Psychotherapy Bulletin

Psychotherapy Bulletin

Editors’ Note: This article is part of a special student series on supervision and training that will be featured in Psychotherapy Bulletin issues throughout 2019.

Clinical Impact Statement: This article highlights difficult supervision experiences to help other clinical trainees navigate their clinical training while relying on the literature to deepen our understanding of clinical work and the supervisory process/relationship.

Introduction

Clinical supervision comes in many different shapes and sizes. However, clinical supervision remains, at its core, a professional relationship in which the supervisor provides instruction and guidance in order to further develop the supervisee’s knowledge, skills, and attitudes in clinical practice (Falender & Shafranske, 2004; Falender & Shafranske, 2014). Although the style of supervision should largely meet the overall competency guidelines outlined by the American Psychological Association (APA, 2015), training offered to psychology students is often subjectively diverse and dependent on the supervisors’ personal training, personality styles, theoretical orientations, and the overall demands of their workload. 

Given the complex and potentially haphazard nature of clinical supervision caused by external factors, such as different cognitive styles, opposing theoretical orientations, or personalities, or burnout due to being overworked, many trainees might wonder how to navigate these waters while maintaining respect and trust in the supervisory relationship? The following three cases provide examples of how trainees navigated difficult situations related to supervision. These experiences helped the supervisor and supervisee to improve their alliance and the trainee’s professional development. 

Case Example 1: Communication Builds Growth 

The first case example involved a difficult supervision experience that occurred early on in the psychology trainee’s clinical training. The trainee was working in a community mental health setting treating clients with diverse psychological needs ranging from treatment of depression and anxiety to anger management and interpersonal skills training. Clinical supervision at this setting consisted of one hour of individual supervision and two hours of group supervision per week. During individual supervision, the clinical supervisor told the trainee that he had a natural talent in clinical work and complimented him often throughout the supervisory process. In a short time, however, the trainee realized that he was not receiving the type of constructive feedback that he was expecting. 

Although group supervision provided opportunities for the clinical team to review video recordings of therapy sessions, the number of trainees in group supervision limited the number of opportunities to review them. Unfortunately, video recordings and role plays were not implemented in individual supervision, limiting the opportunity to help improve the trainee’s therapy skills. Due to the power dynamic inherent in the supervisory relationship, the trainee was not certain how the supervisor would react if approached, and didn’t know how to proceed. Therefore, the trainee continued with this dilemma of not having his needs met for a number of weeks.

After some time, the clinical trainee realized that if he didn’t voice his expectations to the supervisor, the problems he experienced would continue and he would not be able to receive guidance in the learning style that he needed in order to improve. He thought about how to best communicate his concerns with his supervisor. During the next individual supervision, he shared his expectations and needs with his supervisor. He explained to his supervisor that he would like to receive more assistance in individual therapy consisting of constructive feedback to video recordings of his therapy sessions and incorporating new skills with the use of role play. The supervisor was understanding and responsive to this trainee’s needs. In individual supervision, the supervisor implemented an agenda that focused on discussion concerning the trainee’s clinical work, cultural issues relating to clients, and providing examples of what the trainee might focus on in the next session. They also began using role plays in individual supervision, and the supervisor provided constructive feedback. 

Overall, this was a positive experience in which the trainee learned that supervision was a safe place to be able to voice his concerns and expectations. The trainee learned from this experience to clearly communicate his needs early on in the supervision process at his future practicum sites, which has and will continue to set him up for future success in developing a positive relationship with his supervisors and improving his clinical knowledge and skills. 

Research has shown that in order for clinical supervision to be effective, there are certain components that should be present (APA, 2015; Falender & Shafranske, 2014; Martin, Copley, & Tyack, 2014). Components that were illustrated in this first case example consisted of creating a supervision agreement at the start of the supervision process and using a supervision agenda, effective communication and feedback, and building a positive supervisory relationship (Martin et al., 2014). Another optimal central component addressed in this example was direct observation via video recorded therapy sessions and constructive feedback (Weck, Kaufmann, & Witthoft, 2017). Encouraging effective and open communication, incorporating video-taped sessions and roleplays into individual supervision, providing constructive feedback, and creating a supervision agenda helped this trainee and his supervisor to further develop their positive supervisory relationship, as well as enhance clinical training for the supervisee. 

