Psychotherapy Bulletin

Psychotherapy Bulletin

Safety in Clinical Supervision

A Mechanism to Promote Professional Development Among Trainees

Clinical Impact Statement: This manuscript provides information to clinical supervisors in psychology and clinicians in training in psychology on the importance of self-disclosure and self-reflection allowing safety in supervision. Specific experiences of supervisors’ actions that contributed to trainee’s feeling of safety in supervision and promoted positive outcomes for them are presented.

Introduction

Perceived safety in the supervisor-supervisee relationship can influence the level of supervisee self-disclosure (e.g., of mistakes, countertransference, or personal factors such as self-care; Gunn & Pistole, 2012), as well as supervisee outcomes (e.g., self-awareness and self-confidence in session with clients; Johnston & Milne, 2012; Wheeler & Richards, 2007). The development of safety in this relationship is facilitated by qualities such as consistency, empathy, and warmth among supervisors (e.g., Wilson, Davies, & Weatherhead, 2016). Additionally, supervisor self-disclosure, when used appropriately (e.g., with the clear intent of responding to supervisees’ training needs) is related to greater working alliance between supervisors and supervisees (Knox, Edwards, Hill, & Hess, 2011). In the authors’ experience, when supervisors engaged in judicious self-disclosure, perceived safety in the supervisory relationship increased. This in turn augmented our own level of self-disclosure in supervision and improved our outcomes, as evidenced by greater self-perceived competence in clinical work. To illustrate, we present interactions with supervisors in which self-disclosure promoted our development as trainees across three themes. From our perspective, when supervisors used self-disclosure as a tool to engage in the actions presented, the quality of the supervisory relationship was strengthened through greater perceived safety, furthering our development as clinicians.

Supervisory Example by Author 1: Promoting Self-care in Supervision

Maintaining self-care is an ethical responsibility for both supervisor and supervisee (Falender & Shafranske, 2017b). These authors emphasized supervisors’ duty to maintain a “multiple complex relationship with self-care” (p. 44) in how they encourage supervisees to take care of themselves. Maintaining one’s health through self-care is especially important when providing services to clients in a process that is challenging, “full time, intimate, confidential, and nonreciprocal” (Falender & Shafranske, 2017b, p. 44). Supervisors also want their supervisees to be as productive as possible with clients, and to simultaneously balance clinical training with other training expectations (e.g., thesis or dissertation, teaching assistantships). As Falender and Shafranske (2017b) discussed, supervisors may not present self-care as accessible, but rather as another task to be added to an already full agenda. In Barnett and Molzon’s (2014) discussion of supervisors’ legal and ethical responsibilities, self-care emerged as essential in therapeutic work.

Setting the stage. As a practicum student who sets high expectations for herself, it has been easy for me to invest many hours into clinical work at the expense of self-care. However, some of my supervisors noticed this tendency, and encouraged my self-reflection on the implications of these choices through different means. One supervisor pointed out my tendency to avoid self-care in a formal competency evaluation, while another used examples from her own experience to highlight the importance of self-care. The following exchange highlights how supervisors’ discussion of self-care benefitted my professional development.

Modeling. While reviewing a competency evaluation with a supervisor, she pointed out my substantial investment in both clinical work (i.e., readings, preparation, writing, reviewing) and in several academic projects outside of this work. This supervisor discussed the importance of having a work-life balance in the psychology profession and encouraged me to pursue an interest or a hobby that would promote my health. Through the discussions, this supervisor helped me set limits with clients by being firmer with my availabilities and work to be done with them. This in turn helped me to ensure sufficient time to pursue my other interests. My supervisor was also helpful in reinforcing the importance of self-care: She described her challenges in maintaining her own self-care and helped to normalize my difficulty in balancing work and high expectations. She validated my concerns about this balance and empathetically clarified that it can be difficult to lower one’s expectations and take time to do things to maintain my own health.

Supporting supervisee’s self-reflection. These exchanges helped increase my awareness of the importance of self-care, not only to live a fulfilling life but also to maintain my energy and empathy as a clinician. I felt safe discussing my difficulty prioritizing self-care because the supervisory environment was open, confidential, and above all without judgment. Supervisors also disclosed about their own journeys as students in clinical psychology, allowing me to reflect on mine and share it with them. I felt that I could be vulnerable and could discuss my thoughts and emotions with these supervisors. These supervisors’ ability to support me while maintaining our professional relationship allowed me to feel that they cared about my well-being as much as about my work with clients. This encouraged the development of my professional identity and helped me to increasingly appreciate the work done for and with my clients.

