This online course presents best practices in supervision and reviews the structure of the supervisory relationship. Topics presented will include developmental models of supervision, goals of the supervisory experience, ethics and risk management in the supervision process, and diversity awareness training for the supervisee. The vital and, at times, challenging relationship between supervisor and supervisee will be discussed and compared to the therapy relationship.

The important topic of self-care of both the supervisee and the supervisor will be presented. A review of the type and structure of performance evaluations will be included, along with information about successful termination. Essential resources for the supervisor to utilize throughout the training experience will be provided at the end of the course. The author of this online course is Rebecca E. Williams, Ph.D.

Learning Objectives
Upon completion of this course participants will be able to:

• Distinguish among various developmental models of supervision.



• Name the four main functions of a supervisor.



• List Nagy’s seven guidelines for ethics in providing supervision.



• Identify six client factors associated with a high risk of violence.



• Name ten activities that can contribute to therapist self-care.



• Distinguish between the supervision relationship and the therapeutic relationship.



• Name five areas to be covered in a supervision performance evaluation.

                     

The beginning of wisdom is calling things by their right names.
Chinese Proverb

Clinical supervision is the heart and soul of psychotherapy training. Supervising therapists is, to be sure, a multifaceted endeavor. Both the supervisor and the supervisee have specific and important activities to accomplish within the tenure of the supervisory experience. Hess (1980) defined clinical supervision as a dyadic relationship in which one person assists another in modifying behaviors, cognitions, and emotions in order to provide more effective services to patients. Stricker and Fisher (1990) suggested that (1) the patient’s needs should be paramount in the therapeutic situation, (2) the therapist’s interventions should be tailored to meeting these needs, and (3) the supervisor’s role is to facilitate the occurrence of the first two conditions. According to Holloway (1995), to supervise is to “oversee,” to view another’s work with the “eyes of the experienced clinician, the sensitive teacher, the discriminating professional” (p. 1).

Supervision offers an opportunity for the student to capture the essence of the psychotherapeutic process as expressed and modeled by the supervisor and then, to recreate this process in an actual psychotherapy relationship (Holloway, 1995). Falender and Shafranske (2004) assert that supervision is a “distinct professional activity in which education and training aimed at developing science-informed practice are facilitated through a collaborative interpersonal process. It involves observation, evaluation, feedback, facilitation of supervisee self-assessment, and acquisition of knowledge and skills by instruction, modeling, and mutual problem solving. In addition, by building on the recognition of the strengths and talents of the supervisee, supervision encourages self-efficacy. Supervision ensures that clinical consultation is conducted in a competent manner in which ethical standards, legal prescriptions, and professional practices are used to promote and protect the welfare of the client, the profession, and society at large” (Falender & Shafranske, 2004, p. 3). What at first glance may appear as straightforward training actually entails many layers of attention and commitment to the craft of supervision.

Just as no two patients bring the exact same concerns to therapy, no two supervisory relationships will be alike. Each supervisory relationship is unique in its texture and each supervisee develops at his or her own pace. Layered throughout the duration of the experience is the relationship between the supervisor and the supervisee, the clinical work of the supervisee, the material presented by the patients, the teaching of assessment and psychotherapy, the management of administrative duties, and the development of the supervisee as an effective therapist. The environment of practice, the types of patients receiving treatment, the events of the times, the theoretical orientation of the supervisor, and the complex personalities and life experiences of both the supervisor and supervisee weave an intricate fabric from which to learn therapy.

Holloway and Wolleat (1994) assert that because the goal of clinical supervision is to unite science and practice, supervision is among the most elaborate of all activities associated with the practice of psychology. The competent clinical supervisor must embrace not only the “province of psychological science, but must have strong footing in client service and trainee development. The competent supervisor must not only comprehend how these various knowledge bases are connected, but also must regularly apply them to a variety of individual cases” (Holloway and Wolleat, 1994, p. 30). Add to this the importance of self-care in a field well known for its high level of fatigue and discouragement, and it is easy to suggest that the practice of supervision requires targeted attention. With this level of complexity attributed to supervision, it is surprising that more consideration isn’t afforded it during graduate training. In point of fact, supervision is responsible for the survival, strength, and direction of the counseling profession. Without sound clinical supervisors, the mental health professions are in jeopardy of losing the quality of services needed for the betterment of the human condition. With this in mind, let us turn our attention to models of supervision that have been helpful in structuring the supervisory experience.


The world is not to be put in order; the world is in order incarnate.
It is for us to put ourselves in unison with this order.
Henry Miller

The experience of clinical supervision involves distinct stages of change and growth. Each supervisee passes through stages of growth dependent on a number of critical factors. The types of patients treated, the types of problems encountered in therapy, the level of experience, the level of awareness, and the trust in the supervisory relationship are all factors working together to provide the framework for successful intrapersonal change. These factors should be kept in mind as we review models of supervision.

A number of researchers in the field of supervision endorse a developmental model of supervision (Bernard & Goodyear, 1992; Loganbill, Hardy, & Delworth, 1982; Stoltenberg and Delworth, 1988; Stoltenberg, McNeill, & Delworth, 1998; Worthington, 1987). For example, Loganbill, Hardy, and Delworth (1982), writing nearly twenty-five years ago, suggested that many supervisees pass through three stages of development called “stagnation, confusion, and integration.” In the “stagnation stage,” the supervisee may have a childlike sense of security and may demonstrate a simplistic approach to thinking about patients and their problems. For example, a beginning therapist upon presenting a case of a forty-five year old male patient with rapid mood swings, sleepless nights, binge drinking, and marital infidelity may say that the patient is simply having a ‘midlife crisis’ rather than assigning the client a mental illness.

In the “confusion stage,” the supervisee may experience insecurity, bewilderment, and internal discord as he or she struggles with the ambiguity of the therapeutic process. For instance, a trainee working for a number of months with a patient with a dependent personality disorder may experience a sense of making no progress in therapy and may even question whether he or she is cut out for the mental health field. This trainee may be experiencing a deep internal struggle to make sense of the treatment with the client, whether or not therapy works, and how to proceed.

In the “integration stage,” the supervisee is able to restructure his or her understanding of both the work of psychotherapy and the experience of being a therapist. In this final developmental stage, a new therapeutic dexterity emerges along with a greater sense of personal efficacy. An example of this stage is the therapist exhibiting a greater degree of mental flexibility when working with a patient with depressive symptoms. In this stage, the therapist has an ability to see the importance of the therapeutic relationship, has an ability to see the progress that has been made, yet has an ability to have a healthy respect for symptom relapse in the course of treatment. These stages are passed through gradually and a trainee may even cycle back if faced with an exceedingly challenging patient or if faced with a great deal of countertransference with a particular patient.

Stoltenberg and Delworth (1987) present an integrated developmental approach to supervision that also encompasses unique stages. Their model includes four developmental levels that occur across time. The beginning of the journey is called the “dependency stage.” This is when the trainee is completely reliant on the supervisor for direction and decision-making. Even after a supervision session, the trainee may not utilize the feedback of the supervisor for fear of “doing something wrong.” Trainees may take notes during supervision but may not know how to integrate the information in the notes into the actual work with clients.


The trial and tribulation of practicing therapy is called the “dependency-autonomy conflict.” This occurs when the trainee makes strides in independent thinking but still may experience feeling unsure and dependent on the supervisor.


The experience of challenge and growth is called the “conditional dependency stage.” During this stage, the trainee experiences an increase in self-determination. The trainee feels more confident in the work that she is doing but may have periods of self doubt. However, the trainee is determined to acquire experience in both the process and content of effective therapy.


The final stage where the trainee experiences competence as the therapist is labeled as the “master counselor stage.” At this stage, the therapist has successfully incorporated theory and practice and feels confident to work independently. The objective for the trainee is to integrate developmental milestones into the practice of therapy with the mentorship of the supervisor.


