Please see the attachment.
Wk 1 Discussion – Clinical Supervision
Respond to the following in a minimum of 175 words:
REMEMBER
Please include a peer-reviewed APA reference, utilizing the correct format for the referencing.
How can your clinical supervisor affect your development as a counselor? What do you expect from the clinical supervision experience?
Respond to the following in a minimum of 175 words:
MK Classmate:
As a student seeking clinical experience, I want to be prepared or fully prepared to have the needed tools and skills for being prepared for the counseling comprehensive exam. I hope to gain the necessary skills that will provide me with the knowledge that is needed to pass the comprehensive exam with above average scores, and allow me to enter into the next chapter of my career (Glenn, Garcia, Li Li, & Moore,1998). I am hoping to receive a great foundation that will lend me the mindset to follow and adhere to a foundation that is honored by professional worldwide, and where greatness is shown by the care that is provided to the people served (Bernard, & Goodyear, 2014).
During my classroom experience, I expect that my clinical supervision experience will allow me to be exposed to the skills that I can build from which would include how certain techniques and approaches are implemented, as well as how knowing or having the knowledge of what code of ethics align with specific issues displayed by the certain clients. From this clinical supervision experience, I hope to be prepared for the real-life issues that clients face in an effort to provide skills that will be helpful in the client’s recovery and/or success (Glenn, Garcia, Li Li, & Moore, 1998).
References:
Bernard, J. M., & Goodyear, R. M. (2014). Foundations of Clinical Supervision (5th ed.) Pearson
Glenn, M., Garcia, J., Li Li, & Moore, D. (1998). Preparation of rehabilitation counseling to serve people with living with HIV/AIDS. Rehabilitation Bulletin Counseling, 41(3), 190.
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nts are not only taught psychotherapy by their supervisors, they are also evaluated
by them. . . . Supervisors are thus not only admired teachers but feared judges who
have real power. (Doehrman, 1976, pp. 10–11)
Supervision’s evaluative function means that the relationship is hierarchical.
To the extent that hierarchy recapitulates issues related to ethnicity and
gender, this can be problematic. Feminists, for example, have wrestled with
the best means by which to balance their collaborative stance of work
between two equals with the fact of hierarchy in supervision (see, e.g.,
Prouty, Thomas, Johnson, & Long, 2001). Some (e.g., Edwards & Chen,
1999; Porter & Vasquez, 1997), in fact, suggest the term covision as an
alternative to supervision to signal a more collaborative relationship. Yet
hierarchy and evaluation are so intertwined with supervision that to remove
them makes the intervention something other than supervision.
Evaluation is, then, an important and integral component of supervision, but
it is one that often is the source of problems for supervisors and
supervisees alike. Therefore, we devote an entire chapter of this text to the
topic of evaluation (see Chapter 10 ) and address it as well in our
chapter on ethics (Chapter 11 ). Although there is no way in which
evaluation could (or should) be removed from supervision, there are ways
to enhance its usefulness and to minimize problems attendant to it.
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Supervision Extends over Time
A final element of our definition of supervision is that it is an intervention
that extends over time. This distinguishes supervision from training, which
might be brief, for example, in a short workshop intended to impart a
specific skill; it distinguishes supervision, too, from consultation, which
might be very time limited, as one professional seeks the help of another
to gain or regain objectivity in his or her work with a client.
The fact that it is ongoing allows the supervisor–supervisee relationship to
grow and develop. Indeed, many supervision theorists have focused
particular attention on the developing nature of this relationship. In
recognition of this, we devote Chapters 3 , 4 , and 5 to the
supervisory relationship, including the ways in which it evolves and
changes across time.
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Purposes of Supervision
Our definition suggests that supervision has two central purposes:
1. To foster the supervisee’s professional development—a supportive
and educational function
2. To ensure client welfare—the supervisor’s gatekeeping function is a
variant of the monitoring of client welfare
Vespia, Heckman-Stone, and Delworth (2002) show how central
supervisors find these two purposes. When supervisors rated the extent to
which each of 53 supervisee behaviors characterized individuals “who use
supervision well” (p. 59), two of the three highest rated items corresponded
to one of these purposes: “Implements supervisor’s directives when client
welfare is of concern to the Supervisor” and “Demonstrates willingness to
grow.” Each is an essential focus, although it is possible for a particular
supervisor to emphasize one more heavily than the other. For example, a
student working at a field placement might have both a university-based
and an on-site supervisor. In this situation, it is possible for the university-
based supervisor to give relatively greater emphasis to the teaching–
learning goals of supervision, and the on-site supervisor to give relatively
greater emphasis to the client-monitoring aspects. Feiner (1994) alludes to
this dichotomy of goals when he suggests the following:
Some supervisors assume that their most important ethical responsibility is to the
student’s patient. This would impel them to make the student a conduit for their
own expertise. Others make the assumption that their ultimate responsibility is to
the development of the student. . . . Their concern is the possible lowering of the
student’s self-esteem when confronted by the supervisor and his rising fantasy
that he should become a shoe salesman. (p. 171)
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It is important to acknowledge other possible purposes for supervision. For
example, Proctor (1986) asserts that supervision serves three purposes
that she labeled (a) formative, equivalent to our teaching–learning purpose;
(b) normative, generally equivalent to ensuring client welfare; and (c)
restorative, providing supervisees the opportunity to express and meet
needs that will help them avoid burnout (see Hyrkäs, 2005, for results that
provide preliminary support for this function). Howard (2008) extends the
restorative purpose by drawing from positive psychology to suggest as
well that supervision should also have the goals of enhancing work
engagement, “flow” (see Csikszentmihalyi, 1990), and resilience.
Occasionally, too, supervision is mandated as a method to rehabilitate
impaired professionals (see, e.g., Frick, McCartney, & Lazarus, 1995). This
overlaps with both the training and client-protective purposes of
supervision, but really should be considered an additional purpose.
Although we do not specifically address this purpose of supervision in this
text, interested readers might consult discussions by Cobia and Pipes
(2002) and Walzer and Miltimore (1993).
Both the restorative and rehabilitative purposes of supervision are
important. Knudsen, Ducharme and Roman (2008) found, for example, that
being supervised reduced substance abuse counselors’ emotional
exhaustion and job turnover. However, restorative and rehabilitative
purposes are not common across all supervision, whereas the two
purposes that are part of our definition of supervision (i.e., client protection
and development of supervisee competence) are. Each is addressed in turn
in the two subsections that follow.
Before turning to those discussions, however, we add one additional,
ultimate goal, which is to prepare the supervisee to self-supervise (Dennin
& Ellis, 2003). At the point of licensure, practitioners, at least in the United
States, no longer are required to be supervised and so must be able to
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monitor their own work, knowing how to learn from it and also when to
seek consultation. Supervisees work with a number of supervisors; a
psychologist will work with about eight supervisors prior to obtaining a
doctorate (M. V. Ellis, personal communication, August 31, 2006, from data
obtained as part of an instrument validation study). In the process of that
work, they should develop a sort of internal supervisor that incorporates
what they have learned from each of their supervisors.
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Fostering the Supervisee’s Professional
Development
We state the teaching–learning goal simply as “to enhance professional
functioning.” This is a pragmatic definition that meets our need to provide a
succinct and generally applicable definition of supervision. It is silent about
any performance criteria that supervisees are to meet or even about the
content of learning. To that end, however, the APA’s competency benchmark
task group (Fouad et al., 2009) performed important work in articulating
those expected performance criteria, breaking them out by level of training.
In Chapter 10 , we also address performance criteria.
To enhance professional functioning speaks to the development of
supervisee competence. The form of that competence typically derives
from some combination of the supervisor’s own theory or model, the
supervisee’s particular developmental needs, and the supervisee’s
expressed wishes.
In addition, the supervisor almost certainly wants the supervisee to develop
skills and competencies necessary for eventual licensure or certification.
This utilitarian goal has the virtue of specificity—that is, supervisors
generally know what competencies the supervisee must demonstrate for
licensure, at least in his or her own state. Moreover, this is a logical target
in that to attain licensure is, at least in the United States, the point at which
the supervisee makes the transition to an autonomously functioning
professional who no longer has a legal mandate to be supervised.
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The truth is that no one knows or tracks in any systematic way what transpires
between therapist and client once the therapist escapes the onus of training and
supervision, and unlike most medical procedures of significant consequence,
there’s generally no one present to observe other than the provider and the
recipient—neither of whom is apt to be vested with an unbiased view or
recollection. (Gist, 2007, personal communication via email)
The assumption undergirding this right to practice without supervision is
that the person has developed metacompetence (Roth & Pilling, 2008), or
“the ability to assess what one knows and what one doesn’t know”
(Falender & Shafranske, 2007, p. 232). It is a professional’s
metacompetence that allows him or her to seek consultation when faced
with an issue beyond his or her expertise; to engage in the self-supervision
to which we alluded earlier.
In a now-famous statement to the press, U.S. Secretary of Defense Donald
Rumsfeld (2002) describes “known knowns,” “known unknowns,” and
“unknown unknowns.” Metacompetence reduces the number of “unknown
unknowns” a professional will face; however, until they develop it, they
must rely on their supervisors. We suppose it should go without saying that
it is essential that supervisors’ own metacompetence is an important
means of helping to ensure that supervisees develop that in themselves.
Whereas it is the norm in the United States to permit licensed professionals
to work without formal supervision, this is not true in other countries, which
may be wise given Gist’s observation earlier. In the United Kingdom, for
example, many mental health professionals are expected to continue
receiving supervision throughout their professional lives (West, 2003). This
is codified in the British Association for Counselling and Psychotherapy’s
(BACP) ethical code, which stipulates: “There is an obligation to use regular
and on-going supervision to enhance the quality of the services provided
and to commit to updating practice by continuing professional
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development” (BACP, 2007, p. 3). BACP expectations are that practitioners
will participate in supervision at least 1.5 hours per month. Australia has a
similar rule (see Grant & Schofield, 2007). This convention recognizes that
professional development is ongoing and extends even after a professional
develops expertise; supervision in this context is understood to have more
than a training function.
Fried (1991) offers the folk wisdom that it takes 10 years to become a
really good psychotherapist. In fact, Hayes (1981) estimates that it
requires about 10 years to become an expert in any skill domain, an
assertion that others (e.g., Ericcson & Lehmann, 1996) document as well.
Yet, for many professionals, time alone is insufficient to attain expert status
or clinical wisdom. However, even if a mental health professional attains
expertise or wisdom, it still is useful for him or her to have continuing
supervision to foster lifelong learning and help address our field’s
knowledge half-life (see, e.g., Lichtenberg & Goodyear, 2012).
In fact, many—perhaps most—postgraduate, credentialed practitioners want
and do continue some level and type of supervision, even if it is not
mandated (see, e.g., Borders & Usher, 1992; McCarthy, Kulakowski, &
Kenfield, 1994; Wiley, 1994). This is good not only for them, but for their
clients as well. Slater (2003, p. 8) states: “I remember a patient once
asking me, ‘Who do you talk about me with?’ He wasn’t asking out of fear,
but hope. What suffering person doesn’t want many minds thinking about
how to help?”
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Monitoring Client Care.
In addition to their responsibilities to the supervisees’ professional
development, supervisors must also ensure that supervisees are providing
adequate client care. In fact, this was the original purpose of clinical
supervision. Supervision in the mental health disciplines almost certainly
began with social work supervision, which “dates from the 19th-century
Charity Organization Societies in which paid social work agents supervised
the moral treatment of the poor by friendly visitors” (Harkness & Poertner,
1989, p. 115). The focus of this supervision was on the client.
Eisenberg (1956) notes that the first known call for supervision to focus on
the professional, rather than exclusively on the client, was in 1901 by
Zilphia Smith. This supervisory focus became more prominent two
decades later, when, as Carroll (2007) observes, “Max Eitington is thought
to be the first to make supervision a requirement for those in their
psychoanalytic training in the 1920s” (p. 34).
However, the need to ensure quality of client care is one job demand with
particular potential for causing dissonance in the supervisor. Most of the
time, supervisors are able to perceive themselves as allies of their
supervisees. Yet they also must be prepared, should they see harm being
done to clients, to risk bruising the egos of their supervisees or, in extreme
cases, even to steer the supervisee from the profession—an ethical
obligation we have to the public.
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Person-Specific
Understandings of
Supervision
A formal definition of supervision is important, but it is inevitable that
supervisors and supervisees also will operate according to their own
idiosyncratic and personally nuanced definitions. Because these more
individualized—and usually implicit—definitions can affect supervision
processes in important ways, they too should be acknowledged as
complements to the more formal definition.
To consider these nuanced definitions, it is useful to invoke the concept of
the schema (in the plural, schemata) that Bartlett (1932, 1958) introduces
and that now is widely used among cognitive psychologists and mental
health professionals. A schema helps us interpret our world by providing a
mental framework for understanding and remembering information. More
formally stated, a schema is a knowledge representation based on our past
experiences and inferences that we use to interpret a present experience. In
short, people have a tendency to understand one domain of life experience
in terms of another. Our perceptions and responses to a new situation are
organized and structured as they were in a previous similar situation.
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FIGURE 1.2 Life and Professional Roles That Affect Supervisory Role
Behavior
Because of their apparent similarities, we respond to the new situation as if
it were the earlier one. Moreover, the more ingrained the particular role we
have learned, the more it is likely to intrude on later learned roles. The
schema people develop for supervision is shaped in this manner. Figure
1.2 shows, for example, that gender and ethnicity roles are among the
most ingrained, and therefore permeate much of our behavior, including
supervision (see Chapter 5 for a discussion of these roles in
supervision).
Professional roles are learned later and are therefore less an ingrained part
of ourselves. Yet, even so, earlier learned professional roles (such as that
of counselor) are likely to affect later learned professional roles. For those
taking on the later learned roles, it is natural, perhaps inevitable, to attempt
to understand them in terms of things we do know. It is merely human to
attempt to understand that which is new in terms of that which is familiar.
It should be no surprise, then, that the roles of supervisor and supervisee
are at least partially understood as metaphoric expressions of other life
experiences. Proctor (1991), for example, invokes the concept of
archetypes, which actually could be understood as schemata:
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A number of my colleagues asked me what archetypes went into taking the trainer
role; we immediately identified a number. There are the Guru, or Wise Woman,
from whom wisdom is expected, and the Earth Mother—the all-provider,
unconditional positive regarder. In contrast there is the Clown or Jester—enjoying
performance, and cloaking his truth in riddles, without taking responsibility for how
it is received. The Patriarch creates order and unselfconsciously wields power.
The Actor/Director allocates roles and tasks and holds the Drama; the Bureaucrat
demands compliance to the letter of the law. The Whore gives services for money,
which can be indistinguishable from love, and re-engages with group after group.
There is even the Warrior—valiant for truth; and of course the Judge—upholding
standards and impartially assessing. The Shepherd/Sheep-dog gently and firmly
rounds up and pens. (p. 65)
These are some possible metaphors for the supervisor. There also are
metaphors that speak to the process or experience of supervision,
independent of other life roles. Therefore, a supervisee (or supervisor)
might understand supervision as akin to a lighthouse beacon that provides
one with bearings in often foggy situations. Participants in workshops led
by our colleague, Michael Ellis, describe supervision as a shepherd and
flock, as an oasis in the desert, and (more ominously) as going to the
principal’s office. Milne and James (2005) use the metaphor of supervision
as tandem bicycle riding.
We believe that these metaphors exist at various levels of awareness, but
they are often present and affect participants’ expectations and behaviors.
The following discussions of more frequently occurring metaphors are
therefore in the service of making them available for consideration.
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Family Metaphors
Family metaphors (middle of Figure 1.2 ) seem especially common in
supervision. The most basic of these is that of the parent–child
relationship. Lower (1972), for example, uses this metaphor in alluding to
the unconscious parent–child fantasies that he believed are stimulated by
the supervisory situation itself. In fact, Itzhaky and Sztern (1999) caution
supervisors against allowing themselves to behave without awareness of
what they term a pseudo-parental role (p. 247).
Of course, many theorists use this metaphor of parent–child relationship as
a way to think about therapy. As it may apply to supervision, the metaphor
is simultaneously both less and more appropriate than for therapy. On the
one hand, it is less apt in that personal growth is not a primary goal of the
intervention, as it is in therapy, but rather is an instrumental goal that works
in the service of making the supervisee a better therapist. It is more apt, on
the other hand, in that supervision is an evaluative relationship, just as
parenting is—and therapy presumably is not.
Just knowing that they are being evaluated is often sufficient to trigger in
supervisees an expectation of a guilt–punishment sequence that
recapitulates early parent–child interactions. Supervisors can, through their
actions, intensify such transference responses among supervisees,
triggering perceptions of them as a good or bad parent. We have heard, for
example, of instances in which supervisors posted publicly in the staff
lounge the names of supervisees who had too many client “no-shows.” The
atmosphere created in situations such as this can easily establish
supervisory staff as “feared parents.”
Still another parallel between parent–child and supervisor–supervisee
relationships is that status, knowledge, maturity, and power differences
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between the participants eventually begin to disappear. The parties who
today are supervisor and supervisee can expect that one day they might
relate to one another as peers and colleagues.
The parent–child metaphor is suggested, too, in the frequent use of
developmental metaphors to describe supervision. We describe these in
Chapter 2 .
A second family metaphor that can pertain to supervision is that of older
and younger siblings. For many supervisory dyads, this probably is more
apt than the parent–child metaphor. The supervisor is further along on the
same path being traveled by the supervisee. As such, she or he is in a
position to show the way in a nurturing and mentoring relationship.
However, as with siblings, issues of competence can sometimes trigger
competition over who is more skilled or more brilliant in understanding the
client.
The older–younger siblings metaphor is structurally similar to the
relationship between master craftspersons and their apprentices. Such
relationships have existed for thousands of years and are perpetuated in
supervision. In these relationships, master craftspersons serve as mentors
to the people who aspire to enter the occupation, showing them the skills,
procedures, and culture of the occupation. In this manner, too, master
craftspersons help perpetuate the craft. Eventually, after what is usually a
stipulated period of apprenticeship, the apprentices become peers of the
craftspersons.