Supervisory Example by Author 2: Supporting Disclosure of Countertransference

Therapists are not neutral beings, and each has a set of experiences and beliefs that influences how they feel, think, and act in relation to other people. These reactions, when they occur in the therapeutic context, are called countertransference (CT; Ponton & Sauerheber, 2014). CT can lead therapists to engage in unhelpful behaviors towards clients. In their meta-analysis of CT studies, Hayes, Gelso, and Hummel (2011) found that CT was inversely related to therapy outcomes. However, when therapists effectively managed CT, it was related to improved therapy outcomes and greater therapist self-awareness (Hayes et al., 2011).

Managing CT is an important skill for therapists. To develop this skill, clinicians must reflect about how their personal experiences (e.g., memories and beliefs) interact with client characteristics. For trainee therapists, this self-reflective process can be facilitated by the guidance of competent, empathic supervisors. However, supervisees are reluctant to disclose CT in supervision (Hess et al., 2008). Reasons for this include personal characteristics (e.g., the degree to which they value self-reflection) and the perceived quality of their relationship with their supervisors (Spence, Fox, Golding, & Daiches, 2014). Thus, while supervisees’ decision to disclose CT is voluntary, supervisors can contribute to their students’ growth by providing a safe environment in which to do so. Described below are a few actions by supervisors that promoted my disclosure of CT in supervision.  

Setting the stage. Supervisees’ initial interactions with their supervisors can set the tone for the remainder of the relationship. At the onset of the supervisory relationship, a recommended task between supervisor and supervisee is the establishment of a supervision contract (Thomas, 2007). In this contract, goals and expectations for supervision are discussed. This is an excellent opportunity for supervisors to build the foundation for a secure supervisory relationship by adopting a collaborative approach and asking about supervisees’ needs, strengths, and areas for growth (Barnett & Molzon, 2014). In my experience, I have felt most comfortable with supervisors who allowed me to take up space in supervision and responded to my early self-disclosures (e.g., areas for growth) in an empathic and nonjudgmental way. This set the stage for further self-disclosure throughout the supervisory relationship.

Modeling. Supervisees can feel self-conscious about their personal reactions to clients. In my case, this has sometimes prevented me from disclosing CT in supervision. However, supervisors who judiciously disclosed their own reactions to clients, as is promoted in the literature (Wilson et al., 2016), have helped to normalize my own CT and build safety in the supervision environment. I have learned the most from supervisors who discussed their emotional responses to clients, the self-reflective process that followed, and how they learned to manage these reactions. For example, one supervisor discussed how she had taken on a “rescuing” role with a particularly distressed client (e.g., adding additional sessions for this client throughout the week and feeling a disproportionate sense of responsibility for the client’s safety outside of sessions). She explained that after self-reflection, she realized this reaction was related to similarities between her client and a family member, and she learned to manage her CT by addressing it with her own therapist. This and other supervisors’ modeling of their management of CT helped to normalize my own reactions to clients and set me on the path toward developing a self-reflective practice.

Supporting supervisee’s self-reflection. In my experience, choosing to disclose CT in supervision meant accepting being vulnerable with my supervisors. As Coburn (1997) suggested, supervisors who are empathic and nonjudgmental can increase supervisees’ sense of safety and encourage the process of self-reflection. Supervisors who are aware of supervisees’ CT can also offer guidance by proposing alternative reasons for their emotions, based on their own experiences or those common to trainees. I had the most positive experiences with supervisors who presented such explanations as possibilities, rather than facts, and respected my own self-reflective process. These experiences contributed to my professional growth by allowing me to develop greater self-awareness and to learn to distinguish between my clients’ emotions and my own.

Supervisory Example by Author 3: Acknowledging Developmental Level

Throughout clinical training, supervisees’ skill development may progress in patches: Some domains strengthen more quickly than others, and it is advantageous to supervisees’ development to evaluate their training needs across domains (Barnett & Molzon, 2014). At different points in a supervisee’s training, support that is more intensive may be required to promote growth in areas of weakness; this can be achieved by considering the supervisee’s experience, knowledge, and skill (Falender & Shafranske, 2017a). Supervision can thus develop supervisees’ self-awareness (Johnston & Milne, 2012) and clinical confidence (Wheeler & Richards, 2007) by highlighting areas of strength and domains in need of support throughout training. A powerful learning opportunity may also arise when supervisees report perceived failure, as supervision can support self-reflection on areas of difficulty (De Stefano et al., 2007). The following example highlights the potential for growth when a supervisor demonstrated awareness of my developmental level across skill areas and modeled self-reflection on his own supervisory style.