Case Example 2: Getting the Support You Need

In order for the supervisory relationship to work, both individuals need to be present, both physically and cognitively. The relationship will not be effective if either the supervisor or the trainee is not engaged (Falender & Shafranske, 2014). In this second case example, the trainee worked at a shelter with homeless and at-risk youth. There were many training opportunities because there was a diverse population with varying degrees of psychopathology and comorbid substance use disorders. The shelter was co-ed and had a maximum capacity of 20 adolescents aged 12 to 17 years old. The vast majority of clients met clinical criteria for a formal diagnosis, and one of their main clinical challenges was emotion regulation. Many of the clients who struggled with insecure attachment styles also demonstrated maladaptive coping strategies, which often maintained and exacerbated the symptoms of their psychopathology. 

A common maladaptive coping strategy among this client population was the use of alcohol and other substances to numb distressing emotions. One of the trainee’s responsibilities was to run individual and group psychotherapy that focused on treating a client’s substance abuse and co-occurring mental health concerns. The treatment protocol utilized cognitive behavioral therapy and motivational interviewing with a harm reduction stance. The clients were encouraged to discuss what they enjoyed about their substance use in order to better understand their maladaptive coping strategies and build therapeutic alliances based on trust. What made this approach effective was giving each client autonomy over their choices, which was a stark contrast to most of their experiences with family and other authority figures.

The trainee would sometimes co-facilitate groups with another trainee, but often ran the groups independently. As one can imagine, many clients were reluctant to engage in treatment, as many clients were often badgered by counselors or court-mandated to attend sessions. Most clients were never given an opportunity to reflect on why they used substances or provided a safe place to talk about it. One client, a male in his mid-teens, told the trainee that he smoked marijuana to avoid an argument with his stepfather, which he was afraid would escalate into a physical altercation. He smoked marijuana because he didn’t know any other way to regulate his anxiety or his anger. The client was on probation and court mandated to attend treatment. He was reluctant to engage, and the trainee struggled to help him at first. This client was one of seven, each ambivalent about treatment. Due to limited experience, the trainee needed guidance from his supervisor. 

With such a demanding clinical population, the trainee looked forward to supervision each week. This specific supervisor was a personable individual who was easy to talk with and provided valuable guidance and training. However, he was overwhelmed and overworked. When the supervisor was engaged in supervision, he helped the trainee practice different cognitive strategies, problem solve specific dilemmas, and with case formulation. Unfortunately, this supervisor was busy with many responsibilities; therefore, he was rarely fully engaged during supervision and would often cut supervision short or miss supervision entirely by sending out a brief email an hour before the scheduled time.

This situation put the trainee in an awkward position because of the power dynamic of their professional relationship; he did not know how to address this problem with the supervisor. At first, he was stuck and didn’t know what to do. Therefore, the trainee reached out to a fellow peer for support and guidance. This other trainee also facilitated the same individual and psychotherapy group. She was a valuable source of support, especially when the supervisor was unavailable. The trainee also sought guidance and support from another supervisor, who made herself readily available, and was always present for their meetings. It was through consultation with colleagues that the trainee was able to manage his caseload when his supervisor was busy. However, the trainee realized that this approach was not sustainable. After consulting with multiple peers, the trainee decided that he needed to confront the supervisor about his absence, and his need for more support in supervision. 

During the next scheduled individual supervision, the supervisor answered a phone call during their meeting and stood up to leave the room. However, the trainee stopped the supervisor by voicing his concerns related to the supervisor’s prioritizing other issues above the trainee’s supervision. He let the supervisor know that their supervision time was not only important to him and the clients, but it was also mandatory. He then told the supervisor that he needed more supervision than what he was getting. Although the trainee said this to the supervisor in a respectful manner, he was still nervous and was uncertain how the supervisor would respond. The supervisor was surprised and then apologized to the trainee, he took responsibility for his actions, and he began to be more engaged in the supervision process. Both the supervisor and trainee became flexible with their time in order to accommodate the trainee’s needs. Instead of having supervision all in one session, often it was divided into multiple sessions to accommodate their schedules. The supervisor was more mindful of the trainee’s time and turned his cell phone off during their supervision sessions to fully engage in their meetings. The trainee greatly benefited from the changes that were implemented in supervision, and so did his clients. 

