Four
FORMATS FOR CLINICAL SUPERVISION
Once a model for supervision has been selected, the next step is to select a structure in which to actualize the model. Even though historically the design for delivery of clinical supervision is one where supervisor and supervisee sit down together for an hour and review cases, there are actually a number of other possible formats, such as group, peer, or team supervision. Live observation, cotherapy, videotaping, written exercises, demonstrations and role-play are examples of methods and techniques that could be combined within each of these formats to enrich the supervision experience.
Even the most experienced supervisor would do well to spend significant time pondering all of these possibilities for a number of important reasons. First, the format for delivery of supervision, along with the selection and combination of methods and techniques, will play a significant part in the growth and development of supervisees. Second, the choice of format, methods, and techniques serves a key function in monitoring the activities of supervisees and facilitating a high quality of care for clients. Third, the use of a variety of formats, methods, and techniques will also be an integral piece of ethical clinical supervision practice as they enhance the fair treatment of supervisees, especially in the area of dual relationships, multicultural differences, and evaluation. (See Rapid Reference 4.1.)
Rapid Reference 4.1
Goal of Supervision Formats, Methods, and Techniques
• Improve knowledge, skills, and self-awareness of supervisees
• Increase objectivity to avoid bias and impaired judgment
• Improve monitoring and control of supervisees activities
• Facilitate independent functioning and decision making
When considering all the options for supervision structure, it might be helpful to familiarize oneself with the advantages and disadvantages of each of the formats. It is also important to consider the supervisor’s own level of competency in utilizing each of the formats. Other considerations are time, money, resources, requirements for supervision, the developmental level of the supervisee, their learning style, the client population, and multicultural differences.
Regardless of the format selected for supervision, knowledgeable supervisors realize that having some elementary structure for the selected format is essential to success. Applying the developmental perspective, the role of structuring belongs primarily with supervisors with beginners, whereas when working with more experienced supervisees this structuring process should be done collaboratively.
DON’T FORGET
Whatever supervision format is selected, it will be necessary to orient supervisees to the purpose and goals for each one, to supply some type of structure for the format, and to provide for the supervisee’s safety.
INDIVIDUAL SUPERVISION
Since Freud’s time, individual face-to-face case consultation has been the primary modality for clinical supervision. Traditionally, supervisees bring in case material about their clients to discuss with the supervisor. This may be done in a formal session, usually once a week for 1 hour, or informally as needed. Today, most graduate programs and state licensure boards require a minimum of 1 hour of individual face-to-face supervision per week for all pre- and post-degree trainees. Sometimes supervisors are allowed to substitute group supervision on an every-other-week basis, but such sessions never entirely replace individual meetings. The supposition is that regular one-on-one individual meeting time with clinical supervisors is necessary both for the growth and development of supervisees as well as for monitoring purposes.
The structure for individual supervision doesn’t need to be elaborate, but some modicum of organization will increase the benefit. Rapid Reference 4.2 provides suggestions for structuring individual supervision. Certainly beginning supervisees appreciate supervisors who have a plan for supervision sessions as it helps to reduce their anxiety. Experienced supervisees also appreciate some structure and direction, but they usually want to have more say about what happens in supervision. All supervisors need to think through the purpose and goals for supervision and, at a minimum, create some initial structure for the relationship.
DON’T FORGET
There will be a need for structure and direction on the part of supervisors in any crisis situation, regardless of the level of expertise of supervisees. In other words, there will always be an interaction between the supervisor, supervisee, and the needs of clients.
Rapid Reference 4.2
How to Structure an Individual Supervision Session
1. Think ahead to the purpose and goals for the session.
2. Include the supervisee in planning for the session.
3. Ask the supervisee what they need most from the session.
4. Create a structure for the session: Start with successes, not problems.
5. Create questions to stimulate thinking.
• “What are your feeling responses to the client?”
• “How was it for you to sit with this client?” (Irma Rahtjen, workshop participant, Kansas City)
• “How connected do you feel to this client?” (Michael Winters, workshop participant, Houston, TX)
• “ What is your plan of action [intervention strategy, treatment goal] with this client? ”
• “Can you identify any multicultural issues that may affect your relationship with this client?”
• “What did the client say or not say was the problem and how might this be important to success? ”
• “What personal issues are you aware of that may affect working with this client?”