Stoltenberg and Delworth (1987) suggest that there are three overriding structures that are experienced within the individual during the stages of development. These structures include the therapist’s awareness of self and others, the therapist’s motivation, and the therapist’s autonomy. Essentially, a developing therapist must have a sense of curiosity about him or herself as a therapist and a sense of curiosity about the patient that moves beyond the surface material. Maintaining a level of motivation and perseverance in the face of patient challenges and non-compliance is especially helpful towards developmental progress. Experiencing a sense of autonomy and self-confidence is important for the therapist moving towards independent practice.


In addition to the stages and overriding structures of the integrated developmental approach to supervision, the authors formulated eight specific domains of clinical competency. These eight domains of competency include (1) intervention skills competence, (2) assessment techniques, (3) interpersonal assessment, (4) client conceptualization, (5) individual differences, (6) theoretical orientation, (7) treatment goals and plans, and (8) professional ethics (Stoltenberg & Delworth, 1987). These domains of clinical competency are the foundation of training and provide a guideline for assessing proficiency during each level of a supervisee’s growth. Chances are, some supervisees will be strong in some, but not all, of the domains. It is the responsibility of the supervisor to explore the less developed areas with patience and understanding.

Norcross (1988, also see Norcross, 2002) has pointed out that the level of experience of the trainee usually calls for significantly different supervisory styles. Beginning trainees are more interested in the acquisition of skills, mid-level trainees are more inclined to develop formulations, and advanced trainees are most intrigued by the examination of personal dynamics affecting therapy. Stricker (1990) characterizes development as a process in which trainees initially are most helped by “a focus on technique, followed by more concentration on theory, and culminating with emphasis on transference and counter transference” (p. 177). No matter what model is adopted, research has informed the practice of supervision as providing a fertile ground for a developmental process as the trainee moves toward becoming an independent practitioner.





I have just three things to teach: simplicity, patience, compassion. These three are your greatest treasures.         
Lao-Tzu

There are four main functions a supervisor needs to perform. These functions are to monitor client welfare, to enhance supervisee growth within stages, to promote transition from one stage to the next, and to evaluate supervisees. The art and craft of supervision lie within how each of these functions is performed coupled with the goal of the supervisory experience. The goal of the supervisory experience is to provide a safe and trusting environment for the teaching and learning of psychotherapy towards the development of a competent therapist. The path each supervisor takes to achieve this goal may be wide-ranging, yet there are core characteristics that inform a mutually successful experience. Core characteristics are those unique qualities of the supervisory process that account for positive change and growth in the supervisee. Core characteristics are also those unique qualities that encourage the supervisor to return to the experience of supervising year after year and provide the foundation for managing conflict that may arise during the process.

Sussman (2002) outlined six core characteristics that may enhance the supervisory experience. First and foremost, it is important to establish a strong working alliance between the supervisor and the supervisee. Ladany and colleagues (1999) have reported that a strong working alliance has been correlated with a greater degree of satisfaction with supervision. The working alliance encompasses the emotional bond between the parties as well as the agreed upon goals and tasks of supervision. Clearly outlining the goals and tasks at the start of the supervision process enhances the development of a working alliance. Utilizing a written supervisory agreement form may help organize the experience for both parties (see Fall and Sutton’s 2004 “Disclosure Statement of a Practicum Instructor” or “Disclosure Statement for Clinical Supervision of Counselors in Agencies and Private Practice” for examples of written statements used at the start of supervision). Returning to review the goals and tasks of supervision when there are questions about, or problems during, supervision is also quite helpful.

Many supervisees have reported that they really appreciate having clear guidelines at the start of supervision.


Second, it is vital to have an atmosphere of trust and safety. Consistency in time and place of supervision, respect for the confidential nature of the content of the session, and an experience of mutual respect have a positive effect on the supervisee’s experience of trust and safety. A strong emotional bond, enveloping trust and respect resulted in less role conflict and role ambiguity in the supervisory process (Falender & Shafranske, 2004). Along with a written agreement outlining the goals and tasks of supervision, the supervisor may wish to verbally review each area with the supervisee and tackle any questions that may arise. Trust and safety develop over time and integrate managing both the administrative aspects as well as the emotional aspects of supervision.

Emotional safety incorporates the trainee’s sense of feeling safe to share not only the successes as a counselor but, more importantly, the rough spots and confusion as a counselor. Physical safety includes reviewing early and often, how to handle clinical emergencies, personal safety with regard to aggressive patients, and office safety with respect to the protection of all other individuals in proximity to a challenging patient. Setting clear guidelines for managing crisis situations will go a long way to enhancing the trainee’s experience of safety. Role playing managing a difficult or dangerous patient prior may also be helpful for beginning trainees.

Third, both supervisor and supervisee must have an interest in supervision and aninterest in the learning and development of the competent therapist. Good supervision requires that both parties “show up” and attend to the task at hand. The supervisor creates an atmosphere of encouraging strengths and managing anxiety and vulnerabilities. Within in the framework of supervision, it is beneficial to normalize the struggle for the supervisee and to acknowledge that periods of frustration are part and parcel of psychotherapy.

Along with feelings of anxiety and frustration, supervisees might also experience feelings of anger, fear, apathy, confusion, sympathy, grief, boredom, distance, hopelessness, resentment, apprehension and protectiveness toward their patients. Some counselors may experience a range of feelings in a single session and may have difficulty making sense of disparate feelings towards the same patient. Fall and Sutton (2004) state that it is the supervisor’s responsibility to assist the supervisee in finding his or her own answers to therapy challenges, the “expertise of the supervisor is most often in the use of the skills of supervision rather than in the knowledge of the field of therapy” (Fall and Sutton, p. 8).

Fourth, the supervisor should provide a framework for understanding the theoretical and technical underpinnings of the treatment approaches. A supervisor is valued who is competent in facilitating technical learning and skill acquisition (Henderson, Cawyer, & Watkins, 1999; Watkins, 1995). In most instances, counselors will already have taken the required coursework in theory and practice of psychotherapy or counseling. Reviewing with the supervisee, what coursework has been completed and what further training is upcoming will be helpful. However, most supervisors will find that the coursework their trainees have completed provides the foundation on which more training is needed. Recommending books, chapters, and articles throughout supervision will most likely be necessary to round out the trainee’s education (a list of recommended readings for trainees is provided at the end of this course).

It is very likely that supervisors will have a diverse reference library in their office and will refer to it often. Keep a file of all books and articles you have recommended to past trainees organized by topic area for easy reference. Include in the supervisory notes which book, article, or DVD you have recommended so that you can reference it later on in supervision. Encourage your trainees to include in clinical notes which books or resources they have recommended to their patients.


Fifth, supervisor and supervisee self-disclosure gives permission to acknowledge mistakes in the craft of therapy, and allows a deepening of the relationship. Supervisory disclosures, according to Ladany and Walker (2003), directly impact the emotional bond of the supervisory relationship by conveying a sense of trust. Many supervisors question how often and how much to self-disclose. In most instances, if the self-disclosure aids in the trainee’s ability to understand a clinical issue or helps normalize a client’s experience, self-disclosure makes sense in the context of supervision. If self-disclosure is solely in the interest of the supervisor and not for the benefit of the trainee, then it is clearly not recommended.


And, finally, the art of pacing and leading the supervisee provides a direction to time-limited supervisory experience. Acknowledging that there is a beginning, middle, and endpoint to each supervision session and to the whole supervisory experience provides an environment where true work can take place.


Trainees experience a host of emotions during their supervisory experience. One of the primary and consistent emotions supervisees present with is anxiety. Sussman (2002) has uncovered six guidelines to reduce anxiety in supervision. First, negotiate, review, and update a written training contract. The written training contact provides a structure for the supervision process and is an important first step in the organization of supervision. Second, match methods to mental stage of the supervisee. Supervisors develop along with their supervisees by mapping mental stages and providing more in-depth methods as supervision progresses.