The trainee was able to help the teenage client mentioned above address the reasons for his substance use, which were his clinical anxiety symptoms and insecure attachment with his parents and peers. 

The trainee was also able to help facilitate positive changes in his other clients. He was able to help his clients reduce their substance use, maladaptive behavior, and clinical symptoms. 

Research demonstrates that not only do trainees greatly benefit from supervision, but so do the clients they are treating (Watkins, 2011). When a trainee is struggling, it will impact the quality of the work (Watkins, 2017). It is important that trainees address problems with their supervisors and ask for additional support or guidance when needed (Falender & Shafranske, 2014). Although the trainee was concerned that confronting his supervisor would negatively impact their professional relationship, it had the opposite effect. By being honest with the supervisor and asking for more support, their professional relationship improved, as did his clinical abilities.

Case Example 3: All It Takes Is Suspicion

The third case example involves a trainee who had been working at her practicum site for several months. She was beginning to feel confident in her ability to perform at her best while juggling the many components of graduate school. The trainee also started creating strong therapeutic alliances with her clients and was becoming invested in their progress. She began to discuss trauma history with one of her clients, and their session became increasingly emotionally laden. The trainee was worried she might get caught up in the intensity of the session’s content and overlook potential risk issues, leading to her client’s safety being jeopardized. She consulted with her supervisor, who reassured her by explaining that knowing when to report to child protective services (CPS) would come with time and training. In the meantime, her supervisor instructed the trainee to consult with an on-call supervisor if she suspected child abuse or neglect. 

A few weeks later, the trainee had another emotionally heavy session with her client. Within a few minutes, the trainee realized she needed to consult with a supervisor to ensure she did not need to submit a CPS report. She knew that stepping out would impacting the focus and flow of the session, but she had a suspicion that CPS needed to be contacted. She went to consult with the on-call risk supervisor and briefly explained the situation. The on-call supervisor laughed and inquired how the trainee thought she would be able to submit a CPS report with the little detail that the client had provided. The trainee explained that the client refused to provide more information and that she was under the impression that if the perpetrators still had access to children she was mandated to report. 

The on-call supervisor asked the trainee to explain, in detail, how she intended to make the CPS report by conducting a role-play. The trainee provided her rationale and the details the client provided. She felt confident that the on-call supervisor would agree with her rationale and instruct her to submit a CPS report. However, the on-call supervisor stated again there was clearly not enough information to submit a report. The trainee felt uncomfortable not reporting, but felt pressured to follow the on-call supervisor’s recommendations. She inquired if she should write up a risk summary and briefly explain the supervisor’s rationale for not reporting at this time. The on-call supervisor responded that the trainee should not write up the summary. 

The trainee felt unsure and uncomfortable about the response provided by the on-call supervisor, as it was different from what she had learned from her primary supervisor: Document actions (and non-actions, such as not reporting) taken, especially when it comes to risk. She followed the on-call supervisor’s direction but decided to follow up by consulting with her primary supervisor. 

After explaining the situation to her supervisor, she also indicated her concern regarding the lack of documentation. The supervisor was flabbergasted by the on-call supervisor’s response, especially as there was clear evidence of sexual and physical child abuse as well as knowledge that the perpetrator still had access to minors. The supervisor reminded the trainee that all that was required to submit a CPS report was suspicion of abuse or neglect. The supervisor also reminded the trainee that if she felt a report was needed, she may submit one without the on-call supervisor’s permission. The supervisor added that if someone in the future recommended to not document a consultation, the trainee should consider this as a red flag and document with great detail. The supervisor also clearly stated the on-call supervisor was wrong to instruct the trainee not to report to CPS. The supervisor instructed the trainee to submit a CPS report immediately, and to document why the report was delayed. 