• “Are there any ethical issues present in this client situation?”
6. Whenever possible, combine case consultation with other methods and techniques, such as a written case review sheet, role-play, or a short demonstration.
7. Include some time for a teaching component within each session (more on creating a topical focus for supervision follows).
8. Ask the super visee at the end of each supervision session about the benefit of supervision that day.
• “What is one thing you will take away from supervision today?”
• “How was supervision helpful to you?”
• “What was missing? ”
• “ What do we need to talk about more next time? ”
9. Document the session. (See Chapter 6.)
A number of factors can influence the structure of individual supervision such as the purpose of the supervision, identified goals, supervision rules and requirements, level of expertise of supervisees, client needs for monitoring, as well as time, availability, and other organizational concerns. Decisions about how to best use the supervision time could be made weekly by supervisors simply asking “How do you want to use your supervision time today?” or “How can I be most helpful to you today?” Nonetheless, as time progresses, supervisors still need to give consideration to the overall goals for supervision to be sure progress continues in that direction.
Adding a topical learning component to supervision sessions can also enrich the experience. Subjects such as suicide, trauma, abuse, anger and resistance, multicultural differences, termination, or substance abuse might not have been covered in graduate school, or, if they were, application of classroom materials to actual client situations may require considerable effort. There are a number of possibilities for how to do this within individual supervision. (See Rapid Reference 4.3.) For example, a topic such as learning to address client resistance or noncompliance could be inserted into a case review or selected as the focus for a portion of a supervision session or a series of supervision sessions.
Rapid Reference 4.3
Three Examples of How to Utilize a Topical Approach in Supervision
Supervisor: “As you were talking about your frustration with Mr. Smith, I realized that you have been struggling with several clients who don’t say much, and you don’t get much of a verbal response to your questions. I know when I started out, I felt the same way you do and so have had to develop different ways of approaching such clients.” Three types of supervisor suggestions could follow this introduction:
1. “Let’s role-play this situation with Mr. Smith and see what comes up. It may give you new ideas as to how to approach other clients similar to Mr. Smith.”
2. “For the next month or so, let’s take a closer look at working with clients who are difficult to engage. I think it will be beneficial to spend some time in supervision on that topic. I have one or two articles on suggested approaches that you are welcome to look at. However, I expect that you will want to research the subject yourself to see if you could come up with at least one different approach to try with Mr. Smith. We’ll start our next supervision meeting talking about your ideas.”
3. “One fruitful area for exploration in supervision is the topic of transference and countertransference with clients. In other words, looking at what a client is doing or not doing that is affecting our relationship with him or her. I know it goes on with me sometimes with my clients, and, of course, there is a lot of literature out there on this topic, so, to my way of thinking, it would be a good idea to spend time in supervision examining our hot buttons with clients. It is a very important part of ethical practice. How does that sound?”
CAUTION
Avoid beginning a supervision session with “What do you want to talk about today? ” This implies that you have no idea what to do as a supervisor. A better statement would be “How would you like to use our supervision time today as to be of best benefit to you?”
There are a multitude of advantages to individual supervision. First, supervisors are able to give each supervisee their complete attention. They can individualize supervision, which will facilitate building trust and a working relationship. The supervisee may feel safer with the supervisor in such a situation and be more willing to take risks and be open. As a result of such trust, both supervisor and supervisee may feel freer to experiment with other modalities beyond traditional case consultation and explore issues more deeply.
There are also disadvantages to relying exclusively on individual case consultation. First is the problem of isolation and the potential for an inaccurate view of the supervisee. By not watching the supervisee interact with others, the supervisor is relying on the supervisee’s self-report and may not have a true picture of the supervisee’s skills and abilities. Another issue is that individual supervision could be open to bias, impaired judgement, exploitation, and harassment on the supervisor’s part. On the other hand, supervisees may withhold information or lie because of worries about criticism or a poor evaluation (Hantoot, 2000). Along with the problems of supervisor bias and supervisee deception, individual supervision can also become repetitive and boring over time. Both supervisor and supervisee would need to continually suggest new ideas and activities to avoid such a quandary.
CAUTION
Because of vicarious liability and other monitoring issues (see Chapter 2), supervisors today should be careful about relying completely on individual case consultation as the only means for supervision. Try at least one other way to get more direct information about the supervisee’s activities with clients, such as direct observation, review of case notes, or taping.