Third, directly address anxiety in the trainee. Call it what it is. Anxiety is always a part of learning to be a therapist and learning to be a supervisee. According to the research, supervisees prefer supervisors to take the lead in identifying and discussing difficult situations (Falender & Shafranske, 2004). Fourth, develop a collaborative supervisor attitude. Supervision is a team sport; it is a process of mutual involvement where the supervisee does not succeed without the experience of true collaboration. Fifth, create evaluative focus. Ellis and Ladany (1997) recommend the scope of competence be in the areas of therapy behavior, skill development, case formulations, and assessment (see the Performance Evaluation and Termination Section of this article for more ideas on structuring evaluation).

Sixth, encourage trainee independence. Trainees are in a constant state of “working towards” and, during the course of supervision, the supervisor should see an increase in independent thinking and behavior, matched with symptom improvements in the patients treated. If the supervisor does not observe an increase in independent thinking and behavior on the part of the trainee, steps should be in place to provide clear feedback. The evaluation process may need to be more frequent and more directed to specific behaviors. Remediation, such as required viewing master training tapes of therapy or increase use of role playing in supervision, may be useful to help the trainee observe, practice, and reflect on therapy technique.

Just as important as the didactic training model of supervision is the use of silence. Epstein (1995) wrote, “the teacher’s silence does not convey absence or lack of interest. The teacher is very much present, and her presence, conveyed through the quality of her attention, is a powerful emotional force that evokes a strong response” (p. 185). The ability to include periods of silence, quiet reflection, and emotional peace within the supervisory session will uncover new material for review and will also model the importance of using silence in psychotherapy.

“The lesson for psychotherapy is that the therapist may well have as great an impact through her presence as she does through her problem solving. The therapist’s ability to fill the present moment with relaxed attentiveness is crucial” (Epstein, 1995, p. 187) in providing an environment designed for change and growth. It is recommended that supervisors practice relaxed attentiveness in supervision and notice how it differs from a more active, didactic role in training. A good rule of thumb is if the supervisor feels an impasse, or a sense of feeling stuck, in the supervisory process, it may be a perfect time for relaxed attentiveness and a return to silence.




One can travel this world and see nothing. To achieve understanding it is necessary not to see many things, but to look hard at what you do see.
Giorgio Morandi

An effective therapist is one who is competent at performing his or her role and the tasks associated with that role. The effective therapist is impartial, open, nonjudgmental, interested, patient, and fearless. The ability to integrate knowledge, skills, and attributes within the work environment is a central component of effectiveness. Beyond the basics of skills and knowledge acquisition are the softer factors that fall within the realm of therapeutic commitment. Leiper (2001) has outlined five therapeutic commitment factors that lend themselves to understanding the effective therapist: these are motivation, work satisfaction, therapeutic self-esteem, personal resilience, and personal support.

Motivation is the therapist’s drive to take on the work and be successful at it. Work satisfaction is described as the level of personal fulfillment resulting from the work itself. Therapeutic self-esteem is the level of confidence the therapist feels in the type of work being conducted. Personal resilience is the therapist’s capacity to experience difficult situations as challenging rather than threatening. Fifth is personal support, which includes the therapist’s available resources of support and renewal away from work. These factors interact with one another to form the tapestry of the effective therapist.


Once a level of competence is achieved, the therapist must be able to sustain it across patients, settings, and time. Leiper (2001) has outlines three factors within role security that may be sustaining factors for the therapist: these are role adequacy, role support, and role legitimacy. Role adequacy is the level at which training and experience has prepared the therapist with the skills needed to meet the challenges of therapy. If the level of training has been insufficient, chances are the therapist will not adequately meet role obligations. The beginning therapist’s feeling of anxiety and nervous may not lessen with time if he or she does not feel adequately prepared for the work at hand.

Another aspect of sustaining oneself as an effective therapist for the long term is role support. Role support is the availability of resources such as supervision, consultation, and a positive work environment that contain, encourage, and inform the therapist’s work during tough times. Are there sufficient supports in place for the trainee and are these supports consistently available across the length of the training experience? For therapists working in an organization or agency, role legitimacy is another important factor in sustainability. Role legitimacy is the degree to which the organization endorses the kind of therapeutic work the therapist is providing and recognizes the complexity inherent in the work (Leiper, 2001, p. 214). For instance, a therapist working in a hospital setting that espouses the medical model for the treatment of psychological problems may not have the support or validation for the use of psychotherapy. It is important for the therapist to utilize all of the factors in role security to enhance his or her environment of effectiveness and sustainability over time, settings, and diverse patient populations.

Most writers in the field exploring the factors inherent in the effective therapist will say that the relationship between therapist and patient is one of the most important ingredients for success. Yalom (2002) states that “therapists must convey to the patient that their paramount task is to build a relationship together that will itself become the agent of change” (p. 34). Beginning therapists may battle with this idea and hold fast to utilizing specific skills or techniques, sometimes at the expense of the relationship. However, for patients to return week after week to therapy, there must be a sense that the therapist cares for them as a person and that there is a collaborative approach to the work at hand. Without the formation of a relationship, there is little likelihood of therapeutic change and a greater likelihood of intense frustration on the part of both the therapist and the patient. When trainees present in supervision complaining of multiple no shows across patients, it is fertile ground to discuss their feelings about the therapeutic relationship. It is not uncommon for new therapists to be very uncomfortable joining with patients, especially if the patient’s symptoms seem daunting.



A review of what makes an effective therapist will always include a discussion of countertransference. Countertransference is any reaction the therapist has to the patient in the course of the therapeutic work. These reactions may be positive, such as being exceedingly attracted toward a patient, or negative, such as being rejecting toward a patient. Therapists’ reactions may be “the consequence of the manner in which the client treats the therapist, the unresolved issues on the part of the therapist, or a combination of both” (Koch, 1998, p. 241). On the one hand, unaddressed countertransference greatly interferes with the therapist’s ability to see and hear the patient’s process, structure, or developmental task in therapy.

On the other hand, being comfortable enough with one’s own material to use it in the best interest of the patient adds immeasurably to the therapist’s effectiveness. A review of the literature by Gelso and Hayes (2001) suggest that a therapist’s reaction to counter-transference feelings is detrimental and that the management of these feelings is necessary for effective therapy. In addition, Hayes and colleagues (1997) found that in those cases where countertransference feelings were not managed successfully, a less than satisfactory therapeutic outcome resulted. Below is a sample of questions supervisors can utilize to understand counter-transference feelings in trainees.


Thus, it is important for the supervisor to explore the supervisee’s countertransference frequently throughout the course of supervision. According to Yourman and Farber (1996) the more supervisors discussed countertransference, the more trainees experienced satisfaction with supervision. Countertransference will be apparent in a variety of ways. The supervisor may notice an inflexible stance in the supervision session while discussing a particular case or in direct response to the supervisor. This is a golden opportunity to help the supervisee bring the unconscious processes closer to awareness. Exploring the supervisee’s reactions of frustration, boredom, distraction, confusion, or irritation are good entry points for discussion of counter transference reaction. In addition, exploring breaks in the therapeutic frame, or exploring instances when the treatment is going nowhere are also good avenues to take to address counter transference (Falender & Shafranske, 2004). Working first with the supervisee’s reaction to the supervisor may be an effective jumping off point. These reactions will lay the groundwork for understanding how countertransference affects the supervisee’s therapeutic work. Further exploration of emotional reactions may occur in the supervisee’s own personal therapy.

Another important aspect of the relationship between the patient and therapist is called parallel process. Within the therapy relationship, parallel process occurs when situations in the patient’s external world are reenacted in the therapy relationship. These are opportunities to gain insight into the troublesome ways in which the patient organizes and makes sense of his or her relationships. Parallel process also occurs when the relationship between the therapist and patient is reenacted in the relationship between the supervisor and therapist. The supervisor may experience reactions and feelings that the patient experiences, or reactions and feelings that the therapist experiences in working with the patient. Understanding what the supervisee experiences in treatment will help the supervisor understand the inner workings of the supervisee. Bringing the concept of parallel process to the supervisory work will aid in setting the stage for the effective therapist.

