show that everyone makes mistakes and can admit to and learn from these mistakes.

Rely first on direct observation of your counselors and give specific feedback. The best way to determine a counselor's skills is to observe him or her and to receive input from the clients about their perceptions of the counseling relationship.

Have and practice a model of counseling and of supervision; have a sense of purpose. Before you can teach a supervisee knowledge and skills, you must first know the philosophical and theoretical foundations on which you, as a supervisor, stand. Counselors need to know what they are going to learn from you, based on your model of counseling and supervision.

Make time to take care of yourself spiritually, emotionally, mentally, and physically. Again, as role models, counselors are watching your behavior. Do you "walk the talk" of self-care?

You have a unique position as an advocate for the agency, the counselor, and the client. As a supervisor, you have a wonderful opportunity to assist in the skill and professional development of your staff, advocating for the best interests of the supervisee, the client, and your organization.

Basic Issues in Supervision

The following are key issues that must be managed in supervision. They may take the form of challenges in the form of ethical dilemmas, legal issues, rights of supervisee and client, confidentiality as well as minimizing and addressing personal problems among and between supervisees.

Competence

Competence is increasingly becoming an area of concern as mental health and supervision have become more detailed and therefore more complicated. Clinician and supervisor competence are essential for effective and ethical treatment.

Supervisor competence is the cornerstone of supervisee competence, as a supervisee is not yet ready to practice independently. Supervisors are ethically and legally responsible for the supervisee. Although supervisors must oversee all of the supervisee's actions, supervisees must be challenged in order to learn. The supervisor's must take extra care in creating opportunities that will challenge the supervisee without putting the client in danger or offering substandard services. Whenever a dilemma arises, supervisors must keep in mind that their primary obligation is to the client, the public, the profession, and the supervisee -- in that specific order. The supervisor must decide on a consistent basis if the supervisee is good enough to work with any particular client.

It is important that the supervisor is the expert in the process of supervision. The agreement between supervisor and supervisee mandates that supervision must ultimately result in education, guidance and better clinical skills for the supervisee.

Ethics, Law, and Liability

It is important to be aware of potential ethical and legal issues surrounding cases, while also meeting the needs of the supervisee. It is easy to look past a legal issue when faced with a frantic supervisee, as most of the attention and focus will be on helping the supervisee through the process. Supervising individuals is much like therapy – it is best to remain objective and not get too emotionally involved in order to see the situation clearly.

Here is an example of a supervisor who let the chaos of a case blind her from underlying ethical and legal issues. 'Jane' had been supervising 'Kara' for a few weeks, and had been helping her with a particularly difficult case. Kara was a young trainee and very upset over a session she had with a client. In this session, Kara's client expressed to her that a friend's older brother was molesting her. Kara was so distraught over this because a friend's relative had also molested her when she was young. Supervision was focused around helping Kara deal with her own issues surrounding the case, and Jane; her supervisor completely forgot that she needed to report this incidence immediately to the authorities since Kara's client was 16 years of age. This example is a bit extreme, but one can see how ethical and legal issues can be overshadowed by the needs and demands of the supervisees.

A review of the ethical guidelines of your national organization can help refresh your memory for the principles that you need to reinforce during supervision. Many situations will arise in which you will want to spell out the exact ethical guideline that applies to the situation and why it applies.

Liability often scares experienced individuals from supervisory positions. There are items the supervisor can undergo regarding liability. It is important for supervisors to seek continuing education, especially in terms of current professional opinion regarding ethical and legal dilemmas, consult when needed with well educated and credentialed colleagues and thorough documentation of supervision. It is important for supervisors to be diligent about ethics surrounding their behaviors as well as their supervisee's behaviors. Education, awareness, consultation and documentation are the best protection against any sort of malpractice.

Later in this course, there will be a full section on legal liability issues in supervision.

Fairness in Administrative Processes

In some literature on supervision, the reader will find reference to due process. The term refers to rights protected in proceedings by the federal government, especially the executive and judicial branches. Some writers have, however, adopted this term in referring to fairness and respect for contractual agreements and adherence to the policies of an organization in dealing with a supervisee. (Borders & Brown, 2005)

For example, when the supervisor has a concern about the performance of a supervisee, the supervisor should go through a formal process that may lead to termination or other action. This process should adhere to the contract with the supervisee, any regulations and laws that have bearing on the relationship and circumstance, and generally fair steps such as providing a warning rather than an unexpected action, whenever appropriate. This protects the supervisee from capricious behavior. However, there are circumstances in which the supervisor may need to take drastic or immediate action without warning, as when a supervisee engages in sex with a client.

The supervisor should make sure that the supervisee understands what is considered fair in the relationship, as well as any procedures that are in place in the agency.

Maturity and Life Experience in the Supervision Process

According to Lyman, Storm, & York (1995), many young professionals go into healing process without the life experience necessary to understand the problems with which they are intervening. Here are a few of their arguments:

1.Theoretically, a supervisee should exclude from their caseload families who are at a developmental stage that they have not yet experienced themselves. Several kinds of life experiences are cited in the literature as important. The enhanced understanding of oneself and others gained from experiencing a variety of life events is considered crucial by many.

2. It is important for trainees to have an "identity crisis", which enables them to lose their self-importance in order to deal empathetically with others. The understanding of self is important because it is the self that is the instrument of therapy.

3. Important also to many is the experience of participating in one's own marital family. This experience provides trainees with an understanding of family patterns via their own interactions with other family members.

4. Previous employment is considered to be another influential life experience. Many feel that trainees with previous employment bring more self-confidence with them.

5.Some credit experience gained from the process of maturing through aging as a contributor to trainees' therapeutic effectiveness. With age, people seem to gain skills in different kinds of social behaviors, enabling them to adopt a variety of therapeutic approaches.

6. Others believe it is difficult for supervisees to develop fully without the experience of resolving issues from their families of origin. They argue that unless trainees examine their own reactions based on their life experiences, they may only learn to hide behind theory and become stagnant in their therapeutic abilities.

7. Personal maturity is frequently cited as a critical admissions criterion for applicants into Masters level programs and/or practices. This often results in younger, less experienced applicants being hesitantly accepted, if at all. Faculty may feel compelled to require that these applicants obtain volunteer or related professional work experience before seriously considering them.

8. Age does not always equate knowledge and experience. Each individual is different and has different life experiences.

Supervisee's life experience, competency, and therapeutic outcome during the process of training are of particular interest. Life experience may also play a more important role for models that emphasize the personality of the supervisee, such as the symbolic-experiential approach. It is important to keep in mind a supervisee's life experience and maturity level during the supervision process to properly guide and educate them according to their abilities and personality.

Preventing Violation of Boundaries

Preventing boundary violations is essential to the therapeutic process and is dependent upon the proper education of professors, supervisees, supervisors and other professionals. It is important that training programs consist of frank discussions and thorough education surrounding the field's standards

A highly effective method of educating professionals is through the process of supervision. Prevention of boundary violations depends the availability to readily consult with others in the field, particularly at times of difficulty. Therapists who routinely present their work to others in consultation, supervision, peer discussion groups, or case presentations are less likely of becoming isolated and lose perspective on what is constituted as 'appropriate' interaction between client and practitioner.
Educating practitioners about key elements of the therapeutic process such as transference, counter transference, and enactment is helpful to preventing boundary violations. Educating practitioners about potential issues and emotions that may arise during the therapeutic process is helpful in preparing them to be competent, and ethical practitioners.