Setting the stage. This exchange occurred during an assessment in which a child’s functioning was impacted by a medical condition. At the beginning of the practicum placement, the supervisor assessed my clinical experience, as well as areas of relative strength and weakness. As I became more confident in communicating results, the supervisor gradually transferred leadership of feedback sessions to me, contributing as needed. In areas where I lacked expertise, the supervisor collaboratively presented results, allowing me to present aspects with which I felt comfortable while also benefitting from the supervisor’s explanations.

Through this approach, I increasingly gained independence in communicating results. One feedback session, however, did not proceed as planned and I stumbled to present the case conceptualization. Directly after the appointment, I disclosed to my supervisor that I regretted my performance. My supervisor and I discussed what I thought contributed to my difficulty and how to strengthen my skills in delivering feedback in the future.  

Modeling. The following week the supervisor returned to the feedback. He disclosed that, upon reflection, he believed that he could have better supported me after the feedback by focusing on the aspects of the appointment that had gone well, rather than on what had gone poorly. The supervisor reported that though it was clear that I wanted to learn from my errors, it was also important to highlight my areas of strength.  

Supporting supervisee’s self-reflection. The supervisor then disclosed that he perceived me as advanced for my developmental stage, making it easy to forget that there were areas in which my skills were relatively less developed—in this case, in understanding the interplay between relevant medical conditions and functioning. This was helpful for me to develop my skills in self-reflection, both in witnessing my supervisor’s modeling of reflecting on his actions, and in recognizing my areas of weakness. This exchange supportively emphasized my skills that needed further development in a manner that encouraged self-reflection. It also underscored the value of using moments of perceived failure as learning opportunities. Finally, this experience reasserted that clinical skills do not develop at an equal pace across domains, and that when supervisees engage in open discussions with supervisors about both weaknesses and strengths, our clinical development benefits.

Lessons Learned

Safety in supervision is essential, given its relation to positive outcomes for supervisees, such as improved confidence, motivation and therapeutic perceptiveness (Nelson & Friedlander, 2001) as well as perceived trainee growth. In the cases presented above, safety in supervision was promoted by supervisors’ own self-disclosures, and led supervisees to feel comfortable self-disclosing and reflecting on their development as clinicians. Gunn and Pistole (2012) recommended that supervisors focus on the relationship aspects of supervision, and not only on skill development, to build a foundation for safety in supervision. As trainees, we believe that it is important to highlight supervisors’ actions that contribute to this safety in supervision and promote positive outcomes for trainees. In our experiences, we have valued and benefitted from the following circumstances:

  1. When supervisors adopted a warm and nonjudgmental attitude toward supervisees from the beginning of the supervisory relationship.
  2. When supervisors and supervisees collaboratively developed a supervision contract. This provided an opportunity for supervisors to empathically assess our developmental levels and discuss our needs in supervision.
  3. When supervisors empathically and collaboratively addressed supervisees’ areas for growth according to their developmental levels, including discussion of the interaction between personal and professional development (e.g., the importance of self-care).
  4. When supervisors encouraged professional development by using judicious self-disclosure. This included addressing mistakes or missteps made by the supervisor in supervision, disclosing examples of managing countertransference with clients, and disclosing personal experiences of self-care.

Examples such as these can contribute to trainees’ professional and personal development. More specifically, by promoting a healthy work-life balance, encouraging the practice of self-reflection in therapy, respecting supervisee's developmental level and identifying and addressing areas for continued growth, the trainee’s development may progress beyond concrete skill acquisition and encourage self-reflective practice. Supervision guidelines developed by the Canadian Psychological Association (CPA, 2009, p. 3) recommend that supervisors take the lead on resolving challenges in the supervisor-supervisee relationship, and we agree that it is essential that the supervisor create an open and accepting environment. We also recognize that supervisees play a role in supporting the development of this environment: By approaching supervision with an openness and nondefensiveness to feedback on both strengths and weakness, and an awareness of how their actions may influence the supervisory relationships, trainees can also promote the development of a safe supervisory relationship.