The objective is to understand the dynamic of the interpersonal relationships and prevent difficulties in the process of supervision. According to Falender and Shafranske (2004) “no matter the nature of their origins, parallel processes hold the potential to sweep all of the participants into a counterproductive cycle of enactments, straining both the therapeutic and supervisory alliances” (p. 84-85). Providing further reading in both counter-transference and parallel process to the new therapist will be valuable for laying the foundation for successful work together.


The key question you must always ask yourself: “What is the right thing to do?”
F. C. Harrison

Supervision is a quality assurance activity geared toward preventing harmful therapy and reinforcing professional standards. As such, discussion and modeling of ethical behavior begins at the start of supervision and continues throughout the course of the supervisory experience. Supervision is where trainees can reflect on their ethics coursework, present ethical problems, and show the supervisor how they think through challenging situations. Although all mental health licensure renewals require at least one course in law and ethics, few include supervision ethics topic in the coursework. This section will review the ethical guidelines of psychologists. It is recommended that all mental health supervisors review the guidelines provided by their professional organizations (see the list of websites at the end of the further reading section). Questions for reflection and review will be included following each section of ethical guidelines listed below.

Nagy (2002) outlines a number of guidelines worth reviewing here. First, the supervisor must have extensive working knowledge of supervisees’ competence. Ongoing “monitoring of unlicensed supervisees is essential whenever professional duties are assigned to trainees. If the supervisor finds that the policy, structure, or functioning of the institution prohibits the proper supervision of trainees for whom he or she is responsible, then the supervisor should correct the situation. After all, patients or others could be harmed and the supervisor could be held responsible” (Nagy, 2002, p. 45). Supervisors should be available to respond to clinical issues of their supervisee’s patients. Check with your state’s professional organization to learn more about coverage responsibilities.


Second, it is recommended that the supervisor “always take the time and effort to conduct supervision satisfactorily, with regularly scheduled meetings, to ensure competence and responsibility in supervisees” (Nagy, 2002, p. 45). Committing to provide supervision is committing to an expected schedule of appointments both for the supervisor and the supervisee. This can be challenging with competing professional demands and role requirements. It is recommended that supervisors have an avenue for receiving feedback regarding their supervision. This feedback could be in the form of a biannual written evaluation of the supervisory process, as well as continual feedback during the course of supervision.


Third, supervisors “should notify supervisees that they must always inform patients at the outset of treatment that they are under formal supervision. Supervisees are required to give their patients the name and telephone number of their supervisor because he or she is legally and clinically responsible for the work” (Nagy, 2002, p. 90). Supervisors should make sure the supervisee clearly informs the patients in writing about the limits of confidentiality and the instances when confidentiality may be breached. Confidentiality may be breached if the therapist suspects child abuse, elder/dependent adult abuse, danger to self or others, or if there is a court order for treatment. Designing the consent form to include all of this information will be useful. Teaching supervisees to utilize clear consent forms and release of information forms will also be valuable in ethics training.


Fourth, supervisors should “always have a well-defined and efficient process for giving feedback to supervisees about their performance. It is recommended that supervisors base grades and evaluations on how a supervisee actually performs according to program requirements and criteria” (Nagy, 2002, p. 135-136). See the course section on Performance Evaluations for further information on structuring feedback to supervisees. There may be occasions when the trainee disagrees with the supervisor’s evaluation of his or her work. Processing this disagreement in the supervision session is advisable and setting clear behavioral guidelines for improvement is encouraged. For example, a supervisor may find that a trainee consistently omits important information from intake reports but the trainee may believe that he is doing a good job with report writing. Reviewing the structure of report writing and the content requirements may be helpful along with feedback after each report is completed.


Fifth, the supervisor “should not use his or her power or authority over employees, patients, students, supervisees, or others to his or her advantage” (Nagy, 2002, p. 37). It is recommended that supervisors “acknowledge the power and influence held over supervisees when teaching or training. To this end, never demean or personally undermine students in any way” (Nagy, 2002, p. 133). Although at face value, this guideline appears obvious, there are instances in training where supervisors could, knowingly or unknowingly, use their power to their own advantage. One instance that supervisors may use their power over trainees may be in a dual relationship role.

For example, if a supervisor is also a faculty member in the academic program of the trainee and, unknowingly, utilizes the trainee as a type of teaching assistant for the class this could have an impact in the supervisory relationship. Or perhaps, the supervisor who is also the instructor of a current course the trainee is enrolled in may look upon the trainee favorably in the classroom, thus giving the trainee an unfair advantage over the other students enrolled in the class. It is best to review any potential dual roles prior to the activities undertaken and get consultation with colleagues on how to handle any concerns.

In no instances should the supervisor take on the role as professional therapist to the trainee. It is recommended that supervisors provide referrals to local providers if a trainee is experiencing mental health concerns that may significantly impact work with patients. After all the supervisors role is to protect with welfare of the patients seen by the trainee. Having a list of local providers available prior to beginning the work of supervision is helpful. The supervisor may need to assure the trainee that outside therapy is a confidential experience and the supervisor will have no access to information from the trainee’s personal psychotherapy.


Sixth, when teaching or training, supervisors “should be sure to be accurate and objective. It is best for supervisors not to distort or bias the material in favor of their own theoretical orientation. All supervisors have blind spots, and it is a good idea to be aware of them as supervision progresses” (Nagy, 2002, p. 132). Many programs give supervisees surveys to determine if their experience with a particular supervisor has been valuable and to get feedback on the process of supervision (for example, see Ladany, et al, 1999). If patterns develop in the feedback received, a review of blind spots is highly recommended.


Seventh, supervisors who are responsible for teaching or training, are required to “plan their programs competently and to deliver what is promised. It is the supervisors’ responsibility to provide the proper experiences that meet the requirements for licensure, certification or other goals that are claimed by the program” (Nagy, 2002, p. 129). A sample supervision contract outline is included in the work of Falender and Shafranske (2004) that can be modified to fit the experience and requirements of specific programs. In addition, if supervisors are responsible for education and training programs they must have an “accurate and up-to-date description of the program content, goals and objectives, and the requirements that must be met for satisfactory completion of the program. This information must be made readily accessible to anyone who requests it” (Nagy, 2002, p. 130).


It is a good idea to review professional ethical guidelines before embarking on supervision and annually thereafter. Stay ahead of the changes in each of the professional licensure requirements by checking in on the websites periodically. Keep in contact with the trainee’s university and ask for updates in program changes.



I know that the enterprise is worthy. I know that things work well. I have heard no bad news.
Henry David Thoreau

There are a number of legal considerations supervisors must review during their work with trainees. Supervisors are legally responsible for evaluating and encouraging their supervisee’s work and progress. There is increasingly more demand for accountability. The failure to adequately supervise a counselor who is treating a disturbed patient is a leading complaint of current malpractice suits. Legal problems with dual relationships (exploitation) can provide a basis for an allegation of failure to provide adequate supervision in a lawsuit.

Failure to warn a potential victim (Tarasoff) carries the highest malpractice risk in the mental health profession. Training supervisees on the duty to warn guidelines prior to them seeing any patients, as well as providing easy to follow written guidelines, is the best course of action. The wise advice to “document and consult” is always useful if a supervisee faces a patient who poses a clinical challenge.

Because failure to warn a potential victim is one of the most risky issues in supervision, here is a sample checklist supervisors can use as a guide in working with trainees. Reviewing this, or a similar, checklist at the start of work together is encouraged.


