|Men in Therapy Clinical Mastery Mindfulness Symposium 2012 Clinical Excellence Wendy Behary Attachment David Schnarch The Future of Psychotherapy Brain Science Gender Issues Community of Excellence CE Comments Alan Sroufe Challenging Cases Great Attachment Debate William Doherty Mind/Body Narcissistic Clients Etienne Wenger Linda Bacon Couples Therapy Couples Future of Psychotherapy Attachment Theory Anxiety Trauma Mary Jo Barrett Ethics Diets|
|In Consultation, The 4 Stages of Supervision|
Establishing a lasting relationship with your supervisee
Q: I've always been attracted to the idea of being a clinical supervisor, but would like more details about how exactly it's done. Can you enlighten me?
A: As a clinical supervisor, you're part mentor, part administrator, part parent, part advocate, part sheriff, and part den mother. On any given day, you're coaching a new clinician on how to fill out an expense form or a supervisee on how to handle a suicidal teen, attempting to contain burned-out staff members who are testing boundaries, trying to invigorate the ones treading water and counting down the time until retirement, or--it has to be said--weeding out those who don't reach high enough. You also spend your time developing programs, arguing about the budget with your boss, attending boring policy meetings, signing time sheets, seeing your own cases, and making sure everyone is keeping up with theirs.
The administrative stuff plays second fiddle to your real job though: helping the therapists you supervise--from scared beginners to confident (sometimes overconfident) pros to burned-out timeservers--figure out what they need and how to weave together their strengths, skills, and personalities into a unique and personal clinical style. Obviously, you need good supervisory skills, but you must apply those skills in creative ways at different times with different staff because one size definitely doesn't fit all in this work. It's the relationship between supervisor and supervisee (rather than a set of skills, per se) that's the key to helping him or her learn what it really means to be a therapist and practice therapy.
In my work over the past 30-plus years as clinical supervisor and director, I've used as a mental map a four-stage model of supervision. It's a developmental model of clinical growth that helps me anticipate what lies ahead, shift gears when necessary, and do my best to encourage my supervisees to discover their voices, skills, and styles.Stage 1: Teacher
To make the most of your resources as you age, it's helpful to learn to be selective, optimize, and compensate. Older adults who are better at adapting to the aging process limit their options or life choices in order to optimize functioning as their faculties decline. They regularly practice the behaviors that they want to remain intact and seek the types of support they require or use other compensation techniques to be able to carry out the activities they wish to continue doing. As an example, at 80, the renowned concert pianist Arthur Rubenstein was still able to maintain a high level of performance by playing fewer pieces (selectivity), practicing those pieces more often (optimization), and masking his loss of motor speed by learning to slow the overall tempo of the piece, allowing him to contrast its fast and slow segments (compensation).
The first stage of clinical development is about creating a supervisory relationship with a trainee that'll help her begin to find herself as a therapist beneath her painful awareness of her own inexperience. Jean is at the beginning of her career, new to the agency, and just starting to learn the ropes. She's at the stage when she "only knows what she doesn't know." To her, everyone else seems smarter, stronger, and better at their jobs. Her head is filled with facts, but she really doesn't know what to do with them. She smiles a lot, and usually says she's doing okay only because to admit her insecurity would, in her eyes, confirm what she thinks everybody is already thinking about her.
Jean worries about Doing It Right. She goes into therapy sessions with a clipboard of questions to fire at the family, less to get vital information and more to help her structure the time and her anxiety. Her progress notes invariably spill into volume two because she has trouble knowing what information is important and what isn't.
Her clinical goals are often vague and idealistic. In her job interview, she tells me she just wants to "help" people with their lives. She tends to identify with her clients and is easily overwhelmed by their day-to-day problems, so she takes the mom to get food stamps, calls up a friend who may be able to find a family a new couch, and wants to contact anyone she can think of to help the dad get job training. Like her clients, she can get swept up in the crisis of the moment and all the pressing problems that seem to be falling on their heads. What she often fails to see because of her own anxiety and lack of experience is the power of the therapeutic process itself to give clients the energy and emotional resources they need to deal with the content of their lives.
What do you do? You help her feel welcomed and safe. You set realistic and clear expectations--ones that are usually a bit lower than her own. You gently begin to set boundaries so she can do the same with her clients. For example, you help her move from a reactive mode to a proactive one by requiring that she have an agenda for supervisory sessions and that she formulate clear, specific questions, rather than always calling you in crisis and venting. You try to help her see the limits of her power; help her sort out her problems from her clients' problems, and realize what she can control and what she can't. You spend time assessing her skills and helping her fill in weaker skills with knowledge: for example, discussing practical ways of approaching distant yet intimidating fathers, or walking her through the steps needed to coordinate services with the courts. You assess her learning style. You look for what works and help her understand where and why she gets stuck, so that she can do the same with the family. You give her positive feedback to offset the criticism she lays on herself. You pair her up with an older therapist who can be a role model for her, showing her the ropes and helping her put her knowledge into practice.