The awareness of the concept of enactment helps to make practitioners aware of the risky, often messy therapeutic phenomenon that puts them at risk for boundary violations. It is important to educate supervisees of the potential for boundary violations during the therapeutic process.

There is a section on boundaries and dual relationships in a later section of this course.

Spirituality and Religion in Supervision

Spirituality and religion are principal aspects of client diversity in the therapeutic process and supervision. The role that a client's religious convictions will play in therapy should be discussed as part of the process of discovering client beliefs and values.
Differences in religious beliefs are likely to occur between supervisee and client. It is important to guide a supervisee to acknowledge these differences, but do not let the differences impede the therapeutic process in any way.
Here is an example of how religious and spiritual beliefs can complicate the therapeutic process. You have a supervisee, "Grace', who is a devout Christian. She expresses in supervision how the Lord guides her during the therapy sessions and that she feels that faith in Jesus is the way to heal all issues. It is understandable to be concerned with the supervisee's beliefs, as she has the potential to offend a client that does not share the same beliefs as she.

Perhaps more importantly, a highly religious supervisee may believe that the higher authority to which he or she subscribes can call on the supervisee to engage in behavior that violates laws, regulations, or ethical guidelines of the profession. This has taken place when therapists have provided misinformation to clients regarding sexual orientation, or neglected to provide or refer for appropriate and necessary care because divine intervention was anticipated. This has led to grievance board complaints against therapists. In some cases, therapists have come to feel justified that they can treat non-psychiatric medical conditions such as MS because they believed that they could influence the chi (energy flow) in their clients' bodies. This constitutes the unauthorized practice of medicine and application of a theory of medicine that is in disrepute and is contradicted by an extensive base of evidence.

The supervisor must express to the supervisee that although their beliefs and religious convictions are fine, they should take great care to not impose them upon a client. If a client expresses to the supervisee that they have similar religious beliefs, only then can incorporating these beliefs in a session be discussed. It may be necessary for the supervisor to review information with the supervisee regarding policies and procedures as they relate to particular agency requirements and limitations for including spiritual practices. The ultimate task of the supervisee is to provide the utmost respect for the client and to do no harm to the client. This respect extends to all aspects of the person, including his or her religious and spiritual values. The only exception to this is specific institutions that are church affiliated or programs that are of an explicitly religious nature.

Client and Clinician Values

The purpose of counseling and/or social work is to help others improve their wellbeing. Clinicians and clients typically share the same goal of improving wellbeing, but there are often vast differences in opinion about what defines 'significant improvement' and what specific factors contribute to improvement.

Many individuals consider spirituality and/or religion to be significant in their day-to-day life. Many find that progress toward mental and emotional health is enhanced by spirituality.

Regardless of a clients views or values, supervisees and supervisors continue to struggle with the acceptance of spirituality as a significant part of the therapeutic process. This discrepancy between clinicians and clients often causes conflict and hinders rapport. Often clients who are extremely religious and/or spiritual do not understand why their clinician will not join them in their convictions in the therapy session. The may be suspicious of what they may consider an unfriendly environment that will discount, negate, or conflict with their religious values or spiritual beliefs. The best way to counteract this discrepancy is the development of clinician awareness and the knowledge and skills to deal with the cultural diversity of clientele.

How does a clinician effectively attend to the spiritual issues presented by the client? Clinicians will respond in different ways to the client based on variables such as skill level, competency, culture, one's conceptualization of spirituality, and the similarity of clients' and counselors' values. These factors will create the foundation for developing effective intervention and supervision strategies.

Clinician competency is enhanced through the attainment of specific skills. Dexterity is critical because spirituality is an essential aspect that comes before a client's psychological and emotional needs. Here are a few suggestions aimed at helping clinicians become more competent in addressing spiritual issues in the therapeutic process: (a) help the client to feel that his or her religious values are an accepted part of the therapeutic process; (b) view religious values as part of the solution to the client's problem, not just as part of the problem; (c) become more educated about cultures, religious values, beliefs, and practices and strive to understand how these issues are integrated with psychological theory and counseling practice; (d) become involved with community or professional activities that promote interactions with persons from diverse cultures who have a variety of religious values; (e) explore and evaluate personal religious values; (f) be aware of what counselor resistance toward or cautious maneuvering around religious issues may convey to clients; and (g) develop a simple straightforward language to use in communicating with clients about religious values.

It is important to incorporate aspects and teachings of spirituality within the supervision process. Supervisors should engage in dialogue regarding the nature of spirituality, its definition, and its relevance to counseling and particularly to supervision; spend time in self-examination and contemplation regarding personal experiences in spiritual matters.

Theoretical Orientation and Training

There must be a match between the supervisor's expectations and the intern's theoretical orientation and skill level. Supervisors must know what the intern is able to do, and make sure that the needs of clients do not exceed this beyond a reasonable level that can be mitigated through supervision and training in short order. For example, an intern who has no training or experience with dissociative disorders would require specialized training before providing psychotherapy for a highly dissociative client. If the supervisor and intern actually disagree on the validity of a theoretical orientation or modality, then this issue must be sufficiently resolved that neither is concerned about malpractice, liability, or inability of the supervisor to effectively supervise. Supervisors must have at least a well-rounded familiarity with current thinking in the field, including emerging science that is affecting practices, and even the way clinicians communicate about clinical issues.

Diversity

Supervisees will encounter individuals that are different from them in terms of culture or other diversity factors. Also, the supervisee is likely to have some prejudices regarding some kinds of diversity that can obstruct effective delivery of services. It is likely that such biases are unconscious, and can benefit from inspection in developing constructive awareness of diversity in order to improve treatment. Diversity includes factors such as gender, race, age, language, religion, disability, and sexual orientation. Regardless of how well educated a supervisee is about different cultures, religions etc, it is important to acknowledge that conducting therapy with a client that is different from the supervisee can be challenging. Various cultural, racial-ethnic aspects in each individual supervisor and supervisee will shape beliefs, attitudes, judgments and values of each person. This can lead to preconceptions, misunderstandings, neglect of clinical issues, or outright alienation or hostility.

Cultural competence, for example, "refers to the ability to honor and respect the beliefs, language, interpersonal styles, and behaviors of individuals and families receiving services, as well as staff who are providing such services. Cultural competence is a dynamic, ongoing, developmental process that requires a commitment and is achieved over time" (U.S. Department of Health and Human Services, 2003) Culture has a tremendous influence on belief systems, especially where mental health and illness are concerned. It influences how symptoms are expressed and experienced, how individuals cope, how they relate to health care providers and others, and how families and communities respond.

There has been a large increase in the recognition for multicultural perspective when working with clients with corresponding revisions in supervision and therapeutic techniques. The supervisory process can be seen as having three levels of cultural considerations.