At the start of supervision, it is important to review with the trainee the factors associated with a high risk for violence. According to a number of authors (for example Kaplan & Sadock, 2002; Meloy, 2000), the three best predictors of violent behavior are 1) excess alcohol or drug intake, 2) a history of violent acts with arrest or criminal activity, 3) a history of childhood abuse. Other factors associated with a high risk for violence include: 1) intent: (a) a specific plan for injuring someone, (b) possession of a weapon; 2) history: (a) previous acts of violence, (b) history of homicidal threats, (c) antisocial behavior in childhood or adolescence, (d) abused as a child, (e) recent provocation; 3) behavior: (a) signs of tension/agitation(pacing), (b) loud, abusive, or bizarre speech; 4) personality characteristics: (a) poor impulse control, (b) excessive aggressiveness, (c) extreme or labile affect; 5) diagnosis: (a) drug or alcohol intoxication/withdrawal, (b) delirium, (c) Paranoid Schizophrenia, (d) Delusional Disorder, (e) Mania, (f) Temporal lobe epilepsy, (g) Antisocial, borderline, or Paranoid Personality Disorder, (h) Dissociative Disorder, (i) Impulse control Disorder; 6) demographic factors: (a) male, (b) lower socioeconomic status.

Assessing dangerousness is for many beginning therapists a challenging and often anxiety-provoking experience. It behooves the supervisor to offer clear guidelines for assessment.


Review the Mental Status Exam with the trainee. Over the course of training, the Mental Status Exam should be an organized way to collect important information about patients and enhance the assessment of dangerousness. There are twelve assessment criteria of the Mental Status Exam that can be reviewed in depth: 1) Appearance: how does the patient’s dress, grooming, and general health appear to the trainee, 2) Behavior: how is the patient’s speech flow, use of language, posture, facial expression, eye contact, body movement, and interaction style, 3) Mood and Affect: how is the patient’s emotional state and range of emotions, 4) Perception: is the patient experiencing illusions or hallucinations (if so, have the trainee be specific about the type and frequency of the illusions or hallucinations), 5) Sensorium: how is the patient’s level of consciousness, orientation, and concentration (has the trainee determined if the patient is oriented times three), 6) Memory: is the patient able to recall immediate, recent, and remote events, 7) Intelligence: assess the patient’s verbal ability, educational and occupational status, 8) Insight: is the patient aware of changes in his or her own behaviors and emotions (if so, have the trainee describe specific changes presented by the patient), 9) Judgment: how are the patient’s decision-making and problem-solving abilities, 10) Thought content: is the patient experiencing delusions, obsessions, and morbid preoccupations (if so, what are the specific thoughts and how frequently do these thought occur), 11) Thought Process: is the patient experiencing blocking, flight of ideas, loosening of associations, 12) Coherence: does the patient have incoherent or rambling speech. Have the trainee develop an abbreviated version of the Mental Status Exam and provide an environment where the trainee can practice using the MSE until it becomes easier.

One of the building blocks of risk management is excellent documentation. Teach supervisees how to write clinical notes, reports, and intakes as if the reports will be read by an attorney. No personal opinions or anecdotes should be including in the final documentation. Both supervisor and supervisee should sign and date all case notes and reports. In addition, during supervision, it is a good idea for supervisors to take notes on cases presented and the dispositions of the cases. This has a twofold benefit. As a risk management strategy, first, it provides proof of monitoring the case and second, it jogs the supervisor’s memory week to week of the progress of therapy. Supervisor notes should include, impressions, recommendations, and detail around any critical incidents or high-risk cases. The supervisor should make independent assessments of very disturbed or possibly dangerous patients. Supervisors must keep in mind each patient is actually their patient and the supervisor is ultimately responsible for all of the trainee’s cases.

Both the supervisor and the supervisee would be well served to keep track on a weekly basis of the number of patient hours completed, along with the demographic information of each patient. Monthly summary tables supervisees give to supervisors listing active patients and the treatment plans are helpful. Supervisors should have copies of all patient documents including release of information forms, protective service reports, letters, mental health summaries, and diagnostic reports in their own files for reference. Videotaping or audiotaping therapy sessions, although not always feasible, is recommended for supervisory purposes.

There are some commonly asked questions with respect to the role of supervisor. (1) can the supervisor be held liable for the work of the person supervised? The answer is yes, the supervisor does assume essentially the same risk for patients seen by the supervisee as those seen by the supervisor. An employer is generally held liable (legally responsible) for the negligence of the employee. If employed as a supervisor, the risk is somewhat more limited. While the supervisor does have risk, it is generally limited to the quality and the appropriateness of the supervision. In other words, the supervisor can be held liable for negligent supervision. The employer who employees the supervisor and the supervisee assume the bulk of the liability in such as case. Supervisors can protect against liability by being well-informed about the supervisee process, by utilizing effective supervision techniques, by being accessible to the supervisee, by adequately monitoring the work and work setting of the supervisee, by recognizing and helping the supervisee to correct and improve deficiencies, and by maintaining a learning environment throughout the process of supervision (Practical Applications in Supervision, pp. 32-41). It is recommended that the supervisees obtain liability insurance during their tenure as trainees. Of course, supervisors should have adequate professional insurance to cover their responsibilities of supervised patients. Coursework in supervision is mandatory for supervisors when renewing their professional licenses. Of course, supervisors must stay informed about any changes regarding the legal aspects of supervision through their professional organizations and through ongoing coursework.

Research has addressed the importance of sexual ethics training during graduate school and internship due, in part, to the increase in sexual misconduct in psychotherapy. Supervision is the appropriate environment to discuss sexual feelings in therapy or supervision in order to prevent sexual boundary violations. Hamilton and Spruil (1999) emphasized that faculty must lead by their examples of ethical behavior. “Sexual relationships between trainees and their supervisors should be prohibited, and the faculty who become aware of such behavior on the part of a colleague must act decisively to put an end to it” (p. 325). At times, it may be useful to consult with colleagues on the issue of boundary violations and to review all ethical guidelines.

Since feelings of sexual attraction towards patients is common in the profession, it is important to include a discussion of it in this section on risk management. According to Blanchard & Lichtenberg (1998), between 80 and 88% of psychologists report having been attracted to, or having sexual feelings for, at least one patient. Of particular interest for supervisors is that more than half of the student sample surveyed reported sexual attraction (Housman & Stake, 1999). Of the group surveyed who reported sexual feelings toward patients, 34 to 45% reported that they did not disclose these feelings in supervision (Housman & Stake 1999).

Supervisors must be competent in their training in boundary issues and sexual attraction, must be firm about presenting these issues in supervision (Falender & Shafranske, 2004), and must be aware of their own blind spots that may impede effective supervision on this important topic. Supervisors must immediately consult with other mental health or legal professionals or their respective boards if they find their trainees are demonstrating questionable or troubling behavior with patients. The best way to circumvent sexual attraction challenges is to address the topic early and often in the course of supervision and have trainees review ethics and law guidelines.

Hamilton and Spruill (1999) suggest that a strategy to prevent sexual-boundary violations is education about the risks of such behavior. These authors have developed “Risk Management: A Checklist for Trainees and Supervisors,” a valuable tool to identify risk and prevent inappropriate behavior. In addition, supervisors must give each trainee the pamphlet “Therapy Never Includes Sex” (available at the Department of Consumer Affairs website for each state) at the start of formal supervision. This pamphlet reviews the warning signs that occur prior to exploitation in the therapeutic setting and are important to review with supervisees at the start of their work, as well as during the course of supervision if red flags are noticed. Supervisors would be well served to document in supervisory notes that the “Therapy Never Includes Sex” pamphlet was given to the trainee and the topic was discussed at the start of the trainee’s clinical work. This, although at times uncomfortable, is a necessary first step in supervision.
Providing further reading material in the topic of law and ethics to add to the trainee’s knowledge and skill level is useful. There is a list of further reading provided at the end of this course divided in topic categories. Recommendations for reading topics will most likely change as the trainee develops as a therapist and tackles new clinical challenges. Once again, supervisors would be well served to invest in a number of law and ethics books for their office reference library. These books would be for quick reference as well as would provide excellent modeling behavior for trainees who in the future may take on the role of supervision to a new generation of mental health providers. Risk management is an everyday process.