There are several challenges in this stage of supervision. If Jean remains intimidated, wary, and closed around you, or continues to put up the "I'm okay" front in your presence, you essentially have no supervisory relationship. If you can't help her relax and trust you, she'll be saying one thing (that Mrs. Jones is doing well) and possibly doing another (taking crisis calls from Mrs. Jones 12 times a day), and your ability to provide quality control is shot. If she feels she can't come to you for support, she'll bond with her peer in the next-door office, bring her questions to her and use her as the de facto supervisor, or talk to no one and remain isolated and overwhelmed. Openly, but delicately, you need to talk to her about her fear, normalize her feelings, and bring up all the things you think she may be thinking, so she knows it's okay to discuss these issues out loud. Use self-disclosure to offset the distorted impression that you've never been anything but fully confident and in control. Resist the urge to calm any anxiety you may have about her work by doing remote-control therapy through her.
The danger at this stage is that her fear will stop her in her tracks, and she'll decide that she isn't cut out for doing therapy. The ethical danger is that she'll do too much for clients-- lending mom $20 for groceries, picking Billy up from school, rather than helping mom figure out how to get him herself--and in the process blur her personal and professional boundaries. So you need to set the limits (tell her that she can't be lending clients money or picking up Billy) and help her understand the clinical rationale, rather than merely scolding and frightening her away. Treat her the way she needs to treat her clients.
Stage 2: Guide
If you do a good job and lay a strong foundation, supervisees like Jean will naturally grow into the next stage. The official end of probation will allow the clinician to breathe a sigh of relief and settle down. Often this parallels what's been happening with her clients as they, too, settle down. The initial focus on crisis and problem-solving passes, and both client and clinician get into a calmer frame of mind and are ready to look at deeper issues and causes.
For example, Ed was initially much like Jean--frenetic, overwhelmed, overresponsible. But within six months of starting supervision, his questions are shifting from "What form do I use" or "How do I help my client when she complains that her kids refuse to go to bed on time?" to "How do I think about helping my client with a history of childhood sexual abuse?" and better yet, "How do I handle my own discomfort when she talks about it." Ed is becoming curious about what lies below the surface of the client's repeated emotional crises, and is beginning to see the larger dysfunctional patterns that affect the client's life, which his anxiety kept him from seeing before. Now he wonders about the impact of the past (the mother's death when the client was a teen) or of the larger environment (the way the violence in the neighborhood fuels the client's PTSD symptoms). Furthermore, feeling less insecure, he can begin to relax and share more of himself.
This is the stage in which the developing therapist "doesn't know what he knows"--he's being a better therapist than he realizes. He's as likely to see his successes as being due to luck as being due to his good interventions. Rather than talking about helping clients with their "feelings," he can define specific behavioral goals, but the steps to achieving them can still seem elusive and mysterious.
At this point, you do less direct teaching and more guiding. You encourage Ed to pursue his hunches, to follow the thread of conversation in the room more closely, to let a session unfold a bit without feeling driven to intervene at every step. You begin to help him see that he doesn't need to fix all the client's problems, but can focus upon and help change those exhibited right there in session. Rather than scrambling, for example, to help his client keep from having his phone turned off, he can focus instead on exploring with the client why he's always struggling to pay his phone bill on time.
This second stage of oversight is a good time for group supervision because the clinician is no longer worried about sounding stupid in front of more experienced peers, and can learn from others' experiences without trying to mimic their styles. Questions in supervisory sessions are now less about wanting to do things right to avoid your disapproval and more about picking your brain and using you as mentor. The clinician no longer tries hard to be the supervisor's "good child"; for a time, in fact, he becomes more deeply dependent upon the supervisor, more genuine, less self-conscious, more open and intimate--ways of interacting that help him to better absorb what he's learning.
This dependency can be reflected in the clinician-client relationship. Clients who were distrusting and manipulative now relax into the therapeutic relationship and use it in a healthier way. The more vulnerable clinician may now overidentify with the vulnerability of others--children, for example, or the chronic poor. As before, he may do too much, not so that clients will like him, but out of his deeper compassion. For less experienced, "good-child" clinicians, the increased intimacy of the therapeutic relationship can be seductive. As they hear the back-story of their clients' lives, they may feel for the first time what it's like to have others trust and appreciate them. And for some therapists, this can become a real danger. Relationships with clients can go on and on because the client's dependency is unconsciously or subtly encouraged.