1) The client's cultural background

2) The  supervisee's cultural background

3) The cultural nature of the agency, community, and other contextual factors

There are thee key ways that culture and context must be considered in supervision:

1) Building the working alliance in the supervisory relationship

2) Meeting the client's needs

3) Furthering the capacities of the supervisee

A good starting point in building cultural competence is to maintain an open discussion of the above cultural considerations. The same goes for all diversity issues that may have a bearing on a case, from politics and religion, to race and sexual orientation. Counselors can, likewise, maintain open communication with their clients on issues of diversity. A good strategy for counselors that are naive to something that makes a client different from the counselor, is for the counselor to ask the client to clarify or explain some of the differences. A friendly and curious attitude can help to build rapport. Additionally, by doing some independent study of the diversity in question, the counselor will be able to display their commitment to understanding the client and being committed to the client's welfare.

To be an effective, and culturally competent professional here are some characteristics that are essential as defined by Hofstede (1984):

1. Express respect for the client in a manner that is felt, understood, accepted, and appreciated by the client. Respect may be communicated either verbally or non-verbally with voice quality or eye contact.

2. Feel and express empathy for culturally different clients. This involves being able to place oneself in the place of the other, to understand the point of view of the other.

3. Personalize his/her observations. This means that the counselor recognizes that his/her observations, knowledge, or perceptions are "right" or "true" only for him/herself and that they do not generalize to the client.

4. Withhold judgment and remain objective until one has enough information and an understanding of the world of the client.

5. Tolerate ambiguity. This refers to the ability to react to new, different, and at times, unpredictable situations with little visible discomfort or irritation.

Self-knowledge: Each individual has unique characteristics that can measure their effectiveness at connecting with a client. Every supervisor and supervisee has a very different biological, social and psychological background. These features mesh with the distinct cultural and personality factors of a client. The effectiveness of a practitioner depends on their ability to adjust the specific techniques and theories to the distinctive individual needs of each client. This is only achieved when the practitioner is able to see the client as both an individual and as a member of their distinct cultural group.

Self-awareness or self-understanding is necessary before one can begin the process of understanding, and helping others. Intrapersonal and interpersonal dynamics must be evaluated and examined as significant components in the projection of one's beliefs, attitudes, opinions, and values. The assessment of one's own innermost thoughts, beliefs and emotions allows the therapist to better understand the underlying issues he or she will bring into the situation of helping another.

It is important for the therapist to be aware of his or her own cultural beliefs and values. Due to one's particular beliefs and values, they have expectations surrounding appropriate behaviors and manners, communication styles etc.

Awareness of societal issues such as racism, sexism, and poverty within a culture is essential to better understand the perspective of others. If a client is from a culture that experiences constant racism, that client will be shaped by his or her experiences. It is important for the supervisee to be aware of the client's background as well as potential issues that may come up as a result of racism that the client may or may not have experienced.

Multicultural counseling requires the recognition of the importance of racial/ethnic group membership on the socialization of the client, the uniqueness of the individual, the presence of and place of values in the counseling process and the uniqueness of learning styles, specific goals, and dreams of clients.

The Multicultural Awareness Continuum was designed to demonstrate areas of awareness, which a therapist must demonstrate when working with a culturally diverse client. The process is developmental, and occurs through out one's life.

It is, of course, essential that the supervisor address his or her own, "culturally influenced values, attitudes, experiences, and practices and to consider what effects they have on your dealings with supervisees and clients." (U.S. Department of Health and Human Services, 2009) Look for hints of judgmental or moralistic thinking in your own responses to clients, and for twinges of discomfort or awkwardness in your physical responses to clients. For example, you might notice what images or expectations are generated in your mind simply from seeing a client's last name.

Constantine (2003) offers that supervisees consider questions such as these in exploring their own diversity responses:

What demographic variables do you use to identify yourself?

What worldviews (e.g., values, assumptions, and biases) do you bring to supervision based on your cultural identities?

What struggles and challenges have you faced working with clients who were from different cultures than your own?

The Association for Multicultural Counseling and Development (AMCD) has created material outlining multicultural counseling standards and the Association for Counselor Education and Supervision adopted comprehensive standards for culturally competent counseling supervision.

Due to the confusion and differing beliefs of the term 'multicultural', multicultural in this training will be defined as by AMCD Standards, referring to "visible racial-ethnic groups, African-Americans, American Indians, Asian Americans, Hispanics and Latinos, and Whites". Although the term 'multicultural' is defined primarily by race, multicultural has also come to represent differences in gender, religion, sexual preference etc.

It is equally important to make supervisees aware of the judgments, assumptions and mistakes that will be made during the therapeutic process due to their own culture. For example, if an African American therapist works with an Asian client, she may be too direct in her approach and offend the client, as communication in certain Asian cultures is not as direct as in African American culture. Creating awareness of the supervisees belief systems, values and communication styles will help them to be more aware of possible areas of conflict when working with individuals from different cultures than their own.

The therapist must acknowledge and realize that his or her cultural way of communicating needs to be tailored to match her clients to effectively form rapport and connect with the client. Often supervisees do not realize this or understand what a large part their own cultural beliefs as well as how the lack of knowledge about other cultures can deeply hinder therapeutic progress. This is why the supervisor role is so important in educating supervisees about cultural differences and the effect they can have in therapy.

Open communication: It is imperative to remind supervisees that it is OK to acknowledge the differences between themselves and their clients, and that it is much more productive to do so. Ignoring a large difference in culture between practitioner and client (e.g., a Caucasian therapist working with a Latino client) will inhibit the therapist-client relationship and obstruct the creation of rapport. Expressing to supervisees that is more professional and conductive to acknowledge the differences in culture between client and practitioner is important.

The supervisor's role is to encourage supervisee growth and education by challenging cultural assumptions, cheering on emotional expression, as well as understanding and validating any conflict of culturally based attitudes and values. The supervisor must help the supervisee work past differences between their core beliefs, and the beliefs of their clients.

Activities and learning: such as cultural education, exploration of supervisee culture and beliefs about other cultures, role playing possible difficulties that may occur due to differing cultural beliefs can all be incorporated into supervision to train and educate the supervisee on how to be a more culturally competent practitioner. It is also important to include culturally relevant information on all questioners, assessments, intake forms etc to get as much information as possible from incoming clients. The more information obtained from each client, the easier it is to learn and educate oneself about the client's culture.

Knowledge and awareness of other cultures as well as the diversity that lies within each culture is an essential part to becoming a culturally competent practitioner. Education surrounding other cultures should be a mandatory part of a supervisee's course work. The supervision process is where supervisees can begin to learn the individual differences that are present within each person that belongs to a cultural group. The supervisee should be able to successfully identify certain traits about their client's culture, but also take the time to learn about the client's distinct beliefs, values and attributes.

It is extremely important to not over generalize things learned about a specific culture and apply that information to all members of the culture. Treating each client as an individual, as well as keeping beliefs and values of their particular culture in mind is the best way to successfully interact with a client.

Minorities, power and social class: Diversity is not just a matter of difference, but can involve many issues that stem from power differentials and social class. Many members of society are very poorly informed about the extent and nature of these dynamics and effects on significant numbers of people. Supervisors should assist their supervisees in becoming informed in order to better understand the behavior of clients who have experienced poverty and other class distinctions. Minority status is, by definitions, a status vulnerable to stigma and oppression. This is the basis of legislation and judicial decisions regarding issues such as segregation and the separation of church and state. At the same time, the supervisee must learn to neither blame the victims of oppression, or become preoccupied with talking about oppression, when it would take away from resolving trauma, determining what resources to connect the client with, and teaching the client how to navigate social systems. Preoccupation with oppression or unfairness can distract from providing real assistance. Insensitivity to the realities of power differentials and prejudice can alienate clients and impede treatment as well. It is a well-known cognitive distortion to blame people for bad circumstances they experience. Training supervisees to recognize such automatic distortions can help them perform more objectively as professionals.

