In the early stages of supervision, supervisors may wish to structure case consultation, whereas more advanced supervisees should be the ones to suggest the focus and content for the consultation. For example, supervisors could decide they want a quick overview of most of the supervisees’ cases, or they may want specific detailed information about particular ones. Some supervisors concentrate exclusively on problem clients while others want to hear about supervisees’ successes as well as difficulties. Supervisees themselves may want to detail a specific problem with a client, or they may seek more extensive assistance from the supervisor with an entire client situation. At issue for all supervisors is how to maximize the use of time in case consultation to the greatest benefit to clients. As experienced supervisors know, having a focus for each case consultation session will help improve the profit gained from the time spent. Another suggestion is to include some kind of thought-provoking questions as supervisees discuss their cases. More information about the use of questions in case consultation follows in the next section.

A strong argument can be made for the number of benefits accrued from using the case consultation method. This method helps supervisees organize information; conceptualize problems; make assessments; decide intervention strategies; consider the larger context of a problem, such as the role of cross-cultural issues or ethical dilemmas; develop a theoretical model of change; integrate theoretical understanding with practice; process relationship issues, such as parallel process or transference; promote self-awareness on the part of supervisees; and encourage independence (McCollum & Wetchler, 1995 ; Noelle, 2002). Rapid Reference

5.2 summarizes the benefits that can be gained from case consultation.

However, there are also a number of important drawbacks to relying exclusively on case consultation as the only supervision method. First, case consultation is a self-report method and therefore can be subject to deception, especially when supervisees are fearful of criticism or making mistakes (Noelle, 2002; Webb & Wheeler, 1998). In the article “Lying in Psychotherapy Supervision: Why Residents Say One Thing and Do Another,” Hantoot (2000) reported psychiatry residents frequently left out information or misrepresented facts in order to avoid conflict, criticism, or poor evaluations from supervisors. Second, the success of self-report methods depends on the observational and conceptual abilities of the supervisee and is, in itself, a skill honed by years of practice. Expecting novice supervisees to be able to identify and select potential problem situations; to know what the supervisor needs to know; and to be willing to bring mistakes, difficulties, and vulnerabilities into case consultation might be unrealistic. If self-report is the only method of supervision, not only does it make the supervisor vulnerable to missing potential problems but it also limits the supervisor’s effectiveness as a teacher and trainer.

To avoid such difficulties, especially in the beginning of the supervisory relationship, it is recommended that supervisors include at least one more direct method of gaining information about supervisees’ interactions with clients, such as the use of taping, live observation, or review of some or all of the written documentation for clients (Saccuzzo, 2002). Additionally, including a case review sheet or written assignment along with self-report might help focus supervision sessions and add benefit from both a teaching and monitoring perspective.

If general open-ended questions do not bring the desired information forth or supervisees seem bewildered, supervisors will need to back up and be more specific (Munson, 2002). Probing-style questions, such as “Can you give me an example of what you mean by that statement?” or a focused-style question, such as “What were you thinking right then? ” may also help elicit more detail or give direction to case consultation.

Rapid Reference 5.4 presents some examples of specific probing-style questions to use in case consultation.

Additionally, asking supervisees to keep a journal to process their thoughts and feelings while in supervision can encourage self-exploration. This supervision strategy is especially popular for graduate students and beginning counselors. Supervisees could be given a series of structured exercises and self-awareness questions to process in the journal. The focus of a supervision journal is to heighten the supervisee’s awareness of any personal thoughts, feelings, beliefs, or values that might impact client care, not for reasons of personal growth or psychotherapy. Therefore, the supervisor would not necessarily have to read any of the journal entries but instead prompt the supervisee to relate material to current client cases. For example the supervisor might ask “Did anything come up for you—thoughts or feelings—that you see might be important in your work with your clients [or this particular client]?” More material on how to use self-awareness exercises in supervision can be found in Chapter 9.

Process recording and verbatims are also popular techniques used in the early stages of supervision. With process recording, supervisees are asked to write up a client session on one side of a page and then process their thoughts and feelings on the other side. Verbatims involve supervisees recreating on paper an entire client session or part of a session that can then be reviewed in supervision.