These metaphors, particularly those of parent or sibling, occur at
fundamental and often primitive levels. Because they influence in an
immediate and felt way, they have a special and probably an ongoing
influence on the supervisory relationship. Moreover, such metaphors
probably operate outside the awareness of the supervisor.
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If it is true that supervision is a unique intervention, then one might
reasonably infer that there is a unique role characteristic of supervisors in
general. In a broad sense, this is true, and we can identify at least two
major components of this generic supervisory role. The first of these is the
perspective from which the supervisor views his or her work; the second
pertains to the commonly endorsed expectation that the supervisor will
give feedback to the supervisee.
This topic of supervisor roles is one to which we give greater attention in
Chapter 4 , where we discuss social role models of supervision. There
are, however, aspects of it that are important to cover at this point.
Liddle (1988) discusses the transition from therapist to supervisor as a
role-development process that involves several evolutionary steps. An
essential early step is for the emerging supervisor to make a shift in focus
—that is, the supervisor eventually must realize that the purpose of
supervision is neither to treat the client indirectly through the supervisee nor
to provide psychotherapy to the supervisee, a point which Borders (1992)
also makes. She maintains that the supervisor-to-be must make a cognitive
shift as he or she switches from the role of counselor or therapist. To
illustrate how difficult this often is for new supervisors, she gives the
example of a neophyte supervisor who persisted for some time in referring
to his supervisee as “my client.” Until he was able to label the supervisee’s
role correctly in relation to himself, his perceptual set remained that of a
therapist.
This shift, then, requires the supervisor to give up doing what might be
thought of as therapy by proxy, therapy by remote control, or what Fiscalini
(1997) calls therapy by ventriloquism. We would note, however, that the pull
to doing this may always remain present, even if unexpressed in practice. In
part, this is reinforced by the supervisor’s mandate always to function as a
monitor of client care and remain vigilant about how the client is
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functioning. Similarly, the longer the person has functioned as a therapist,
the harder it may be for the supervisor to make the necessary shift in
perspective. It is interesting to note, for example, that Carl Rogers talked
about having occasionally experienced the strong impulse to take over the
therapy of a supervisee, likening himself to an old fire horse heeding the
call (Hackney & Goodyear, 1984).
Borders (1992), in fact, observes that untrained professionals do not
necessarily make this shift on their own, simply as a result of experience as
a supervisor. As a matter of fact, some “experienced” professionals seem
to have more difficulty changing their thinking than do doctoral students
and advanced master’s students in supervision courses.
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A Conceptual Model of
Supervision
The conceptual model depicted in Figure 1.3 , an adaptation of the
competencies cube developed by Rodolfa and colleagues (2005), provides
a complementary perspective that influenced our organization of this text.
This is a three-dimensional model in which the three dimensions are what
we have labeled Parameters of Supervision, Supervisee Developmental
Level, and Supervisor Tasks.
Parameters of Supervision
The parameters of supervision are the features of supervision that
undergird all that occurs in supervision, regardless of the particular
supervisory function or the level of the supervisee. For example, the
supervisor’s model or theory is a factor at all times, as is the supervisory
relationship and each of the other of the parameters listed in the figure.
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Supervisee Developmental Level
We assume that supervisees need different supervisory environments as
they develop professionally and that the manner in which supervisors
intervene differs according to supervisee level. As well, the expression of
each parameter (e.g., relationship, evaluation) is affected by the
supervisee’s developmental level.
As we discuss later in the text, different supervision theorists suggest a
different number of stages through which the supervisee progresses.
Figure 1.3 , however, is drawn in a way to suggest
FIGURE 1.3 Conceptual Model of Supervision
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that we do not take a stand on exactly how many of these stages there
actually are. We believe it is sufficient here simply to make clear that
developmental processes affect all that we do as supervisors.
Supervisor Tasks
Supervisor tasks are the actual behaviors of the supervisors. In this text, we
discuss the four tasks depicted in Figure 1.3 (i.e., organizing
supervision, individual supervision, group supervision, and live
supervision). It is possible, of course, to think of more, but we believe
these four are the most frequently used.
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Using the Model
We assume that the three dimensions interact with one another. To
illustrate, consider the supervisor using individual supervision: He or she
does so within the context of a relationship, and that work is guided by the
supervisor’s particular theory or model, attention to supervisee’s individual
differences (e.g., ethnicity, gender), and ethical and legal factors; the fact of
evaluation affects it as well. The developmental level of the supervisee,
then, moderates each of these things.
We should note that we are not attempting in this model to capture all that
occurs in supervision. This is especially true with respect to our discussion
of supervisor tasks. We recognize, for example, that individual, group, and
live supervision are not the only modalities. Kell and Burow (1970), for
example, discuss the use of conjoint treatment as a supervision modality.
However, although this is not a modality included in Figure 1.3 , it is
easy enough to see how conjoint treatment might fit into the conceptual
model.
The next 10 chapters each address features of this model. We hope that
with this conceptual framework, the reader will more readily see how the
particular topic being covered fits within the larger picture of supervision,
as least as we envision that picture.
The text’s final chapter does not speak specifically to the conceptual
model. Instead, it addresses topics—the teaching of supervision and
supervision research issues—that have the purpose of enhancing
supervisory practice.
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Explicitly Focusing on Personal Values.
If much ethical decision making occurs automatically, then the decision-maker’s personal values and morality becomes a central consideration. Hansen and Goldberg (1999) assert that professionals are influenced by personal (e.g., political or religious) values, what Handelsman, Gottlieb, and Knapp (2005, p. 59) refer to as ethics of origin. In fact, Pope and Bajt (1988) found that 75 percent of a sample of senior psychologists, all of whom were known for ethics expertise, believed that formal codes and statutes should sometimes be violated to ensure client welfare or because of personal values.
It is useful, therefore, to help supervisees to explore their personal values and attitudes. Betan and Stanton (1999), for example, conclude that awareness of how one’s emotions may influence ethical decision making can lead to appropriate management of these emotions. Supervisors and educators can facilitate this exploration in various ways, including the use of an ethics biography (Bashe, Anderson, Handelsman, & Klevansky, 2007).
Mastering the Content of Ethical Codes.
Kahneman (2011) states that, in the interest of efficiency, System 2 thinking tends to migrate to System 1, meaning that situations that initially require deliberate thought eventually, with enough repetition, become so routinized that they are automatic and occur outside of awareness. Anderson (1995) and other cognitive psychologists term this the shift of declarative to procedural knowledge. The same phenomenon occurs with respect to retrieval of ethical knowledge. To accomplish this, supervisees should be exposed to ethics codes consistently enough that they overlearn them, and then the information is retrieved automatically in System 1. To illustrate this, consider the analogy of drilling students in multiplication tables so that eventually the student can retrieve 9 × 9 = 81 without having to think it through.
This is not to suggest a checklist mentality or rote application of ethics codes; however, knowing the codes is a prerequisite for learning to apply them in real-world, professional situations.
Opportunities to Apply Ethical Knowledge.
Many ethical mishaps result from acts of omission, not intentional malice (Bernard, 1981). Such omissions are more likely if professionals have not had an opportunity to experience the ins and outs of a similar situation. The use of simulation and behavioral rehearsal is an excellent way to allow both trainees and supervisors to face difficult situations, try alternative resolutions, and evaluate their outcomes safely. Formal academic settings provide one venue in which students learn to apply ethical knowledge through the use of experiential learning or case analysis (e.g., Plante, 1995; Storm & Haug, 1997).
Much ethical decision making is context based: What may be unethical in one context may not be unethical in another, and so there is a reasoning process to be used. Therefore, it is important that ethical decision-making opportunities are presented in the review of case material that occurs in supervision. Riva, Erickson, and Cornish (2008) surveyed a national sample of group supervisors who were asked about content covered in their groups; 94.5 percent indicated that ethical and legal content was being addresssed. A study of critical incidents reported by supervisors and supervisees found that ethical issues were among those reported, although less frequently than such other issues as relationship and competence issues (Ellis, 1991a).
Modeling Ethical Behavior.
Observing and modeling others is a powerful way to learn, and this extends to the learning of ethical behavior. Supervisors provide that modeling, whether they are conscious of doing it or not (Tarvydas, 1995).
Teaching Explicit Ethical Decision-Making Models.
The default is for people to respond intuitively when they deal with familiar situations, but they shift to rational, deliberate, reflective thinking (i.e., Kahneman’s System 2) when they encounter a novel situation (Anderson, 1995) or one that is somehow puzzling or upsetting. Because many ethical situations have these effects, it is also important that supervisees know of and are prepared to use explicit decision-making models. Some models are specific to a particular issue, such as addressing multiple relationships (Gottlieb, 1993); others focus on more general ethical decision-making processes (Cottone & Claus, 2000; Lipshitz & Strauss, 1997).
The moral principles of autonomy, beneficence, nonmaleficence, justice, and fidelity are of primary importance when evaluating a difficult situation (Beauchamp & Childress, 2001; Bersoff & Koeppl, 1993; Hansen & Goldberg, 1999; Kitchener, 1984). Hansen and Goldberg (1999) outline a seven-category matrix of considerations that could be used to assess ethical and legal dilemmas, both in training and in actual situations. They rightly argue that in a linear model of ethical decision making, one that begins by identifying an ethical dilemma and ends with a decision to act, belies the complexity of most situations with ethical and legal overtones. By considering multiple influencing variables as being interfaced with a linear process, the mental health professional is more likely to arrive at a sound course of action.
The second consideration involves clinical and cultural factors. For example, as stated earlier in our discussion about the duty to warn, the therapist and supervisor must make an assessment of a client’s level of risk in order to make an informed decision about a course of action. What may be ethical in one situation may violate a client’s rights in another. In addition to clinical assessment, cultural assessments must be made. The boundaries of confidentiality can take on different meaning when viewed with cultural sensitivity (Hansen & Goldberg, 1999).
The next four considerations are less fluid and include professional codes of ethics; agency or employer policies; federal, state, and local statutes; and rules and regulations that elaborate statutes, all of which call for a certain amount of vigilance from the professional to stay informed about changes in professional and regulatory pronouncements. At the same time, it must be said that codes, statutes, rules, and regulations are not sufficient for all (or even most) difficult situations.
Finally, because case law calls for interpretation regarding its relevance for a particular ethical or legal dilemma, it could be viewed as more fluid than statutes and codes of ethics. In addition, case law represents the history of our most dramatic struggles as mental health professionals, thus providing a rich context for deliberation (Hansen & Goldberg, 1999).
Once we have carefully attended to the multiple factors already noted, we must eventually return to a process that ends in some form of resolution, including consideration of alternative courses of action (often weighing one aspect of the situation against another), an attempt to predict the consequences of each potential course (both short term and long term and for each of the parties involved), and making a decision about which course of action to take that includes a willingness to take responsibility for the consequences of the selected action (Hadjistavropoulos & Malloy, 2000).
Seeking Consultation.
Finally, supervisees should understand the importance of seeking consultation when they encounter an ethical dilemma. Supervision should reduce the incidence of supervisees’ ethical misbehavior (Pope & Vasquez, 2011). It is interesting, therefore, to speculate whether the effect of lifelong supervision (as in Britain) is an overall reduction in problematic ethical behavior. This intriguing question, however, has yet to be investigated.
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1. established between the injury and the negligence or improper
conduct.
We are not aware of any suits brought against supervisors by trainees for
inadequate supervision. It is more likely that supervisors would be involved
in legal action as a codefendant in a malpractice suit (Snider, 1985) based
on the alleged inadequate performance of the supervisee.
Therapists’ (and supervisors’) vulnerability is directly linked to their
assumption of professional roles. When they take on the role of therapist
or supervisor, they are expected to know and follow the law, as well as the
profession’s accepted practice and ethical standards. Also, professionals
seem to have difficulty in judging peers’ or sometimes even supervisees’
competence (Forrest et al., 1999; Haas, Malouf, & Mayerson, 1986; Wood,
Klein, Cross, Lammers, & Elliot, 1985), and are reluctant to report known
ethical violations of peers or supervisees (Bernard & Jara, 1986; King &
Wheeler, 1999) as well as to exercise their responsibilities as gatekeepers
(e.g., Johnson et al., 2008), as noted earlier.
Sociological factors also contribute to the increase in lawsuits against
helping professionals. Cohen (1979) suggests three primary factors for the
increase—factors that are at least as relevant today: (a) a general decline in
the respect afforded helping professionals by clients and society at large;
(b) increased awareness of consumer rights in general,; and (c) highly
publicized malpractice suits for which settlements were enormous, leading
to the conclusion that a lawsuit may be a means to obtain easy money. All
these factors increase the likelihood of potential lawsuits (however
spurious) against the practitioner (however ethical). As Williams (2000)
observes, there is little that therapists or supervisors can do to totally
protect themselves from persons who attempt to use the court for
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disturbed or vengeful reasons. At the same time, there are some
precautions that professionals can take, and these are covered later in this
section.
Although failure to warn potential victims accounts for a very small number
of legal claims (Meyer et al., 1988), the Tarasoff case has made this issue
highly visible. It also involved a clinical supervisor, and thus introduces the
concept of vicarious liability, or respondeat superior (literally, “let the
master answer”). Following the discussion regarding the duty to warn,
therefore, we review salient issues with respect to direct and vicarious
liability.
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The Duty to Warn.
The duty to warn stems from Tarasoff v. Regents of the University of
California, 1976, a landmark case in which a university therapist believed
that his client (Poddar) was dangerous and might do harm to a woman who
had rejected Poddar’s romantic advances (Tatiana Tarasoff). Because
Poddar refused voluntary hospitalization, the therapist notified police to
have him taken to a state hospital for involuntary hospitalization. The police
spoke to Poddar and decided that he was not dangerous.
On the advice of his supervisor, who feared a lawsuit for breach of
confidence (Lee & Gillam, 2000), the therapist did not pursue the matter
further. Poddar did not return to therapy. Two months later, Poddar killed
Tarasoff. Although most mental health professionals believe that the
Tarasoffs won this case based on the duty to warn, actually the court only
determined that they could file a suit on these grounds. Rather, the case
was settled out of court (Meyer et al., 1988). Furthermore, the Supreme
Court of the State of California actually heard the Tarasoff case twice and
articulated the duty to protect at this second hearing (Chaimowitz, Glancy,
& Blackburn, 2000). Chaimowitz et al. argue that the duty to warn,
therefore, must be assessed as it relates to the duty to protect, and that
warning an intended victim may be insufficient to meet the duty to protect.
They also note that there may be times that warning an intended victim
could actually exacerbate a tenuous situation. In short, these authors
suggest that more than a knee-jerk decision to warn is called for. Rather,
they suggest a reasoned strategy that holds the duty to protect at its center.
The duty to warn and protect has become a legal standard for all mental
health professionals and has become the law in several states. It is
imperative, then, for supervisors to inform supervisees of conditions under
which it is appropriate to implement the duty to inform for the protection of
an intended victim(s). Two issues are embedded in this duty: (a) assessing
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the level of dangerousness of the client and (b) the identifiability of
potential victims (Ahia & Martin, 1993; Lee & Gillam, 2000). The
practitioner and supervisor are not expected to see the unforeseeable; there
is no foolproof way to predict all human behavior. Rather, there is an
expectation that sound judgment be used and reasonable or due care is
taken regarding the determination of dangerousness. For this reason, most
authorities on such legal matters strongly advise that both consultation
with others and documentation of all decisions are vital in any questionable
case.
The second embedded issue emerges when there is some indication that
the client might be dangerous, but no potential victim has been named; for
example, the client’s hostility might be nonspecific with no particular
person in danger. At present, ethical standards and legal experts seem to
lean in favor of client privilege unless there is clear evidence that the client
is immediately dangerous and there is an identifiable (or highly likely)
victim (Ahia & Martin, 1993; Fulero, 1988; Lee & Gillam, 2000; Schutz,
1982; Woody and Associates, 1984), which means that therapists and
supervisors are not expected to, nor should they, read between the lines
when working with clients. Many clients make idle threats when they are
frustrated. It is the job of mental health practitioners to make a reasonable
evaluation of these threats. In fact, in the eyes of the law, it is more
important that reasonable evaluation be made than that the prediction be
accurate.
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Direct Liability and Vicarious Liability
Direct liability would be argued when the supervisor’s actions themselves
caused harm. For example, if the supervisor did not perform supervision
adequate for a novice counselor, or if the supervisor suggested (and
documented) an intervention that was determined to be the cause of harm
(e.g., suggesting that a client use “tough love” strategies with a child, which
resulted in physical harm to the child). Montgomery et al. (1999) found
that direct liability is still rare for supervisors, although two reported
malpractice suits involved supervision (evaluation of a supervisee and a
billing issue). Potentially, all supervision practice standards, including such
issues as violation of informed consent, breach of confidentiality, inability
to work with cultural differences, or an inappropriate multiple relationships,
could lead to a supervisor being found to be directly liable if violated (Maki
& Bernard, 2007).
Vicarious liability, however, may represent the clinical supervisor’s worst
nightmare. In this case, the supervisor is held liable for the actions of the
supervisee when these were not suggested or perhaps even known by the
supervisor. In such cases, the supervisor becomes liable by virtue of the
relationship with the supervisee, and the supervisor generally is held liable
only “for the negligent acts of supervisees if these acts are performed in
the course and scope of the supervisory relationship” (Disney & Stephens,
1994, p. 15). Falvey (2002) outlines three conditions that must be met for
vicarious liability to be established:
1. Supervisees must voluntarily agree to work under the direction and
control of the supervisor and act in ways that benefit the supervisor
(e.g., see clients who might otherwise need to be seen by the
supervisor).
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2. Supervisees must be acting within the defined scope of tasks
permitted by the supervisor.
3. The supervisor must have the power to control and direct the
supervisee’s work. (pp. 17–18)
Additional factors that might be used to establish whether an action fell
within the scope of the supervisory relationship include the time, place, and
purpose of the act (e.g., was it done during counseling or away from the
place of counseling?); the motivation of the supervisee (e.g., was the
supervisee attempting to be helpful?); and whether the supervisor could
have reasonably expected the supervisee to commit the act (Disney &
Stephens, 1994, p. 16). Should the supervisor be found guilty based on
vicarious responsibility, then the supervisor, if found not to be negligent in
subsequent court proceedings, could recover damages from the supervisee
(Disney & Stephens, 1994).