Between supervisor and supervisee: Multicultural issues between the supervisor and supervisee must also be taken into consideration. It is likely that the supervisor will differ culturally from their supervisees. Incorporating discussion surrounding the supervisor's cultural beliefs and values, as well as how they may differ from supervisee beliefs and values is an excellent way to address potential areas of tension.

It is fine for supervisors as well as supervisees to acknowledge differences in cultural values, opinions and it is OK to admit you do not know everything there is to know about a certain culture. The purpose is to break down previously held beliefs and learn as much information possible about other cultures to become a more culturally competent practitioner.

Dual and Therapeutic Relationships with Supervisees

Dual relationships are very complicated between supervisors and supervisees. Because of the nature of conducting supervision with others who are in the same field and who have similar interests- it is inevitable that there will be times where dual relationships will be formed. The important thing is to make sure that the dual relationship does not exploit a supervisee or supervisor and that the relationship remains within the scope of practice.

For example, a supervisor might also be a supervisee's professor or even run a group with a supervisee as a co-facilitator. This is deemed as an appropriate dual relationship between supervisor and supervisee, as it is still within the context of therapy and education. An inappropriate dual relationship between supervisor and supervisee would be a relationship such as a supervisee babysitting for a supervisor's child etc that is unrelated to therapy and/or education. It is also important to be up front about any dual relationships. Do not make a dual relationship a secret; it will be automatically assumed that there is something wrong in the relationship if it is hidden from others.

A mandatory part of a supervisor's role is to determine if the supervisee is in a position to perform therapy and treat others. If a supervisee is not in a position to help others, the supervisor should not attempt to correct this by becoming the supervisee's therapist. It is of the utmost importance for a supervisor to monitor and evaluate the mental health of their supervisees to determine if they are in a position to help others, or if they need to do more personal work before they begin treating clients.

Support through supervision results from a combination of techniques and attitudes. This highlights the need for planning and defining all work as well as the need to recognize the difference between supervision and therapy. Supportive attitudes and supportive relationships must be differentiated from specific techniques of treatment or therapy. A supportive attitude, which often includes empathy, is fundamental to many beneficial relationships that are not therapies. Though a supportive attitude helps maintain the therapeutic alliance, it is not a technique in itself. Neither is a supportive relationship a technique, although it may be an important component of therapy or supervision.

Supportive relationships between supervisor and supervisee can create self-awareness and personal growth. The concern is, in what way does supportive supervision differ from a process of supportive therapy? The supervisee can only become the 'client' under a model of therapeutic supervision, or a model of supervision that promotes both personal and professional growth without refinement. Of course, there is nothing wrong with developing self-understanding, but how shall we differentiate supervision from therapy?

Actual therapy between supervisee and supervisor, not merely a therapeutic relationship, or a supportive supervisory relationship should not be part of supervision. A supervisee must seek outside help if they are struggling with issues and are constantly seeking 'therapy' from their supervisor or peers. The process of providing 'therapy' to a supervisee disrupts the supervision process on many levels. It can alienate and anger other supervisees who feel that they are not receiving equal treatment, can distract the supervisor from issues within the supervisee's client load and can ultimately jeopardize the supervisor-supervisee relationship.

It is of the utmost importance that the supervisor is aware of the professional responsibility for maintaining professional roles and boundaries. The ethical responsibilities to supervisees must be held in the highest regard. It is not merely that supervision is not therapy, it cannot be therapy. Any therapeutic benefits are merely incidental, and are secondary to the primary teaching goal of learning therapeutic skills.

Discussing clients and one's therapeutic work, before oneself and one's personal issues, is the basis of supervision. By combining the two process of personal and professional growth into one, a poor representation of both therapy and supervision occurs.

Relational or Psychological Issues in Supervision

There are many ways that interpersonal issues can challenge the supervisory process. However, such challenges should be considered to be a natural and necessary part of supervision. If such issues didn't not arise and be processed, they could impede the effectiveness of the supervisee potentially throughout his or her career. A detailed exploration of this topic is outside the scope of this course, but we will review some key topics in this area.

Over-identification: Beginning counselors may not realize that they are over-identifying with clients who share issues or demographic characteristics. This can cause a loss of objectivity.

Moralizing: Supervisees may express unconscious or even conscious feelings that some clients deserve to have bad things happen to them because it is just or because it will teach them a lesson such as empathy. This can stem from a number of vague and deep-seated beliefs that must be discussed in a conscious manner. Many clients do things that are troubling or utterly reprehensible to counselors, and coming to terms with this is part of the maturation of a therapist.

Triggering of latent issues: Supervisees may have unresolved trauma or other issues that are triggered by similar or related issues in clients. This can cause a loss of objectivity or even destabilization. Part of assessment and self-awareness in supervisees will, ideally, prepare them for or prevent this eventuality.

Reticence to expose or address needs and weaknesses: Part of supervision is recognizing areas of weakness in a supervisee and working with them to improve their skills and ability as a therapist. Often, supervisee's are defensive and embarrassed when they are corrected in supervision or when there are areas of improvement needed in their techniques. This embarrassment is very common and can sometimes lead supervisee's to become defensive and resist further input from their supervisor. Supervisees may have unconscious defenses that serve to insulate the supervisee from awareness of weakness or even information with which the supervisee has not developed a confident connection. Supervisors may be caught off guard, because defenses are not expressed in an overt way that is readily discussed. By definition, they exist to function outside of awareness. Therefore, the supervisor must have good skills in consciously recognizing these defenses, and responding to them in a manner that helps the intern more consciously, assertively, and constructively engage in the process of professional maturation.

Unconscious resistance and emotional self management: Very similar to unconscious defenses are patterns of behavior that have been unconsciously shaped by incentives or aversive. Again, the supervisor can work with the supervisee in expanding awareness and resourcefulness in moving forward.

When a supervisee is resistant to the process of supervision, or resistant to the supervisor, they will act out in various ways. Most of the time, the supervisee will stop sharing as much information about the therapy session with the supervisor as an attempt to diminish any negative feedback/criticism. Often a supervisee will attempt to distract the supervisor with random details about the client, or random things about him or herself to distract from what is actually being done in therapy. Unnecessary questioning or critiquing of the supervisor's

Knowledge or credentials may be an attempt to distract, as is excessive praise. Other methods of acting out in supervision include selectively sharing information to obtain only positive feedback.

Unconscious attempts to manage anxiety may include persistent or obsessive attempts to get precise instructions from the supervisor on how to therapy, where these instructions seem to need to accommodate for every possibility, rather than simply to elucidate a specific procedure or principle. Excessive reliance on and solicitation for reassurance is a regressive effort to manage anxiety. The supervisor in such situations should assist the supervisee in recognizing the issue and seeking therapy for reducing anxiety if needed.