The greatest drawback to individual supervision, which relies exclusively on the self-report narrative of supervisees about their clients, has to do with monitoring the quality of client care. If not combined with other formats, methods, and techniques that allow supervisors more direct observation of the supervisee’s activities, potentially serious liability issues for clinical supervisors could arise.
Putting It Into Practice
Case Example
Sandra, a new and inexperienced counselor, was assigned to work with an African-American couple that had just called the agency for an appointment. The presenting issue was the husband’s recent loss of his job and the turmoil created by this fact. Each reported the other partner as “depressed and not doing well.” The wife wanted them to move back in with her parents as a temporary solution to their financial problems. She felt this would give them needed time to straighten things out. The husband was adamantly against such a solution. Sandra was bewildered by the level of arguing between the couple during the session and came to the conclusion that the husband was “angry and abusive” because the wife kept saying she wanted to move back in with her family. At the beginning of supervision, her supervisor asked her “What would you like to talk about today? ” and Sandra said she wanted help with this couple. Her supervisor asked her what was her assessment of the situation and plan for counseling with them. Sandra launched into her analysis of the problem as being the husband’s anger and probable abuse of the wife. In response to this report, the supervisor gave Sandra a series of actions to take to protect the wife and recommended the husband be referred to an anger management group.
Teaching Point: The supervisor made the error of assuming a certain level of conceptualization and assessment skills on the part of this new, inexperienced supervisee. By not following up very broad, open questions with more specific ones, much pertinent information was lost. For example, in order to access more detailed information, the supervisor might have inquired about what the couple was doing that led her to that conclusion. Another important question that should have been asked concerns multicultural differences between the supervisee, Sandra, and the couple. A multiculturally competent supervisor would know that culture has an effect on how people respond to crisis situations. Knowing the cultural aspects of this couple’s situation, the supervisor would have made other recommendations. Certainly this points to the potential mistakes that can be made by supervisors relying completely on the self-report of supervisees and not following broad questions up with requests for specific examples of behaviors that support the supervisee’s perceptions and conclusions.
GROUP FORMATS FOR SUPERVISION
In addition to individual supervision, there are three other supervision formats that take place in a group: group, team, and peer supervision. There are distinct differences in structure and leadership function among these three formats for supervision. However, overall, they are alike in that supervisors in each format have to address identical issues of managing group dynamics; understanding group process; building group cohesion; establishing structure; setting rules and boundaries; and handling issues of confidentiality as well as decision making and the leadership role. Therefore, this section contains the majority of general material on working with groups in supervision, while the sections on team and peer supervision cover information specific to that format.
Group Supervision
Group supervision is another supervision format that has advantages as well as drawbacks. Group supervision can serve as a complement to individual supervision. When coupled with audio- or videotaping and experiential techniques, it can become an even more efficient learning tool (Ray & Altekruse, 2000). However, much of the time it is selected simply as a means to solve the supervisor’s time constraints rather than to increase learning benefits for supervisees. The most common structure selected for group supervision is actually individual supervision in a group setting where each supervisee is given an allotted time to present cases, and most interactions are between the supervisor and this one individual. Depending on the size of the group, this may appear to be a satisfactory solution for overworked supervisors.
However, with more forethought, group supervision can have more far-reaching benefits, such as encouraging team building, promoting risk-taking, diffusing issues of power and authority, addressing multicultural differences, and invigorating bored or burned out supervisees. Haynes et al. (2003) make a strong case for the value of group supervision as providing a heightened learning environment with the use of experiential techniques such as role-play and role reversal. Certainly when supervisees progress much beyond the beginning stage of development, moving out of the traditional model of individually focused group supervision into a more group-focused model will expediently increase the benefits.
Many of the same universal therapeutic factors Yalom (1995) identified for group therapy exist in group supervision and represent the largest part of its benefit. For example, checking out perceptions, trying out new behaviors in a safe environment, seeing that one is not alone, learning to give and receive feedback, engaging in self-exploration, seeing alternative ways to solve problems and intervene with clients, developing tolerance for ambiguity, and appreciating differences in perspectives on problems are all benefits of group supervision.