Despite these stated parameters, some court cases demonstrate a more
far-reaching responsibility for supervisors. For example, Recupero and
Rainey (2007) discuss Simmons vs. United States, in which respondeat
superior was used to hold a social work supervisor liable for the sexual
misconduct of the supervisee. The court argued that the supervisee had
mishandled transference, which was ruled as a foreseeable supervision
issue. Recupero and Rainey therefore advised that “prudent supervisors
aware of this risk, may watch carefully for early warning signs of boundary
violation” (p. 192).
Remley and Herlihy (2001) caution that because each legal case is unique,
generalizability from one situation to another may be limited. They stress
the importance of establishing the amount of control a supervisor has over
a supervisee in order to arrive at a judgment of vicarious liability, and
indicate that supervisors at the clinical site are more likely to be held
accountable for a therapist’s negligence than off-site (e.g., university)
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supervisors. It stands to reason that a campus supervisor who is receiving
information about a client seen elsewhere is not being remote, but is
fulfilling a role different from that of a supervisor on site. Still, if a campus
supervisor should receive information that causes concern, the supervisor
should act on the concern, which often entails contacting the site directly.
Whereas acknowledging the general principle that more control over the
supervisee generally increases the risk of liability for the supervisor, Hall,
Macvaugh, Meridith, and Montgomery (2007) argue that supervisor
remoteness is not a protection, and that supervisors must be as vigilant as
their role dictates.
Moving to the contractual arrangements between supervisor and
supervisee, Falvey (2002) speculates that supervisors who received part of
a fee paid to a supervisee were more likely to be found vicariously liable,
because such a situation clearly benefits the supervisor, meeting one of the
conditions for vicarious liability. Finally, Knapp and VandeCreek (2006)
observe that supervisors who follow reasonable standards of practice may
be unaware of a supervisee’s actions that were contrary to what the
supervisor advised or instructed. In which case, Knapp and VandeCreek
advise that the supervisor might be exonerated—but that supervisors
should not count on such exoneration. In short, relatively close supervision
may be the best antidote for a claim of vicarious liability. However, an
interesting argument that goes against conventional wisdom: Recupero
and Rainey (2007) suggest that the less direct information the supervisor
has about the supervisee’s work with the client, the less risk to the
supervisor, because they could not be presumed to have all relevant details
about the case.
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Preventing Claims of Malpractice
Falender and Shafranske (2004) discuss the fact that there are very
specific safeguards that must occur in supervision to reduce the risk of
malpractice: (a) supervision on a regular basis, (b) being aware of what
occurs in the therapy sessions, and (c) provision of high-quality
supervision. Snider’s (1985) guidelines to supervisors to reduce the
likelihood of being named as a codefendant in a malpractice suit continue
to be relevant today:
1. Maintain a trusting relationship with supervisees. Within a context of
mutual trust and respect, supervisees are far more likely to voice
their concerns about their clients, themselves, and their work. We
add to this the importance also of obtaining behavioral samples of
the supervisee’s work (if not through live supervision or videotape
review, at least audiotape review), at least some of which were of
segments or sessions that were not chosen by the supervisee. U.S.
President Reagan famously used the phrase “Trust, but verify” to
refer to relationships with the former Soviet Union. Despite seeming
an oxymoron, it is a useful concept for supervisors in their work with
supervisees as well.
2. Keep up to date regarding legal issues that affect mental health
settings and the profession in general. In addition, supervisors must
have a healthy respect for the complexity of the law and recognize
the need for competent legal aid.
3. If the supervisor is the administrative head of an agency, it is
essential that the supervisor retain the services of an attorney who
specializes in malpractice litigation. If this is not the supervisor’s
decision, the supervisor should ensure that the organization has
appropriate legal support.
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4. Supervisors should have adequate liability insurance and be sure
that their supervisees also carry it. This does not reduce the chances
of being sued, but does, obviously, minimize the damage that could
accrue from such an unfortunate experience.
In addition to these admonitions, supervisors are advised to stay current
with professional standards of practice and seek consultation with trusted
colleagues when necessary (Ogloff & Olley, 1998); establish boundary
expectations with supervisees (Recupero & Rainey, 2007); and keep
detailed records (Falvey, Caldwell, & Cohen, 2002; Recupero & Rainey,
2007; Woodworth, 2000). (Methods of documenting supervision are
covered in Chapter 6 .) Finally, helping professionals (including
supervisors) must attend to their emotional and physical well-being. Being
professionally or personally overextended is too often a precursor to
making foolish errors (Woodworth, 2000).
Regrettably, there is little comfort to offer the timid supervisor who is afraid
of the tremendous responsibility and potential legal liability inherent in
supervision. Short of refusing to supervise, we believe protection for the
supervisor lies in the same concepts of reasonable care and sound
judgment that protect counselors and therapists, including an awareness
and command of the concepts and skills presented in this text. It also
includes a commitment to investing the time and energy to supervise
adequately and document all supervisory contacts. Ultimately, the most
fruitful approach to practice
involves a unique blend of professional wisdom and human wisdom. In addition to
some distinct knowledge, skill, and good work habits, healthy, respectful
relationships and keen, unencumbered self-knowledge add significant protection
to the clinical supervisor. In short, insight, integrity, and goodwill are enormous
barriers to professional difficulty. (Maki & Bernard, 2007, p. 363)
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Preparing Ethical Decision
Makers
Worthington, Tan, and Poulin (2002) identify 31 questionable supervisee
behaviors and asked more than 300 supervisors and supervisees
(combined) to judge each item on its ethicality. Twenty-eight of the
behaviors, ranging from forging a supervisor’s signature on case material
(viewed as the most unethical) to gossiping about a conflict with her or his
supervisor without discussing the issue in supervision (considered mildly
unethical), were viewed as more unethical than ethical. As might be
expected, supervisees reported that they engaged in behaviors considered
less unethical more often than the most egregious behaviors.
Supervisees, especially at the precertification level, have uneven knowledge
and understanding of their ethical responsibilities (see, e.g., Cikanek,
McCarthy Veach, & Braun, 2004). The challenge for supervisors and
educators, then, is to reduce the incidence of trainee ethical misconduct to
the lowest possible levels. This is complicated by the fact that there often
are contextual matters to consider, and in some cases one ethical principle
(or the moral norms that underlay them) may be in conflict with another.
All moral norms can be justifiably overridden in some circumstances. For
example, we might not tell the truth in order to prevent someone from killing
another person; and we might have to disclose confidential information about one
person in order to protect the rights of another person. (Beauchamp & Childress,
2001, p. 5)
In short, ethical decision making requires more than the rote application of
a set of rules. However, most discussions concerning this topic make
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assumptions about human reasoning processes that are not necessarily
true. Therefore, we begin this section with a brief coverage of cognitive
science research and how it can inform discussions concerning how
supervisors and training programs might foster that ethical reasoning.
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Lessons from Cognitive Science
There is consensus in the overlapping literatures of decision making
(Kahneman, 2011), cognitive psychology (Anderson, 1995), and moral
psychology (Haidt, 2001, 2008; Narvaez & Lapsley, 2005) that people
function with dual cognitive processing systems: one system is automatic,
fast, effortless, occurs outside awareness, and is more heavily affective;
the other system is deliberate, reflective, relies on verbal thinking, and more
explicitly cognitive.
There also is consensus that, when making decisions, people tend to be
“cognitive misers” (Taylor, 1991) who rely heavily on intuition (e.g., Klein,
2003; Narvaez, 2010; Narvaez & Lapsley, 2005) and the simplifying
shortcuts that the use of heuristics provide (see, e.g., Kahneman, 2011;
Tversky & Kahneman, 1974). Narvaez and Lapsley (2005) note that “If
automatic cognitive processes govern much of the behavior of everyday
life, very little human behavior stems from deliberative or conscious
thought and far less receives moral deliberation” (p. 143).
Haidt (2001), in fact, makes the cogent argument that moral reasoning
typically is a post-hoc construction that people use to justify decisions they
have made automatically and outside awareness. Kahneman (2011) offers
a complementary perspective. Referring to our automatic cognitive
processes as System 1 and to our deliberate and reflective cognitive
processes as System 2, he observes
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The way to block errors that originate in System 1 is simple in principle: recognize
the signs that you are in a cognitive minefield, slow down, and ask for
reinforcement from System 2. . . . Unfortunately, this sensible procedure is least
likely to be applied when it is needed most. We all would like to have a warning bell
that rings loudly whenever we are about to make a serious error, but no such bell
is available. . . . The voice of reason may be much fainter than the loud and clear
voice of an erroneous intuition, and questioning your intuition is unpleasant when
you face the stress of a big decision. More doubt is the last thing you want when
you are in trouble. The upshot is that it is much easier to identify a minefield when
you observe others wandering into it than when you are about to do so. (p. 417).
Although these processes are recognized in the more academic domain of
moral psychology, they have been less used in the literature on ethical
decision making in counseling and psychology. It seems, however, that this
work has several important implications for supervisors’ work in helping
their supervisees develop ethical decision-making skills. The suggestion
that follows certainly applies to supervisees, but is also relevant in the
preparation of novice supervisors as well.
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Implications Teaching Ethical Decision
Making
The following strategies for helping supervisees develop expertise in
ethical decision making roughly approximates Narvaez and Lapsley’s
(2005) suggestions for developing what they term moral expertise, a four-
step process that begins with immersion in examples and opportunities; it
then progresses to attending to facts and skills, practicing moral problem
solving, and then integrating knowledge and procedures (p. 159).
Explicitly Focusing on Personal Values.
If much ethical decision making occurs automatically, then the decision-
maker’s personal values and morality becomes a central consideration.
Hansen and Goldberg (1999) assert that professionals are influenced by
personal (e.g., political or religious) value
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1. tudy (Lamb & Catanzaro, 1998) found no such correlation.
2. The rate of supervisor–supervisee sexual contact is substantially
lower than that between educators and students, and seems to be
dropping over time. In the Lamb and Catanzaro (1998) study, 1.5
percent of psychologists reported having been sexually involved
with a supervisee; for Lamb, Catanzaro, and Moorman (2003), that
figure was less than 1 percent. However, neither study focused
specifically on people who were supervisors, so the rates are likely
higher. For example, 4 percent of the Lamb et al. (2003)
respondents reported that as supervisees, they had been involved
sexually with supervisors. Encouragingly, Zakrzewski’s (2006) data
from psychology graduate students showed the rate to be less than
0.5 percent, and none of the supervisees in the Ladany et al. (1999)
study reported sexual involvment with a supervisor, although 1.3
percent reported inappropriate sexual discussions.
Expectations about the ethical implications of such supervisor–supervisee
sexual relationships now are much clearer than a few decades ago. All
relevant ethical codes for the mental health professions, for example, make
some reference to multiple relationships between supervisors and
supervisees. Moreover, accreditors and others now are monitoring to
ensure that programs have written grievance procedures and that students
are aware of them. Presumably, these efforts are having a positive effect
on the extent to which faculty and supervisors are becoming sexually
involved with students and supervisees.
Whereas this discussion has focused so far on incidence of sexual contact,
there are related issues that must also be considered. Sexual issues
between supervisors and supervisees have been addressed in several ways
in the professional literature and are separated here for discussion,
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followed by nonsexual relationships that could involve boundary crossing
or violations.
Sexual Attraction.
Sexual attraction between supervisors and supervisees is common.
Rodolfa, Rowen, Steier, Nicassio, and Gordon (1994) found that 25
percent of interns in postdoctoral internship sites reported feeling sexually
attracted to their clinical supervisors, and Ellis and Douce (1994) identify
sexual attraction as one of eight recurring issues in supervision.
Significantly, however, Ladany et al. (1996) found that 9 percent of
supervisees were unwilling to disclose to their supervisors their attraction
to either their clients or the supervisor. Ladany and Melincoff (1999) found
as well that 10 percent of supervisors chose not to disclose their own
attraction to their supervisees. Yet addressing these issues is important,
because as Ellis and Douce (1994) warn, acting on sexual attraction in
supervision results in “calamity.”
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Sexual Harassment.
Sexual harassment is a different matter than attraction. Expecting or
requesting sexual favors or taking sexual liberties with their supervisees is
a clear abuse of the power afforded supervisors by their professional
status, is unethical, and clearly falls into Pearson and Piazza’s (1997)
category of the predatory professional. Sexual harassment can be insidious
and subtle, leaving the victims doubting themselves (Anonymous, 1991) or
manipulated into the role of caretaker (Peterson, 1993). Moreover, the role
modeling this provides future therapists is toxic (Corey, Corey, & Callanan,
2003).
Supervisors also should be sensitive to the possibility that their
supervisees can be sexually harassed by their clients. DeMayo (2000)
found that 45 percent of the experienced supervisors he surveyed recalled
at least such one incident. Most supervisors reported that they discussed
the incident in supervision, helped the supervisee clarify events, and
assisted the supervisee in establishing firm boundaries with the client. At
other times, they held a joint session with the client; transferred the client to
another therapist; or, in extreme cases, they took action to ensure the safety
of the supervisee.
DeMayo suggests that all supervisees should have a conceptual framework
for understanding harassment in therapy, ranging from understanding that
sexualized feelings are commonplace to trusting their “gut” feelings of
harassment. He also reiterates the suggestion of others that supervisors
who are candid and self-disclose with their supervisees are more likely to
hear about these important incidents from their supervisees.
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Intimate Committed Relationships.
A minority of intimate relationships that begin within supervision far outlive
the supervisory relationship (Lamb et al., 2003). Many of us, in fact, know
at least one dual-career couple whose relationship began while one was in
training and the other had supervisory status. Yet it is not possible to know
in advance which relationships will evolve into these long-term ones, and
so all the cautions we offer above pertain to entering such a relationship.
Moreover, even should a clear firewall be created that would preclude the
former-supervisor-now-intimate-partner from having any evaluative role with
respect to the supervisee, these relationships can cause problematic ripple
effects in a training program. Other trainees or interns, for example, may
well feel resentful at the special status one of their own now enjoys. And if
there are performance problems with the supervisee, it can create
awkwardness between the former supervisor and his or her colleagues who
are left to do the evaluations.
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Nonsexual Multiple Relationships.
Lloyd (1992) charges that some professional writings have created “dual
relationship phobia.” In fact, we noted earlier that it is common for
supervisors and their supervisees to have multiple relationships (see, e.g.,
Aponte, 1994; Clarkson, 1994; Cornell, 1994; Goodyear & Sinnett, 1984;
Gottlieb et al., 2007; Lamb Catanzaro, & Moorman, 2004; Magnuson,
Norem, & Wilcoxon, 2000; Ryder & Hepworth, 1990) that are not
necessarily problematic.
However, Kolbert, Morgan, and Brendel (2002) found that, in general,
students were more cautious about multiple relationships with faculty and
the possibility of exploitation than were faculty. However, it does appear
that supervisors are aware of these issues and working to handle them
appropriately. Lamb et al. (2004) found that a large percentage of
supervisors they surveyed discussed with their supervisees not only social
interactions, but also additional collegial relationships.
One type of ethically problematic multiple relationship that warrants
particular notice is doing therapy with one’s supervisee. Because
supervisees’ personal issues emerge in supervision, supervisors often are
faced with the challenge of determining where supervision ends and
therapy begins. Many authors (e.g., Bridges, 1999; Burns & Holloway, 1989;
Green & Hansen, 1986; Kitchener, 1988; Patrick, 1989; Stout, 1987;
Whiston & Emerson, 1989; Wise, Lowery, & Silverglade, 1989) recommend
that supervisors be clear from the outset that personal issues might be
activated in supervision and, if these issues are found to be substantial,
that the supervisee will be asked to work through them with another
professional; any therapy-like work with the supervisee should be (a) very
limited and (b) linked specifically to helping the supervisee address a
particular treatment issue occurring with a client.
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Preventing Supervisor Transgressions.
As implied in our earlier discussions, there are multiple relationships on a
behavioral continuum (Dickey, Housley, & Guest, 1993), from
nonproblematic to extremely inappropriate and unethical. Neither end of
the continuum causes much confusion among clinical supervisors.
Soberingly, Erwin (2000) found that supervisors displayed less moral
sensitivity when dealing with issues in the middle areas; as Peterson
(1993) calls it, “the murky pool of ambiguity” (p. 1).
Gottlieb et al. (2007) also address the complexity of the issue, making the
point that supervisees frequently rate as their best supervisors those with
whom they eventually developed positive personal relationships. In fact,
many applicants to training programs are looking for programs in which
they will be mentored in a fashion that feels as personal as it does
professional, but this fact does not alter the “slippery slope” about which
supervisors must remain vigilant.
Gottlieb et al. admonish that the greater the number of relationships with a
supervisee, the more risk of boundary violation. Therefore, they suggest
that supervisors ask themselves if any new relationship is really necessary.
Will it be beneficial to the supervisee? Will it compromise the primary
supervision relationship? They also advise supervisors to remain only in
evaluative relationships with supervisees. Therefore, having a supervisee as
a course teaching assistant should pose no serious issue. Finally, they
suggest that public supervision (i.e., live supervision or group supervision)
be used as well as individual supervision when there are multiple
relationships to help reduce the risk of boundary violations.
Ladany et al. (2005) advise supervisors to take inventory of their own
relationship biases. What types of persons do they find attractive? Do they
prefer supervisees who are dependent, or who are autonomous? Are they
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pulled more by students who exhibit vulnerability, or who are self-
confident? They argue that such an a priori assessment helps prepare the
supervisor for attraction to a supervisee if it occurs.
Koenig and Spano (2003) propose an educational approach to assist
supervisees similar to that suggested by Hamilton and Spruill (1999). They
argue instead that sexual attraction should be normalized and suggest that
supervisor training should include a comprehensive review of human
sexuality and the interconnectedness of its various parts: sensuality,
intimacy, sexual identity, reproduction, and sexualization. They also argue
that through modeling and parallel process, dealing effectively with these
issues in supervision improves supervisees’ ability to address sexual
dynamics in therapy as well.