Decreasing supervisee resistance: The goal is to educate and guide supervisee's with as little criticism as possible in order to prevent defensiveness and corresponding resistance. This is achieved in many ways. It is key to form a good rapport with supervisees and make sure they can trust in their supervisor. Providing plentiful positive feedback, re-framing feedback in a positive manner along with gently discussing areas that need to be improved is one way to help diminish this resistance. Also providing examples of mistakes that you have made in the past can help the supervisee's to feel less defensive and not as embarrassed about their mistakes/areas that need improvement. The idea is to maintain a good relationship with the supervisee where feedback and critique can be given, but in a way that is therapeutic in of itself.

If there is resistance, it is important to discuss this resistance and acknowledge the conflict that is occurring. It can be helpful to discuss and brainstorm ways that the supervision process can become less threatening to the supervisees. Supervisors can help supervisees to discover the source of their resistance if it is not altogether conscious. Conscious or not, simply pointing it out in an open-minded manner will often get a very informative response. This sets the stage for problem solving and negotiating as needed.

The more you know about your supervisee, the better you can tailor your work together to elicit good cooperation from the supervisee and to generate good relevance in your contribution to the relationship.

Strategies and Methods of Supervision

There are various strategies and methods for supervisors to use with individuals whom they supervise. Discussing various methods and strategies is designed to acquaint supervisors with techniques for enhancing supervisee's knowledge and skills, while keeping in mind their individual needs and preferences for learning.

The most important aspect in supervision in the ability to assess how a supervisee is doing. This assessment allows the supervisor to identify areas of needed improvement; specific errors a supervisee is making and what can be done to maximize the full potential of a supervisee. This assessment is made by analyzing the interaction between supervisee and client.

It is very important for a supervisor to be well educated on details surrounding their supervisee's case. It is important to review a client's history, the results of current psycho diagnostic testing to assess the status and potential diagnosis of a client.

Examination of the supervisee's interaction with their client via methods such as audio, video, and observation through a one-way mirror or even joining in a session are all ways to assess the supervisee's interaction with the client.

Real time, or live supervision methods are particularly useful for immediate feedback regarding a supervisee's interaction with a client. Observation via one-way mirror allows a supervisor to provide immediate feedback and also lets the supervisor assess how well the supervisee can implement suggestions and feedback. Live supervision can be supplemented by review of a session immediately following the session or delayed by a day or so.

Supervision using audio or videotapes of the supervisee's session can be especially helpful to the supervisor. Audio/video tape provides a clear picture of what actually happened between supervisee and client, not just what the supervisee reported that happened. It is important that the supervisor review the supervisee's recording before a session, and determine what questions will be asked of the supervisee once in supervision.

Actual data, weather in the form of live, one-way mirror format, audio or video tape should be used in conjunction with self-reporting to obtain an actual sample of what the supervisee is doing. Supervision using strictly self-reporting methods is unreliable and can diminish credibility on the part of the supervisee's work, as well as on the effectiveness of the supervisor.

Group and Individual Supervision

The format of supervision depends upon various factors. It is most common to have group supervision, but many licensing agencies require one-to-one supervision as well.

Group Supervision

Group supervision has a large drawback of limited time and attention between supervisor and supervisee because of the ratio of supervisor (1) to supervisees (many). Although this type of supervision is not ideal, group supervision provides many benefits that cannot occur in individual supervision.

When surrounded by peers, supervisees can hear other cases, and get a feel for others styles and skills. This is a very effective learning tool and is an invaluable part of group supervision. Hearing what others do, where they make mistakes, where they find success can help a supervisee refine and model techniques in their own practice. The process of group supervision can be particularly helpful for supervisees that learn by observing others.

During group supervision a variety of learning techniques can be used. Didactic presentations are the most common way a supervisee will learn while in group supervision. The process of a supervisee presenting a particular client to their peers and supervisor helps to create case conceptualization, individual development, as well as group development.

The process of group supervision are specifically created to enhance the supervisees' overall knowledge, self-concept, ability to relate to others, and confidence when speaking and interacting with others.

Group supervision naturally will increase feedback among peers via structured layout. Supervisees should be encouraged to provide feedback to their peers and assume more responsibility in the group. It is very helpful to a supervisee to receive as much feedback as possible from his or her peers, as this type of feedback is offered from several viewpoints. The diverse viewpoints of others will help to guide and educate the supervisee in group supervision that would not occur in a one on one style, or individual supervision.

It is important for supervisors to be well prepared to use their knowledge of group process while guiding supervisees in group supervision. The supervisor should be aware of potential areas of conflict, difficulties that may arise, and the basic phases of group. Yalom suggests that supervisor and supervisees often cited guidance from peers and self-understanding as the most important "therapeutic factors" present in the group process. The supervisor is the one in charge of the group process, and should strive to find a balance between guiding supervisees as well as letting the group process naturally develop.

Based on existing literature surrounding the process of group supervision, the following guidelines are offered to supervisors who wish to address process in group supervision:

1. Five to eight supervisees meeting weekly for at least one and one half hours over a designated period of time (i.e., semester) provides an opportunity for the group to form and develop.

2. Organization of the supervision group needs to be an intentional decision made to include some commonalities and differences among the supervisees (e.g., cognitive/developmental level, experience level, personality, compatibility etc).

3. A plan is needed to list the procedure for how time will be used during supervision that will provide an intentional focus on content and process issues. This plan can be modified in accordance with group's progress and personality.

4. A session prior to the beginning of group with supervisees can be used to detail expectations and describe the degree of structure. This session allows the formation of a group self-responsibility that does not interfere with the group process itself.

5. Supervisors may summarize and reflect what appears to be occurring in the here-and-now in the group. Validating observations with the supervisees is using process. Be active, monitor the number of issues, use acknowledgements, and involve all members.

6. Supervisees' significant experiences may be the result of peer interaction that involves feedback, support, and encouragement. Exploring struggles of supervisees with clients, even with one another supports learning and problem-solving.

7. Rivalry between supervisees is a natural part of the group experience. Acknowledge its existence and frame the competitive energy in a positive manner that fosters excellence, creativity and naturalness.

8. In preparation for group supervision, communicate the following to the supervisees about how to use group process:

A. Learning increases as your listening and verbal involvement also increases. Take risks and reveal your responses and thoughts to the group.

B. Decrease your internal frustration with the therapeutic process by sharing with your peers. It is quite common for other supervisees to be experiencing the same thoughts and feelings.

C. Consciously and actively assess the similarities as you contemplate the relationships you have with your peers in the group with the relationships you are having with clients. Discuss similarities and differences.

D. Progress from client dynamics to counselor dynamics as you present your case. Know ahead of time what you want as a focus for feedback and ask directly.

Individual Supervision

Individual supervision is the preferred method of supervision due to the large amount of time and attention devoted to the supervisee. One to one supervision is often difficult because of time and financial constraints, and many supervisees prefer group supervision because it is less costly.

Stages, Personality and Developmental Level

Every supervisee is unique in the way they learn new skills and respond to feedback. Techniques and teaching methods that work for some may not always work for others. This is why it is significant to assess and take into consideration each supervisee personality and learning style, as well as their stage of development.

Beginning Stage

The first stage of supervision is filled with nervousness, self-doubt and anxiety on the part of the supervisee. The supervisee is new to the process of 'therapy', even if they have been helping others for years. It is important to reassure them that they will make mistakes and that their clients will be OK when they make a mistake. It is also a good time to stress the importance of forming rapport with a client. Often new supervisees are so all consumed with the details surrounding what they are and aren't supposed to do that they completely forget to relax and help the client feel at ease.