As the supervisor, you need to stay alert to this. Your work at this stage focuses on helping supervisees see these patterns in their clinical relationships and across their caseloads. You need to ask the hard questions and help the clinician separate clinical rationale from clinical rationalization, the client's therapeutic needs from their own. Most of all, you need to be sensitive to the parallel process, and ask yourself if the clinician is, in fact, merely replicating what you may be inadvertently doing in the supervisory relationship: that is, encouraging the clinician's dependence upon you because of your needs and fears of losing the control or intimacy of the relationship. At this stage, it's important to look at your own patterns of supervision and talk to your own supervisor to gain a wider perspective.
Stage 3: Gatekeeper
Again if you've done your job, the clinician moves on, emotionally and professionally. This is the stage at which the growing therapist "doesn't know what he doesn't know"--he thinks he knows it all--and it's your job to disabuse him of this illusion. This is the world of Tom. The clinician has soaked up your ideas and perhaps even your style of therapy, but is beginning to develop his own. Tom goes off to a weekend conference on EMDR or Internal Family Systems or something else that you may not know much about, and he comes back ready to use it on all his clients. He gets a bit cocky and loose, and starts pushing the boundaries. He shows up late for meetings, "forgets" about your supervisory session, and tries turning in his paperwork late.
This is the most dangerous of the stages because the clinician is blind to his own limits. He feels powerful, believes he can treat anybody for anything, and will try to do so without telling you about it unless you pin him down. He's impatient with clients who don't want to change, and lets them know that if they don't want to work, they can leave. He feels powerful, invulnerable, and certain he can do pretty much what he wants to without getting caught, and it will all turn out fine in the end. It's during this stage that clinicians might rationalize having sex with their clients. They can overidentify with the adolescents they see, encouraging them in sessions to let it out and tell their parents how they really feel. Anger and confrontation, once scary, become their modus operandi of change.
As a supervisor, you could have a loose cannon on your hands. You need to support these therapists' increasing skill and independence, yet monitor them carefully, and set and enforce clear boundaries. But this can be a difficult time, no less so for the supervisor. This is the stage at which Sigmund Freud invariably got stuck--as when, for example, Carl Jung, in effect, declared his independence and his determination to work on his own heretical ideas. Freud coped by throwing Jung out of the psychoanalytic family. This is the stage in which your own history of separation and loss mingles strongly with your professional role, and when, if you push too hard, you only create a power struggle and the clinician may decide to walk.
Some do seek greener pastures, feeling angry and misunderstood, held back and entitled. Others think about career change. Of course, when people leave at this stage, particularly if they go to greener, better-paying pastures, you may wonder why you're still hanging around.
One way to avoid sudden leave-takings of clinicians at this stage is to channel their restlessness and power. Let them supervise the interns or represent the team on an agency personnel committee. Encourage them to enter a three-year certification program in object relations, or play therapy because it's different and enticing. What's important is to avoid destructive fights by valuing their strengths and helping them find creative ways to express them.
Stage 4: Consultant
If you both get through this time of testing and individuation, the process shifts again. The previous stage may have damaged your relationship. If the rupture wasn't repaired, you both may continue not so much working together as limping together. If, however, you were honest and straightforward and the two of you can talk your way into a repair of the relationship's fault lines, you both will come to respect each other's styles and strengths. While you may remain an administrative head, clinically, you're approaching becoming peers.
Now the supervisory sessions are more case consultations. This is the stage when the clinician "knows what she doesn't know." She recognizes and acknowledges her blind spots, and knows she can't and shouldn't do it all. Now, she's likely to come to you to recruit your strengths. She knows and respects your way with angry couples and seeks your advice on a difficult case, just as you may pick her brain about applying EMDR to your new client with post-traumatic stress.
This can be a good time for the relationship, one of mutual respect and comfort. The danger of this stage is boredom, both for the clinician and within the supervisory relationship. The clinician is doing good work, but she may not be as creative and curious as she once was.
As with all the other stages, you set the pace. You're the role model. Your job is to avoid the undertow of stagnation that you sometimes feel by continuing to move toward your own anxiety in supervisory sessions. Continue to ask the hard questions--How does this work fit into your life now?--and encourage risk-taking. If you haven't already done so, begin training the clinician to be a clinical supervisor, and provide supervision of her supervision. Provide challenges. For example, put her in charge of handling the upcoming agency reaccreditation. If you believe your relationship is vital, that your role is creative and important, then you both will continue to grow.
This model of supervision provides a frame in which you can create infinite variations. The interaction of your personalities, the interplay of your personal histories, the level of your own skill, and your ability to take risks and confront the uncomfortable will be the determining factors of supervision outcome. The excitement of supervision is that the work is always in the moment, always right there in the room.
Letters to the Editor about this department may be e-mailed to letters@psychnet worker.org.