Multiple relationships represent the broadest category of ethical challenges
for the supervisor. Although the mental health professions have evolved in
their understanding of multiple relationships, there is still much that calls
for judgment one situation at a time.
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Example :
Vanessa has been a marriage and family therapist at an agency for 6
months. Gary, one of the other three therapists in the agency and the
only other single therapist, is her clinical supervisor. It will take Vanessa
2 years under supervision to accrue the experience she needs to be
eligible to sit for the state licensing examination for her LMFT. One
evening, Gary calls Vanessa to inquire whether she would like to go to a
day-long workshop with him. The speaker for the workshop specializes
in a kind of therapy in which Vanessa has expressed interest. Vanessa
accepts and the workshop turns out to be an excellent professional
experience. On the way home, Vanessa and Gary stop for dinner.
Vanessa picks up the tab to thank Gary for including her.
The following day, Vanessa is sharing some of the experiences of the
workshop with Camille, another therapist at the agency. When Camille
asks, “Isn’t Gary your supervisor?” Vanessa feels defensive and
misunderstood. Later that day, Vanessa decides to go to her agency
director and ask his opinion of the situation. He tells her not to be
concerned about it, and that Camille “worries about everything.” During
her next supervision session, Vanessa chooses not to mention either
conversation to Gary.
Is Gary in danger of violating the principle of avoiding multiple
relationships? Has he already violated this principle? Was Camille’s
reaction appropriate? The agency director’s? How do you evaluate
Vanessa’s choice to talk to her agency director? To not apprise Gary of the
conversations with Camille and the agency director?
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Example :
Derek is a training director at a university counseling center. Gail is his
new supervisee. Derek works hard to establish a positive working
alliance with his supervisees. He believes it is important to establish a
good relationship early in supervision. Gail ended the second
supervision session asking Derek if he had a family. He told her that he
was separated from his wife and had one small child. After the session,
he was aware that his answer disclosed more than it needed to. He is
also aware that he finds Gail very attractive and realizes that he will
need to be careful about this. At the next supervision session, Gail
arrives without any tape to review. She also seems to hold eye contact
longer than in past sessions and is dressed in a manner that Derek finds
extremely attractive. Derek decides not to push the issue of Gail coming
without a tape and they spend the majority of the session continuing to
get to know each other. After the session, hindsight again makes Derek
feel uncomfortable about how the session transpired. He wonders if the
attraction is mutual.
How should Derek proceed at this early juncture? How can he be sure that
he is not projecting his own feelings onto Gail? What interventions should
he consider? What if he is correct, and he and Gail are mutually attracted to
each other? Is this grounds for transferring Gail to another supervisor?
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Example :
Sharon is a good therapist. In her work with Jeanne, her supervisor, she
has been very open and unguarded. Sharon had a very troubled past and
she has struggled hard to get where she is. A couple of times Sharon
shared some of her personal pain with Jeanne during intense
supervision sessions. Sharon and Jeanne feel very close to each other.
In the past couple of weeks, Sharon has not looked well. She’s jumpy
and short with Jeanne. When Jeanne pursues this change in behavior,
Sharon begins to cry and tells Jeanne that she has recently returned to
an old cocaine habit. She begs Jeanne not to share her secret,
promising that she will discontinue using the drug. She also asks that
she be allowed to continue seeing clients.
How is power being negotiated in this example? How does each person
stand to be damaged by this relationship? Has Jeanne been inappropriate
up to this point? What should Jeanne do at this point to be ethical?
Example :
Margaret is a school counselor who has been assigned a trainee from
the local university for the academic year. As she observes Noah
working with elementary school children, she is increasingly impressed
with his skills. She asks him to work with Peter, a 9-year-old, who has
not adjusted well to his parents’ recent divorce. Again, she is impressed
with Noah’s skill, his warmth and understanding, and ultimately, with the
success he has in working with Peter. Margaret is a single parent who is
concerned about her 9-year-old son. She decides to ask Noah to see
him. Noah is complimented by her confidence in him. Margaret’s son
attends a different school, but she arranges to have Noah see him after
school hours.
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How is Noah vulnerable in this example? How is Margaret’s son vulnerable?
If Noah had had second thoughts about this situation, what are his
recourses for resolution?
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Supervisor and Supervisee Competence
We all remember the feelings we had when we saw our first client. We
might have doubted the sanity of our supervisor to trust an incompetent
with such responsibility. If our work was observed, it was even worse. (I
recall a nightmare in which I am electrocuted by my audio recorder as I try
to record my first counseling session!) For most of us, those feelings
waned with time, helped by the encouraging feedback our supervisors
provided and the accumulation of experience. Of course the relationship
between felt- and actual competence is imperfect (see, e.g., Dawes, 1994),
but we grew in both—and most of us continue to do so as we engage in
new interventions and incorporate emerging knowledge into the work we
do.
As supervisors, we have the dual obligations of being competent in our role
of supervisor and of ensuring our supervisees’ competence. We discuss
each responsibility in turn next.
Supervisor Competence
Various authors offer lists of very specific competencies that supervisors
should develop (see especially Borders, Bernard, Dye, Fong, Henderson, &
Nance, 1991; Falender et al., 2004). However, the simplest and most molar
perspective is that there are two broad competence areas for supervisors:
(a) knowledge and skills to provide the type of services one’s supervisees
are providing, and (b) knowledge and skills in supervision itself (see, e.g.,
Barnett, 2010; Falender et al., 2004; Roth & Pilling, 2008; Supervision
Interest Network, 1990).
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Competence in the Area Being Supervised.
It seems obvious that a supervisor should be competent in the area of
supervisee work for which they are providing oversight. The finding of
Rønnestad, Orlinsky, Parks, and Davis (1997) that psychologists’ self-
ratings of therapeutic skill strongly predicted their confidence as
supervisors seems relevant to this point. However, self-ratings of
competence are not always completely valid, and so supervisors are wise
to have a clear sense of the kinds of cases that they would either not
supervise or that they would supervise only under certain conditions (e.g.,
for a limited number of sessions; for the purposes of referral; as suggested
by Hall, 1988a, and Sherry, 1991, with the aid of a consultant).
Most supervisors realize that they cannot be all things to all people, yet
they are tempted to ignore this wisdom when a supervisee wants to gain
some experience in an area in which the supervisor is unfamiliar; and
sometimes, the supervisor simply may have difficulty determining the
sufficiency of his or her competence (e.g., Stratton & Smith, 2006). This is
an instance in which metacompetence, discussed in Chapter 1 (see
Falender & Shafranske, 2007; Roth & Pilling, 2008), is important.
Metacompetence and the corresponding task of ongoing self-reflection are
important, for example, with respect to multicultural competence (ACA,
2005; D’Andrea & Daniels, 1997; Gonzalez, 1997; Lopez, 1997; Pack-
Brown & Williams, 2003; Sherry, 1991; Vasquez, 1992). We discuss this
issue of multicultural competence in greater detail in Chapter 5 .
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Competence in Supervision.
We discussed in Chapter 1 the expectation that supervisors should
develop supervision-specific competence, receiving formal preparation in
that domain. This means not only becoming knowledgeable about
supervision theory and research, but also receiving supervision of initial
supervisory experiences, just as novice therapists are supervised for their
work with clients before they are deemed sufficiently competent to function
autonomously. In their use of the ethical standards of the ACES Ethical
Guidelines for Counseling Supervisors (Supervision Interest Network,
1993) to examine the work of field supervisors, Navin, Beamish, and
Johanson (1995) found that the most frequent infraction was the failure to
have formal training in supervision.
Supervision training lessens the likelihood of inadequate supervision, which
is synonymous with incompetent supervision—and therefore unethical.
Ellis, Siembor, Swords, Morere, and Blanco, (2008) found that “an
astounding 59% of participants stated that they received inadequate
supervision in their current supervisory relationship, in another supervisory
relationship, or both” (p. 6). They used a measure with items that included
the following:
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I end up supervising my supervisor.
Supervision is a complete waste of time.
My supervisor does not know what to do in supervision.
My supervisor is frequently distracted during supervision sessions.
My supervisor does not listen to me.
(pp. 10–11)
Finally, we note that supervisees typically know a great deal more about
their supervisors’ clinical competence than they do about their supervisory
competence. Therefore, Kurpius, Gibson, Lewis, and Corbet (1991)
suggest that supervisors develop a professional disclosure statement that
informs supervisees of the nature and extent of the supervision training
they have obtained. This seems to be an important component of informed
consent for supervision.
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Remaining Competent.
Competence is not static. In fact, knowledge half-life in the mental health
professions has been estimated to be roughly 10 years, depending on the
specific type of knowledge (Cronbach & Snow, 1977; Dubin, 1972;
Vandecreek, Knapp & Brace, 1990). Therefore, it is important—even an
ethical obligation—that supervisors continue to read the professional
literature, attend professional meetings, and participate in workshops
(Campbell, 1994).
Lichtenberg and Goodyear (2012) make the point that once professionals
complete formal training programs, they then must become autodidactical
(Candy, 1991), taking responsible for their own learning. Some of this
learning occurs incidentally, as we come across new ideas and knowledge
just by chance; an important but unreliable means to maintain current
knowledge. Some occurs through more intentional and informal means as
we seek out new information, often in response to a situation that left us
puzzled or otherwise uncomfortable. The third type of learning concerns
continuing education activities. All are important mechanisms for
maintaining competence.
Of course, supervisors have the dual obligations of maintaining their
competence both in the clinical domains they are supervising and in the
domain of supervision itself. For supervisors to obtain routine feedback
from supervisees about their work provides them with essential feedback
to aid their continuing professional development, helping them identify
areas in which they might profit from additional competence development.
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Example :
Dwayne has been a licensed psychologist in private practice for more
than 20 years. His therapeutic approach is primarily psychodynamic.
Dwayne receives a call from a small group practice consisting of
mental health counselors and marriage and family therapists. They are
looking for a psychologist who wants to contract with them for
supervision. Their interest is mostly that the psychologist be able to
evaluate certain clients for possible referral to a psychologist or a
psychiatrist. Dwayne has never supervised anyone and is ready for a
new challenge. He makes an appointment to meet with the staff of the
practice group.
What are the competency issues embedded in this example? If Dwayne
decides to take this group on, what must he consider in order to be
ethically sound? What conditions for supervision are advisable? As you
understand it, is this arrangement legally defensible?
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Developing and Monitoring Supervisee
Competence.
Being a competent supervisor means, by definition, being able to enhance
the competence of their supervisees. It also means that supervisors are
responsible for helping their supervisees develop self-evaluation skills
(Vasquez, 1992), discussed previously as self-supervision (Dennin & Ellis,
2003) or metacompetence (see Falender & Shafranske, 2007; Roth and
Pilling, 2008) and is a form of reflective practice (Schön, 1987). Although
each of these terms has a slightly different nuance, all speak to the ability
to recognize a gap in knowledge and then to seek a remedy, including
appropriate consultation or supervision.
In other words, supervisees must become able to determine for themselves
when they have crossed a competence boundary. Notably, Neukrug,
Milliken, and Walden (2001) found that incompetence was the second
most frequent complaint made to counseling licensure boards. Yet, as we
discussed in Chapter 10 , the jury is still out regarding a supervisor’s
ability to influence the important skill of self-assessment.
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Supervisor as Evaluator and Gatekeeper.
It is impossible to discuss the development of supervisee competence
without also considering its verification and the ethical issues that
presents. Ladany (2007) correctly notes that “as a field, we have not
properly considered the gatekeeping role, and as a result, we are graduating
many therapists who have no business functioning in the role as therapists”
(p. 395). Brear and Dorrian (2010) cite data from both Forrest et al. (1999)
and Gaubatz and Vera (2002) to conclude that any given year, between 4
and 6 percent of students are performing below expected standards of
competence. We devote Chapter 10 to supervisee assessment
processes, but address it here as an ethical matter.
Many supervisors have a difficult time providing summative evaluations of
supervisee competence. That difficulty increases when the summative
evaluation will result in adverse consequences to the supervisee, such as
dismissal from a training program or failure to become licensed. And yet,
supervisors have an obligation both to the supervisee and to the society we
serve to handle this responsibility well.
Ladany et al (1999) found that supervisees reported supervisors’ evaluation
and monitoring of their work to be their most frequent ethical concern (see
Figure 11.1 ). In fact, this was reported at nearly twice the rate of the next
most frequently expressed concern. It should be unsurprising, then, that
supervisor evaluation of supervisees is a frequent source of ethical
complaints (Koocher & Keith-Spiegel, 2008).
Most supervisors were drawn to the mental health professions by a desire
to be helpful, which requires maintaining relatively nonjudgmental stances
with their clients. When they must be an evaluator, they are faced with a
value conflict especially when doing so results in negative consequences
to the supervisee (Bogo, Regehr, & Power, 2007); this is “advocacy–
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evaluation tension” (Johnson, Elman, Forrest, Rodolfa, Schaffer, and
Robiner, 2008, p. 591). Nelson, Barnes, Evans, and Triggiano (2008) found
that most of the “wise supervisors” they studied reported experiencing
“gatekeeping anxiety.”
We work closely with our supervisees and grow close to them. Therefore,
when really difficult decisions must be made about supervisees, it can be
too easy to rationalize that the supervisee’s next supervisor will make that
decision; a process Johnson et al. (2008) dubbed the hot potato game
(Johnson et al., 2008) or gate slippage, a term Brear and Dorrian (2010)
credit Gaubatz and Vera (2002) with coining. As a result, supervisors
certify too many people as competent when they are not (Ladany, 2007).
We close this subsection by noting that whereas some low performing
students have been described as psychologically impaired, the current
convention is to use only the lens of competence. To invoke the concept of
impairment shifts the “focus from supervisee professional conduct to ill-
advised speculation about personality or other factors hypothesized to
underlie problematic supervisee behavior” (Falender, Collins, &
Shafranske, 2009, p. 241). Competence is measurable.
Most of these decisions occur within the context of a training program.
Significantly, then, Brear and Dorrian (2010) found that approximately half
(53 percent) of the counselor and counseling psychology educators they
surveyed mentioned a program-wide leniency bias, sometimes augmented
by their fear of litigation.
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Example :
Dr. Roark has been supervising Susan, who is repeating a practicum
placement in a program-affiliated university clinic. The placement has
been one aspect of a remediation plan her program designed for her to
address identified competence problems. Whereas she has mastered
various theory-related techniques that she always is eager to use with
clients, she continues to struggle with basic relationship skills. As she
nears the end of this placement, she continues to perform below
expectations in that domain—although not by much.
Because this work was being done to remediate earlier-identified
problems, an adverse evaluation would endanger her continuing in the
program. However, Dr. Roark has personally enjoyed working with
Susan, who seems to be trying hard, and he has noticed that she has
made some progress on these issues over the time they have worked
together. He also knows that were she to complete this placement
successfully, her next step would be to pursue and internship where he
knows her work would be monitored carefully, and so there would be
additional opportunities to help her refine her relationship skills.
What are the ethical issues embedded in this example? If you were Dr.
Roark, what decisions would you make that would balance Susan’s rights
versus those of the clients she eventually would serve?
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Confidentiality
When asked to identify an ethically problematic issue that had occurred
during the previous year, some aspect of confidentiality was the most
frequently cited issue by psychologists in a U.S.-based study (Pope &
Vetter, 1992) as well as in aggregated studies across multiple countries
(Pettifor & Sawchuk, 2006). Similarly, Fly et al. (1997) found that trainees’
most frequent ethical violation concerned confidentiality. Therefore, it
seems that the most sacred trust in mental health practice is also the most
vulnerable to insult. And as with all therapeutic components, the
implications for supervision are more complex still, because it concerns
attention both to supervisee information and disclosures and to those
concerning the client. We address each of these in turn next.
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Confidentiality with Respect to Supervisee
Information and Disclosures.
Supervisees in the Ladany et al. (1999) study mentioned supervisor–
supervisee confidentiality issues as among the several most common
ethical issues they encountered (see Figure 11.1 ), yet ethics codes are
silent on this issue. Supervision is essentially an evaluative relationship,
and therefore information received in supervision is not typically
considered confidential; the gatekeeping responsibility of supervisors may
require that supervisors share personal information of supervisees with
others. Nevertheless, best practice should include clear guidelines
presented to supervisees prior to the beginning of supervision. These
guidelines should indicate that the goal of supervision is the professional
development of the supervisee, and that personal information will be
honored and treated as sensitively as possible.
The trainee might, for example, share some painful aspect of his or her
childhood that is affecting his or her response to a particular client’s
situation. Absent some compelling reason otherwise, this information
should be considered confidential. Most trainees understand that training in
a mental health profession may involve grappling with personal issues that
affect their work. Still, knowing that evaluative information from
supervision may be passed along to faculty and that any particular issue
that troubles the supervisor may be discussed with faculty colleagues
allows the supervisee to make an informed decision about what to reveal in
supervision (Sherry, 1991). It has also been our experience that issues that
ultimately must be shared in evaluations are rarely about trainee secrets
and more about patterns of behavior that are fairly obvious.
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Confidentiality with Respect to Client Information
and Disclosures.
The supervisor must ensure that the supervisee keeps all client information
confidential except for the purposes of supervision. Because supervision
allows for third-party discussion of what is occurring in therapy, the
supervisee must be reminded that this type of discourse cannot be
repeated elsewhere. In group supervision, the supervisor must reiterate this
point and take the extra precaution of having cases presented using first
names only, and with as few demographic details as possible (Strein &
Hershenson, 1991).
When videotape or live supervision is used with additional supervisees
present, the only recourse for the supervisor is to emphasize and
reemphasize the importance of confidentiality. When students are asked to
tape their sessions, they must be reminded that they have confidential
documents in their possession. Notes concerning clients should use code
numbers rather than names and be guarded with great care.
Supervisors increasingly use such technologies as video conferencing and
asynchronous methods such as email (Abbass et al., 2011; Conn, Roberts,
& Powell, 2009; McAdams & Wyatt, 2010; Yozwiak, Robiner, Victor, &
Durmusoglu, 2010). These are important tools; however, at the same time,
they can raise confidentiality concerns to which supervisors must attend
(Barnett, 2011).