This is not the time to try any confrontational methods of learning or be overly critical to the supervisee. Gentle guidance with lots of positive feedback and positive reframing is essential for building a supervisee's confidence level.

Intermediate Stage

During the intermediate stage of supervisee development, the supervisee should begin to grow in their ability and technique. They should be able to take feedback and tailor their methods accordingly. They most likely have more confidence in what they are doing, and feel able to take on more challenges.

Advanced Stage

During the advanced stages of supervision, a supervisee should be able to take on clients with more demanding and complex issues as well as implement more complex therapeutic techniques.

Less traditional methods of working with a client may be explored, as well as more advanced therapeutic techniques applied. The supervisee should be able to work no just one on one with a client, but with couples as well as families.

The supervisor should have no qualms about giving the supervisee honest, real feedback about their methods and progress. At this stage, the supervisee- supervisor relationship may shift, and dual relationships, such as working as co-facilitators for a group, can be permitted.

Supervision Sessions

The following is an example of one format for an individual supervision session. This format needs to be adapted to both the needs of the setting and persons involved in the supervision session:

Preparation:

Ensure that sessions are set in advance and occur at regular intervals.

Where possible avoid late afternoon sessions particularly on Fridays.

Take 10-15 minutes to get yourself in the right space.

During this time you might read over the notes from the last session and consider what this session may focus on.

Notify reception that you do not want any interruptions and place a PLEASE DO NOT DISTURB sign on your door, so that when you close your door once the supervisee arrives, you have reduced the likelihood of any interruptions.

The Session

Phase	Opening Question
Establish the Supervisee's Comfort	How are you?
Clarify purpose/agenda	What have you?
Decide on a starting point	What shall we start with?
Explore issue	How did you?
Imagine alternatives	What if you?
Focusing the supervisee	What now for you?
Supervisory suggestions	Perhaps you could?
Planning	You will?
Summarizing	Did we?
Set next session	When can we meet next?

Phase one highlights the importance of checking out how the supervisee is prior to embarking on establishing the agenda and purpose of the session. Sometimes the best thing a supervisor can do is listen to a supervisees concerns and this can take up most of the session. However I would suggest you check this out with the supervisee shortly after their initial response to the How are you? (Morrison,1993).
Clarifying the purpose of the session and setting the agenda this should generally follow the supervisee's wishes. The main exception to this is when safety and ethical issues arise, and when these matters arise they should take priority.

Phases four to eight help the supervisee move from their experience through to new through the process of a reflective conversation with the supervisor. Phase nine checks out whether what you discussed was what the supervisee wanted to discuss.

Then phase ten closes the session.

For your own learning you may wish to consider the following questions:

How do you prepare for sessions?

How do you structure your supervision sessions?

To what extent does this structure mirror the client- social worker session?

Ethics, Examples from the NASW

All major professional clinical organizations have well-developed ethical guidelines. Great efforts are made to harmonize them with the legal environment as much as possible. Generally, this is not conflictual, because there is an ethical basis for development and judicial response to legislation and regulation. This section takes sections from the NASW code of ethics that are especially germane to supervision, in order to exemplify and review the standards to which supervisors are to adhere.  (NASW, 1999)

Boundaries: The Guidelines address boundaries:

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

2.08 Sexual Harassment

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

Competence in supervisees: They also confer responsibility for ensuring competent practice in supervisees, indirectly, though this general text:

2.09 Impairment of Colleagues

(a) Social workers who have direct knowledge of a social work colleague's impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.

(b) Social workers who believe that a social work colleague's impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.

2.10 Incompetence of Colleagues

(a) Social workers who have direct knowledge of a social work colleague's incompetence should consult with that colleague when feasible and assist the colleague in taking remedial action.

(b) Social workers who believe that a social work colleague is incompetent and has not taken adequate steps to address the incompetence should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.

2.11 Unethical Conduct of Colleagues

(a) Social workers should take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues.

(b) Social workers should be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. Social workers should be familiar with national, state, and local procedures for handling ethics complaints. These include policies and procedures created by NASW, licensing and regulatory bodies, employers, agencies, and other professional organizations.

(c) Social workers who believe that a colleague has acted unethically should seek resolution by discussing their concerns with the colleague when feasible and when such discussion is likely to be productive.

(d) When necessary, social workers who believe that a colleague has acted unethically should take action through appropriate formal channels (such as contacting a state licensing board or regulatory body, an NASW committee on inquiry, or other professional ethics committees).

(e) Social workers should defend and assist colleagues who are unjustly charged with unethical conduct.

3. Social Workers' Ethical Responsibilities in Practice Settings

Supervisor ethics: The Guidelines directly address supervision in areas of supervisor competence, boundaries, dual relationships, exploitation, fairness, and respect.

3.01 Supervision and Consultation

(a) Social workers who provide supervision or consultation should have the necessary knowledge and skill to supervise or consult appropriately and should do so only within their areas of knowledge and competence.

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

(c) Social workers should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee.

(d) Social workers who provide supervision should evaluate supervisees' performance in a manner that is fair and respectful.

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.

(b) Social workers who function as educators or field instructors for students should evaluate students' performance in a manner that is fair and respectful.

(c) Social workers who function as educators or field instructors for students should take reasonable steps to ensure that clients are routinely informed when services are being provided by students.

(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.

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.

Adequate supervision and work environment: They also address the responsibility of administration to ensure adequate supervision and an appropriate working environment in various ways:

3.07 Administration

(c) Social workers who are administrators should take reasonable steps to ensure that adequate agency or organizational resources are available to provide appropriate staff supervision.

(d) Social work administrators should take reasonable steps to ensure that the working environment for which they are responsible is consistent with and encourages compliance with the NASW Code of Ethics. Social work administrators should take reasonable steps to eliminate any conditions in their organizations that violate, interfere with, or discourage compliance with the Code.

The Guidelines support the value of supervision, and confer related responsibilities upon supervisors for competent services:

3.08 Continuing Education and Staff Development

Social work administrators and supervisors should take reasonable steps to provide or arrange for continuing education and staff development for all staff for whom they are responsible. Continuing education and staff development should address current knowledge and emerging developments related to social work practice and ethics.

Employers and potential issues: Social work has historical roots in social activism and concern for issues such as poverty, inequality, and oppression. This has led to special attention from the NASW and schools of social work regarding ethical responsibilities that may be at odds with employers. While any ethical guidelines can be key to supervision, these are reviewed here because of the supervisors potential role as both representative and stress point in the relationship between an employer and intern. Of course, such a potential rift is not isolated to the social work profession, and has challenged licensees and interns in all areas of practice.

3.09 Commitments to Employers

(a) Social workers generally should adhere to commitments made to employers and employing organizations.

(b) Social workers should work to improve employing agencies' policies and procedures and the efficiency and effectiveness of their services.

(c) Social workers should take reasonable steps to ensure that employers are aware of social workers' ethical obligations as set forth in the NASW Code of Ethics and of the implications of those obligations for social work practice.

(d) Social workers should not allow an employing organization's policies, procedures, regulations, or administrative orders to interfere with their ethical practice of social work. Social workers should take reasonable steps to ensure that their employing organizations' practices are consistent with the NASW Code of Ethics.

(e) Social workers should act to prevent and eliminate discrimination in the employing organization's work assignments and in its employment policies and practices.