“I’ve tried relaxing, but—I don’t know—I feel more comfortable tense.”
Caption for Hamilton cartoon

Maintaining a sense of balance as a professional in the mental health field is very seldom discussed during graduate training, practicum, internship, or supervision. I don’t remember one professor talking about his or her personal self-care or the need for beginning therapists to address their own self-care during my graduate school, practicum, or internship experience. However, most would agree with Yalom (2002) that psychotherapy is “a demanding vocation, and the successful therapist must be able to tolerate the isolation, anxiety, and frustration that are inevitable in the work.” (p. 251). It is appropriate to initiate the discussion of self-care in a course on supervision because the supervisor may be the only person in the supervisee’s training experience who delves into the topic in any meaningful way. Talking about self-care behaviors to trainees is as important as modeling one’s own self-care.

Therapists, especially beginning therapists, are notoriously hard on themselves when they do not live up to their unrealistically high standards of success (Kottler, 1999). New therapists coming into the profession may have unusually high desire to “cure” or “fix” the problems of their patients, only to be disappointed when things do not go as planned. Not meeting this high level of achievement may lead to feelings of despair, anger, or even sadness. These feelings have the tendency to cross over not only to other patient hours but also to the beginning therapists’ personal lives.

Students in graduate training in psychology and counseling have struggled with personal and relationship problems as a result of the stress of training. For instance, some graduate programs have a higher than average level of divorce or separation in their student population. And it can be hypothesized that feelings elicited in therapy can exacerbate or even uncover personal problems (see Rabinowitz, 1998). Supervision is the environment to address some of these challenges, and attempt to prevent an escalation of personal problems. Referring to mental health professionals in the community is one of the roles supervisors must take on to help the trainee manage stress and continue to provide satisfactory care to patients.

According to Yalom (2002), “disruptive life experiences encountered by the therapist – relationship strains, birth of children, child-rearing stresses, bereavement, marital discord and divorce, unforeseen reversals, life calamities, illnesses – all may dramatically increase the strain and difficulty of doing therapy” (p. 252). Add to this the stress of national and international current events, it seems clear that addressing self-care is a necessary part of all supervisory experiences. Better to begin the discussion of self-care at the early stages of training than to wait or miss the opportunity completely.

Research suggests that 35 to 40 percent of therapists report levels of personal difficulty that have lessened the quality of their work significantly during their career (Sherman, 1996). Supervisors and therapists need to be alert to risk factors for depletion, burnout, and impairment. Leiper (2001) has outlined these risk factors as personal characteristics, patient characteristics, and work organization characteristics. Some of the personal characteristics of the therapist include social and professional isolation, idealistic, self-sacrificing, compulsive givers, over-controlling, perfectionistic, or undergoing prolonged crises. Some of the patient characteristics include presentation of suicidal threats, hostility, passive-aggressiveness, slow to change, and communication of chronic suffering. Some of the work organization characteristics include role ambiguity, role overload, inconsequentiality, lack of pay-off, and lack of results in therapy (see Leiper, 2001 for a complete listing).


Therapist demoralization is related also to one’s range of practice. Overspecialization, especially in clinical areas loaded with great pain and desolation – for example, working with the dying, or the severely chronically impaired or psychotic –puts the therapist at significant risk. Yalom (2001) believes that balance and diversity in one’s practice vastly contributes to a sense of renewal. Supervision support groups are also a very effective means to manage demoralization and feelings of professional fatigue. If trainees work in a hospital or agency setting, accepting support from team members is vital to managing the strains of the clinical work.
Both therapists and supervisors need sufficient “reserves” to call upon (Leiper, 2001) during a career in the mental health profession. What are the ways therapists and supervisors manage that reserve and add to it? Think of the activities you have utilized to renew. These activities will help provide balance in the practitioners life and may help refresh mind, body and spirit: meditation, aerobic exercise, weight training, martial arts, yoga, pilates, hobbies, reading, movies, humor, vacation, time with family and friends, gardening, religious or spiritual connection, playing or watching sports, doing artwork, decorating your home, woodworking, volunteering in the community, craftwork, being in nature, getting a massage, photography, cooking or baking, and traveling. If the supervisee or supervisor is not doing one or more of these activities on a regular basis, there is a higher likelihood for exhaustion from the demands of the profession.




In all human affairs there are efforts, and there are results, and the strength of effort is the measure of the result.
James Allen

The supervision relationship has a number of key factors that are different from the therapy relationship. Similar to the start of treatment when therapists provide a consent form that outlines what can be expected in therapy, at the outset of supervision, the supervisor must provide information that outlines what is to be expected. Included in this might be information on the ways supervision is different from psychotherapy.

One of the central issues in supervision is the establishment of appropriate boundaries between supervision and therapy (Falender & Shafranske, 2004). All professional organizations have ethical guidelines providing principles to follow in conducting therapy. For example, the APA Ethical Principles of Psychologists and Code of Conduct asserts that “faculty who are or are likely to be responsible for evaluating students’ academic performance do not themselves provide therapy” (American Psychological Association, 2002). While some graduate programs require psychotherapy as part of the training to become a mental health provider, others do not. If the supervisor believes that the personal problems are significantly impacting the trainee’s therapeutic work it is wise to address this in supervision and make appropriate recommendations.

However, according to Falender and Shafranske (2004), “it is important to delineate the trainee’s rights of due process before recommending counseling services and to clearly differentiate supervision from a counseling relationship” (p. 175). In many instances, it will be a relief for the trainee to receive referrals to outside counseling providers for personal concerns and keep the supervisory relationship available to address the tasks at hand.

One of the best ways to prevent from being in the dual role of counselor and supervisor is for the supervisor to remain focused on the professional development and training of the trainee.

Falender and Shafranske (2004, see p. 58 for a comprehensive summary) provide a number of attributes of good supervision that are important to review here. First, good supervision must have the capacity to enhance the trainee’s self-confidence through support, autonomy and encouragement. Reinforcing the trainee’s sense of “self as therapist” is a critical step in early supervision. Second, good supervision must have the capacity to model a strong working alliance and develop a strong supervisory alliance with the supervisee. All roads lead back to the relationship and how the relationship is nurtured.

Third, good supervision provides the environment to give feedback and provide useful evaluations. Of course, once a strong alliance has been formed, there is a greater likelihood that feedback will be heard and acted upon to the benefit of the patients treated. Fourth, in good supervision, the trainer has knowledge of multiple formats of supervision and skill in each of these formats. Matching supervision to the level of trainee as the trainee matches treatment to the needs of the patient (Beutler & Harwood, 2002) is first-rate work.

Fifth, good supervision is adaptable and flexible. In fact, the character of the supervisory relationship will change over time and renewed goals should be discussed periodically. Sixth, good supervision demonstrates superb communication of case conceptualization, with a strong theoretical foundation. Seventh, in good supervision, a sense of equilibrium and a sense of humor are worth their weight in gold. Appropriate humor as a part of supervision allows a little levity and lightness in a professional with its share of challenge and crisis.

A good supervisor has the ability to identify and address potential areas of discomfort with the supervisee and uses the supervisory environment to work through any discomfort. These attributes have been demonstrated to be helpful in successful supervision and certainly assist in differentiating the supervisory relationship from the psychotherapy relationship.


Another avenue to help with understanding the difference between supervision and psychotherapy is to provide the trainee information about the structure and tasks of supervision.

Fall and Sutton (2004) have provided a very nice overview of ways to think about the phases of supervision. Below is a sample of some of Fall and Sutton’s (2004) recommendations:

Structure of Supervision
Here are some examples of what the supervisee can bring to supervision:

A. Content Items

• present new cases or intakes
  
• review previous cases
  
• discuss administrative concerns
  
• evaluation of work
  
• handling crises and breaches of confidentiality
  
• legal and ethic concerns
  
• professional development
  
• office environment
  
• referring client to other resources
  

B. Process Items

• start of psychotherapy
  
• transference
  
• counter-transference
  
• therapy techniques and skills
  
• client challenges
  
• cultural issues
  
• repairing relationship following a crisis
  
• limitations of the counselor
  
• termination of psychotherapy
  

It is up to the trainee to structure the supervision session with material that is most important to his or her current work. The best way to structure the time is for the trainee to come prepared to discuss the issues that are most pressing. During supervision, it makes sense for the trainee to take notes on what is discussed and the recommendations made. Once the supervision is over and the trainee sees the client again, how does he or she translate the work done in supervision to the work to be done in the therapeutic session? Returning back to the question of how supervision is influencing the trainee’s work may be a good jumping off point for future supervision and may become an aspect of overall evaluation of the trainee.