There is still some occasional confusion in the helping professions
regarding the distinctions between confidentiality, privacy, and privileged
communication. Siegel (1979) defines confidentiality as follows:
“Confidentiality involves professional ethics rather than any legalism and
indicates an explicit promise or contract to reveal nothing about an
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individual except under conditions agreed to by the source or subject” (p.
251). Privacy, the other side of confidentiality, is the client’s right not to
have private information divulged without informed consent, including the
information gained in therapy. Finally, privileged communication gives
privacy legal status, and refers to the client’s right not to have their
confidential communications used in open court or revealed to others
without their consent. Therefore, “although all privileged communications
are confidential communications, some confidential communications may
not be privileged” (Disney & Stephens, 1994, p. 26).
Knowing the limits of each of these terms is as serious a responsibility for
the clinician as honoring their intent. It is ultimately an individual decision
as to when the therapist or supervisor decides to overturn the client’s (or
supervisee’s) right of privacy and break confidentiality. However, in a
number of cases, legal precedent, state law, or a value of a higher order
dictates such a direction. Falvey (2002) reports typical exceptions to
privilege as
follows:
When a client gives informed consent to disclosure
When a therapist is acting in a court-appointed capacity
When there is a suicidal risk or some other life-threatening emergency
When a client initiates litigation against the therapist
When a client’s mental health is introduced as part of a civil action
When a child under the age of 16 is the victim of a crime
When a client requires psychiatric hospitalization
When a client expresses intent to commit a crime that will endanger
society or another person (duty to warn)
When a client is deemed to be dangerous to himself or herself
When required for third-party billing authorized by the client
When required for properly utilized fee collection services (p. 93)
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Because privileged communication is a legal matter, it is always wise to
receive legal counsel when confidential information is demanded. Outside
court proceedings, many situations fall into gray areas.
The trend in the helping professions seems to be toward a less robust view
of confidentiality. This professional obligation seems to be increasingly
vulnerable to legal interpretation (Falvey, 2002). It is considered wise,
therefore, to make a discussion of confidentiality and its limits a common
practice in therapy and supervision.
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Business-Related Issues in Supervision
Past common practice involved the supervisor “signing off” for
supervisees, often not because supervision was taking place, but because
the supervisor’s credentials allowed for third-party payment, whereas the
supervisee’s did not. This practice is, of course, both unethical and illegal.
Virtually all (92.5 percent) psychologists who responded to the Pope,
Tabachnick, and Keith-Spiegel (1987) survey rated this practice as
“unquestionably unethical.”
Supervision of postcertification professionals regularly occurs in some
countries and is increasing in the United States (Magnuson, Norem, &
Wilcoxon, 2000). It is imperative, therefore, that supervisors stay informed
of changes in mental health delivery systems and that they avoid any
business arrangements that would prove to be unethical or illegal.
However, other marketplace issues are more ambiguous ethically. For
example, should a supervisor accept payment from a supervisee for
supervision that will lead to certification or licensure? Under what
conditions might this be acceptable? If one is a supervisor for someone
outside one’s place of employment, what kinds of protections are
necessary for the clients of the supervisee? The supervisee? The
supervisor? (Wheeler & King, 2000). How do particular third-party payers
affect supervisory practice? What is the implication of supervising
counseling services offered over the Internet? (Kanz, 2001; Maheu &
Gordon, 2000). In short, the marketplace is changing dramatically as a
result of legislation, changes in healthcare systems, and advances in
technology. It is the ethical and legal responsibility of clinical supervisors
to stay abreast of relevant developments and to assure that supervisees’
practice is consistent with ethical mandates and the law.
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Legal Issues in Clinical
Supervision
Law is “the body of rules governing the affairs of persons within a
community, state or country” (Committee on Professional Practice, 2003,
p. 596). One might assume that avoiding litigation in one’s supervision
practice is simply a matter of behaving ethically, but as established at the
beginning of this chapter, it is not that simple. In fact, it is possible even
that sometimes a moral act could subject one to retaliatory litigation.
This section of the chapter, then, addresses several legal issues that are
particularly relevant to U.S. supervisors. Some legal issues (i.e., due
process and informed consent) are addressed in the section concerning
ethics. There are others we are unable to cover in the space here, although
they could affect supervisors under U.S. law, and include the Americans
with Disability Act and Family Educational Rights and Privacy Act (FERPA)
(see Gilfoyle, 2008). We next focus particularly on select issues that could
lead to malpractice claims.
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Malpractice
An ethical violation becomes a legal issue only when the aggrieved party
makes such a claim (Maki & Bernard, 2007), which means that the
difference between a claim of an ethical violation and a claim of
malpractice is not determined by the egregiousness of the professional’s
behavior, but rather by whether the aggrieved chooses to bring their
complaints to a regulatory body or to civil court. In fact, the same claim is
often brought to both a regulatory body and to court as a malpractice
lawsuit (Montgomery, Cupit, & Wimberley, 1999).
That being said, it is safe to assume that there are far more complaints
made to regulatory bodies than there are lawsuits. There are at least two
reasons for this: (a) The cost of litigation is a deterrent, and (b) whereas a
regulatory body (peer review board) investigates whether the professional
breached relevant professional ethics, civil court is quite different. Briefly, a
legal complaint is restricted by tort law; therefore, the defendant must be
able to prove that the negligence claimed resulted in harm. Many
complaints cannot meet such a level of proof.
There are two types of torts (i.e., civil wrongs other than breach of
contract): intentional and unintentional (Swenson, 1997). It is highly unlikely
that the therapist or supervisor would be sued for an intentional tort. For
this to be the case, the supervisor’s or therapist’s motivation would be to
cause harm. To illustrate with an unlikely example: a supervisor could
decide to be overly critical with a supervisee in order to force the
supervisee out of a training program.
Virtually all malpractice cases in the mental health professions, however,
are unintentional torts, or negligence cases (Swenson, 1997). Malpractice
is defined as
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harm to another individual due to negligence consisting of the breach of a
professional duty or standard of care. If, for example, a mental health professional
fails to follow acceptable standards of practice and harm to clients results, the
professional is liable for the harm caused. (Disney & Stephens, 1994, p. 7)
Similarly, failure to act on serious concerns about a supervisee may be
grounds for negligent supervision (Recupero & Rainey, 2007).
Four elements must all be proved for a plaintiff to succeed in a malpractice
claim (Ogloff & Olley, 1998):
1. A fiduciary relationship with the therapist (or supervisor) must have
been established. Within supervision, this means that the supervisor
is working in the best interests of the supervisee and the
supervisee’s clients, and not in his or her own interests (Remley &
Herlihy, 2001).
2. The therapist’s (or supervisor’s) conduct must have been improper
or negligent and have fallen below the acceptable standard of care.
3. The client (or supervisee) must have suffered harm or injury, which
must be demonstrated.
4. A causal relationship must be
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Chapter 1 Introduction to
Clinical Supervision
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Many professions have a signature pedagogy (Shulman, 2005a), a
particular instructional strategy that typifies the preparation of its
practitioners. In medicine, for example, a team of physicians and medical
students visit a prescribed set of patients during clinical rounds,
discussing diagnostic and treatment issues related to each patient, along
with what has happened since the team last discussed that patient. In law,
students come to class prepared to be called on at any moment to
describe the essential arguments of a particular case, or to summarize and
respond to the arguments another student has just offered. During these
interactions, their professor engages them in a type of Socratic dialogue.
Clinical supervision is the signature pedagogy of the mental health
professions (Barnett, Cornish, Goodyear, & Lichtenberg, 2007; Goodyear,
Bunch, & Claiborn, 2005). Like the signature pedagogy of other
professions, it is characterized by (a) engagement, (b) uncertainty, and (c)
formation (Shulman, 2005a): engagement in that the learning occurs
through instructor–learner dialogue; uncertainty because the specific focus
and outcomes of the interactions typically are unclear to the participants as
they begin a teaching episode; and formation in that the learner’s thought
processes are made clear to the instructor, who helps shape those ideas so
that the learner begins to “think like a lawyer (Shulman, 2005b, p. 52), a
physician, a psychologist, and so on. In this text, we also are concerned
with a higher level shift, which is to that of thinking like a supervisor (cf.
Borders, 1992).
Shulman (2005a) notes that signature pedagogies are “pedagogies of action,
because exchanges typically [end] with someone saying, ‘That’s all very interesting.
Now what shall we do?’” (p. 14)
Clinical supervision qualifies as a signature pedagogy against all these
criteria; criteria that underscore both supervision’s importance to the mental
health professions and its complexity. This text is intended to address that
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complexity by providing the technical and conceptual tools that are
necessary to supervise.
We assert that every mental health professional should acquire supervision
skills, because virtually all eventually will supervise others in the field. In
fact, supervision is one of the more common activities in which mental
health professionals engage. For example, in each of the three surveys
conducted over a 20-year span (summarized by Norcross, Hedges, and
Castle [2002]), supervision was the third most frequently endorsed
professional activity (after psychotherapy and diagnosis/assessment) by
members of the American Psychological Association’s Division of
Psychotherapy. Surveys of counseling psychologists (e.g., Goodyear et al.,
2008; Watkins, Lopez, Campbell, & Himmell, 1986) show similar results.
This is true internationally as well. In a study of 2,380 psychotherapists
from more than a dozen countries, Rønnestad, Orlinsky, Parks, and Davis
(1997) confirm the commonsense relationship between amount of
professional experience and the likelihood of becoming a supervisor. In
their study, the number of therapists who supervised increased from less
than 1% for those in the first 6 months of practice to between 85% and 90%
for those who have more than 15 years of practice.
In short, this text is for all mental health professionals. Its focus is on a
training intervention that is not only essential to, but also defining of those
professions; an intervention that has developed in a complementary way to
psychotherapy and so now has more than a 100-year history (Watkins,
2011).
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Foundational Premises
One challenge in writing this text has been our recognition that almost
anyone who reads it does so through a personal lens that reflects beliefs,
attitudes, and expectations about supervision that they have formed
through their own experiences as supervisees; perhaps also as supervisors.
Such foreknowledge can make the reading more relevant and personally
meaningful, but it can also invite critical responses to material that readers
find dissonant with their beliefs. We hope readers who have that experience
find we have presented material in a manner that is sufficiently objective so
that they may evaluate dispassionately any dissonance-producing content
or ideas.
Three premises are foundational to what follows:
Clinical supervision works. As we discuss later, the data show that
supervision has important positive effects on the supervisees and on
the clients they serve.
Clinical supervision is an intervention in its own right. It is possible,
therefore, to describe issues, theory, and technique that are unique to
clinical supervision. Moreover, as with any other psychological
intervention, the practice of supervision demands that those who
provide it have appropriate preparation.
The mental health professions are more alike than different in their
practice of supervision, regardless of discipline or country. Most
supervision skills and processes are common across these
professions. There are, of course, profession-specific differences in
emphasis, supervisory modality, and so on. These might be considered
the unique flourishes each profession makes on our common signature
pedagogy, but we assume there are core features that occur (a) whether
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the supervision is offered by psychologists, counselors, social workers,
family therapists, psychiatrists, or psychiatric nurses and (b) regardless
of the country in which it is offered (see, e.g., Son, Ellis & Yoo, in
press). Therefore, we have drawn from both an interdisciplinary and
international literature to address the breadth of issues and content that
seems to characterize clinical supervision in mental health practice.
In keeping with our interdisciplinary focus, we most often use the term
clinical supervision (versus such alternatives as counselor supervision,
psychology supervision, or social work supervision). Figure 1.1 draws
from Google’s database of more than 5.2 million scanned books spanning
200 years (available through ngrams.googlelabs.com) and depicts the
relative frequency with which clinical supervision and several alternatives
have been used as a term in English-language books between 1940 and
2009. Because the black and white rendering of this graphic makes it
difficult to differentiate categories, we note that clinical supervision is
depicted in the top line, showing it to be the most widely used term.
Notable too is the slow linear growth in the use of the term between the
mid-1940s and the late 1960s, when the frequency of its use began to
increase substantially (interestingly, it also shows some dropoff in the past
several years).
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Our Convention on the Use of Key
Words
We use counseling, therapy, and psychotherapy interchangeably, because
distinctions among
FIGURE 1.1 Occurrence of clinical supervision and related terms in
English-language books: 1940–2008
these terms are artificial and serve little function. We also follow the
convention first suggested by Rogers (1951) of referring to the recipient of
therapeutic services as a client.
We distinguish between supervision and training as well. Training differs
from supervision in being “structured education for groups of trainees . . .
[and] involves a standardized set of steps” (Hill & Knox, in press, msp. 3).
The trainer’s primary role is that of teacher (see our discussion later in this
chapter distinguishing the roles of teacher and supervisor).
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Paralleling this training-versus-supervision distinction is the one that we
make between trainee and supervisee. We believe that supervisee is the
more inclusive term—that is, trainee connotes a supervisee still enrolled in
a formal training program and so seems less appropriate for postgraduate
professionals who seek supervision. In most cases, we use supervisee.
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Supervision’s Centrality to the
professions
Supervision’s crucial role in the preparation of professionals has been
recognized for thousands of years, as is suggested in the first few lines of
the famous Hippocratic Oath:
I swear by Apollo the physician, and Asclepius, and Health, and All-heal, and all the
gods and goddesses, that, according to my ability and judgment, I will keep this Oath
and this stipulation —to reckon him who taught me this Art equally dear to me as
my parents, to share my substance with him, and relieve his necessities if
required; to look upon his offspring in the same footing as my own brothers.
(Hippocrates, ca. 400 bc, from Edelstein, 1943; bold ours for emphasis)
In this oath, the veneration being accorded a teacher or supervisor is clear;
moreover, the comparison of that teacher to one’s parents suggests the
power and influence the neophyte physician cedes to the teacher. To
appreciate that power and influence requires an understanding of the nature
of the professions (see, e.g., Goodyear & Guzzardo, 2000), especially of
the ways in which they are distinct from other occupations. Those
distinctions include that (a) professionals work with substantially greater
autonomy; (b) professionals need to make judgments under conditions of
greater uncertainty (Sechrest et al., 1982), an attribute of the work that
Schön (1983) vividly characterized as “working in the swampy lowlands”
(p. 42) of practice (this is in contrast to technicians who work from a
prescribed protocol on situations that typically are carefully constrained);
and (c) professionals rely on a knowledge base that is sufficiently
specialized so that the average person would have difficulty grasping it and
its implications (Abbott, 1988).
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Because of these qualities of professions, it is generally understood that
laypersons would not have the knowledge necessary to oversee them, and
so society permits the professions to self-regulate. The implicit contract,
however, is that this self-regulation is permitted in return for the assurance
that this profession will place the welfare of society and of their clients
above their own self-interests (see, e.g., Schein, 1973; Schön, 1983). This
self-regulation includes controlling who is admitted to practice, setting
standards for members’ behavior, and disciplining incompetent or unethical
members.
Within the mental health professions, three primary mechanisms of self-
regulation are (a) regulatory boards, (b) professional credentialing groups,
and (c) program accreditation. Supervision is central to the regulatory
functions of each, because it provides a means to impart necessary skills;
to socialize novices into the particular profession’s values and ethics; to
protect clients; and, finally, to monitor supervisees’ readiness to be
admitted to the profession. In short, “supervision plays a critical role in
maintaining the standards of the profession” (Holloway & Neufeldt, 1995,
p. 207).
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Regulatory Boards
State and provincial—and in some countries (e.g., Australia, England,
Korea), national—regulatory boards codify the practice of supervision. They
often stipulate (a) the qualifications of those who supervise; (b) the
amounts of supervised practice that licensure or registration candidates are
to accrue; and (c) the conditions under which this supervision is to occur
(e.g., the ratio of supervision to hours of professional service; what
proportion of the supervision can be in a group format; who can do the
supervising; as an example, see the practicum supervision guidelines
adopted by the Association of State and Provincial Psychology Boards,
www.asppb.net/files/public/Final_Prac_Guidelines_1_31_09.pdf).
Somerequire that members of a particular profession who wish to
supervise obtain a separate license in order to do so (e.g., Alabama
licenses counseling supervisors).
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Professional Credentialing Groups
Independent groups, such as the Academy of Certified Social Workers
(ACSW), the American Board of Professional Psychology (ABPP), the
National Board for Certified Counselors (NBCC), the American Association
for Marriage and Family Therapy (AAMFT), the British Association for
Counselling and Psychotherapy (BACP), and the Korean Counseling
Psychology Association (KCPA) also credential mental health
professionals, usually for advanced practitioners and to certify competence
above the minimal level necessary for public protection (the threshold level
of competence for licensure is the reasonable assurance that the person
will do no harm). Like the regulatory boards, these credentialing groups
typically stipulate amounts and conditions of supervision a candidate for
one of their credentials must have. In some countries (e.g., Korea), these
groups serve as de facto regulatory boards.
Some groups (e.g., AAMFT, NBCC, BACP) also have taken the additional
step of credentialing clinical supervisors. In so doing, they make clear their
assumption that supervision is based on a unique and important skill
constellation.
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Accrediting Bodies
Whereas licensure and credentialing affect the individual professional,
accreditation affects the training programs that prepare them. Each mental
health profession has its own accreditation body, and their guidelines
address supervision with varying degrees of specificity. For example, the
American Psychological Association (APA, 2008) leaves it to the individual
training program to establish that supervised training has been sufficient.
However, other groups are very specific about supervision requirements.
For example, any graduate of an AAMFT–accredited program is to have
received at least 100 hours of face-to-face supervision, and this should be
in a ratio of at least 1 hour of supervision for every 5 hours of direct client
contact (AAMFT, 2006). The Council for Accreditation of Counseling and
Related Educational Programs (CACREP, 2001) requires that a student
receive a minimum of 1 hour per week of individual supervision and 1.5
hours of group supervision during practicum and internship; CACREP
doctoral program standards also specify requirements for supervision-of-
supervision.