Perhaps the most effective and easiest written technique for both training and monitoring purposes is to use a standard case review form. This form could be used with beginners in order to assist them in organizing their thinking or with those at a more advanced level to verify expertise. The case review form can be structured to focus attention on the conceptualization of client problems, assessment and diagnosis, selection of intervention strategies, ethical concerns, multicultural issues, or to increase self-awareness about personal responses to clients. Supervisors may wish to create their own case review form to fit their particular circumstances or use the one provided in Rapid Reference 5.5. In addition, there are a number of other case consultation forms available in the literature on supervision (Bernard and Goodyear, 2004; Bradley & Ladany, 2001; Falvey, Caldwell, & Cohen, 2002; Haber, 1996; Munson, 2002; Powell, 1993).

There is another important area of writing to focus attention on in clinical supervision: the obligatory client documentation in the mental health field, such as record keeping, charting, intake forms, process notes, and other paperwork required by third-party payers and accrediting bodies. Supervisees often struggle to learn correct documentation procedures and to do them in a timely fashion; consequently, clinical supervisors find themselves spending large amounts of time assisting their supervisees in this critical but complex area of practice. One commonsense suggestion to facilitate this learning process is for agencies and organizations to provide all clinical supervisors with a number of excellent examples of proper documentation and forms. Clinical supervisors could then use these examples for teaching and training purposes. Fill-in-the-blank forms or structured outlines that walk supervisees step by step through the thought process considered necessary to complete the paperwork may also offer additional assistance to those supervisees who struggle with writing.

Reviewing a part or all of a supervisee’s documentation is a necessary addition to any supervision plan for monitoring purposes. Depending on the circumstances, job task, and the level of training and responsibility, this review of documentation might start out being inclusive, covering intakes, diagnosis or case conceptualization, progress notes, charts, and treatment plans or protocols. As skill increases, the review might become more random. However, reviewing all diagnosis and treatment plans for doctoral or postdoctoral level psychologists, especially in private practice settings, is suggested by Saccuzzo (2002) because of liability issues.

Interactive techniques include cotherapy, use of a mirror with phones or a bug in the ear (a tiny microphone placed in the ear of the supervisee through which the supervisor can communicate during a therapy session), modeling, and demonstration. With interactive live supervision, the supervisor takes a more active role. A number of possibilities exist when the supervisor is actually in the room with the supervisee and the client: The supervisor may interrupt periodically to make suggestions, stop the session and take over to model a particular technique and then ask the supervisee to continue, or stop after half the session and process what has occurred to that point with the supervisee while the client is still in the room. In this instance, to clarify roles and boundaries and prevent confusion, Haber (1996) recommended that a chair be set aside in the room for the supervisor to move to whenever commenting or giving corrective feedback to the supervisee. Limiting comments and interruptions to a small number is also recommended in order to avoid the impression of the supervisor taking over the session.

Cotherapy is another time-efficient method of interactive live supervision that can easily be used with either individual or group supervision and would be an excellent adjunct to traditional case consultation (McGee & Burton, 1998). Supervisors can explain and model techniques at the same time as they learn about the supervisee’s needs and style. For some supervisees, it can also help reduce anxiety and encourage risk-taking. However, for others the opposite may be true. Hence, supervisors will have to discuss with their supervisee their needs as a cotherapist and then, as things progress, check on how the cotherapy relationship is proceeding. Another common issue facing some supervisors is managing the dance of power with the supervisee. There are times when supervisors will want to exercise power and direct the client session but other times when they will need to take a secondary role in order to promote the supervisee’s independence.

To maximize the benefit of live supervision, a few activities are recommended. First, the supervisor needs to be oriented to the particular client case selected for live observation—the background, the goals for the session, and the planned approach. The supervisee could submit this information in writing before the session to save time. Next, decide whether to observe the entire meeting with the client or just a part of one. Most important, allow 10 or more minutes for supervisor-supervisee feedback immediately following the actual session while thoughts are fresh. Even overwhelmed practitioners, if convinced of the value of live supervision, can negotiate this at least once during a supervision experience. Rapid Reference 5.6 outlines a number of hints to maximize the value of live supervision.