CAUTION
Groups will be more effective as training vehicles if the leader is not involved in the evaluation process. If the group leader is both the administrator and the clinical supervisor, he or she must disclose the extent to which self-disclosure and participation in the group will be a part of evaluation.
However, creating a cohesive and safe group environment for this type of learning to take place is a complicated balancing act requiring more preparation and skill on the supervisor’s part than many realize. In most instances, the supervisor’s level of training and experience with group methods will be more important to effective group supervision than the type of supervisee.
CAUTION
Supervisors in group supervision should not mistake supervision sessions for group psychotherapy and should make sure supervisees understand the distinction.
Thus, supervisors engaged in group supervision will need to be well versed in group dynamics, understand group development and the role of conflict in groups, as well as be comfortable with confrontation. Additionally, supervisors must be familiar with the difference between group supervision and group therapy and be able to draw a clear line between the two. As those who have a background in groups know, it will be just as important in group supervision as in group counseling and therapy to establish at the onset group goals and expectations and create a structure and some guidelines for behavior in order to increase success.
There are many advantages to group supervision. The greatest benefit is that it expands both the supervisor’s and supervisee’s perspective of each other and of clients. Using group dynamics and group process can increase involvement and empower supervisees to solve problems, develop tolerance for differences, and build teamwork. Groups provide a wonderful place for experiential techniques, such as role-play, role reversal, and family sculpting, which can enrich and enliven the supervision experience. Through sharing anxieties and life experiences, checking out intuition, and learning to give and receive feedback, most supervisees will increase in their confidence and self-efficacy (Page & Hulse-Killacky, 1999). As supervisees exchange insights and points of view, they develop an appreciation for the value of peer consultation so essential to ethical practice. Group supervision also helps supervisors to see their supervisees in a different light as they interact with others. Furthermore, there is less danger of improper or harmful behavior on the part of supervisors.
Success with group supervision also depends greatly on how it is presented to supervisees (Yalom, 1995). It is possible that some supervisees will have no real background or experience with groups outside the classroom, sports, or social activities. For others, the primary group experience will be a therapy or a support group. Thus, supervisors will need to emphasize the educative purpose of the supervision group as an assured way to help clients. Offering choices in the selection of the group structure and including supervisees as much as possible in goal setting and planning will also help build a positive group experience for members. Another concern that should be tackled is anxiety. Group members, especially beginners, may bring a host of fears, sometimes rational and sometimes not, to the group that if not addressed to some degree, can linger and create barriers to group cohesion and interfere with learning (Fitch & Marshall, 2002).
Just as there are many advantages to utilizing group supervision, there are also many drawbacks. Perhaps the biggest drawback is providing equal time to all supervisees in the group. Overlooking some supervisees can contribute to gaps in monitoring of client care as well as missed opportunities for learning. If the supervisor is not skilled in group dynamics and facilitation, instead of building safety and a sense of trust, the opposite may occur. For example, both supervisors and supervisees could overstep boundaries and fall into the trap of turning group supervision into group therapy. When the clinical supervisor is also the administrator, keeping boundaries clear will take continuing effort. Another important issue is confidentiality. Just as with group therapy, without strict rules and vigilance on everyone’s part, information gained in the supervision group can spill out into other arenas and become problematic.
Other disadvantages include using the group as a forum for complaints; scapegoating of members; splitting into subgroups that compete against each other; or, after time, becoming so internally focused on the group dynamics and group process that discussing client cases becomes secondary. All of these possibilities will result in poor monitoring of client care (Munson, 2002).
Stages of Group Development
The first step for supervisors to insure success of group supervision is to have a basic understanding of group dynamics (Linton, 2003). One model of group development that might be helpful to all supervisors is the five-stage developmental model for groups: forming, storming, norming, performing, and adjourning (Tuckman & Jensen, 1977). According to the theory, there is a task component and a relationship component within each stage of development. During the forming, or first stage, as groups get organized, the primary task is orientation to group goals and the setting of rules, structure, and purpose. The relationship component at this stage is characterized by members’ needs for safety and dependence on the group leader. Schutz (1977) refers to this stage as the inclusion stage typified by members’ concerns such as “Will I be heard and understood?” “Will I be liked?” or “Will I be seen as competent?” Supervisors set the stage for the group by modeling behaviors that increase participation and development of group cohesion.