“I was gratified to be able to answer promptly. I said I don’t know.”
Mark Twain

Although no supervisor will have limitless information about all types of diversity issues presented in treatment or presented by the supervisee, providing an atmosphere to discuss questions of diversity is critical for trainee development. Diversity is a broad subject and encompasses gender, nationality, ethnicity, socioeconomic status, religion, sexual orientation, disability/ability status, age, medical status, level of education, and legal status. Indeed, many times supervisees and patients will have multiple layers of diversity issues that require special attention. For instance, a new patient may be a 24 year old Caucasian man recently released from prison with a significant learning disability or a 70 year old Jamaican American woman recently diagnosed with cancer. Supervisors are required to provide multicultural training, yet may not have had sufficient training themselves (Constantine, 1997; Ridley, Mendoza, & Kanitz, 1994). It is important for supervisors first to be aware of their own strengths and limitations in the area of diversity, to educate themselves in areas of limited knowledge, and to continue to learn from both patients and supervisees who present with diverse backgrounds.

In diversity, as in all other areas of training, there are skills to develop a level of competency. For example Falender and Shafranske (2004, p. 149) have summarized six skills of supervisor competency that may help set the foundation for training therapists working with diverse populations. First, the supervisor should possess a working knowledge of the factors that affect worldview. How both the supervisee and his or her patients see the world is important to understanding diversity and its impact on psychotherapy. Second, the supervisor should have self-identify awareness with respect to diversity in the context of the self, the supervisee, and the patient or family. The more the supervisor is aware of his or her own cultural identity the greater the likelihood he or she will be able to comfortably discuss diversity in supervision.

Third, the supervisor should exhibit proficiency in assessment of the multicultural competence of trainees, including self-ratings, observational ratings, and supervisor and client ratings. Evaluations should include a section on rating levels of improvement in managing diversity issues in psychotherapy. Fourth, the supervisor should model diversity and multicultural conceptualizations throughout the supervision process. Talking through how the supervisor thinks about diversity issues and their impact on the therapeutic relationship and therapy will be an ongoing process. Fifth, the supervisor should model respect, openness, and curiosity towards all aspects of diversity and its impact on behavior, on interaction, and on the therapy and supervision processes.

For example, a supervisee of Middle Eastern descent who is currently providing therapy for an America veteran returning from war in the Middle East would provide a rich environment of curiosity, learning, and mutual respect. And sixth, the supervisor should initiate discussion of diversity factors in supervision. Recommending further reading in a particular area of diversity may be a good starting point for discussion (see Resource Section on Diversity Awareness at the end of this course for further reading). These factors are some of the most important in developing a level of supervisors’ competency in the complex world of diversity. Review the case below with your trainee and write down all of the diversity issues that are present both in the trainee and in the patient. Reflect on how the supervisor’s diversity may have an impact on the case.

.


There is no meaning in life except the meaning that man gives his life
by the unfolding of his powers.
Erich Fromm

Most supervisors would agree that providing the trainee with an outline of an evaluation form prior to beginning supervision is helpful. Alerting the trainee to what will be expected of him or her during the course of supervised therapeutic work allows for an organized approach to learning. The following is an example of topics to be covered in an evaluation tool: (1) documentation, (2) therapeutic skills, (3) trainee-agency relations, (4) supervision, and (5) professional skills.

Documentation
includes the trainees ability to write clear, well-constructed short and long term goals, the ability to write high quality case reports, the ability to maintain updated progress notes, the ability to write in an organized, clear, professional, and grammatically correct manner, the ability to maintain patient files in a confidential manner, and the ability to track professional hours. Progress notes should also include documentation of any child, elder, or dependent adult abuse reports, signed releases of information on behalf of the patient, and any court mandated information (such as documentation of attendance, no shows, urine toxicology reports, etc.). Assessment reports should be written clearly and should include all pertinent identifying data, test results, summaries, and recommendations for treatment, accommodations, and community resources.


Therapeutic skills
include the trainee’s ability to form a therapeutic alliance with patients, the ability to respond with accurate empathy, the demonstration of a caring attitude about patients, comfort in interviewing and working with multiple family members, or patients with severe mental illness. In addition, therapeutic skills include the ability of the trainee to take charge of therapeutic sessions, the ability to collect necessary patient history or background information on presenting problems, the ability to match theoretical approaches to patients’ needs. Assessment and diagnosis are central skills in the training process, does the trainee have the ability to understand the DSM-IV-TR (2000) and appropriately diagnose patients, have adequate knowledge of psychopharmacology, and have the ability to assess danger and intervene when a crisis arises.

Therapeutic skills also include the ability to develop a treatment plan, awareness of the impact of diversity factors on assessment and treatment, the ability to maintain continuity from session to session, and the ability to track content of sessions. Does the trainee have the ability to facilitate and work with the patient’s affect, the ability to distinguish process and content, the ability to explore the patient-therapist relationship, and the ability to recognize transference and counter-transference.

Good therapeutic skills also include the appropriate use of self-disclosure, the ability to challenge and confront appropriately, the ability to motivate patients towards change, and the ability to engender hope. Finally, does the trainee demonstrate the ability to make interventions that are consistent with therapeutic goals, the ability to identify when a therapeutic impasse has been reached and modify approach accordingly, and the ability to recognize when it is time to terminate treatment. Clearly, the majority of the supervisory work will be in this area of the development and implementation of therapeutic skills.


Trainee-agency relations
include the trainee’s ability to relate well to other staff members, the ability to represent the agency with other agencies, and the ability to reliably follow agency procedures. More often than not, trainees will have practicum and internship in agencies with a multidisciplinary staff, and the ability to interact well with physicians, nurses, psychologists, marital and family therapists, counselors, physical, recreational, and occupational therapists, and other health professionals is vitally important. Many trainees will be thrust into bureaucratic environments such as hospitals, governmental agencies, universities, or other large organizations that have strict procedures to follow in order to provide care. Trainees must follow the procedures of the organization and process any confusion or disagreement in the supervision sessions.


Evaluation of the process supervision
includes the trainee’s ability to contribute to one-on-one or group discussions of clinical issues in supervision, the ability to be well prepared for supervision, and the ability to request an appropriate amount of assistance and communicate professionally with the supervisor. In addition, the trainee must have the ability to integrate and implement the supervisor’s feedback, the willingness to expose problem areas in supervision, the ability to accept constructive criticism in supervision, and the ability to process ethical issues in supervision. Evaluation of the supervisory process is an ongoing endeavor and takes real commitment to the craft at hand.


Professional skills
include the trainee’s ability to respect confidentiality of all professional activities, the dependability in fulfilling clinical responsibilities, the demonstration of punctuality with assignments and meetings, and the maintenance of a professional appearance and demeanor. Of course, professional skills also includes the demonstration of a good working knowledge of legal and ethical principles that govern the practice of therapy and the ability to recognize professional limitations and stay within the boundaries of training. Additionally, professional skills include the demonstration of independence and resourcefulness and the demonstration of healthy behaviors and emotions. In other words, the trainee does not exhibit impairment that would significantly reduce the ability to conduct therapy.


Although this list of evaluation topics and Questions for Reflection is not exhaustive, they are a good starting point from which to guide training. Different setting may need additional areas of evaluation. Whatever evaluation tool is used, it is recommended that the trainee receive a copy of it at the start of supervision. Evaluation should be conducted at the midway point of the training experience, and at the end of the training period. Providing an evaluation review at the midway point of the trainee’s work will be a guide to the strengths and weaknesses of the trainee’s work. This will enable the supervisor and the trainee to focus on the areas of weakness for the second half of the training period.