(f) Social workers should accept employment or arrange student field placements only in organizations that exercise fair personnel practices.

(g) Social workers should be diligent stewards of the resources of their employing organizations, wisely conserving funds where appropriate and never misappropriating funds or using them for unintended purposes.

3.10 Labor-Management Disputes

(a) Social workers may engage in organized action, including the formation of and participation in labor unions, to improve services to clients and working conditions.

(b) The actions of social workers who are involved in labor-management disputes, job actions, or labor strikes should be guided by the profession's values, ethical principles, and ethical standards. Reasonable differences of opinion exist among social workers concerning their primary obligation as professionals during an actual or threatened labor strike or job action. Social workers should carefully examine relevant issues and their possible impact on clients before deciding on a course of action.

Liability and Risk Management

This section discusses strategies for reducing legal risks while maintaining commitment to clinical outcomes and the development of interns. Supervision provides two functions: protecting the public and enhancing the education of therapists and interns. By monitoring the quality of care with an eye to issues of quality and legal compliance, the public as well as the professionals and agency are protected. Supervisors are vulnerable to legal liability according to two legal theories: 1) vicarious liability arising from the negligence of interns; 2) direct liability as a result of negligence on their own part in supervision or in administration. Risks include those regarding both misconduct on the part of the intern and liability to third parties such as the victims of a patient that has harmed them. The legal issues are not simple or predictable, as many aspects are unresolved and change over time as court decisions, legislation, regulation, and discussions of liability take place.

Supervisors play several roles in enhancing mental health services. They include: 1) teaching future therapists, 2) supervising care, and 3) protecting the public. This latter point requires that supervisors ensure that only qualified interns go on to higher levels of responsibility and to licensure. This means that supervisors must be aware of and document deficiencies, and ensure that they are remedied or otherwise responded to appropriately. Consequences of negligence in supervision may include professional penalties such as license revocation, civil liability, or even criminal prosecution. Such negative consequences are not common (Recupero & Rainey, 2007), but provide a strong incentive to exercise caution in an organized fashion that includes consistent use of risk-management strategies.

While it is well-known that an overburdened staff is more likely to commit errors of omission or even commission, supervisors must also recognize that this can create liability for them and their agency. This issue should be on the table in various ways. It should be a subject of open discussion whereby supervisees can recognize any warning signs in their own behavior or feelings. This can include beginning to see clients as statistics rather than as people, becoming burned out or depressed, experiencing excessive anxiety regarding new intakes or other responsibilities, and having difficulty with remembering or following through on matters such as time-sensitive case management matters tasks. The agency should also have a means of monitoring and responding to this risk. Mitigation efforts can include management of benefits to improve the well being of staff, providing stress management and health programs for staff, and conscientious management of workload distribution. Sometimes size of a caseload can be irrelevant if, though luck of the draw, a counselor happens to have a large proportion of clients that have very high needs for case management, crisis management, or sheer emotional investment. 

Vicarious Liability Prevention

Supervisors may be found liable for the torts of residents without necessarily being shown to have had direct involvement in the harmful conduct. This liability, under the theory of respondeat superior, requires some form of agency or employer relationship that is determined to confer a degree of responsibility.

It is understood, however, that there are many forms that supervisory roles may take. Supervisors are often not the employer and may not even be employed at the agency site where an intern is providing services. The supervisor may not have direct responsibility for clinical decisions. Should there be a dispute regarding the intern's performance, it may be appropriate for the supervisor to inform the individual with administrative responsibility at the site in which the intern is working. Generally, the more direct intervention opportunity the supervisor has, the more liability there is for the supervisor. However, a higher level of scrutiny also allows the supervisor a greater ability to recognize problems. If the supervisor has less direct involvement and must rely on the intern's self report, it is recommended that the supervisor perform additional auditing of clinical quality through means such as chart reviews. Also, signs of poor progress or other problems warrant closer inspection through means such as reviewing recorded session material that is acquired with client permission.

A financial arrangement may result in vicarious liability in the form of "enterprise liability." This may exist when the supervisor gains financially from the resident's work. This may apply to an institution, as when an agency derives financial benefit from an intern's work. In generating bills, it is important to avoid billing trainees for a portion of any payments for treatment that is supervised, because this may be interpreted as a fee-splitting arrangement that may be considered to be unethical or illegal. (American Psychiatric Association, 1980)

Direct Liability Prevention

Negligent supervision: Supervisors must avoid negligent supervision in the form of acts such as failing to maintain adequate oversight and awareness of an intern's actions, not teaching needed material, and not meeting with the intern as required and according to the intern's needs. Since directly liability does not hinge upon an employer or agency relationship, it is easier to establish, especially since it stems from specific acts or omissions on the part of the supervisor.

The following may constitute negligent supervision:

Instructing an intern to do something contraindicated in the case

Failing to take corrective action upon learning of an error or deficiency

Failing to report concerns regarding an intern's behavior or abilities to the proper authority

Authorizing an intern to treat a client for whom the intern is not appropriately qualified or competent to treat

Negligent Administration: Supervisors have various administrative responsibilities arising from laws and regulations such as documentation requirements. Of course, the is much overlap between administrative and supervisorial negligence, as either can have effects of clinical importance. Supervisors must make sure that they are fully acquainted with such requirements and have means for tracking their compliance. Further, supervisors must be aware of such requirements pertaining to interns and ensure that interns are managing such requirements. Documenting these efforts and tracking compliance are valuable here. Supervisors can avail themselves of resources such as those published by the licensing board, legal consultation from an attorney provided by their state or national organization.

Competent crisis coverage must be maintained, and the supervisor must be prepared to intervene in a timely manner to ensure safety and competent care or referrals when crises or a changing level of care need arises. Failure here can result in a breach of duty to the client, or a breach of policy. Clear policies and understandings between interns, supervisors, and clients are helpful here. There may be liability for failure to develop and enforce appropriate policies for such matters. Safety is the highest priority in developing such policies. This can range from safety of interns in entering and leaving the agency to interns exercising appropriate means for deescalating potentially violent clients. By including competency testing and supervision standards, supervisors can help to ensure that appropriate measures will be taken. Policies can be drawn from professional resources such as national organizations.

Caregiver Misconduct

 Sexual Misconduct: A large portion of lawsuits arise from misconduct. Most are either sexual misconduct or intentional torts. Sexual misconduct claims are often characterized as malpractice, rather than intentional torts. This is based on the idea that the practitioner mishandled transference, violated the client's boundaries, or abandoned the client. Sexual relationships are often preceded by warning signs. Supervisors can reduce risk of sexual misconduct by monitoring for red flags such as confusion regarding boundaries, appointments not ending on time, and excess appointments. They should also document that policies regarding sexual misconduct have been reviewed with interns and that clients are provided appropriate information about such policies.