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Fostering Supervisees’
Professional Competence
Our remarks thus far speak to the role supervision plays in the professions
and to the broader society they serve. This section addresses supervision
as a mechanism to ensure that supervisees develop necessary
competencies, as well as to the less-direct effects of supervision that
occur through supervisees’ exercise of those competencies.
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Integration of Research and Theory with
Practice
During their training, novice mental health professionals obtain knowledge
from (a) formal theories and research findings, and (b) the practice-based
knowledge of expert practitioners. However, there is a third type of
knowledge as well—about themselves. For example, they identify aspects
of their own personality and interpersonal behavior that affects their work
as professionals. Skovholt (2012) refers to this last as an inevitable “loss
of innocence” (p. 286).
Clinical supervisors are key to the integration of these several types of
knowledge. Supervised practice provides the crucible in which supervisees
can blend them, and it is the supervisor who can help provide a bridge
between campus and clinic (Williams, 1995), the bridge by which
supervisees begin to span what often is a “large theory–practice gulf”
(Rønnestad & Skovholt, 1993, p. 396).
Practice is absolutely essential if supervisees are to develop professional
skills. This is Peterson’s (2002) point when he tells the joke about a New
York City tourist who, lost, stops a cabbie and asks, “How can I get to
Carnegie Hall?” The cabbie’s response is, “Practice, practice, practice!”
Peterson notes that this joke’s punch line is significant in that the cabbie
does not say, “Read, read, read!”
However, practice alone is an insufficient means to attain competence:
Unless it is accompanied by the systematic feedback and guided reflection
(the operative word being guided) that supervision provides, supervisees
may gain no more than the illusion that they are developing professional
expertise. Dawes (1994) asserts:
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Two conditions are important for experiential learning: one, a clear understanding
of what constitutes an incorrect response or error in judgment, and two,
immediate, unambiguous and consistent feedback when such errors are made. In
the mental health professions, neither of these conditions is satisfied. (p. 111)
Dawes’ assertions about the two conditions necessary for experiential
learning are compelling. Yet we believe his assertion that neither condition
is met in the mental health professions is overstated. We predicate our
writing of this text on the assumption that supervision can satisfy these
and other necessary conditions for learning.
It is true a supervisor (by whatever name) may be unnecessary for attaining
many motor and performance skills. In these domains, simply performing
the task may provide sufficient feedback for skill mastery. Learning to type
is one example. Learning to drive an automobile is another (Dawes, 1994):
When driving, the person who turns the steering wheel too abruptly receives
immediate feedback from the vehicle; the same is true if he or she is too
slow applying the brakes when approaching another vehicle. In these and
other ways, experience behind the wheel gives the person an opportunity to
obtain immediate and unambiguous feedback. Driving skills are therefore
likely to develop and improve simply with the experience of driving.
However, psychological practice skills are of a different type. These skills
require complex knowledge for which experience alone is rarely able to
provide either of the two conditions that Dawes stipulated as necessary for
experiential learning to occur. Practitioner skill development requires
intentional and clear feedback from another person, such as is available
through supervision. Research data confirm that unsupervised counseling
experience does not accelerate the clinical progress of trainees (Hill,
Charles, & Reed, 1981; Wiley & Ray, 1986), a conclusion complemented by
that of educational psychologists who examined the broader domain of
instruction (see especially Kirschner, Sweller, & Clark, 2006).
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Competence to Supervise
Whereas the literature gives a great deal of attention to fostering the
competence of new professionals, a great deal less attention has been
given to the development of competence in the supervisors themselves.
Milne and James (2002) comment that this has been something of a
paradox that the field must address.
Developing supervisor competence implies systematic training. It was
disappointing, therefore, to see that internship supervisors responding to
the Rings, Genuchi, Hall, Angelo, and Cornish (2009) survey gave only
lukewarm endorsement for the two items, “Supervisor has received
supervision of his or her supervision, including some form of observation
(audio or video) with critical feedback,” and “Supervisor has completed
coursework in supervision.” In contrast, Gonsalvez and Milne (2010) note
that “expert opinion is unanimous in identifying the need for supervisor
training, often in forceful terms” (p. 234). It is increasingly rare to encounter
people who believe that being an effective therapist is a sufficient
prerequisite to being a good supervisor; analogous, we believe, to
assuming that if a person is a good athlete, she or he inevitably will make a
good coach or sports announcer.
Research literature that focuses on the effectiveness of supervisor training
is still small and developing. Importantly, though, it does document
positive outcomes. We summarize that research in Chapter 12 .
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Availability of Training for Supervisors
In the early 1980s, several authors (e.g., Hess & Hess, 1983; McColley &
Baker, 1982) comment on what seems the limited availability of
supervision training for mental health professionals. Fortunately,
circumstances have changed quite significantly since then (except, perhaps
in the case of psychiatry; e.g., Rodenhauser, 1996). Accrediting bodies
(i.e., APA, CACREP, and AAMFT) have been important in this shift, through
their stipulations that students in doctoral programs they accredit should
receive at least some preparation to supervise.
Some organizations also have specified levels and type of training for
those mental health professionals who do move into supervisory roles. For
example, the Association for Counselor Education and Supervision (ACES)
endorses Standards for Counseling Supervisors (ACES, 1990), a variant of
which later was adopted by the Center for Credentialing and Education as
the basis for its Approved Clinical Supervisor credential. AAMFT, too, has a
supervisor membership category that requires specified training.
Regulatory boards also are beginning to require that mental health
professionals who provide supervision receive supervision training. For
example, psychologists licensed in California who want to supervise must
to participate in one 6-hour supervision workshop during every 2-year
licensure cycle; at this writing, several other state and Canadian provincial
psychology boards either mandate some level of supervision training or are
considering doing so (Janet Pippin, personal communication, September
13, 2011). Sutton (2000) reports that 18% of counselor licensure boards
require a course or its equivalent for persons providing supervision, and
another 12% require training in supervision.
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Similar trends in supervision training are evident in other countries as well.
For example, programs accredited by the Canadian Psychological
Association are to provide supervision training. In Britain, supervision
training is readily available to qualified professionals through a number of
freestanding training “courses” (i.e., programs), and the National Health
Service’s Improving Access to Psychological Therapies (IAPT) group
developed a proposal to create structures to permit briefer (e.g., 5–7 day)
supervision training (IAPT, 2011); to inform that training, it also
commissioned the development of a document to identify supervision
competencies (Roth & Pilling, 2008). Korean counselors and psychologists
often can obtain supervision training in their academic programs, although
not universally (see Bang & Park, 2009).
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The Competence Movement and Its
Implications for Supervisor Training
Regulatory boards always have been concerned that the practitioners they
certify for practice are competent. A relatively recent development,
however, has been the attention being given to operationalizing, training for,
and assessing competencies. The emergence of what has been called “the
competence movement” (Rubin et al., 2007, p. 453) roughly coincides with
the increasing demands for accountability seen in higher education in, for
example, U.S. accreditation and in Europe’s Bologna Process (Adelman,
2008). Essential to that movement is some common working definition of
competence. It is useful, then, to consider the definition put forth by Epstein
and Hundert (2002):
the habitual and judicious use of communication, knowledge, technical skills,
clinical reasoning, emotions, values, and reflection in daily practice for the benefit
of the individual and community being served; [it relies on] habits of mind, including
attentiveness, critical curiosity, awareness, and presence. (p. 227)
Their definition of medical competence has been sufficiently useful to have
been embraced as well in the mental health professions (see, e.g., Rubin et
al., 2007). It makes clear that competence is not merely a disparate
collection of knowledge and skills, but rather something that requires the
exercise of judgment. It seems highly similar to Aristotle’s concept of
phronesis, or practical wisdom, which “concerns how individuals ‘size up’ a
situation and develop and execute an appropriate plan of action”
(Halverson, 2004, p. 94).
The 2002 Competencies Conference (Kaslow et al., 2004) was something
of a watershed in U.S. psychology. Although competencies had been an
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explicit aspect of the National Schools of Professional Psychology’s
training model (Peterson, Peterson, Abrams, & Stricker, 1997), this
conference signaled broad embrace of competencies. Important to note is
that there was clear consensus among conference attendees that
supervision is a core competence of psychologists. In fact, a task group of
supervision experts attending that conference articulated competencies
they believed supervisors should attain and demonstrate (Falender et al.,
2004).
However, all conceptions of competence are grounded in expert opinion,
and these opinions can differ across groups of experts or across time
within a group of experts, and so are inherently value laden. Understandably,
then, authors have varied some in the focus and specificity with which they
have addressed competencies (see, e.g., Falender et al., 2004; Roth &
Pilling, 2008; Tebes et al., 2010).
Deist and Winterton’s (2005) assertion that competence is a fuzzy concept
seems borne out to some extent in these several conceptions of
supervision competence. This is not to say that these conceptions are
contradictory or unimportant; in fact, despite its fuzziness, we absolutely
embrace the importance of competence as a central focus of this text.
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Defining Supervision
We assume that anyone reading this text is bringing some understanding of
what supervision is. However, an important next step is to provide a more
formal definition, and then to address the aspects of this definition.
In parsing the term, it is possible to infer that its practitioners exercise
super vision. In fact, supervisors have the advantage of a clarity of
perspective about counseling or therapy processes precisely because they
are not an involved party. Levenson (1984) speaks to this when he
observes that, in the ordinary course of his work as a therapist, he spends
considerable time perplexed, confused, bored, and “at sea,” but, “When I
supervise, all is clear to me!” (p. 153).
Levenson (1984) also reports finding that theoretical and technical
difficulties were surprisingly clear to him. Moreover, he maintains that
people he supervised and who seemed confused most of the time that they
were supervisees reported that they attained a similar clarity when they
were supervising. He speculates that this is “an odd, seductive aspect of
the phenomenology of the supervisory process itself” (p. 154) that occurs
at a different level of abstraction than therapy. Perhaps this is the
perspective of the “Monday-morning quarterback.”
The Merriam-Webster (n.d.) online dictionary reports, however, that the
etymological definition of supervision is simply “to oversee,” from the Latin
word supervises, and that the first known use of the term in English
occurred in about 1645. To provide oversight is a key function of
supervisors in virtually any occupation or profession. Yet as important as
this is, it is an insufficiently precise description of what occurs during the
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clinical supervision of trainees and practitioners in the mental health
professions.
Definitions of supervision offered by various authors differ from one
another as a function of such factors as the author’s discipline and training
focus. Our intent is to offer a definition that is specific enough to be
helpful, but at the same time broad enough to encompass the multiple
roles, disciplines, and settings associated with supervision.
We have offered, with only the slightest of changes, the following working
definition of supervision since the first edition of this text (Bernard &
Goodyear, 1992):
Supervision is an intervention provided by a more senior member of a profession
to a more junior colleague or colleagues who typically (but not always) are
members of that same profession. This relationship
is evaluative and hierarchical,
extends over time, and
has the simultaneous purposes of enhancing the professional functioning of
the more junior person(s); monitoring the quality of professional services
offered to the clients that she, he, or they see; and serving as a gatekeeper for
the particular profession the supervisee seeks to enter.
The earlier version of this definition has been informally adopted as the
standard in both the United States and the United Kingdom (see, e.g.,
Milne, 2007). In this edition, we make two changes to that definition:
1. Whereas the definition we use in prior editions asserts that
supervision is a relationship between two people of the same
profession, this revised definition acknowledges that this is not
always true.
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2. Whereas the final clause stipulates that supervisors serve as
gatekeepers for those entering the profession, the revised version
acknowledges that gatekeeping can occur at other points as well.
Because this definition is succinct, it merits further explication. Each of the
following sections addresses a specific element of this definition.
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Supervision Is a Distinct Intervention
Supervision is an intervention, as are teaching, psychotherapy, and mental
health consultation. There are substantial ways in which supervision
overlaps with and draws from these other interventions (see, e.g., Milne,
2006), yet still remains unique. Table 1.1 summarizes what we believe
to be the most salient similarities and differences.
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Teaching versus Supervision.
Teaching is central to supervision, and the supervisee’s role of learner is
suggested in the title of the classic supervision book, The Teaching and
Learning of
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TABLE 1.1 Supervision versus Teaching, Counseling, and Consultation
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Similarities Differences
Teaching • Both have the purpose of
imparting new skills and
knowledge.
• Both have evaluative and
gatekeeping functions.
• Whereas teaching is
driven by a set curriculum or
protocol, supervision is
driven by the needs of the
particular supervisee and his
or her clients.
Counseling
or Therapy
• Both can address recipients’
problematic behaviors,
thoughts, or feelings.
• Any therapeutic work with
a supervisee must be only to
increase effectiveness in
working with clients.
• Supervision is evaluative,
whereas counseling is not.
• Counseling clients often
have a greater choice of
therapists than supervisees
have of supervisors.
Consultation • Both are concerned with
helping the recipient work more
effectively professionally. For
more advanced trainees, the two
functions may become
indistinguishable.
• Consultation is a
relationship between equals,
whereas supervision is
hierarchical.
• Consultation can be a one-
time event, whereas
supervision occurs across
time.
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• Consultation is more
usually freely sought by
recipients than is
supervision.
• Supervision is evaluative,
whereas consultation is not.
Psychotherapy (Ekstein & Wallerstein, 1972). Teaching and supervision
also have in common an evaluative aspect reflected in their gatekeeping
functions, regulating who is legitimized to advance further into training or
into the workplace.
Teaching, however, typically relies on an explicit curriculum with goals that
are imposed on everyone uniformly. However, even though the focus of
supervision at its broadest level might seem to speak to common goals
(i.e., to prepare competent practitioners), the actual intervention is tailored
to the needs of the individual supervisee and the supervisee’s clients.
Eshach and Bitterman’s (2003) comments about the challenges in
preparing physicians to address the needs of the individual—and therefore
about the need for an educational context that is flexible and adaptive to
the needs of the trainee and the person she or he is serving—apply just as
well to the training of mental health practitioners (and, notably, have the
characteristics of a signature pedagogy).
The problems are often poorly defined. . . . The problems that patients present can
be confusing and contradictory, characterized by imperfect, inconsistent, or even
inaccurate information. . . . Not only is much irrelevant information present, but
also relevant information about a case is often missing and does not become
apparent until after problem solving has begun. (Shulman, 2005a, p. 492)
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Counseling versus Supervision.
There are elements of counseling or therapy in supervision—that is,
supervisors often help supervisees examine aspects of their behavior,
thoughts, or feelings that are stimulated by a client, particularly as these
may act as barriers to their work with the client. As Frawley-O’Dea and
Sarnat (2001) observe, maintaining “a rigidly impenetrable boundary
between teaching and ‘treating’ in supervision is neither desirable nor truly
achievable” (p. 137).
Still, there should be boundaries. Therapeutic interventions with
supervisees should be made only in the service of helping them become
more effective with clients; to provide therapy that has broader goals than
this is ethical misconduct (see, e.g., Ladany, Lehrman-Waterman,
Molinaro, & Wolgast, 1999; Neufeldt & Nelson, 1999), as we discuss in
Chapter 11 .
It also is worth noting that clients generally are free to enter therapy or not,
and usually have a voice in choosing their therapists. However, supervision
is not a voluntary experience for those who have committed to a training
program, and they often have scant voice in whom their supervisor is to be.
Given this circumstance, it is salient to note that Webb and Wheeler (1998)
found in their study that supervisees who had chosen their own supervisors
reported being able to disclose to their supervisors more information of a
sensitive nature about themselves, their clients, and the supervisory
process than supervisees who had been assigned a supervisor.
Page and Woskett (2001) differentiate supervision from counseling
according to their respective aims (in counseling, to enable a fuller and
more satisfying life, versus in supervision, to develop counseling skills and
the ability to conceptualize the counseling process); presentation (clients
present material verbally, whereas supervisees present in multiple ways,
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including not only verbally, but via audio and videotape, live observation,
etc.); timing (clients choose the pace, whereas supervisees often must
have new understanding or skills in time for their next counseling session);
and relationship (in counseling, regression may be tolerated or even
encouraged, whereas that is not so in supervision; although some
challenging of boundaries is expected in counseling, there is no such
expectation in supervision).
The single most important difference between therapy and supervision,
however, may reside in the supervisor’s evaluative responsibilities. This can
create challenges to supervisors, which we discuss in Chapters 10 and
11 .
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Consultation versus Supervision.
For more senior professionals, supervision often evolves into consultation
—that is, the experienced therapist might meet informally on an occasional
basis with a colleague to get ideas about how to handle a particularly
difficult client or to regain needed objectivity. We all encounter blind spots
in ourselves, and it is to our benefit to obtain help in this manner.
Consultation, however, is more likely than supervision to be a one-time-only
event, and the parties in the consultation relationship often are not of the
same professional discipline (e.g., a social worker might consult with a
teacher about a child’s problem; Caplan, 1970). Two other consultation–
supervision distinctions echo distinctions already made between therapy
and supervision. One is that supervision is more likely imposed, whereas
consultation typically is freely sought. More significantly, whereas
evaluation is one of the defining attributes of supervision, Caplan and
Caplan (2000) observe that consultation
is non-hierarchical. Our consultants reject any power to coerce their consultees to
accept their view of the case or to behave in ways the consultants may
advocate. . . . consultants have no administrative power over the consultees or
responsibility for case outcome. (pp. 18–19)
In summary, specific aspects of teaching, therapy, and consultation are
present as components of supervision. Supervision should be thought of
as an intervention composed of multiple skills, many of which are common
to other forms of intervention. Yet their configuration is such as to make
supervision unique among psychological interventions. Moreover, there is
at least one phenomenon, that of parallel or reciprocal processes (e.g.,
Doehrman, 1976; Searles, 1955), that is unique to supervision and
distinguishes it from other interventions (parallel processes are discussed
in Chapter 3 ).
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Typically a Member of the Same
Profession
The widely acknowledged purposes of supervision are to facilitate
supervisees’ development and to protect clients. It is possible to
accomplish these purposes when the supervisory dyad is composed of
members of two different disciplines (e.g., a marital and family therapist
might supervise the work of a counselor). In fact, almost all supervisees
will be supervised by someone outside their immediate profession.