CAUTION
If using experiential techniques in group supervision, such as role-play, role reversal, Gestalt empty chair, or doubling and soliloquy from psychodrama, be careful to maintain clear boundaries and focus activities on helping clients, not on conducting therapy with supervisees.
CAUTION
It is a mistake to assume lack of disagreement is a sign of group cohesion. Instead, this can be symptomatic of group flight from conflict and confrontation and indicate a lack of safety on the part of group members.
As the group progresses over time and people get comfortable, the group accordingly will move to the next stage, storming. At this point, members may feel safer to disagree with the group facilitator or other members of the group. Differing viewpoints on client problems and disagreements about intervention suggestions and theory are natural and normal as supervisees become more confident and experience level increases. Certainly with highly experienced clinicians, open discussion of this kind is the heart of the group process. Although some conflict can be healthy, supervisors need to work hard to manage the conflict so as to maintain safety and trust and keep the group focused on the task at hand.
If successful in resolving differences and creating a structure for positive disagreement, the group then moves on to the norming stage that is characterized by a collaborative atmosphere, free exchange of ideas, and openness to differing viewpoints that are seen as helpful to the group purpose. On a relationship level, the group begins to form a sense of “we-ness” or positive morale, and members will be eager to attend each session (Kormanski, 1999). Group members act friendly, warm, and supportive of others’ suggestions and ideas. Decision making is deemed a shared responsibility and seeking consensus an implicit value for the group. Helpful feedback occurs among members as well as from the leader. Members will have more insight about group process and parallels between what is occurring in the group and what is occurring with clients and are able to use such information productively to further aid client care.
Putting It Into Practice
Example of Noting Parallel Process in Groups
Mary, a supervisee, is presenting a client case in a very monotone voice, with little affect. Sam’s (the group supervisor) attention begins to drift off. Recognizing his state, Sam says to Mary, “Mary, as you talk about this client, you have little energy in your voice, it sounds very flat and matter of fact, and, as a result, I find myself becoming bored and my mind drifting. I am wondering if that is similar to how you feel with this client? Are you bored working with him? How involved do you feel?” Mary notes the accuracy of the feedback and begins to talk more directly about her experience with this client.
Establishment of such group norms propels the group into the performing stage whereby the group becomes very task oriented, and much is accomplished during group time. At this stage, the focus will be on client care, and the relationship component of the group will take the shape of member abilities to understand group process and willingness to self-correct when getting off target. For example, in the early stage of group development, as supervisees discuss cases, the leader might jump in with a reflective comment on the group process and invite the group to ponder the existence of parallel process. At this stage, however, supervisees themselves would suggest such a possibility without leader intervention and come up with their own ideas for correction.
The last stage of group development is called the adjourning stage, which signals the end of the structured group experience or accomplishment of the identified group purpose. The relationship task for group leaders at this point is to help members end the experience on a positive note. Typically, endings are formalized with rituals and ceremonies that give closure, recognize achievement, and help members say good-bye. With group supervision, the adjourning stage could be for an individual member as the required supervision time comes to a close or for the group itself. In open-ended supervision groups, consideration might be given to the idea of structuring the supervision group to periodically have a beginning and an end in order to force consideration of group structure and dynamics and propel members to new action.
Observation of Group Dynamics
One excellent suggestion to improve group supervision is to appoint a group process observer for one or more meetings at the beginning stage of the group and then follow up with observation of the group at various other times over the life of the group. Supervisors who are interested in the safety of group members and in building a collaborative supervision team would find the addition of group observers very helpful to this end.
The observer could track group member behavior and communication patterns for short time periods and then share his or her observations with the group as a means to encourage self-awareness, improve communication, track stages of group development, and advance the goals for the group (Treadwell, Kumar, Stein, & Prosnick, 1997). The observer may wish to monitor the level and type of participation by various group members or who talks to whom and how often. For example, one supervisee may speak directly to the person he or she thinks is most likely to disagree with his or her ideas, whereas another supervisee may address all remarks to the person perceived to have the most power and influence in the group. Sometimes supervisees may couch all remarks with disclaimers or use generalities and avoid addressing any remarks directly to group members because of concern for safety. The group observer could point out these behaviors as a means to facilitate discussion about safety, power, and influence in the supervision group.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