Another tort can occur when a clinician intentionally or recklessly inflicts severe emotional distress, particularly where the client has a known emotional vulnerability. Yelling at a client who has a prn prescription for benzodiazepines is a good example. Such behavior is known as the tort of outrage, because it involves outrageous behavior. Such behavior often occurs because of the intern's poorly managed countertransference. Battery is a similar tort, and refers to a physical assault. Neither of these torts support claims of respondeat superior, because the act is by its nature outside of the scope of employment or the agency relationship. Nonetheless, there may be liability for negligent supervision. Supervisors can mitigate risk for such torts and liability through vigilance for countertransference problems or poor ability to manage emotions when under stress. Prompt action on reports regarding intern misconduct or concerns is also important here. It is important to document all concerns and resulting actions in the intern's file. Corrective action policies and plans help to document and guide the response. The response to a concern regarding an intern must be guided by sound clinical thinking and a realistic understanding of the intern's capacities and needs. Failure of an intern to comply with the conditions of a corrective action plan can be grounds for reduced responsibility or even dismissal from an internship program. In a sense, a corrective action plan can be a very focused diagnostic. A vertical response in the agency must be a matter of policy, that is, all levels of the agency must have a role in knowing and acting on clinical and administrative policies.

A common source of trouble is the supervisor taking a red flag too lightly. For example, a psychiatric intern that admitted to having pedophilic impulses was permitted to serve in a ward for children. This occurred because the resident's prior supervisor failed to notify the reviewing committee of this. This eventually resulted in allegations of molestation and a lawsuit by the victim against the prior supervisor.

Third Party Liability

The above example shows that harm may occur to third parties such as foreseeable future victims of an intern. Tarasoff liability is another example, where failure to warn an identified potential victim may result in harm to that individual. It is important to make sure that all appropriate or required individuals or authorities are notified. This may include a potential victim, the police, the licensing board, a protective services agency for children, disabled adults, or seniors, or agency administration. The supervisor must take decisive and prompt action.

Informed Consent

Informed consent is extremely important in protecting the supervisee and/or supervisor from a malpractice lawsuit. Informed consent is defined as: knowledge by the recipient of what will be done to help them with their issues, the potential risks of intervention, and alternative services or interventions to enable the recipient to make an informed decision regarding participation.

Supervisors must be meticulous regarding informed consent. The supervisor must 1) Be confident that the supervisee has informed the client regarding the details of service; 2) Be positive that the client is aware of the structure of supervision, and 3) Inform the supervisee about the actual process of supervision and expectations of the supervisee, including the evaluation criteria.

An aspect of informed consent is for clients to know that they are being treated by a supervisee. This should be added to the informed consent or disclosure form that clients are asked to sign in acknowledging that they have received the information. Clients should know that any comments or concerns regarding the intern are desired by the supervisor. This information must include means for contacting the supervisor and the supervisor's identity. It is very important that interns understand the concept and rationale for informed consent. Informed consent can even be applied to the supervisory relationship, by ensuring that interns understand what services will be provided in supervision and the nature of the relationship.

Confidentiality

Confidentiality is a tricky concept within supervision because the supervisee is disclosing information that is confidential to the supervisor as well as other supervisees. It is important that these limits are discussed with clients and incorporated into the intake paperwork that the client acknowledges by signature. The client must consent to their case being discussed with a supervisor. This is rarely a problem, as clients understand that this is part of working with an intern. It extremely important that the supervisee understands confidentiality and knows when and how to keep client confidentiality as well as situations where confidentially needs to be broken (a suicide threat, underage abuse etc).

Knowledge regarding confidentiality within supervision and its limits is also important. Supervisees should be able to trust their supervisor with personal information, as well as be informed about exceptions to the assumption of privacy. There may be state laws pertaining to confidentiality in the relationship as well.

Additional Strategies

Emergency procedures: The supervisor and agency should have clear, established protocols for responding to emergency or high-risk situations such as suicidality, as well as routine matters of assessment, case management, and referral.

Awareness of client risk factors or special needs: Supervisors should think in terms of individual clients and interns. Many clients have individual vulnerabilities, behaviors that a given intern may react to in an unresourceful manner, and other risk factors. The supervisor should identify and research any such factors if the supervisor is not sufficiently familiar with them. The supervisor should provide a higher level of supervision and scrutiny where risk is higher. Likewise, some treatments have unique risks, such as the potential for catharsis, dissociation, or destabilization in some clients exposed to some somatic or exposure approaches such as EMDR.

Awareness of intern risk factors or special needs: Supervisors should directly inquire about any special concerns or needs that the intern brings. This can include any complaints or comments about performance. The intern, the academic program, and the previous position may all provide relevant information. Interns may be able to tell the supervisor a great deal about their specific needs and challenges, especially in an atmosphere of trust and accountability. Being specific, rather than vague, about the process of supervision in addressing the development of the intern in a positive way may elicit much more cooperation and transparency from an intern than a more negative or unstructured approach.

Back to basics: Supervisors should not hesitate to review fundamentals such as the definition and examples of boundaries and boundary crossings. Reviewing things to avoid may be more helpful for many interns because they may not have translated some clinical guidelines in to "what not to do" on their own as effectively as the supervisor might assume.

Modeling is central to supervision. Demonstrating boundaries with interns is an excellent example of modeling. This includes adhering to hours established for availability, maintaining back up for crisis calls, and maintaining regular supervision sessions.

Documentation: Keep good documentation and audit supervisees documentation sufficiently to ensure that it is being maintained consistently. This includes documentation of the fulfillment of continuing education and other requirements for supervisors. 

 

Citations

American Psychiatric Association. (1980). Guidelines for Psychiatrists in Consultative, Supervisory, or Collaborative Relationships With Nonmedical Therapists. APA Resource Document, Reference No. 800001, June.

Bernard, J. M. (2008). Fundamentals of clinical supervision, 4th Edition. Allyn & Bacon. 

Borders, L. D., and Brown, L. L. (2005). New handbook of counseling supervision, 2nd ed. Lawrence Erlbaum Associates.

Center for Substance Abuse Treatment. (2009) Clinical Supervision and Professional Development of the Substance Abuse Counselor. Treatment Improvement Protocol (TIP) Series 52.  DHHS Publication No. (SMA) 09-4435. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

Constantine, M. G. Multicultural competence in supervision: Issues, processes, and outcomes. In: Pope-Davis, D. B.,  Coleman H. L. K., Liu, W. M., Toporek, R. L., editors. (2003). Handbook of Multicultural competencies: In counseling & psychology. Thousand Oaks, CA: Sage Publications, pp. 383–391.

Hofstede, G. (1984) Cultures consequences: International differences in work-related values. Beverly Hills, CA: Sage.

Locke, D. C. (1990). A not so provincial view of multicultural counseling. "Counselor Education and Supervision," 30, 18-25.

Locke, D. C. (1986a). Cross-cultural counseling issues. In A. J. Palmo & W. J. Weikel (Eds.), "Foundations of mental health counseling" (pp. 119-137). Springfield, IL: Charles C. Thomas.

Lyman, B., Storm, C., and York, C. (1995). Rethinking assumptions about trainees' life experience. Journal of Marital and Family Therapy, 21(2), 193-203.

National Association of Social Workers. (1999). Code of Ethics. Retrieved 12/29/2007 http://www.socialworkers.org/pubs/code/code.asp

Patricia R. Recupero, P. R. and Rainey, S. E. (2007). Liability and risk management in outpatient psychotherapy supervision. Journal of the American Academy of Psychiatry and the Law, 35(2), 188-195.

Pedersen, P. B. (1991). Introduction to the special issue on multiculturalism as a fourth force in counseling. "Journal of Counseling and Development," 70, 4.

U.S. Department of Health and Human Services. (2003). Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations (Rep No HHS Pub No SMA 3828). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

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