Suggestions for Future Research

Safety in supervision is related to improved outcomes for trainees in terms of their professional development (Gunn & Pistole, 2012), and future research could explore which factors contribute to the development of this quality in supervisory relationships. For example, elucidating supervisor-specific factors (e.g., training in supervision practices, personal experiences of supervision, values) that may contribute to a supervisory practice that promotes safety would be helpful in developing recommendations for best practices in supervision. Further, examination of trainee-specific variables (e.g., personal experiences of supervision, openness to feedback, comfort with vulnerability, perception of supervisory relationship) could clarify trainees’ contributions to the supervisory relationship. This could support the development of concrete recommendations for trainees’ approaches to supervision and how they can positively influence supervisory relationships to support their development throughout clinical training.

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Cite This Article

Vandette, M., Burns, S., & Shesko, D. (2019). Safety in clinical supervision: A mechanism to promote professional development among trainees. Psychotherapy Bulletin, 54(1), 17-24.

References

Barnett, J. E., & Molzon, C., H. (2014). Clinical supervision of psychotherapy: Essential ethics issues for supervisors and supervisees. Journal of Clinical Psychology, 70, 1051-1061. doi: 10.1002/jclp.22126

Canadian Psychological Association. (2009). Ethical guidelines for supervision in psychology: Teaching, research, practice, and administration. Retrieved from https://www.cpa.ca/docs/File/Ethics/EthicalGuidelinesSupervisionPsychologyMar2012.pdf

Coburn, W. J. (1997). The vision in supervision: Transference-countertransference dynamics and disclosure in the supervision relationship. Bulletin of the Menninger Clinic, 61, 481-494.

De Stefano, J., D’Iuso, N., Blake, E., Fitzpatrick, M., Drapeau, M., & Chamodraka, M. (2007). Trainees’ experiences of impasses in counselling and the impact of group supervision on their resolution: A pilot study. Counselling and Psychotherapy Research, 7, 42-47. doi: 10.1080/14733140601140378

Falender, C. A., & Shafranske, E. P. (2017a). Competency-based clinical supervision: Status, opportunities, tensions, and the future. Australian Psychologist, 52, 86-93. doi: 10.1111/ap.12265

Falender, C. A., & Shafranske, E. P. (2017b). Supervision essentials for the practice of competency-based upervision. American Psychological Association: Washington, DC: American Psychological Association.

Gunn, J. E., & Pistole, M. C. (2012). Trainee supervisor attachment: Explaining the alliance and disclosure in supervision. Training and Education in Professional Psychology, 6, 229-237. doi: 10.1037/a0030805

Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy, 48, 88-97. doi: 10.1037/a0022182

Hess, S. A., Knox, S., Schultz, J. M., Hill. C. E., Sloan L., Brandt S., … Hoffman, M. A. (2008). Predoctoral interns’ nondisclosure in supervision. Psychotherapy Research, 18, 400-411. doi: 10.1080/10503300701697505

Johnston, L. H., & Milne, D. L. (2012). How do supervisee’s learn during supervision? A Grounded Theory study of the perceived developmental process. The Cognitive Behaviour Therapist, 5, 1-23. doi:10.1017/S1754470X12000013

Knox, S., Edwards, L. M., Hill, C. E., & Hess, S. A. (2011). Supervisor self-disclosure: Supervisees’ experiences and perspectives. Psychotherapy, 48, 336-341. doi: 10.1037/a0022067

Nelson, M. L., & Friendlander, M. L. (2001). A close look at the conflictual supervisory relationships: The trainee’s perspective. Journal of Counseling Psychology, 48, 384-395. doi:10.1037//0022-0167.48.4.384.

Ponton, R. F., & Sauerheber, J. D. (2014). Supervisee countertransference: A holistic supervision approach. Counselor Education and Supervision, 53, 254-266. doi: 10.1002/j.1556-6978.2014.00061.x

Spence, N., Fox, J. R., Golding, L., & Daiches, A. (2014). Supervisee self-disclosure: A clinical psychology perspective. Clinical Psychology and Psychotherapy, 21, 178-192. doi: 10.1002/cpp.1829

Thomas, J. T. (2007). Informed consent through contracting for supervision: Minimizing risks, enhancing benefits. Professional Psychology: Research and Practice, 38(3), 221-231. http://dx.doi.org/10.1037/0735-7028.38.3.221

Wheeler, S., & Richards, K. (2007). The impact of clinical supervision on counsellors and therapists, their practice and their clients. A systematic review of the literature. Counselling and Psychotherapy Research, 7, 54-65. doi: 10.1080/14733140601185274

Wilson, M. N. H., Davies, J. S., & Weatherhead. (2016). Trainee therapists’ experiences of supervision during training: A meta-synthesis. Clinical Psychology and Psychotherapy, 23, 340-351. doi: 10.1002/cpp.1957

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