If the trainee has more than one supervisor, it may be helpful to communicate with the other supervisor, especially if there are skills that need to be significantly improved upon. It is also a good idea to get input from the supervisees on how they felt they performed. Integrating both supervisee and supervisor input into the final evaluation enhances the learning process. There should be no surprises at the end of the training experience as to the level of work performed and the evaluation of that work.

One of the central learning tools in supervision is the ability of the supervisee to conceptualize a case and present it to the supervisor. The follow is an example of a case conceptualization format, which can be modified to fit the needs of the trainee’s clinical work:

1. Identifying Data: include all relevant demographic information such as age, sex, race marital status, number and ages of children, occupation and/or years unemployed, current living situation, physical appearance, level of income, reason for referral, and who referred patient to the agency.
   
2. Presenting Problem: include a list of the problem areas from the patient’s perspective, noting the patient’s view of the order of importance of the problem areas, precipitating set of circumstances, how long the problems have persisted, past occurrence of problems.
   
3. History of Presenting Problem: include a full history and description of the problem or problems. Make an attempt to put the description of the problems in the order that they were reported to have occurred.
   
4. Past Psychiatric History: include chronological history of diagnosis and treatment, hospitalizations, suicidal ideation and attempts (include means of suicidal attempts) and homicidal ideation and attempts, and current and past medications (dosages of medications if possible). This section can also include past marital or family therapy (include the names of family members that attended treatment and include the duration of the family or marital treatment).
   
5. History of Alcohol/Drug Use/Abuse and Treatment: include a chronological picture of substance use, abuse and treatment (include inpatient and outpatient treatment here), note duration of use and duration of abstinence, also include self-help group attendance. Include cigarette smoking history and use here.
   
6. Medical History: include past and present medical problems, treatments and hospitalizations, and prescribed medications in chronological order. A list of doctors may also be helpful here in case collateral information is needed.
   
7. Social History: include family of origin information (history of mental illness and/or substance abuse in family), level of education, work history and unemployment history, military experience and discharge, marital (include past separation and divorce), relationship, and sexual functioning,
   
8. Current Life Functioning: include income sources, living arrangements, social networks and friends, strengths and limitations, spiritual and religious affiliations, and contacts with the community.
   
9. Legal Problems: include past and present legal problems, felons, misdemeanors, time spent in jail or prison, parole or probation information, and review of conditions of parole or probation. Include the name and telephone number of the parole or probation officer and a release of information form here. Include any legal problems in the military here.
   
10. Mental Status Exam: include appearance, attitude and behavior, orientation, intellectual and cognitive functioning, proverb interpretation, performance on calculations, short-term and long-term memory recall, mood, affect, suicidal and homicidal ideation, speech, thinking processes, content of thought, insight, and judgment.
    
11. Test and assessment results: include all assessment results and scores in a concise format.
    
12. DSM-IV Diagnoses Axis I – IV: use code numbers and full names from manual, include all axes, even if deferred. Review the Global Assessment of Functioning scoring system, make sure it is consistent with the agency standards.
    
13. Master Treatment Plan: include problems and short and long term goals for treatment.
    
14. Expected Treatment Outcomes: include what is expected if patient follows treatment plan as indicated, include any barrier to following through with treatment.
    
15. Consults and referrals to other services: Include referrals for medical treatment, medication evaluations, community services, social work services, and other collateral consultations for optimum mental health care.
    
16. Signatures and dates: include both the trainee and the supervisor signatures and all of the dates of service. Also include the titles of both the trainee and the supervisor.
    

What should the supervisor do if the trainee is not making adequate progress? Assuming that the supervisor has provided clear written expectations at the start of supervision, a number of recommendations can be made when the trainee’s performance falls below the supervisor’s expectations. First, the supervisor may recommend that the supervisee read a book or article, attend a workshop or conference, take a course, get psychotherapy, or a combination of these. Second, the supervisor may provide additional training to the supervisee to remediate deficiencies. Third, the supervisor may lay the ground rules and inform the supervisee of actions which will be taken should the supervisee not comply with the supervisor’s requirements. Fourth, the supervisor may recommend additional hours of supervision. Finally, the supervisor may terminate the supervision. The supervisor can give the intern or trainee at least one week’s written notice of his/her intent not to certify any further hours of experience [Section 1833.1(c)] Practical Applications in Supervision]. In most instances, remediation can lead to a successful outcome when a trainee is not making adequate progress.

At the end of the evaluation period is the termination phase of supervision. A good termination of the supervisory experience sets the stage for a successful transition. A supervisee may have mixed feelings about ending supervision. On the one hand, he or she may be excited to transition to a more independent role in the field of psychotherapy. On the other hand, he or she may not feel ready to leave the comfort and protection of the supervisory relationship. Indeed, the supervisor may have mixed feelings as well. Witnessing the development of a competent therapist may have been an invigorating endeavor and the supervisor may very well miss the relationship. Instilling a sense hope and confidence in the supervisee’s journey towards being an independent practitioner is vitally important. Reviewing the summary of therapeutic achievements that have occurred throughout the course of supervision may be valuable.

Discussing the supervisor’s availability to provide letters of recommendation to the supervisee may occur during termination. An exchange of small tokens symbolizing the professional work such as a card, a book, a clock, or a business card holder is acceptable. Acknowledging the value of the relationship and wishing the supervisee success in the future sets the stage for a positive end to supervision that will be remembered as the supervisee becomes a supervisor in the future. Most supervisors like to know how their trainees fare in the transition to new careers. Ending supervision with the option to contact the supervisor to inform him or her of the trainee’s professional endeavors is mutually beneficial.

The Next Generation of Supervisors
The trouble with the future is that it usually arrives before we’re ready for it.
Arnold H. Glasow

Although the beginning of training may hold anxiety and worry for many supervisees, training is oftentimes over surprisingly quickly. An underlying role of the supervisor is to provide training in the practice of supervision itself. All supervisors aim to improve the mental health field by training students to a high standard of competence. A supervisee’s experiences form the basis for his or her own future conduct of supervision. According to Falender and Shafranske (2004) “the sum of one’s experiences in supervision influences the development of attitudes and skills that will support meaningful self-assessment and contributions to lifelong increases in competence” (p. 7). It is no wonder that Norcross and Halgin (1997) recommend that the emphasis in training “should be placed squarely on ‘how to think’ rather an on ‘what to think’ (p. 218). Supervisors trained in “how to think” about the complexity of clinical work, how to integrate information, and how to convey knowledge to new students entering the field are our next generation of innovative professionals. The future of the art and science of psychotherapy falls squarely on their shoulders.


This course provided the reader with an overview of models of supervision, the goals of the supervisory experience, information on what makes an effective therapist, ethics and risk management in supervision, self-care for the counselor and supervisor, the supervision relationship vs. the psychotherapy relationship, diversity awareness, and performance evaluation and termination. Included throughout the course were both case studies and topic Questions for Reflection. Many of the Questions for Reflection can be reviewed when specific challenges present themselves in the journey of supervision.

Because developing a competent psychotherapist is a work in progress, a list of further reading for both the trainee and the supervisor has been provided. Feel free to give a copy of the list of resources to your trainees at the start of supervision. Add to this resource list current books and articles valuable to training. It may also be helpful to include writings of other mental health providers who describe first-hand accounts of practicing psychotherapy. Having trainees write about their varied experiences during their training years may also provide a sense of purpose and demonstrate a pathway of growth over time. Supervisors, too, can record their work with trainees and witness their own development over the course of the journey. Each supervisor-trainee session is unique in its own right and should be afforded the respect, curiosity, and attention in the pathway to successful treatment. Supervisors should be proud of their commitment to the science and craft of training and to providing society with its next generation of compassionate, thoughtful, well-trained providers.


For The Supervisee


Copyright Rebecca E. Williams, Ph.D.

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