However, supervision also serves a professional socialization function
missing in cross-disciplinary supervision dyads. Ekstein and Wallerstein
(1972) speak to this when they note that it is possible for a training
program to prepare its supervisees with all the basic psychotherapeutic
skills, but that “what would still be missing is a specific quality in the
psychotherapist that makes him [or her] into a truly professional person, a
quality we wish to refer to as his [or her] professional identity” (p. 65).
Crocket et al. (2009) found that supervisors who were providing
interdisciplinary supervision reported many positive features of this
arrangement, but also note the difficulties of working from different ethics
codes and of having too-limited knowledge of the professional culture of
the supervisee. Kavanagh et al. (2003) found that Australian public mental
health workers perceived that the extent of supervision they received was
related to its impact on them, but only when the supervisor was of the
same profession.
In a cautionary tale concerning the use of members of one profession to
supervise neophyte members of another profession, Albee (1970) invokes
the metaphor of the cuckoo: The cuckoo is a bird that lays its eggs in the
nests of other birds, which then raise the offspring as their own. His case in
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point was U.S. clinical psychology, which had used the Veterans
Administration system as a primary base of training in the decades
following World War II. From Albee’s perspective, the clinical psychology
fledglings were put in the nest of psychiatrists, who then socialized them
into their way of viewing the world. Albee asserts that one consequence is
that clinical psychology lost some of what was unique to it, as its members
began incorporating the perspectives of psychiatry.
Notably, Gabbard (2005) expresses concern about social workers and
psychologists supervising psychiatry residents. He acknowledges that they
can be excellent therapists, but then observes that:
Children become what their parents do more than what their parents say. The
same can be said of psychiatric residency training. If their professional role
models treat psychotherapy as a marginal endeavor taught by allied professionals,
residents will assume that psychiatrists are not really psychotherapists. (p. 334)
In short, counselors and psychotherapists are supervised by people from
different professions and often receive excellent training from them. Our
point is not to argue against that practice, but rather to suggest that for the
sake of professional identity development, it is important that the majority
of supervision be done by someone who is in the profession that the
supervisee is preparing to enter.
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Supervision Is Evaluative and
Hierarchical
We mentioned previously that evaluation stands as one of supervision’s
hallmarks, distinguishing it from both counseling or therapy and
consultation. Evaluation is implicit in the supervisors’ mandate to
safeguard clients, both those currently being seen by the supervisee and
those who would be seen in the future by the supervisee if he or she were
to finish the professional program.
That supervisors have an evaluative function provides them with a tool,
giving them an important source of interpersonal influence. For example,
although most supervisees have a very high degree of intrinsic motivation
to learn and to use feedback to self-correct, evaluation can provide
supervisees with an additional, extrinsic motivation to use supervisory
feedback.
However, despite its importance as a component of supervision, both
supervisor and supervisee can experience evaluation with discomfort.
Supervisors, for example, were trained first in the more non-evaluative role
of counselor or therapist. Indeed, they may well have been attracted to the
field because of this feature of counseling. The role of evaluator therefore
can be not only new, but uncomfortable as well.
The role of evaluator also affects the trainee’s perception of the supervisor. Stude
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Chapter 11 Ethical and Legal
Foundations for Supervision
Practice
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In a perfect world, supervisors would have only positive effects on others.
Their actions always would be wise, virtuous, and just (see, e.g., Sen,
2009); but, of course, supervisors are only human, and so this is not the
case. Ethical codes increase the extent to which professionals exhibit best
behavior from the perspective of their profession; laws exist to help ensure
minimally acceptable behavior toward the society they serve. The focus of
this chapter is on supervisors’ dual responsibilities of comporting
themselves legally and ethically while also preparing supervisees to do the
same.
On the face of it, the very low incidence of ethical infractions by mental
health professionals in both the United States (Van Horne, 2004) and
Britain (Symons, Khele, Rogers, Turner, & Wheeler, 2011) seems
reassuring. When the focus is specifically on supervisory behavior, the rates
are even lower (Pope & Vetter, 1992), although Robiner (2008) did report
that improper or inadequate supervision was the seventh most frequent
reason for disciplinary action by psychology boards. However, these data
concern ethical complaints and their adjudication. When supervisees
describe supervisor behavior, the picture changes substantially. Ladany,
Lehrman-Waterman, Molinaro, and Wolgast (1999), for example, found that
a remarkable 51 percent of the supervisees they surveyed perceived their
supervisors to have engaged in at least one ethical violation. Because
supervisees reported that they then had discussed the perceived violation
with their supervisors only 35 percent of the time, supervisors are not
routinely getting this important feedback. An important qualifier of the
Ladany et al. (1999) results is that not all unprofessional behavior is
unethical, and supervisees are not necessarily prepared to make that
discrimination (Gottlieb, Robinson, & Younggren, 2007); also, a seemingly
contradictory finding by Bucky, Marques, Daly, Alley, and Karp (2010) is
that 85 percent of supervisees surveyed rated their supervisors as “above
average” in ethical integrity. Yet none of this diminishes the essential
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message from the Ladany et al. (1999) data: Supervisory ethical
misbehavior is unacceptably extensive.
The manner in which supervisors exercise their ethical responsibilities can
have multiple effects, including those on (a) the supervisory relationship,
(b) the supervisee, (c) the clients being served by the supervisees, and (d)
even the general public (see Goodyear & Rodolfa, 2012). Moreover, the
effects of any given supervisor behavior typically will be on more than one
of these four domains.
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The Close But Imperfect
Relationship Between Ethics
Codes and the Law
At times, ethical codes and the law can be at odds with one another (see
Knapp, Gottlieb, Berman, & Handelsman, 2007; Pope & Bajt, 1988; Pope &
Vasquez, 2011). But in general, they overlap, however imperfectly. In fact,
the law often qualifies how an ethical principle is implemented. For
example, the ethical principle that client–therapist confidentiality should be
sacrosanct is qualified by the law so that some mental health
professionals, but not others, have the added legal protection of privileged
communication; many jurisdictions require therapists to break
confidentiality when there is suspected child or elder abuse; and case law
from the Tarasoff lawsuit (discussed later) requires the therapist to breach
confidentiality in specific ways when a client threatens to harm others.
Another example of the interplay between ethics and the law is in the ways
in which sanctions for ethical misconduct can support or even trigger legal
sanctions, and the reverse is also true. In fact, ethical standards can
become legally binding (see Meyer, Landis, & Hays, 1988), particularly in
civil cases, because they may be used by the courts to determine
professional duty, and they are indirectly influential because they guide the
thinking of others in the field who may be asked to testify. For a
professional to be considered liable for civil damages, it is generally
accepted that she or he must have acted outside the bounds of accepted
professional practice (Guest & Dooley, 1999; Ogloff & Olley, 1998; Remley
& Herlihy, 2001).
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Yet another distinction is that whereas ethics codes are grounded on
relatively universal and enduring principles (see, e.g., Beauchamp &
Childress, 2001), laws vary across time and jurisdiction. Weinstein (2007)
illustrates this point by noting that in the United States, both slavery and the
use of children for labor in mines and factories once were legal, but now
are not; whereas the laws changed, the ethical issues relevant to slavery
and child labor are the same now as they ever have been.
In short, ethical and legal issues related to clinical supervision are closely
related, but can be sufficiently differentiated to warrant separate coverage.
Therefore, we organize this chapter in three sections: the first addresses
ethical issues; the second addresses legal issues; and the third addresses
the teaching of ethical decision making. We conclude the chapter with a
discussion of the supervisor’s role in preparing ethical practitioners.
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Ethical Issues In Clinical
Supervision
Ethics is a branch of philosophy concerned with what is moral or good
(see, e.g., MacIntyre, 1998). One of its practical expressions is in the
ethical codes the professions adopt that serve as guidelines for member
decision making and, when necessary, provide a basis for regulating
member behavior—the contract with society we discuss in Chapter 1 .
Each mental health profession (e.g., counseling, psychology, social work)
has its own ethics code; most professions then have separate ethical
codes by country, as ethics codes typically are developed by national
associations of the particular profession. In spite of this proliferation of
ethical codes, a number of studies have demonstrated that mental health
professionals encounter similar ethical dilemmas, regardless of profession
and country (see, e.g., Pettifor & Sawchuk, 2006).
Common moral principles also undergird most ethics codes. In his now-
classic work, Ross (1930) suggests that some moral principles are what
he terms prima facie obligations—those that must be fulfilled unless they
compete in a particular circumstance with an equal or stronger obligation.
Ross’s work was foundational for that of Beauchamp and Childress (2001;
see also Bersoff & Koeppl, 1993; Kitchener, 1984), who describe the first
four of the following moral principles; the fifth is from the ethical
guidelines at the outset of American Psychological Association’s (APA’s)
ethical code (APA, 2002).
1. Respect for Autonomy: concerning respect for a person’s right to
make his or her own choices; manifest, for example, in the ethical
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demand to provide informed consent.
2. Beneficence: concerns contributing to the well-being of others and
optimizing benefits over risks; manifest, for example, in the ethical
demand for competence.
3. Nonmaleficence: captured in the Hippocratic oath and stated as
“Above all, do no harm” (in Latin, Primum no nocere); as with
beneficence, this is manifest in the ethical demand for competence.
4. Justice: concerning fairness in distributing risks, benefits, and costs;
manifest, for example, in adhering to due process.
5. Fidelity: concerning keeping promises; manifest in, for example,
adhering to agreed-on processes and not abandoning the
supervisee.
In summary, clinical supervisors in all countries and across professions
address substantively similar ethical issues. In determining what those
issues might be for supervisors, Ladany et al. (1999) suggests a taxonomy
with 15 of those issues specific to supervision and shown in Figure
11.1 , along with the proportion of supervisees in their study who
reported having experienced each issue with their supervisors (more on this
later).
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FIGURE 11.1 Percentage of Supervisees Who Described One or More
Perceived Ethical Breaches in Each of 15 Categories (from Ladany et al.,
1999)
In what follows, we address a smaller set of issues than Ladany et al.
suggest, although their issues certainly are embedded in those we cover.
We cover, in turn, due process, informed consent, multiple relationships,
supervisor and supervisee competence, confidentiality, and business-
related supervisory issues.
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Due Process
Whereas due process is an ethical issue for supervisors, it typically is
exercised in an organizational context—that is, an academic training
program or an internship. Due process concerns ensuring that (a) notice
and hearing is given before an important right can be removed from a
person, and that (b) the criteria being used are fair (Disney & Stephens,
1994). We address it here as an ethical matter, although it is a legal one as
well. For example, the U.S. Constitution’s 14th Amendment asserts that “nor
shall any State deprive any person of life, liberty, or property, without due
process of law; nor deny to any person within its jurisdiction the equal
protection of the laws.”
Due process has two components (see Forrest, Elman, Gizara, & Vacha-
Haase, 1999; Gilfoyle, 2008):
Substantive due process concerns the “substance of a decision, rather
than the process by which it was made, in general using the standard of
whether a decision was ‘arbitrary or capricious’” (Gilfolyle, 2008, p.
203).
Procedural due process has to do with the individual’s right to be
notified; to be apprised of the academic and performance requirements
and program regulations, receive notice of any deficiencies, be
evaluated regularly, and have an opportunity to be heard if their
deficiencies have led to a change in status (e.g., put on probation).
Ethical guidelines developed specifically for supervisors (Center for
Credentialing and Education, 2001; Supervision Interest Network, 1993)
address the issue of due process concerning supervisees most directly
(see the Supervisor’s Toolbox). For example, Section 2.14 of the Ethical
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Guidelines for Counseling Supervisors (Supervision Interest Network,
1993) states:
Supervisors should incorporate the principles of informed consent and
participation; clarity of requirements, expectations, roles and rules; and due
process and appeal into the establishment of policies and procedures of their
institution, program, courses, and individual supervisory relationships.
The most blatant violation of this guideline occurs when a supervisee is
given a negative final evaluation or dismissed from a training program or
job without having had either prior warning that his or her performance was
inadequate or a reasonable amount of time to improve (a procedural due
process issue).
A full due process procedure should ensure that the supervisee in question
is guaranteed an objective and respectful review of the situation, as well as
the expert opinions of both professionals and the person who initiated the
concern. Although most supervisees do not challenge violations of due
process rights, some have litigated (cf. Disney & Stephens, 1994; Forrest
et al., 1999; Gilfoyle, 2008; Jaschik, 2012; Knoff & Prout, 1985; Meyer,
1980). However, when due process procedures have been followed, the
courts have shown great deference to faculty evaluations (Forrest et al.,
1999; Gilfoyle, 2008; McAdams, Foster, & Ward, 2007). Supervisors and
training programs can find a number of effective examples of due process
procedures on the Association of Psychology Postdoctoral and Internship
Centers’ (APPIC’s) website: www.APPIC.org.
Forrest et al. (1999), Frame and Stevens-Smith (1995), and McAdams et
al. (2007) propose the programs develop policy statements to guide
evaluation processes (i.e., procedural due process) and that they establish
descriptive criteria about personal characteristics that are determined to be
essential for success as a mental health practitioner (i.e., substantive due
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process). These criteria must then be used for ongoing evaluation of
students during their training program. In short, students’ due process
rights are protected both by published policy statements and criteria, and
by the availability of the regular evaluations. When students are found to be
in jeopardy, Frame and Stevens-Smith (1995) use a procedure very similar
to that described by Lamb, Cochran, and Jackson (1991).
Example :
“Hannah” is in a master’s program in mental health counseling. She has
completed 10 courses in the program and is currently in practicum.
Hannah has received a great deal of formative feedback throughout the
practicum indicating that she has many areas that need improvement.
At the conclusion of the practicum, Hannah’s instructor assigns Hannah
a grade of F for the course. At this time, Hannah is informed that a
failing grade in the practicum is grounds for dismissal from the
program. Hannah is told that she may retake the practicum one time,
but that the faculty are not optimistic that she will improve enough to
receive a B or better, a condition for her continuing in the program.
Although Hannah knew that she was not doing as well in the practicum
as some others, she had no awareness that she was in danger of being
terminated from the program until the final evaluation.
It is likely that Hannah will take the advice of the faculty and discontinue
the training program. However, have her due process rights been protected?
How vulnerable is her practicum instructor and the program if she should
decide to challenge their decision? Even if Hannah does not appeal, what
are the potential systemic implications of such a process? Whereas there
is no ill will evident in the action of the faculty and no indication that their
decision was capricious or arbitrary, did the process they followed protect
the student adequately, and was it legally defensible?
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Informed Consent
Research participants, therapy clients, and supervisees all have the right
both (a) to the best available information about what they are involving
themselves in, including its risks and benefits; and (b) to choose whether to
participate based on that information. In short, they have the right to
informed consent to their participation. It is fair to assert that there is no
ethical standard as far-reaching as informed consent for the practice of
psychotherapy. This is true as well for supervision. Ellis (2010), for
example, observes that the legal standard of care in supervision is to
provide informed consent or a supervision contract. Yet Ellis found that
“less than 19% of supervisors provided informed consent and only 41%
used a supervision contract” (Ellis, 2010, p. 111).
In fact, the supervisor has three levels of responsibility with respect to
informed consent, and must do the following:
1. Provide the supervisee with the opportunity for informed consent
2. Determine that the supervisee informs clients about the parameters
of therapy
3. Determine that the supervisee informs clients about parameters of
supervision that will affect them.
We discuss each of these in turn.
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Informed Consent with Supervisees Regarding
their Supervision.
It is best practice that supervisees be well informed about the processes
and expectations of supervision (Knapp & VandeCreek, 2006). One
mechanism to accomplish this is the use of a supervision contract (e.g.,
Sutter, McPherson, & Geeseman, 2002; see also the Supervision Toolbox).
Supervisors should clarify their gatekeeping responsibilities with
supervisees at the outset of supervision (Russell et al., 2007), so that
supervisees enter the supervisory experience knowing the conditions
necessary for their success or advancement, including the personal and
interpersonal competencies they will be required to demonstrate (Forrest et
al., 1999). It also should be clear to each member of the team what their
respective responsibilities are.
Supervisees also should be apprised of the supervision methods that will
be used, the time that will be allotted for supervision, the expectations of
the supervisor, the theoretical orientation of the supervisor, and the type of
documentation required for supervision (Cohen, 1987; McCarthy, Sugden,
Koker, Lamendola, Maurer, & Renninger, 1995; Pope & Vasquez, 2011).
Simply put, any surprises the supervisee encounters should be due to the
learning process itself and the complexity of human problems; and not to
oversights on the part of the supervisor.
Thomas (2007) notes that informed consent is only partially applicable to
supervision, because once a person enters a training program (thus
entering a profession), that person’s options become limited. Requirements
for success (e.g., program completion, licensure) are largely
predetermined, although information should have been available to that
student prior to entering the training program. The supervisor’s role from
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this angle stresses the function of the gatekeeper. Barnett (2007), however,
emphasizes the importance of a productive relationship to effective
supervision: Although measuring the supervisee’s performance against
standards is not necessarily in any opposition to forming a supportive
relationship with a supervisee, these dual tasks require skill and open
communication. They also may require ongoing supervision of supervision.
If there is a possibility that personal counseling will be mandated or even
recommended for any trainees in a given program, all trainees should be
cognizant of this practice on entering the program (Whiston & Emerson,
1989). Standard 7.02 in the APA’s Ethical Principles of Psychologists and
Code of Conduct (APA, 2002) is very explicit about this. As well, Standard
7.04 states that prospective students must understand before entering a
program if they will be required to participate in situations (e.g.,
experiential groups) that require them to self-disclose personal information
(Illfelder-Kaye, 2002).
Independent of the issue of informed consent, referring trainees to therapy
is problematic, given the absence of evidence of therapy’s efficacy to
remediate supervisee functioning (Russell, DuPree, Beggs, Peterson, &
Anderson, 2007). Also, Russell et al. note that to refer students to therapy
implies a diagnosis, which then blends the educational relationship
between supervisor and trainee with one that is more clinical. They also
stress, as do others, that a referral to therapy opens the door for the
supervisee to claim discrimination based on a disability by virtue of the
Americans with Disabilities Act. Their conclusion, therefore, is that
“Psychotherapy as an integral part of training for supportive and preventive
purposes is different from selecting out students for therapy as a part of
remediation” (Russell et al., 2007, p. 238).