The trainee was relieved after speaking to her supervisor for several reasons. First, her instinct to report her suspicion of abuse and to document was reinforced, and this instilled more confidence in her clinical abilities. Second, she experienced significant relief after she had a concrete answer surrounding what needed to be done concerning child abuse at her practicum site. The trainee also found solace going into future sessions as her supervisor stated she could always report suspicions of abuse or neglect, even if the on-call supervisor told her she did not have to report to CPS. 

Past literature outlines the complexity behind child abuse reporting and makes notes of the many clinicians who struggle to know when to report. Many clinicians find themselves worrying about the intent of the potential abuser when their only responsibility is to report their own suspiciousness (Shanley, Shropshire & Bonner, 2009). Additionally, not reporting in most states may lead to a misdemeanor or the clinician might be liable for damages (Brown, 2012). Therefore, it is extremely important to know when it is necessary to report abuse, and this skill needs to be passed on to trainees. Professors and supervisors have suggested the need for specialized courses in undergraduate and graduate programs that focus more closely on honing child abuse reporting skills (Peterson & Urquiza, 1993). The main reasons clinicians fail to report are believing they do not have enough information, thinking their local protective services are inadequate, and assuming they can provide more efficient help than CPS (Levin, 2008). Research does indicate that some reporting efforts end with a rupture within the therapeutic alliance, and sometimes the death of a child after they have been removed from their home (McTavish et al., 2017). However, reporting is aimed to secure a child’s safety and well-being and therefore when “reasonable suspicion” (or the equivalent statutory language in a given jurisdiction) is present, a mandated reporter must report (McTavish et al., 2017). Mandatory Reporters of Child Abuse and Neglect written by the Children’s Bureau outlines the reporting requirements by state and serves as a good resource for trainees and clinicians alike (Child Welfare Information Gateway, 2019).

Conclusion

Supervision is an important and crucial stepping stone in the professional development of psychology trainees. The ever-evolving nature of supervision based on the supervisors’ personal training and theoretical beliefs provides psychology trainees an opportunity to further expand their knowledge, skills, and abilities from one clinical setting to the next. As psychology trainees advance in their careers, the supervision experiences will remain with them, and continue to help shape their future clinical practice as well as supervision and consultation opportunities with upcoming trainees and colleagues. No matter where we are in our psychology careers, independent professional or trainee, learning is a lifelong endeavor. Both supervisors and supervisees should always strive to remain self-reflective and aware of how communication styles and actions impact the other member of the supervisory relationship as well as their overall professional development. 

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Cite This Article

Davich, J. A., Saltzman, H. R., & Nijmeh, J. S. (2019). If you give supervisees difficult situations: Examples of conflict in the supervisory relationship. Psychotherapy Bulletin, 54(3), 14-20.

References

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Brown, J. L. (2012). Physicians have ethical, legal obligation to report child abuse. AAP News, 33(3), 20. Retrieved from https://www.aappublications.org/content/33/3/20.1

Child Welfare Information Gateway (CWIG). (2019). Mandatory reporters of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/

Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Retrieved from https://doi-org.paloaltou.idm.oclc.org/10.1037/10806-000

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Martin, P., Copley, J., & Tyack, Z. (2014). Twelve tips for effective clinical supervision based on a narrative literature review and expert opinion. Medical Teacher, 36(3), 201-207. https://doi-org.paloaltou.idm.oclc.org/10.3109/0142159X.2013.852166

Mctavish, J. R., Kimber, M., Devries, K., Colombini, M., Macgregor, J. C., Wathen, C. N., …  Macmillan, H. L. (2017). Mandated reporters’ experiences with reporting child maltreatment: A meta-synthesis of qualitative studies. BMJ Open, 7(10). doi:10.1136/bmjopen-2016-013942

Peterson, M. S., & Urquiza, A. J. (1993). The role of mental health professionals in the prevention and treatment of child abuse and neglect. Washington, DC: National Center on Child Abuse and Neglect.

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