Consider the following examples:
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1. Latoya is in her predoctoral psychology internship, working with very
difficult clients. In supervision, she shares that one client in particular has
been “getting to her,” most likely because some of the client’s situation is so
similar to Latoya’s past. Latoya’s supervisor immediately suggests that
Latoya receive counseling regarding this issue. When Latoya says that she
believes her past therapy was sufficient and that she would prefer to view
the situation as a supervision one, her supervisor states that she will only
continue to work with Latoya if she commits to counseling.
2. Ronald, a student in a professional counseling master’s program, makes an
appointment to see his academic advisor to discuss his internship now that
he is near the end of his training program. He plans to do his internship in a
local mental health agency. His advisor tells Ronald that the faculty recently
evaluated students and that he was viewed as not having the capacity to be
successful in clinical work. It was suggested that he pursue an internship in
a “softer” area, such as career counseling. Ronald states that he has no
interest in career counseling. Ronald’s advisor states that such an
internship site is the only type that will be approved for him.
3. Ruth has been assigned to a local mental health hospital for her field
placement to work with patients who are preparing to be discharged. It is
her first day at the site, and she is meeting with her site supervisor. He gives
her a form to fill out that asks for information regarding her student
malpractice insurance. When Ruth tells her supervisor that she does not
carry such insurance, he advises her that it is their policy not to accept any
student who does not have insurance. The supervisor also expresses
some surprise, because this has always been the hospital’s policy, and Ruth
is not the first student to be assigned to them from her training program.
In each situation, how egregious do you find the violation of the
supervisee’s right to informed consent? To what extent can institutional
materials cover issues of consent? How might each situation have been
handled to better address the rights of the supervisee?
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Informed Consent with Clients Regarding
Treatment.
Most who are reading this text already understand how essential it is that
clients have the opportunity for informed consent to treatment. As
supervisors, they are responsible for ensuring that their supervisees provide
this to the clients they are serving.
Haas (1991) suggests seven categories of information that, if provided,
constitute necessary and sufficient informed consent. The first of these
concerns risks of treatment, which may range from mild (e.g.,
embarrassment if others knew) to serious (e.g., the risk of terminating a
marriage if one begins to address chronic relationship issues). Haas’s
second category is the benefits of treatment.
Haas’s (1991) third category encompasses the logistics of treatment,
including the length of sessions, cost, opportunity for telephone
consultations, and so on. It also discusses any limits with respect to
numbers of sessions, such as those that may be imposed by agency policy
or insurance parameters (Acuff et al., 1999; Haas & Cummings, 1991) or
supervisee availability (e.g., being assigned to a site for only a limited
training period).
Haas’ fourth category includes information about the type of counseling or
therapy that clients will be offered. If one is behaviorally oriented and
requires homework, if the supervisee is in training as a marriage and family
therapist and requires additional family members to be present, or if one’s
approach to working with particular issues includes the use of group work,
such stipulations should be explained at the outset of therapy. Disney and
Stephens (1994) suggest that preferred alternatives to the type of
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treatment being suggested, as well as the risks of receiving no treatment at
all, should be explained at this time as well.
Example :
Julian, a supervisee in a mental health agency, has been providing
individual therapy to Ellen for four months. It has become apparent to
him that Ellen and her husband need marriage counseling, an
intervention in which he has been trained. He very much wants to follow
this case to its conclusion, and without discussing alternatives, Julian
suggests that Ellen bring her husband to the next session. Ellen says
that she is relieved that he is willing to work with them. She was afraid
that Julian would refer them to another therapist. Having Julian work
with both her and her husband is exactly what she was hoping for.
In this example, we must consider whether Ellen or her husband has been
given the opportunity to provide appropriate informed consent. Is there
information about the therapy process that Julian should have offered to
help them make the best decision for their present situation? At the very
least, Julian has erred in not discussing alternatives, and his supervisor
must now help Julian backtrack. If the supervisor had any inkling that
marital therapy might be indicated, the supervisor was negligent for not
coaching Julian regarding the client’s informed consent rights, as well as
her husband’s.
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Informed Consent with Clients Regarding
Supervision of Their Treatment.
The client must be aware not only of therapeutic procedures, but also of
supervision procedures. The client needs to know, for example, whether
sessions will be taped or observed, who will be involved in supervision
(e.g., one person, a team, members of a supervision group), and how
intrusive the supervision will be.
The final three of Haas’s (1991) informed consent categories are all
supervision related, and one of these is information to the client about
emergency procedures. The supervisor always should be involved in an
emergency situation. Clients should know if direct access to the therapist
is available in case of emergency. Will the supervisor be available to the
client?
Next is confidentiality. “Supervisees place themselves in a position to be
sued for invasion of privacy and breach of confidentiality if they do not
inform their clients that they will be discussing sessions with their
supervisor” (Disney & Stephens, 1994, p. 50). Most training programs use
written forms to alert clients of the conditions of supervision. It may be
wise for the supervisor to meet with clients personally before the outset of
therapy for a number of reasons: (a) By meeting the supervisor directly, the
client usually is more comfortable with the prospect of supervision; (b) it
gives the supervisor an opportunity to model for trainees the kind of direct
and open communication necessary to ensure informed consent; and (c) by
not going through the trainee to communicate with clients, it is one less
way that the supervisor could be vicariously responsible should the trainee
not be clear or thorough.
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Finally, Haas (1991) suggests that clients understand the provider’s
qualifications. Several authors (e.g., Disney & Stephens, 1994; Harrar,
VandeCreek, & Knapp, 1990; Knapp & VandeCreek, 1997; Pope & Vasquez,
2011; Worthington, Tan, & Poulin, 2002) note that it is vitally important for
ethical and legal reasons that clients understand when they are in therapy
with a supervisee who is in training. Any attempt to obscure the status of a
supervisee may expose both supervisee and supervisor to civil suits
alleging fraud, misrepresentation, deceit, and lack of informed consent.
Even when clients are aware that their therapist is under supervision,
informed consent can be compromised when trainees downplay the
parameters of supervision. Situations occur when supervisees use
ambiguous language, such as, “If it’s all right with you, I’ll be audiotaping
our session,” when what they mean is, “I am required to audiotape our
sessions if I am to work with you.” This leaves the trainee in the awkward
position of setting an unwise precedent, or of having to backpedal to
explain the true conditions of therapy and supervision, and our experience
is that clients sense the ambivalence and can become less inclined to give
permission to record.
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Example :
Beth is a social worker who counsels women who have experienced
domestic violence. She is well trained to do initial interviews with
women in crisis, and her supervisor is confident in Beth’s abilities to
carry out these interviews without taping them. In addition, there is the
obvious concern that the use of audiotape would be insensitive to
women who are frightened and vulnerable during the interview. The
conditions of supervision, however, require Beth to audiotape all
subsequent sessions.
Janell was one of Beth’s interviewees. After the initial session, Janell
decided that she was ready to receive counseling regarding her abusive
marriage. She explained to Beth that she was afraid of her husband’s
reaction to counseling, so she made her first appointment for a day
when she knew he would be out of town. When Janell arrived for
counseling, Beth discussed the conditions of counseling, including the
requirement that she audiotape sessions for supervision. Janell became
quite upset and told Beth that she never would have agreed to
counseling if she had known that the sessions would not be held in
strictest confidence. Beth attempted to explain that would still be the
case, but Janell left and did not return.
How do you react to Beth’s method of handling this situation? Were Janell’s
informed consent rights violated? What alternatives did Beth have that
would protect both her and her client?
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Multiple Relationships
Multiple relationships (dual relationships in earlier literature) occur when
people have more than one social role in relationship toward each other.
For example, a person may be a student in a professor’s class and also
work as that professor’s research assistant. Such situations are common
and not necessarily unethical. They become problemmatic when (a) there
is a power differential between the two parties and (b) the multiple roles
they have in relationship to each other puts the person with less power is
put at risk for exploitation or harm.
The metaphor often invoked in discussions of multiple relationships is that
of a boundary that encloses expected professional roles. Those boundaries
need not, however, be completely rigid. In fact, Vasquez (2007), alludes to
the usefulness of maintaining “permeable” (p. 407) boundaries, particularly
when working with clients or supervisees whose cultural expectations for
these roles may differ from that of the dominant culture. Barnett (2007)
similarly pointed out the usefulness of relaxing boundaries when a client
offers a small gift or might profit from having the session extended
because she or he is experiencing a crisis. As Gabbard and Crisp-Han
(2010) put it so well, “One must not construe boundaries as an admonition
against being human” (p. 371).
It is important, then, to consider the distinction Gutheil and Gabbard (1993)
make between boundary crossing and boundary violations:
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we should adopt the convention that “boundary crossing”. . . is a descriptive term
neither laudatory nor pejorative. An assessor could then determine the impact of a
boundary crossing on a case-by-case basis that takes into account the context
and situation-specific facts, such as the possible harmfulness of this crossing to
this patient. A violation, then, represents a harmful crossing, a transgression, of a
boundary. (p. 190)
Fly, van Bark, Weinman, Kitchener, and Lang (1997) confirm in their work
that boundary transgressions (sexual and nonsexual) were among the most
common ethical transgressions among psychology supervisees, second
only to violations of confidentiality. These two categories of ethical
transgressions combined accounted for 45 percent of the total reported by
training directors.
As is true of many of the ethical issues we address here, supervisors must
address multiple relationships on two fronts: Educating supervisees and
ensuring that they are not engaging in inappropriate multiple relationships
with clients, and ensuring that they are not themselves engaging in
inappropriate multiple relationships with their supervisees. We address
each in turn.
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Multiple Relationships between Supervisees and
Clients.
There are various types of problematic multiple relationships in which
therapists might engage with their clients, including, for example, providing
therapy to a family member or borrowing money from a client. However,
probably the most flagrant is a sexual relationship with the client. The
power differential between therapist and client creates a substantial risk of
exploitation, even should the client express the belief that she or he is
voluntarily entering the sexual relationship. Ethics codes, therefore, prohibit
these relationships (e.g., ACA, 2005; APA, 2002), and in most jurisdictions,
they are grounds for revocation of licensure or certification. Supervisors are
responsible for ensuring that supervisees understand the definition of a
multiple relationship and avoid all such relationships with clients.
The literature concerning therapist misconduct with clients is vast and
cannot be fully addressed here; however, a few authors study multiple
relationships as a supervision issue. Specifically, we speak to the
monitoring of relationships between supervisees and clients and to
assisting supervisees in ways that reduce the likelihood of their
involvement in exploitative relationships in the future.
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Preventing Supervisee Ethical Transgressions.
Although there is no foolproof way to ensure the ethical behavior of
supervisees, several authors encourage a proactive supervisor posture
(Koenig & Spano, 2003; Ladany, Friedlander, & Nelson, 2005). Most
professional literature to date addressing supervisee transgressions
focuses on sexual intimacies with clients. Among the most common
strategies recommended are preventive education (Samuel & Gorton,
1998) and honest discussion between supervisors and supervisees about
the possibility, if not the probability, of occasional sexual attraction to
clients, of supervisors to supervisees, or the converse for each dyad
(Bridges & Wohlberg, 1999; Hamilton & Spruill, 1999; Ladany & Melincoff,
1999; Ladany, O’Brien, Hill, Melincoff, Knox, & Petersen, 1997; Ladany et al.,
2005).
Because persons attracted to mental health fields often have unresolved
personal issues, supervisors should not be surprised that supervisees may
need their assistance negotiating and maintain boundaries (Maki &
Bernard, 2007). Hamilton and Spruill (1999) speculate that supervisee
vulnerabilities to boundary transgressions include loneliness, prior
paraprofessional or friendship “counseling” experiences in which levels of
intimacy were higher than the professional norm, and failure to recognize
ethical conflicts. They also criticize supervisors for not addressing sexual
attraction to clients as normative and for stereotyping the problem in a
sexist manner.
As with other sensitive issues, it is imperative that the supervisor accept
responsibility for raising the topic. Ladany et al. (1997) found that unless
this happens, only about half of supervisees who experience sexual
attraction to clients will disclose it to their supervisors. In a related study,
Heru, Strong, Price, and Recupero (2004) found that supervisees were
more reluctant than supervisors to address sexual topics, including sexual
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attraction, during supervision. Gabbard and Crisp-Han (2010) suggest that
supervisors tell supervisees, “If there is anything at all that you feel like
concealing from me, that is probably the most important thing to discuss”
(p. 371). Bridges (1999) further emphasizes the importance of supervisor
openness and candor in assisting supervisees to manage intense feelings.
“Ethical supervision is embedded in a clearly articulated supervisor–
student relationship that monitors misuse of power and boundary
crossings, yet is capable of deeply personal discourse” (p. 218).
Hamilton and Spruill (1999) suggest that prior to seeing clients, all
supervisees receive instruction in the following:
1. The powerful effects of attraction of familiarity, similarity, self-
disclosure, and physical closeness
2. Testimonials from well-respected clinicians about their encounters
with sexual attraction in therapy
3. Specific actions to take when feelings of attraction arise, with
emphasis on the importance of supervision
4. Suspected risk factors for and signs of client–therapist intimacy
5. Consequences of therapist sexual misconduct on the client
�. Social skills training to increase skill and decrease anxiety related to
enacting ethical behavior
7. A clear explanation of program policy regarding ethical
transgressions, with emphasis on a clear distinction between
feelings that are expected and actions that are unacceptable. (p.
320)
Offering this kind of information in a group format might reduce the
reluctance of any individual supervisee to address the topic.
Ladany et al. (2005) suggest introducing the topic of sexual attraction very
early in supervision. They argue that including such topics in an orientation
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to supervision normalizes them, making it easier to discuss them should
they emerge during supervision. Once such groundwork has been
established, they encourage supervisors to
Recognize what they refer to as markers of a potential boundary
vulnerability, both overt (e.g., supervisee shares strong feelings about a
client) or covert (e.g., supervisee dresses more attractively on days a
particular client is scheduled). Walker and Clark (1999) note similar
cues and include inappropriate gift giving, off-hours telephone calls,
and “overdoing, overprotecting, and overidentifying” (p. 1438).
Engage supervisees in discussion about their feelings; assess their
knowledge of ethical standards; normalize the experience (if, indeed, an
attraction is experienced); focus on any potential countertransference
issues that may be operating; and finally, focus on how the attraction
can be managed without negatively affecting the therapeutic process.
Ladany et al. suggest a similar process for a case in which the attraction is
between the supervisor and supervisee.
Finally, the use of a professional disclosure statement (PDS), both for
supervision (Blackwell, Strohmer, Belcas, & Burton, 2002; Cobia & Boes,
2000) and counseling and for therapy, are well advised as deterrents to
boundary violations. A PDS, which includes details about one’s training and
experience as well as about such issues as confidentiality, has the potential
of alerting both supervisee and client to the professional nature of the
relationship. It also typically includes contact information for an outside
authority should there be some concern about what has transpired in the
relationship. This alone, it would seem, communicates a high regard for
professionalism and integrity. (See the Supervisor’s Toolbox and Fall &
Sutton, 2004, for examples of a PDS.)
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Multiple Relationships between Supervisor and
Supervisee.
Supervisors often have more than one professional relationship with a
supervisee, and these are not necessarily problematic (Gottlieb, Robinson,
& Younggren, 2007). Behnke (2005), for example, observes
Our supervisees are also our students, research assistants, co-authors, and
sometimes our friends. . . . These multiple roles often coexist productively, but
when they do not the supervisor must explore competing values and interests to
resolve potentially harmful tensions. (p. 90)
Simply put, what makes a multiple relationship unethical is the likelihood
that it will impair the supervisor’s judgment and the risk to the supervisee
of exploitation (Hall, 1988b). These factors can come into play when, for
example, doctoral students supervise master’s students in the same
program (Scarborough, Bernard, & Morse, 2006).
As a useful heuristic, Pearson and Piazza (1997) suggest five types of
multiple role of which supervisors should be aware:
1. Circumstantial multiple roles: multiple relationships that happen by
coincidence; for example, a supervisor’s adult son begins dating a
young woman who turns out to be a student in his mother’s
practicum class.
2. Structured multiple professional roles: when supervisor and
supervisee have more than one professional role. This is what is
usually being referred to when authors note that multiple
relationships are ubiquitous to doctoral training programs.
3. Shifts in professional roles: for example, when a doctoral student
who was formerly a classmate in a course with a master’s student
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becomes that student’s practicum supervisor.
4. Personal and professional role conflicts: includes preexisting
professional relationships followed by a personal relationship, or a
personal relationship followed by a professional one.
5. The predatory professional: those who deliberately seduce or exploit
others for their personal gain.
As with the literature regarding supervisees and clients, the type of multiple
relationship between supervisor and supervisee that has received the most
attention is sexual involvement between them. The literature concerning
those issues tells us that:
1. There is some evidence that rates of faculty–student sexual
contacts has been dropping. Reported percentages had been
reported in the 12–14 percent range (Pope, Levenson, and Schover,
1979; Robinson & Reid, 1985; Rubin, Hampton, & McManus, 1997),
with one ranging as high as 17 percent (Glaser & Thorpe, 1986).
However, more recent rates have been in the single digits, ranging
from 2 percent (Zakrzewski, 2006) to 6 percent (Miller & Larrabee,
1995) and 7 percent (Thoreson, Morrow, Frazier, & Kerstner, 1990)
2. Even when the relationship “felt” consensual to the student at the
time, former students looking back saw them as coercive and even
harmful. Glaser and Thorpe (1986) found that in retrospect, 51
percent of former students who had participated in a multiple
relationship saw some degree of coercion. Most respondents in
Robinson and Reid’s (1986) study judged that the relationships had
been detrimental to both parties.
3. A higher proportion of female students have been involved in sexual
contact with male faculty members (Pope et al., 1979; Tabachnick,
Keith-Spiegel, & Pope, 1991; Zakrzewski, 2006).
4. Two studies (Bartell & Rubin, 1990; Rubin, Hampton, & McManus,
1997) found that sexual contact as a student with a faculty member
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may increase the likelihood of similar behavior once that student
becomes a faculty member, although a third s
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